Incidence and progression of cortical and posterior subcapsular opacities: the Longitudinal Study of Cataract. The LSC Group

Evaluation of color vision related quality of life changes due to cataract surgery

Questionnaires have been used as research tools to provide a standardized approach to assess quality of life at various time periods and populations. However, literature shows only a few articles about self-reported color vision changes. Our aim was to evaluate the subjective patient feelings before and after cataract surgery and compare the results with a color vision test result. Our method was as follows: 80 cataract patients filled out a modified color vision questionnaire and performed the Farnsworth-Munsell 100 Hue Color Vision Test (FM100) before, two weeks, and six months after cataract surgery. We analyzed the correlations between these two types of results, which reveal that FM100 hue performance and subjective perception improved after surgery. Additionally, subjective patient questionnaire scores correlate well with the FM100 test results before and two weeks after the cataract surgery, but this effect decreased with longer follow-up times. We conclude that subjective color vision changes can only be noticed at longer periods after the cataract surgery. Health care professionals can use this questionnaire to better understand the subjective feelings of patients and monitor their color vision sensitivity changes.

Crystalline lens changes after selective laser trabeculoplasty in Afro-Caribbean patients with open-angle glaucoma; report 4 of the West Indies Glaucoma Laser Study (WIGLS)

PURPOSE

To characterize changes in nuclear, cortical, and posterior subcapsular lens opacities after selective laser trabeculoplasty (SLT) in Afro-Caribbean eyes with primary open-angle glaucoma (POAG).

SETTING

Three clinical practices, Saint Lucia and Dominica.

DESIGN

Prospective case series.

METHODS

Patients with POAG in the West Indies Glaucoma Laser Study (WIGLS) had 360-degree SLT after medication washout. No antiinflammatory therapy was used after SLT. Nuclear, cortical, and posterior subcapsular lens opacities were graded through dilated pupils using the Lens Opacification Classification System III (LOCS III) at baseline and 12, 24, and 36 months after SLT, with the grader masked to all previous values after baseline assessment. Changes in opacity scores from baseline were evaluated using paired t tests.

RESULTS

Seventy-two patients (142 phakic eyes) were evaluated. The mean (±SD) baseline LOCS III opacity scores in right eyes and left eyes, respectively, were 2.44 ± 1.23 and 2.40 ± 1.16 (nuclear), 0.39 ± 1.08 and 0.30 ± 0.85 (cortical), and 0.22 ± 0.59 and 0.15 ± 0.36 (posterior subcapsular). Other than a small improvement in bilateral nuclear opacity scores at 12 months, no statistically or clinically significant changes in any opacity score occurred in either eye up to 36 months postoperatively. Three eyes (2.1%) with preexisting lens opacities had cataract surgery for progressive lens changes at 3 months, 21 months, and 26 months, respectively, after SLT.

CONCLUSIONS

Selective laser trabeculoplasty was not associated with clinically significant changes in nuclear, cortical, or posterior subcapsular lens opacities in glaucomatous Afro-Caribbean eyes. The rate of cataract surgery is consistent with reported rates from longitudinal natural history studies in Caribbean and non-Caribbean populations.

Development and preliminary evaluation of a decision aid to support informed choice among patients with age-related cataract

OBJECTIVE

Shared decision making and meaningful patient involvement are key in improving cataract treatment outcomes, but no decision aid has been formally developed and validated for this purpose. Our aims were to develop a patient decision aid to guide patients' decision about when to undergo cataract surgery, and to determine patient's comprehension and booklet's acceptability.

METHODS

The patient decision aid was developed and included evidence-based information about general cataract, its benefits, risks of treatment options, and value clarification exercise. A total of 30 patients with age-related cataract aged between 50 and 80 years were interviewed after using either the patient decision aid (n = 15) or the traditional education booklet (n = 15).

RESULTS

The patients who received the decision aid agreed that the information was new (n = 15, 100%), the length of the aid was "just about right" (n = 13, 87%), the information was clear and easy to understand (n = 13, 87%), the decision aid was helpful in making decision (n = 13, 87%) and would like to recommend this decision aid to others (n = 14, 93%).

CONCLUSIONS

The decision aid was assessed positively by patients with age-related cataract. There is a need for its further verification in the context of primary eye care setting.

The prevalence and risk factors for cataract in rural and urban India

Purpose:

To report the prevalence and risk factors of cataract and its subtypes in older age group.

Methods:

A total of 6617 subjects were recruited from both rural and urban areas. A detailed history including data on demographic, socioeconomic and ocular history was obtained. Lens opacity was graded according to the Lens Opacity Classification System III (LOCS III).

Results:

Cataract was present in 1094 of the rural and 649 subjects in the urban population. Monotype subtype cataracts were found in 32% and 25% in rural and urban population and 12.68% and 18.6% were mixed cataracts in the rural and urban groups. In baseline characteristics history of diabetes, alcohol intake and presence of age-related macular degeneration were the risk factors in urban group. On multivariate analysis, the only significant risk factors for any cataract in subjects ≥60 years were increasing age in both rural [odds ratio (OR), 1.07] and urban (OR, 1.08) population, and HbA1c (OR, 1.14) in rural population. Overweight (OR, 0.6) was found to be a protective factor, and lower social economic status (OR, 1.52) a risk factor for cataract in urban population. A significant urban–rural difference was found in the prevalence of cataract and its subtypes (P ≤ 0.05).

Conclusion:

We found the risk factors for any cataract in older age group to be increasing age and HbA1c in rural group. Age and lower social economic status were found to be the risk factors in urban arm. A statistically significant difference was found on comparison of the prevalence of cataract and its subtypes between the rural and urban population.

Cost effect of surgeon and patient discretion in regard to cataract surgery

Purpose

The purpose of this study is to examine the cost effect of surgeon and patient discretion in regard to cataract surgery and how this affects population health care costs.

Methods

A model of cataract progression was created from preexisting published data and combined with mortality data and Medicare cataract statistics to estimate the effect of mortality on decreasing the rate of cataract surgery if surgery was delayed until any cataract progression occurred.

Results

Five-year cataract progression rates were determined for a given patient age, sex, and type of cataract. Combined with 5-year death rates, delaying surgery until progression occurred resulted in a 1.1% decrease in surgery for nuclear sclerosis at age 45 that increased to a 33.8% decrease by age 90; a 1.5% decrease in surgery for cortical cataract at age 45 that increased to a 51.1% decrease by age 90; and a 1.6% decrease in surgery for posterior subcapsular at age 45 that increased to a 59.7% decrease by age 90. The effect of this decrease in surgical volume on Medicare was estimated to result in a 13% overall decrease in cataract surgery annually at a cost of ~$660 million dollars per year.

Conclusion

Overall, we conclude that surgeon and patient discretion in regard to cataract surgery has a substantial cost effect with the potential to reduce surgical volume by as much as 13% by the decision to delay surgery as a result of patient mortality.

Color vision abnormalities in type II diabetes: Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetics Study II report no 2

Purpose:

The purpose of this study is to assess color vision abnormalities in a cohort of subjects with type II diabetes and elucidate associated risk factors.

Methods:

Subjects were recruited from follow-up cohort of Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetics Study I. Six hundred and seventy-three eyes of 343 subjects were included from this population-based study. All subjects underwent detailed ophthalmic evaluation, including the Farnsworth-Munsell 100 hue test.

Results:

The prevalence of impaired color vision (ICV) was 43% (CI: 39.2–46.7). Risk factors for ICV were higher heart rate (odds ratio [OR]: 1.043, [1.023–1.064]) and a higher intraocular pressure (IOP) (OR: 1.086, [1.012–1.165]). Subjects with clinically significant macular edema (CSME) had three times higher chance of having ICV. C1, C2, and C3 are the commonly found Early Treatment Diabetic Retinopathy Study (ETDRS) patterns. The moment of inertia method showed that the angle did not reveal any specific pattern of color vision defect. Although the major and minor radii were high in those with ICV, we did not observe polarity. Confusion index was high in subjects with ICV, indicating a severe color vision defect.

Conclusions:

The prevalence of ICV was 43% among subjects with type II diabetes. The most commonly observed patterns were increasing severities of the blue–yellow defect on ETDRS patterns, but no specific pattern was observed at the moment of inertia analysis. The presence of CSME, a higher heart rate, and IOP was significant risk factors for ICV. This functional impairment in color vision could significantly contribute to morbidity among subjects with diabetes.

Loss of αB-crystallin function in zebrafish reveals critical roles in the development of the lens and stress resistance of the heart

Genetic mutations in the human small heat shock protein αB-crystallin have been implicated in autosomal cataracts and skeletal myopathies, including heart muscle diseases (cardiomyopathy). Although these mutations lead to modulation of their chaperone activity in vitro, the in vivo functions of αB-crystallin in the maintenance of both lens transparency and muscle integrity remain unclear. This lack of information has hindered a mechanistic understanding of these diseases. To better define the functional roles of αB-crystallin, we generated loss-of-function zebrafish mutant lines by utilizing the CRISPR/Cas9 system to specifically disrupt the two αB-crystallin genes, αBa and αBb We observed lens abnormalities in the mutant lines of both genes, and the penetrance of the lens phenotype was higher in αBa than αBb mutants. This finding is in contrast with the lack of a phenotype previously reported in αB-crystallin knock-out mice and suggests that the elevated chaperone activity of the two zebrafish orthologs is critical for lens development. Besides its key role in the lens, we uncovered another critical role for αB-crystallin in providing stress tolerance to the heart. The αB-crystallin mutants exhibited hypersusceptibility to develop pericardial edema when challenged by crowding stress or exposed to elevated cortisol stress, both of which activate glucocorticoid receptor signaling. Our work illuminates the involvement of αB-crystallin in stress tolerance of the heart presumably through the proteostasis network and reinforces the critical role of the chaperone activity of αB-crystallin in the maintenance of lens transparency.

Meta-analysis and review: effectiveness, safety, and central port design of the intraocular collamer lens

The purpose of this review is to summarize relevant data from publications appearing in the peer-reviewed scientific literature over the past decade since US Food and Drug Administration approval of the implantable collamer lens (ICL), and, in particular, to review studies relating to sizing methodology, safety, and effectiveness, as well as more recent studies reporting clinical outcomes of the V4c Visian ICL with KS Aquaport, VICMO. A literature search was conducted using two databases, PubMed.gov and Science.gov, to identify all articles published after 2005 related to the Visian ICL (STAAR Surgical, Inc.). Articles were examined for their relevance to sizing methodology, clinical safety, and effectiveness, and the references cited in each article were also searched for additional relevant publications. The literature review revealed that all currently reported methods of determining the best-fit size of the ICL achieve similarly satisfactory results in terms of vault, the safe distance between the crystalline lens and the ICL. Specifically, meta-analysis demonstrated that sulcus-to-sulcus and white-to-white measurement-based sizing methods do not result in clinically meaningful nor statistically significant differences in vault (two-sample two-sided t-test using pooled mean and standard deviations; t (2,594)=1.33; P=0.18). The reported rates of complications related to vault are very low, except in two case series where additional risk factors such as higher levels of myopia and older age impacted the incidence of cataract. On the basis of preclinical studies and initial clinical reports, with up to 5 years of follow-up, the new VICMO central port design holds promise for further reduction of complications. Given its safety record and the significant improvement in vision and quality of life that the ICL makes possible, the benefits of ICL implantation outweigh the risks.

Impairment of Colour Vision in Diabetes with No Retinopathy: Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetics Study (SNDREAMS- II, Report 3)

PURPOSE

To assess impairment of colour vision in type 2 diabetics with no diabetic retinopathy and elucidate associated risk factors in a population-based cross-sectional study.

METHODS

This is part of Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular-genetics Study (SN-DREAMS II) which was conducted between 2007-2010. FM 100 hue-test was performed in 253 subjects with no clinical evidence of diabetic retinopathy. All subjects underwent detailed ophthalmic evaluation including cataract grading using LOCS III and 45° 4-field stereoscopic fundus photography. Various ocular and systemic risk factors for impairment of colour vision (ICV) were assessed in subjects with diabetes but no retinopathy. P value of < 0.05 was considered statistically significant.

RESULTS

The mean age of the study sample was 57.08 ± 9.21 (range: 44-86 years). Gender adjusted prevalence of ICV among subjects with diabetes with no retinopathy was 39.5% (CI: 33.5-45.5). The mean total error score in the study sample was 197.77 ± 100 (range: 19-583). The risk factors for ICV in the study were women OR: 1.79 (1.00-3.18), increased resting heart rate OR: 1.04 (1.01-1.07) and increased intraocular pressure OR: 1.12 (1.00-1.24). Significant protective factor was serum high-density lipoprotein OR: 0.96 (0.93-0.99).

CONCLUSIONS

Acquired ICV is an early indicator of neurodegenerative changes in the retina. ICV found in diabetic subjects without retinopathy may be of non-vascular etiology.

Prevalence and associations of cataract in a rural Chinese adult population: the Handan Eye Study

BACKGROUND

Cataract remains the leading cause of blindness and visual impairment in the world and in China. However, data on the prevalence of cataract based on standardized lens grading protocols from mainland China are limited. This paper estimated the age- and gender-specific prevalence and risk factor for cataract

METHODS

In a population-based Chinese sample, participants underwent a comprehensive ophthalmic examination, including assessment of cortical, nuclear, posterior subcapsular (PSC) and mixed lens opacities from slit-lamp grading using the Lens Opacities Classification System III.

RESULTS

Of the 7,557 eligible subjects, 6,830 took part in the study (90.4% response rate), and 6,544 participants (95.8%, mean age 52.0 ± 11.8 years) had lens data for analyses. The prevalence of any cataract surgery in at least one eye was 0.8% (95% confidence interval [CI], 0.62, 1.06), with similar rates between men and women. The overall prevalence of any cataract or cataract surgery was 20.8% (95% CI, 19.8, 21.8), higher in women than in men after adjusting for age (23.6% vs 17.6%; OR: 1.78; 95% CI: 1.54-2.07). When distinct lens opacity was categorized in each eye as cortical, nuclear, PSC or mixed, based on one randomly selected eye, cortical cataract was the most common distinct subtype (12.3%), followed by mixed (3.2%), nuclear (1.7%), and PSC (0.2%) cataract. The prevalence of all lens opacities increased with age (P < 0.001). After excluding other causes for visual impairment, the proportion of people with best corrected visual acuity <20/60 was 21% among those with PSC, and 12% among those with mixed opacities in the better-seeing eye. In multivariable logistic regression models, myopia was associated with all cataract types, while higher fasting plasma glucose and diabetes were only associated with PSC cataract.

CONCLUSIONS

Cataract affects 20% of the population aged 30 years and older living in rural China, with cortical cataract the most common subtype. Risk factors for cataract include myopia and diabetes.

Diclofenac sodium topical solution with dimethyl sulfoxide, a viable alternative to oral nonsteroidal anti-inflammatories in osteoarthritis: review of current evidence

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) may offer a safer alternative to their oral counterparts for the management of osteoarthritis. Diclofenac sodium topical solution with dimethyl sulfoxide (TDiclo) was evaluated in five randomized, controlled trials and is indicated for treatment of the signs and symptoms associated with osteoarthritis of the knee. Three studies showed that TDiclo is superior to placebo and vehicle control with respect to pain, physical function, and perception of osteoarthritis symptoms. Two studies showed that benefits are similar to those of oral diclofenac, with one study demonstrating statistical equivalence. The most common adverse event associated with TDiclo in these studies was dry skin. Incidences of gastrointestinal adverse events and abnormal levels of liver enzymes were lower with TDiclo compared with oral diclofenac in active-controlled studies. Based on these studies, TDiclo represents a practical, evidence-based option for the management of osteoarthritis of the knee.

A long-term, open-label study to confirm the safety of topical diclofenac solution containing dimethyl sulfoxide in the treatment of the osteoarthritic knee

To assess the long-term safety of a topical solution of diclofenac sodium in a vehicle containing dimethyl sulfoxide (TDiclo), subjects with radiologically confirmed, symptomatic osteoarthritis of the knee(s) applied the clinical dose of TDiclo (40 drops, four times daily) to each painful knee for up to 52 weeks. Safety assessment included adverse events, skin irritation scores of the treated knee(s), ocular examinations, and routine laboratory tests. There were 793 subjects (mean age, 62.5 years) who applied TDiclo to one or both (72%) knees for an average of 204 days, including 463 subjects for 6 months and 144 for 1 year. The most frequent adverse events were at the application site with no increase in incidence with prolonged exposure: dry skin (25.3%), contact dermatitis without vesicles (13.0%) or with vesicles (9.5%). Skin irritation score was 0 (normal) in 61.0% of subjects, 0.5 (dryness or flaking) in 23.9%, 1 or 2 (erythema without or with induration) in 6.9%, and 3 or 4 (erythema with induration and vesicles/bullae) in 8.2%. Subject dropouts included 114 (14.4%) with an application site skin adverse event. Individual subject laboratory test shift to abnormal occurred for hemoglobin (3.2%), aspartate aminotransferase (6.4%), alanine aminotransferase (7.3%), and creatinine (4.2%), but few shifts (less than 0.3% per variable) were clinically significant. No increased risk of cardiovascular or cataract events was noted. This long-term study of TDiclo revealed a safety profile comparable to that shown in multiple, shorter, well-controlled, double-blind trials with the predominant adverse effect noted being an application site reaction.

Prevalence of posterior subcapsular cataracts in volunteer cytapheresis donors

BACKGROUND

Granulocyte donors routinely receive dexamethasone orally before donation. Steroids may increase the risk of posterior subcapsular cataract (PSC) formation.

STUDY DESIGN AND METHODS

We recruited 100 granulocyte donors (four or more granulocyte donations; any number of platelet [PLT] donations) and 100 age- and sex-matched PLT donors (zero to three granulocyte donations, any number of PLT donations) to examine the risk of PSC. PSC was assessed by a masked ophthalmologist and reading center lens photograph gradings or medical record documentation of PSC as the reason for cataract extraction.

RESULTS

Fourteen eyes of 10 granulocyte donors and five eyes of four PLT donors had PSCs (odds ratio [OR], 2.82; 95% confidence interval [CI], 0.83-9.61; p = 0.10). Risk of PSC increased with number of granulocyte donations: compared to zero to three donations (4.0%), the risk for four to nine, 10 to 19, and 20 or more donations was 8.6% (OR, 2.25; 95% CI, 0.31-13.99; p = 0.30), 9.5% (OR, 2.53; 95% CI, 0.44-14.20; p = 0.21), and 13.0% (OR, 3.60; 95% CI, 0.48-22.81; p = 0.11), respectively (p = 0.06 for trend).

CONCLUSION

We did not demonstrate a statistically significant increased risk of PSC associated with granulocyte donation. However, although this makes a large risk unlikely, we cannot rule out a small to moderate risk and there is biologic plausibility that the steroid administration associated with granulocyte donation could be associated with PSC formation. Transfusion medicine professionals should advise granulocyte apheresis donors to maintain an appropriate frequency of eye examinations.

Four-year incidence and progression of lens opacities: the Los Angeles Latino Eye Study

PURPOSE

To estimate the 4-year incidence and progression of lens opacities.

DESIGN

Population-based longitudinal study.

METHODS

A total of 4658 adult Latinos from Los Angeles County were examined at baseline and 4-year follow-up. Examination included assessment of lens opacities using the Lens Opacities Classification System II (LOCS II). Incidences of cortical, nuclear, and posterior subcapsular opacities (with LOCS II scores >or=2) were defined as opacity development in persons without that opacity at baseline. Single and mixed opacities were defined in persons without any opacity at baseline. Incidence of all lens changes included development of at least 1 opacity or cataract surgery among those without any opacity at baseline. Four-year progressions were defined as increase of >or=2 in LOCS II score.

RESULTS

The 4-year incidence of all lens opacities was 14.2%. Four-year incidence of cataract surgery was 1.48%. The incidences were 4.1% for cortical-only, 5.8% for nuclear-only, 0.5% for PSC-only, and 2.5% for mixed. The incidences for any opacities were 7.5% for cortical, 10.2% for nuclear, and 2.5% for PSC. Incidence increased with age (P < .0001 for all). The progressions were 8.5% for cortical, 3.7% for nuclear, and 2.9% for PSC opacities.

CONCLUSIONS

Our Latino population had a higher incidence of nuclear than cortical opacities, but a greater progression of cortical than nuclear opacities. Incidence and progression of PSC was low. Additional understanding of the natural history and progression of various lens opacities will give us a better understanding of the pathogenesis and management of lens opacities.

Ciclesonide and the treatment of asthma

IMPORTANCE OF THE FIELD

Asthma is a chronic disease characterized by airway inflammation and hyper-responsiveness. Inhaled corticosteroids (ICSs) constitute the guideline-recommended first-line therapy for persistent asthma. However, concerns regarding ICS-related adverse events may contribute to their underutilization by physicians and patients.

AREAS COVERED IN THIS REVIEW

The currently available published data on the pharmacokinetic and pharmacodynamic properties, safety and efficacy of the ICS, ciclesonide, is described. Peer-reviewed publications (1996 - 2009) on the pharmacodynamic and pharmacokinetic profile, safety and efficacy of ciclesonide were reviewed.

WHAT THE READER WILL GAIN

Ciclesonide is delivered as an inactive prodrug, which is cleaved to the active molecule by intracellular esterases located in the lungs. This and other pharmacodynamic and pharmacokinetic properties may limit the amount of active molecule outside the lung and may reduce the incidence of side effects. Randomized placebo-controlled studies found that ciclesonide can initiate and maintain disease control in subjects with persistent asthma of all disease severities. Moreover, studies have found that ciclesonide is as effective as other ICSs in establishing and controlling disease symptoms. Controlled clinical trials also showed that ciclesonide is associated with minimal systemic and local treatment-related adverse events.

TAKE HOME MESSAGE

Published findings indicate that ciclesonide is effective at initiating and maintaining asthma control and is well tolerated, with a positive safety profile.

Myopic refractive shift caused by incident cataract: The Blue Mountains Eye Study

PURPOSE

To assess the myopic shift in refraction caused by incident cataract in the Blue Mountains Eye Study (BMES) population.

METHODS

Five-year prospective follow-up of the BMES, initially performed in 1992. After 5 years, 2335 survivors (75.1%) of 3654 baseline BMES participants were re-examined. Refractive change was assessed by age, sex, incident cataract type and baseline refraction. Slit-lamp and retroillumination lens photographs were graded for presence of incident cataract and signs of previous cataract surgery. Objective and subjective refractions were performed.

RESULTS

In a multivariate model, age (p < 0.0001), incident nuclear cataract (p < 0.0003), hyperopia (p < 0.0009), incident posterior subcapsular cataract (p < 0.0027) and incident cortical cataract (p < 0.025) were factors associated with a relatively modest myopic refractive shift (0.34 diopters). Baseline myopia and gender were not associated with refractive change over the follow-up period. A myopic shift in refraction occurred most frequently in older (> or = 70 years) than younger (< 70 years) participants.

CONCLUSIONS

Older age, baseline hyperopia and all types of incident cataract were principal factors found associated with myopic refractive shift over 5 years in an older population.

Second-eye cataract surgery in elderly women: a cost-utility analysis conducted alongside a randomized controlled trial

AIM

The aim of this study was to evaluate the cost-effectiveness of second-eye cataract surgery for older women with minimal visual dysfunction in the eye to be operated on from a Health and Personal Social Services perspective, compared to waiting list controls who had already undergone first-eye cataract surgery.

METHODS

A cost-utility analysis was undertaken alongside a randomized controlled trial of second-eye cataract surgery in secondary care ophthalmology clinics. A total of 239 women over 70 years old with one unoperated cataract were randomized to cataract surgery (expedited, approximately 4 weeks) or control (routine surgery, 12 months wait). Outcomes were measured in terms of quality-adjusted life years (QALYs), with health-related quality of life estimated using the EuroQol EQ-5D.

RESULTS

The operated group had costs which were, on average, pound646 more than the control group (95% confidence interval, pound16-1276, P<0.04) and had a mean QALY gain of 0.015 (95% confidence interval, -0.039 to 0.068, P=0.59) per patient over 1 year. Therefore, the incremental cost-utility ratio was pound44,263 over the 1-year trial period. In an analysis modelling costs and benefits over patients' expected lifetime, the incremental cost per QALY was pound17,299, under conservative assumptions.

CONCLUSIONS

Second-eye cataract surgery is not likely to be cost-effective in the short term for those with mild visual dysfunction pre-operation. In the long term, second-eye cataract surgery appears to be cost-effective unless carer costs are included.

Chemopreventive and remediation effect of Hydrocotyl bonariensis Comm. Ex Lam (Apiaceae) leave extract in galactose-induced cataract

ETHNOPHARMACOLOGICAL RELEVANCE

Hydrocotyl bonariensis Comm. Ex Lam (Apiaceae) is being widely used in Western Nigeria in treating various symptoms of ophthalmic diseases; however scientific data in support of this medicinal use have not been reported.

AIM OF THE STUDY

This study, investigated the efficacy of Hydrocotyl bonariensis leave extract in offering protection against experimental cataract and also examined its remediation effect when administered after cataract onset.

MATERIALS AND METHODS

Weanling albino rats fed with 30% galactose diet were used in the study. Mechanisms of action of the extract were investigated by measuring the degree of lens peroxidation, lens antioxidant status and lens protein concentration. Severity of cataract was determined by measuring the cataract index.

RESULTS

The extract at 500 mg kg(-1) reduced cataract index significantly and also reduced cataract progression when administered after cataract onset. Administration of this dosage also significantly reduced the degree of lens peroxidation, increased the level of reduced glutathione (GSH) and the lens catalase and superoxide dismutase activity. The extract also prevents protein insolubilization. Administration of the extract at 1000 mg kg(-1) reduced cataract index and lens peroxidation but did not increase the antioxidant status significantly. Administration of the extract after cataract onset reduced cataract index, moderately increased percentage soluble protein above the value prior to the arrest of hypergalactosemia but did not increase the antioxidant status.

CONCLUSION

Our study suggests that Hydrocotyl bonariensis protects against galactose-induced cataract, and that administration of the extract after cataract onset reduced cataract progression but did not reverse cataractogenesis.

A randomized, controlled trial to investigate the effect of ciclesonide and beclomethasone dipropionate on eye lens opacity

BACKGROUND

Inhaled corticosteroids (ICS) are recommended first-line therapy for the treatment of persistent asthma. However, reports from observational studies have suggested that the use of ICS may be associated with systemic adverse events, such as glaucoma and cataract (opacity of the lens) formation.

OBJECTIVE

To compare two ICS over 1 year regarding the formation/progression of lenticular opacities in patients with asthma.

METHODS

Adults (>or=18 years of age) with moderate-to-severe asthma were randomized to ciclesonide 640 micro g/day (n = 785) or beclomethasone dipropionate 640 micro g/day (n = 783) in a multinational, double-blind, active-controlled, parallel-group study. The primary endpoint was the occurrence of a positive Class I grading shift (increase [worsening] in Lens Opacities Classification System [LOCS] III score of >or= 0.5 for nuclear opalescence, >or= 0.8 for cortical opacification, or >or= 0.5 for posterior subcapsular opacification, or cataract surgery) in either eye at any visit over the 12-month, double-blind treatment period.

RESULTS

Mean changes (+/- standard error) in nuclear opalescence and cortical and posterior subcapsular opacification were small and similar between groups (ciclesonide 640 micro g/day: 0.10 +/- 0.02, 0.07 +/- 0.02 and 0.04 +/- 0.01, respectively; beclomethasone dipropionate 640 micro g/day: 0.11 +/- 0.02, 0.09 +/- 0.02 and 0.03 +/- 0.01, respectively). Class I shifts were observed in 34.3% versus 36.8% of ciclesonide-treated and beclomethasone dipropionate-treated patients, respectively. Ciclesonide 640 micro g/day was non-inferior to beclomethasone dipropionate 640 micro g/day regarding Class I shifts (risk ratio of ciclesonide to beclomethasone dipropionate, 0.940 [95% confidence interval, 0.820-1.077]); the 95% confidence interval upper bound was lower than the pre-specified non-inferiority bound of 1.333 (p < 0.0001), thereby excluding the possibility of higher risk ratio values.

CONCLUSIONS

Mean changes in LOCS III scores were very small in both groups. Treatment with ciclesonide 640 micro g/day or beclomethasone dipropionate 640 micro g/day for 1 year has a minimal impact on lenticular opacities development and/or progression.

The Etiology of Steroid Cataract

Steroid-induced posterior subcapsular cataracts (PSCs) exhibit three main distinctive characteristics: (i) association only with steroids possessing glucocorticoid activity, (ii) involvement of aberrant migrating lens epithelial cells, and (iii) a central posterior location. The first characteristic suggests a key role for glucocorticoid receptor activation and subsequent changes to the transcription of specific genes. Glucocorticoid receptor activation is associated in many cell types with proliferation, suppressed differentiation, a reduced susceptibility to apoptosis, altered transmembrane transport, and enhancement of reactive oxygen species activity. Glucocorticoids may be capable of inducing changes to the transcription of genes in lens epithelial cells that are related to many of these cellular processes. This review examines the various mechanisms that have been proposed to account for the development of PSC in the context of recent DNA array studies. Additionally, given that the glucocorticoid receptor can also engender wide-ranging indirect activities, glucocorticoids could also indirectly affect the lens through the responses of other cells within the ocular compartment and/or through effects on cells at more remote locations. These indirect mechanisms, which, for example, could be mediated through alterations to the intraocular levels of growth factors that normally orchestrate lens development and maintain lens homeostasis, are also discussed. Although the mechanism of steroid cataract induction remains unknown, glucocorticoid-induced gene transcription events in lens epithelial cells, and also other intraocular or systemic cells, likely interact to generate steroid cataracts. Finally, although evidence for glucocorticoid-protein adduct formation in the lens is inconclusive, the generation of such adducts cannot yet be discounted as a contributing factor and must necessarily be retained in discussions of the etiology of steroid cataract.

Ten-year incidence of age-related cataract and cataract surgery in an older Australian population. The Blue Mountains Eye Study

PURPOSE

To estimate the 10-year incidence of cataract and cataract surgery in an older Australian population.

DESIGN

Prospective population-based study.

PARTICIPANTS

Persons at least 49 years old living in 2 postcode areas west of Sydney, Australia.

METHODS

Eye examinations were performed at baseline and at 5- and 10-year follow-up visits. Lens photographs were taken and graded by masked graders using the Wisconsin Cataract Grading System.

MAIN OUTCOME MEASURES

Incidences of nuclear cataract, cortical cataract, posterior subcapsular cataract (PSC), and cataract surgery.

RESULTS

Ten-year person-specific incidences were 36.0% for nuclear cataract, 28.0% for cortical cataract, 9.1% for PSC, and 17.8% for cataract surgery. Corresponding rates were 31.7%, 24.4%, 8.2%, and 14.4%, respectively, in men and 39.3%, 30.8%, 9.8%, and 20.1%, respectively, in women. The incidence for each type of cataract and cataract surgery was positively associated with age (P<0.0001). Women had a significantly higher incidence than men for nuclear cataract (P = 0.04), cortical cataract (P = 0.007), any cataract (P = 0.0006), and cataract surgery (P = 0.03) after adjusting for age. There was no significant gender difference for PSC. The mean age at cataract surgery was 75.8 years, and there was no significant gender difference (P = 0.9). Among persons who developed any cataract, 22% had more than one type and 1.3% had all 3 types present. Nuclear cataract and PSC were significantly associated with visual impairment (visual acuity worse than 20/40).

CONCLUSION

Age- and gender-specific cataract incidences in this study were similar to those reported from the U.S. Beaver Dam Eye Study. In this study, 72% of the participants were affected by cataract or had had cataract surgery over the 10-year follow-up period.

Falls and health status in elderly women following first eye cataract surgery: an economic evaluation conducted alongside a randomised controlled trial

AIM

To evaluate the cost-effectiveness of first eye cataract surgery compared with no surgery from a health service and personal social services perspective.

METHODS

An economic evaluation undertaken alongside a randomised controlled trial of first eye cataract surgery in secondary care ophthalmology clinics. A sample of 306 women over 70 years old with bilateral cataracts was randomised to cataract surgery (expedited, approximately four weeks) or control (routine, 12 months wait); 75% of participants had baseline acuity of 6/12 or better. Outcomes included falls and the EuroQol EQ-5D.

RESULTS

The operated group cost a mean pounds sterling 2004 (bootstrapped) more than the control group over one year (95% confidence interval (CI), pounds sterling 1363 to pounds sterling 2833) (p<0.001), but experienced on average 0.456 fewer falls, an incremental cost per fall prevented of pounds sterling 4390. The bootstrapped mean gain in quality adjusted life years (QALYs) per patient was 0.056 (95% CI, 0.006 to 0.108) (p<0.001). The incremental cost-utility ratio was pounds sterling 35 704, above the currently accepted UK threshold level of willingness to pay per QALY of pounds sterling 30 000. However, in an analysis modelling costs and benefits over patients' expected lifetime, the incremental cost per QALY was pounds sterling 13 172, under conservative assumptions.

CONCLUSIONS

First eye cataract surgery, while cost-ineffective over the trial period, was probably cost-effective over the participants' remaining lifetime.

Cataract progression after prophylactic laser peripheral iridotomy: potential implications for the prevention of glaucoma blindness

PURPOSE

To evaluate changes in lens opacity in the first year after prophylactic laser peripheral iridotomy (LPI) performed in fellow eyes of subjects with acute primary angle closure (APAC).

DESIGN

Prospective observational case series.

PARTICIPANTS

Sixty Asian subjects with unilateral APAC.

METHODS

All fellow eyes underwent prophylactic LPI within the first week of presentation, followed by 1 week of topical steroids. The degree of lens opacity was graded at the slit-lamp examination using the Lens Opacity Classification System III (LOCS III) with standard color photographs as the reference for grading of lens opacity. This was performed 2 weeks, 4 months, and 12 months after LPI. Progression in lens opacity was defined as an increase in LOCS III grade by 2 or more units in any lens region.

MAIN OUTCOME MEASURES

Lens Opacity Classification Sytem III grades in nuclear, cortical, and posterior subcapsular (PSC) regions.

RESULTS

Most patients were Chinese (85%) and female (63.3%), with an average age of 61.5 +/- 10.6 years. The mean baseline LOCS grades in the nuclear, cortical, and PSC regions were 3.58 +/- 0.74, 0.57 +/- 1.08, and 0.23 +/- 0.72, respectively. With 12 months of follow-up, 14 of the 60 eyes (23.3%; 95% confidence interval, 16.9-29.7%) showed significant progression in any lens region. Progression in the nuclear, cortical, and PSC regions was documented in 5%, 6.7%, and 16.7% of cases, respectively. By use of logistic regression, the following factors were not found to be significant for cataract progression in any lens region: age, race, gender, history of hypertension or diabetes, presence of peripheral anterior synechiae or angle width at baseline, and total laser energy delivered.

CONCLUSIONS

In fellow eyes of APAC, prophylactic LPI is complicated by significant cataract progression, mainly in the posterior subcapsular region. These findings may have implications for the role of prophylactic LPI in the prevention of angle-closure blindness.

Glucocorticoid-Induced Changes in the Global Gene Expression of Lens Epithelial Cells

AIMS

Clinically, steroid use is accompanied by a risk for posterior subcapsular cataracts (PSCs). PSC possibly involves perturbation of lens epithelial cell proliferation and differentiation; however, the underlying mechanism is unknown. In this study, we aimed to characterize changes in gene expression in human lens epithelial cells exposed to glucocorticoid using DNA microarray hybridization.

METHODS

Human lens epithelial cells (HLE B-3) were treated with dexamethasone (1 microM) for 24 or 48 hours or with vehicle (0.01% dimethylsulfoxide) and the derived cRNA was hybridized to U133A microarrays. Data were processed using the Affymetrix program Micro Array Suite, and ontological analyses were performed using the software dChip, filtering to exclude transcripts up- or down-regulated by less than 2-fold.

RESULTS

At 24 hours, 57 transcripts were upregulated relative to controls by greater than 2- fold and 50 were downregulated by greater than 2-fold. At 48 hours, 92 transcripts were upregulated and 42 were downregulated. Twenty-two upregulated and 2 downregulated transcripts were shared between the 24-hour and 48-hour data sets. The predominant ontological groupings were: signal transduction, transcription factor activity, cytoskeleton/ECM/adhesion, transport, and cell cycle/development. Alternate ontological interpretations are possible.

CONCLUSIONS

The data indicate steroid treatment of lens epithelial cells is associated with significant changes in gene expression in several functional categories and these include transcripts related to cell proliferation.

Associations of cataract with antioxidant enzymes and other risk factors

PURPOSE

To determine the association of potential risk factors, including antioxidant enzymes, with the incidence of cataract.

DESIGN

Cohort study.

PARTICIPANTS

At baseline, the Age-Related Eye Diseases (Pathologies Oculaires Liées à l'Age, POLA) Study included 2584 residents of Sète (southern France) aged 60 years or older. From September 1998 to May 2000, a 3-year follow-up examination was performed on 1947 of the 2436 surviving participants (79.9%).

METHODS

Cataract classification was based on a standardized lens examination at the slit lamp, according to Lens Opacities Classification System III. Biologic measurements were performed at baseline from fasting blood samples.

MAIN OUTCOME MEASURES

At baseline and follow-up, the presence of cataract was defined as: NC or nuclear opalescence (NO) > or = 4 for nuclear cataract, C > or = 4 for cortical cataract, and P > or = 2 for posterior cataract (PSC) opacities, using opacity grades corrected for interobserver variability. Incidence rates were assessed separately for right and left eyes and for each type of cataract.

RESULTS

In the multivariate model, the incidence of cortical cataract was increased in subjects with high red blood cell superoxide dismutase activity (odds ratio [OR] 4.2 [1.5-12.1], P = 0.007). The incidence of PSC cataract was increased in subjects with a high level of plasma glutathione peroxidase (OR 1.8 [1.0-3.3], P = 0.05). In addition to age, gender, and opacities at baseline, significant risk factors for incident cataract were: long-duration diabetes (OR 5.8, P = 0.001 for cortical cataract) and lifetime heavy smoking (OR 2.9, P = 0.006 for PSC cataract).

CONCLUSIONS

Consistent with the baseline analysis, the results of this prospective study suggest that antioxidant enzymes might be implicated in the etiology of cataract.

Risk factors for nuclear, cortical and posterior subcapsular cataracts in the Chinese population of Singapore: the Tanjong Pagar Survey

AIM

To describe risk factors for nuclear, cortical, and posterior subcapsular (PSC) cataracts in Chinese Singaporeans.

METHODS

A population based cross sectional study was carried out on ethnic Chinese men and women aged 40-81 years. A stratified, clustered, disproportionate (more weights to older people), random sampling procedure was used to initially select 2000 Chinese names of those aged 40-79 years from the 1996 electoral register in the Tanjong Pagar district in Singapore. Eligible subjects (n = 1717) were invited for a standardised ocular examination and interview at a centralised clinic, following which an abbreviated examination was conducted for non-respondents in their homes. Cataract was graded clinically using to the Lens Opacity Classification System (LOCS) III system. The main outcome measures were adjusted odds ratio for risk factors for specific cataract types (nuclear, cortical and PSC), any cataract and cataract surgery, examined in multiple logistic regression models.

RESULTS

Out of the 1232 (71.8%) examined, 1206 (70.2%) provided lens data for this analysis. Increasing age was associated with all cataract types, any cataract, and cataract surgery. There was no significant sex difference in presence of any cataract, specific cataract types or cataract surgery. After controlling for age, sex, and other factors, diabetes was associated with cortical cataract (3.1; 95% CI: 1.6 to 6.1), PSC cataract (2.2; 95% CI 1.2 to 4.1), any cataract (2.0; 95% CI: 0.9 to 4.5), and cataract surgery (2.3; 95% CI: 1.3 to 4.1). Lower body mass index was associated with cortical cataract (1.8; 95% CI: 1.1 to 2.9; lowest versus highest quintile) and any cataract (2.3; 95% CI: 1.3 to 4.0). Current cigarette smoking was associated with nuclear cataract (1.7, 95% CI: 1.0 to 2.9; more than 10 cigarettes per day versus none). A non-professional occupation was associated with nuclear cataract (2.9; 95% CI: 1.5 to 5.8; for production or machine operators and 2.6; 95% CI: 1.2 to 5.5; for labourers or agricultural workers, both versus professionals). Lower education was associated with nuclear cataract (2.3; 95% CI: 1.0 to 5.2, none versus tertiary), while lower household income was associated with PSC cataract (4.7, 95% CI: 1.1 to 20.0; income <S$2000 versus >S$4000).

CONCLUSIONS

Age related cataracts are associated with a variety of risk factors among Chinese people in Singapore, similar to those reported in European, Indian, and African derived populations. These data support common aetiological mechanisms for age related cataracts, irrespective of ethnic origin.

Incidence and progression of cataract in the Melbourne Visual Impairment Project

PURPOSE

To determine the 5-year incidence and progression of cataract and cataract surgery in the Melbourne Visual Impairment Project.

DESIGN

Prospective cohort study. methods: Demographic information including race, sex, age, and education level was collected at baseline. Cortical cataract was defined as 4/16 or greater opacity; progression was defined as a more than 2/16 increase. Nuclear cataract was defined as Wilmer standard grade 2 or higher; progression was defined as more than 0.5 increase. Posterior subcapsular (PSC) cataract was defined as opacity 1 mm(2) or greater; progression was defined as greater than 1 mm(2) increase. results: Of the 3040 participants eligible to attend follow-up examinations, 2594 (85% of those eligible) participated. The mean age of participants at follow-up was 62.5 years, and 55% were female. The percentage of patients who had at least one lens extracted over 5 years increased from 0.5% of those aged 40 to 49 years at baseline to 35.7% of those aged 80 years or more at baseline. The overall incidence of the three types of cataract was as follows: cortical 7.7% (95% confidence limits [CL] = 5.8-9.8), nuclear 16.4% (95% CL = 12.1-20.8), and PSC 7% (95% CL = 5.3-8.7). The overall progression of cataract was cortical 14.3% (95% CL = 10.2-18.3), nuclear 19.3% (95% CL = 15.9-22.7), and PSC 20% (95% CL = 8.7-31.1). The incidence and progression rates increased significantly by age, but the rates were not significantly different by sex.

CONCLUSION

These cataract incidence data confirm the public health importance of cataract in Australia. The data also support the need to plan both primary prevention program and adequate surgical services to meet the anticipated increase in demand with the aging population.

Five year incidence of cataract surgery: the Blue Mountains Eye Study

AIMS

To assess the 5 year incidence of cataract surgery in an older population based prospective cohort.

METHODS

5 Year prospective follow up of the population based Blue Mountains Eye Study (BMES) performed in 1992. The follow up study examined 2335 survivors (75.1%) of the 3654 baseline participants. Baseline and 5 year slit lamp and retroillumination lens photographs were graded for presence of cortical, nuclear, or posterior subcapsular cataract using the Wisconsin cataract grading method and cataract surgery was documented from the history and the clinical examination.

RESULTS

An overall cataract surgery rate of 5.7% in first or both eyes was documented. The incidence was 0.3% in people aged 49-54 years at baseline, 1.7% for ages 55-64 years, 7.9% for ages 65 to 74 years, and 17.4% in people aged 75 years or older. The rate of surgery in first or both eyes was 6.0% in women and 5.2% in men, age adjusted p = 0.66. Bilateral cataract surgery was performed during follow up on 2.7% of participants, while 43.1% of unilateral phakic cases had second eye surgery. Presence of any posterior subcapsular (PSC) cataract, either alone or in combination with other cataract types, was the most likely type of cataract at baseline to be associated with incident cataract surgery. Baseline age was the most important non-ocular variable predicting incident cataract surgery.

CONCLUSIONS

This study has documented age specific rates for 5 year incident cataract surgery in an older community. The finding of relatively similar incidence rates and ocular predictors of cataract surgery to those reported by the Beaver Dam Eye Study, Wisconsin, United States, is of interest, given previous documented similarities between these two populations.

Prevalence of lens opacity in Chinese residents of Singapore: the tanjong pagar survey

OBJECTIVE

To determine the prevalence of lens opacity among Chinese residents of Singapore.

DESIGN

Population-based, cross-sectional survey.

PARTICIPANTS

Chinese men and women aged 40 years or more in Singapore.

METHODS

A stratified, clustered, random sampling method, with more weights given to the older age groups, was used to initially select 2000 Chinese persons aged 40 to 79 years from the 1996 electoral register in the Tanjong Pagar district in Singapore. Eligible subjects (n = 1717) were invited for a comprehensive ocular examination at a centralized clinic, after which nonrespondents were examined in their homes with portable instruments.

MAIN OUTCOME MEASURES

Lens opacity, as determined clinically at the slit lamp using a modification of the Lens Opacity Classification System III. Prevalence rates were age adjusted to the 1997 Singapore census population.

RESULTS

Of the 1232 persons examined (71.8%), 1206 (70.2%) provided lens data for this analysis. The age-adjusted prevalence of any cataract surgery was 5.1% (95% confidence interval [CI], 3.6, 6.5), with similar rates between men and women. The age-adjusted prevalence of specific types of lens opacity was 22.6% (95% CI, 19.8, 25.4) for any nuclear opacity, 23.9% (95% CI, 21.0, 26.8) for any cortical opacity, and 7.0% (95% CI, 5.3, 8.8) for any posterior subcapsular opacity. The overall age-adjusted prevalence of any cataract or cataract surgery was 34.7% (95% CI, 31.5, 38.0), increasing from 7.0% in those 40 to 49 years and to 94.3% in those 70 years and older (P < 0.001, test for trend for age). When the prevalence of distinct types of lens opacity in an eye was considered, the most common was mixed (age-adjusted prevalence, 11.5%, based on right eye data), followed by nuclear only (9.7%), cortical only (8.3%), and posterior subcapsular only (0.6%). For all cataract types, the prevalence was similar in men and women and was higher in persons examined at their homes than in those examined at the study clinic.

CONCLUSIONS

These population-based data suggest that cataract is common among adult Chinese residents in Singapore, despite ready access to cataract surgical services. Persons accepting the offer of free eye examinations were less likely to have cataract than those who did not take up this offer.

Long-term intake of vitamins and carotenoids and odds of early age-related cortical and posterior subcapsular lens opacities

BACKGROUND

Proper nutrition appears to protect against cataracts. Few studies have related nutrition to the odds of developing cortical or posterior subcapsular (PSC) cataracts.

OBJECTIVE

We assessed the relation between usual nutrient intakes and age-related cortical and PSC lens opacities.

DESIGN

We studied 492 nondiabetic women aged 53-73 y from the Nurses' Health Study cohort who were without previously diagnosed cataracts. Usual nutrient intake was calculated as the average intake from 5 food-frequency questionnaires collected over a 13-15-y period before the eye examination. Duration of vitamin supplement use was determined from 7 questionnaires collected during this same period. We defined cortical opacities as grade > or = 0.5 and subcapsular opacities as grade > or =0.3 of the Lens Opacities Classification System III.

RESULTS

Some lenses had more than one opacity. No nutrient measure was related to prevalence of opacities in the full sample, but significant interactions were seen between age and vitamin C intake (P = 0.02) for odds of cortical opacities and between smoking status and folate (P = 0.02), alpha-carotene (P = 0.02), beta-carotene (P = 0.005), and total carotenoids (P = 0.02) for odds of PSC opacities. For women aged <60 y, a vitamin C intake > or = 362 mg/d was associated with a 57% lower odds ratio (0.43; 95% CI: 0.2, 0.93) of developing a cortical cataract than was an intake <140 mg/d, and use of vitamin C supplements for > or = 10 y was associated with a 60% lower odds ratio (0.40; 0.18, 0.87) than was no vitamin C supplement use. Prevalence of PSC opacities was related to total carotenoid intake in women who never smoked (P = 0.02).

CONCLUSIONS

Our results support a role for vitamin C in diminishing the risk of cortical cataracts in women aged <60 y and for carotenoids in diminishing the risk of PSC cataracts in women who have never smoked.

The Roche European American Cataract Trial (REACT): a randomized clinical trial to investigate the efficacy of an oral antioxidant micronutrient mixture to slow progression of age-related cataract

CONTEXT

Funding surgery worldwide for age-related cataract (ARC), a leading cause of blindness, is a huge economic burden. Non-surgical means of slowing ARC progression could benefit patients and reduce this burden.

OBJECTIVE

To determine if a mixture of oral antioxidant micronutrients [mg/day] (beta-carotene [18], vitamin C [750], and vitamin E [600]) would modify progression of ARC.

DESIGN

REACT was a multi-centered, prospective, double-masked, randomized, placebo-controlled, 3-year trial.

SETTING

Consecutive adult American and English outpatients with early ARC were recruited.

PATIENTS

Four-hundred-and-forty-five patients were eligible; 297 were randomized; 231 (78%) were followed for two years; 158 (53%) were followed for three years; 36 (12%) were followed for four years. Twelve patients died during the trial (9 on vitamins; 3 on placebo (p = 0.07)). There were no serious safety issues.

INTERVENTION

After a three-month placebo run-in, patients were randomized by clinical center to the vitamin or placebo groups and followed every four months.

MAIN OUTCOME MEASURE

Cataract severity was documented with serial digital retroillumination imagery of the lens; progression was quantified by image analysis assessing increased area of opacity. This measure of area, 'increase % pixels opaque' (IPO), was the main outcome measure.

RESULTS

There were no statistically significant differences between the treatment groups at baseline. The characteristics of dropouts and the mean follow-up times by treatment group were the same. After two years of treatment, there was a small positive treatment effect in U.S. patients (p = 0.0001); after three years a positive effect was apparent (p = 0.048) in both the U.S. and the U.K. groups. The positive effect in the U.S. group was even greater after three years: (IPO = 0.389 (vitamin) vs. IPO = 2.517 (placebo); p = 0.0001). There was no statistically significant benefit of treatment in the U.K. group. In spite of nearly perfect randomization into treatment groups, the U.S. and U.K. cohorts differed significantly.

CONCLUSION

Daily use of the afore-mentioned micronutrients for three years produced a small deceleration in progression of ARC.

Cataracts in systemic diseases and syndromes

In the past year, harmony has developed among diverse areas of research in cataractogenesis. A number of epidemiologic studies have identified new, or strengthened the role of previous, risk factors in the development of cataract. Age, tobacco smoking, alcohol consumption, and inhaled corticosteroids have been implicated. Clinical observation of cataract in diseases such as cystic fibrosis, atopic dermatitis, Alzheimer's disease, and mitochondrial cytopathy have led to hypotheses of formation. The basic science research has, in some cases, given support to the clinical hypotheses, especially with respect to the role of estrogens and protein condensation in cataract as well as other systemic diseases. Although oxidative stress continues to be the leading proposed mechanism of cataractogenesis, genetic mechanisms are gaining increasing popularity. Finally, the results of previously contraindicated surgical management of cataract in the setting of advanced diabetic ocular disease and age-related macular disease are highlighted.

Antioxidant vitamins and nuclear opacities: the longitudinal study of cataract

OBJECTIVE

The association of antioxidant nutrients and risk of nuclear opacification was evaluated in the Longitudinal Study of Cataract.

DESIGN

Nutritional data were collected at baseline on the 764 participants, which included assessment of dietary intake, use of vitamin supplements, and plasma levels of vitamin E. Ophthalmologic and other data were collected at baseline and at yearly follow-up visits, including lens photographs, which were graded using the Lens Opacities Classification System III protocol.

MAIN OUTCOME MEASURES

Analyses examined whether the nutritional factors at baseline were related to increases in nuclear opacification at follow-up. The MULCOX2 approach, an extension of the Cox regression model, was used. Results are presented as relative risks (RRs) and 95% confidence intervals.

INTERVENTION

Intervention was not applicable.

RESULTS

The risk of nuclear opacification at follow-up was decreased in regular users of multivitamin supplements (RR = 0.69; 0.48-0.99), vitamin E supplements (RR = 0.43; 0.19-0.99), and in persons with higher plasma levels of vitamin E (RR = 0.58; 0.36-0.94).

CONCLUSIONS

In regular users of multivitamin supplements, the risk of nuclear opacification was reduced by one third; in regular users of vitamin E supplements and persons with higher plasma levels of vitamin E, the risk was reduced by approximately half. These results are similar to those obtained in our earlier case-control study. Because these data are based on observational studies only, the results are suggestive but inconclusive. The possible effect of nutritional supplements on the lens requires confirmation by ongoing clinical trials.