Macular degeneration and early menopause: a case-control study

Gender differences in retinal diseases: A review

Gender medicine is a medical specialty that addresses gender differences in health and disease. Traditionally, medical research and clinical practice have often been focused on male subjects and patients. As a result, gender differences in medicine have been overlooked. Gender medicine considers the biological, psychological, and social differences between the genders and how these differences affect the development, diagnosis, treatment, and prevention of disease. For ophthalmological diseases epidemiological differences are known. However, there are not yet any gender-based ophthalmic treatment approaches for women and men. This review provides an overview of gender differences in retinal diseases. It is intended to make ophthalmologists, especially retinologists, more sensitive to the topic of gender medicine. The goal is to enhance comprehension of these aspects by highlighting fundamental gender differences. Integrating gender medicine into ophthalmological practice helps promote personalized and gender-responsive health care and makes medical research more accurate and relevant to the entire population.

Menopause and the Risk of Developing Age-Related Macular Degeneration in Korean Women

Previous studies have shown that menopausal hormone therapy in postmenopausal women results in a higher prevalence of age-related macular degeneration. This study aimed to evaluate the effects of menopause and patient factors on the development of age-related macular degeneration in Korean women. Data between 2011 and 2014 were collected from the Korean National Health Insurance database. In this retrospective cohort study, 97,651 participants were premenopausal and 33,598 were menopausal. Participants were divided into menopausal and premenopausal groups to analyze the risk factors associated with the development of age-related macular degeneration. The prevalence of age-related macular degeneration was compared between the two groups. Other patient factors were also analyzed. Using a 1:1 propensity score matching method and adjusting for variables, the incidence of age-related macular degeneration was not significantly different between the two groups. Age and diabetes mellitus were associated with an increased risk of developing age-related macular degeneration, regardless of menopause. Menopause was not a risk factor for age-related macular degeneration. These findings may help physicians identify women with diabetes who are at a greater risk of developing age-related macular degeneration.

Retinal Vascular Changes during the Menstrual Cycle Detected with Optical Coherence Tomography Angiography

Purpose

To evaluate the effects of the menstrual cycle on the retinal vascular status of healthy women by optical coherence tomography angiography (OCTA).

Materials and Methods

Healthy women with regular natural menstrual cycles of 28 to 30 days were recruited for this prospective study. The women's retinal vascular status was measured by OCTA at 3 time points: the early follicular, ovulatory, and midluteal phases of the menstrual cycle. The main outcome measures were foveal avascular zone (FAZ) parameters, perfusion density (PD) percentage in the superficial retinal capillary plexus (SCP), and PD percentage in the deep retinal capillary plexus (DCP). The mean arterial pressure (MAP), spherical equivalent (SE), best-corrected visual acuity (BCVA), intraocular pressure (IOP), and axial (AL) were also measured in a same menstrual cycle.

Results

In total, 62 right eyes of 62 women were included in the study. The mean age was 27.0 ± 1.73 (range, 24 to 31) years, and the mean menstrual cycle was 28.90 ± 0.84 (range, 28 to 30) days. The mean values of the DCP-PD parameters were significantly decreased in the nasal and inferior ETDRS subfields during the ovulatory phase. The mean DCP-PD in the nasal ETDRS subfield in the early follicular, ovulatory, and luteal phases was 54.11 ± 2.85, 56.39 ± 3.03, and 55.70 ± 3.27, respectively. The mean DCP-PD in the inferior ETDRS subfield in the early follicular, ovulatory, and midluteal phases was 52.90 ± 3.30, 54.86 ± 2.51, and 55.21 ± 2.64, respectively. No significant differences were found in MAP, SE, AL, IOP, FAZ area, or other quadrants of PD parameters, and no significant correlation was found between parameters by OCTA and age, MAP,SE, axial length, or IOP.

Conclusions

The DCP-PD decreased in the nasal and inferior ETDRS subfields during the ovulatory phase in our study. This may indicate the need to consider the menstrual phase when interpreting DCP-PD parameters by OCTA in healthy women.

Complement C5 is not critical for the formation of sub-RPE deposits in Efemp1 mutant mice

The complement system plays a role in the formation of sub-retinal pigment epithelial (RPE) deposits in early stages of age-related macular degeneration (AMD). But the specific mechanisms that connect complement activation and deposit formation in AMD patients are unknown, which limits the development of efficient therapies to reduce or stop disease progression. We have previously demonstrated that C3 blockage prevents the formation of sub-RPE deposits in a mouse model of EFEMP1-associated macular degeneration. In this study, we have used double mutant Efemp1R345W/R345W:C5-/- mice to investigate the role of C5 in the formation of sub-RPE deposits in vivo and in vitro. The data revealed that the genetic ablation of C5 does not eliminate the formation of sub-RPE deposits. Contrarily, the absence of C5 in RPE cultures promotes complement dysregulation that results in increased activation of C3, which likely contributes to deposit formation even in the absence of EFEMP1-R345W mutant protein. The results also suggest that genetic ablation of C5 alters the extracellular matrix turnover through an effect on matrix metalloproteinases in RPE cell cultures. These results confirm that C3 rather than C5 could be an effective therapeutic target to treat early AMD.

[Gender medicine in ophthalmology : The "small difference" between women and men]

Gender-specific or sex-specific medicine is part of "personalized" medicine. After differences in heart diseases between women and men were first identified and increasingly published in the field of cardiology since the 1980s, differences between the sexes have also become the focus of interest in other disciplines. Immunological and hormonal aspects indicate significant differences, e.g. in the severity of the disease or the response to treatment. Even in ophthalmology epidemiological differences in some diseases are known but so far these do not lead to a different approach in the practical treatment of patients. This CME article aims to raise awareness of gender medicine also in the field of ophthalmology and at the same time to promote understanding of these differences by presenting the fundamental differences between the sexes.

Risk factors for progression of age-related macular degeneration

Purpose

Age‐related macular degeneration (AMD) is a degenerative disease of the macula, often leading to progressive vision loss. The rate of disease progression can vary among individuals and has been associated with multiple risk factors. In this review, we provide an overview of the current literature investigating phenotypic, demographic, environmental, genetic, and molecular risk factors, and propose the most consistently identified risk factors for disease progression in AMD based on these studies. Finally, we describe the potential use of these risk factors for personalised healthcare.

Recent findings

While phenotypic risk factors such as drusen and pigment abnormalities become more important to predict disease progression during the course of the disease, demographic, environmental, genetic and molecular risk factors are more valuable at earlier disease stages. Demographic and environmental risk factors such as age and smoking are consistently reported to be related to disease progression, while other factors such as sex, body mass index (BMI) and education are less often associated. Of all known AMD variants, variants that are most consistently reported with disease progression are rs10922109 and rs570618 in CFH, rs116503776 in C2/CFB/SKIV2L, rs3750846 in ARMS2/HTRA1 and rs2230199 in C3. However, it seems likely that other AMD variants also contribute to disease progression but to a lesser extent. Rare variants have probably a large effect on disease progression in highly affected families. Furthermore, current prediction models do not include molecular risk factors, while these factors can be measured accurately in the blood. Possible promising molecular risk factors are High‐Density Lipoprotein Cholesterol (HDL‐C), Docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), zeaxanthin and lutein.

Summary

Phenotypic, demographic, environmental, genetic and molecular risk factors can be combined in prediction models to predict disease progression, but the selection of the proper risk factors for personalised risk prediction will differ among individuals and is dependent on their current disease stage. Future prediction models should include a wider set of genetic variants to determine the genetic risk more accurately, and rare variants should be taken into account in highly affected families. In addition, adding molecular factors in prediction models may lead to preventive strategies and personalised advice.

The Effects of Adjuvant Tamoxifen Use on Macula Pigment Epithelium Optical Density, Visual Acuity and Retinal Thickness in Patients with Breast Cancer

Purpose: We aimed to compare best corrected visual acuity, macular pigment optical density and macular thickness in patients with breast cancer, who received oral adjuvant hormone therapy.Materials and Methods: We enrolled consecutive eligible patients with breast cancer who were receiving regular medical tamoxifen treatment. The participants were divided into two groups as cases and controls. Best-corrected visual acuity and retinal thickness were examined. Macular pigment optical density was measured by fundus reflectometry using the one-wavelength reflection method. The output parameters included max optical density, mean optical density, volume and area of the right eye.Results: A total of 104 eyes, cases (n: 50) and controls (n: 54) were included in the study. Mean age in cases was 49.95 ± 9.2 years and 50.21 ± 9.3 years in controls (p = .151). The mean foveal optical density and the maximum optical density differed between cases (0.13 ± 0.03 density units (DU)/0.35 ± 0.07 DU) and controls (0.18 ± 0.04 DU/0.41 ± 0.06 DU) (p = .002/p = .009). Macular pigment optical density volume was 8102.84 ± 2412.67 in cases versus 8280.18 ± 2904.56 in controls (p = .034), and mean MPOD area was 59567.79 ± 11538.06 in cases versus 61748.14 ± 10591.19 in controls (p = .023). The best corrected visual acuity and retinal thickness were similar in both groups (p > .05).Conclusions: Patients in care of oral tamoxifen therapy were found to have significantly reduced macular pigment optical density. In addition, higher drug use duration correlated significantly with reduced macular pigment optical density, suggesting that the poor long-term effects may play a role in macular pigment absorption and incorporation in the retinal tissue.

Uveoretinal Adverse Effects Presented during Systemic Anticancer Chemotherapy: a 10-Year Single Center Experience

BACKGROUND

The present study describes our 10-year experience with uveoretinal adverse events that manifest because of chemotherapy.

METHODS

A retrospective chart review was performed for all patients who presented to the ophthalmologic department while undergoing systemic chemotherapy between July 2005 and June 2015.

RESULTS

A total of 55 patients (mean age, 51.2 years, 38 women [69.1%]) suspected of having uveoretinal disease owing to the use of chemotherapeutic agents alone were enrolled. Breast cancer was the predominant disease (36.4%); noninfectious anterior uveitis (21.8%) was the most common condition. Bilateral involvement was observed in 16 patients (29.1%). Although cisplatin (21.8%) was the most commonly used drug, daunorubicin, cytarabine, tamoxifen, toremifene, and imatinib were also frequently used. The median duration until ophthalmologic diagnosis was 208.5 days (range, 19-5,945 days). The proportion of patients with final visual acuity (VA) < 20/40 Snellen VA (0.5 decimal VA) was 32.7%. However, no relationship was observed between final VA < 20/40 and age, sex, therapeutic agents, and metastasis.

CONCLUSION

Uveoretinal complications were mostly mild to moderate and exhibited a favorable response to conservative therapy. A considerable number of patients exhibited significant irreversible loss of vision after cessation of the causative chemotherapeutic agent. Ophthalmological monitoring is required during chemotherapy.

Gonadal Hormones and Retinal Disorders: A Review

AIM

Gonadal hormones are essential for reproductive function, but can act on neural and other organ systems, and are probably the cause of the large majority of known sex differences in function and disease. The aim of this review is to provide evidence for this hypothesis in relation to eye disorders and to retinopathies in particular.

METHODS

Epidemiological studies and research articles were reviewed.

RESULTS

Analysis of the biological basis for a relationship between eye diseases and hormones showed that estrogen, androgen, and progesterone receptors are present throughout the eye and that these steroids are locally produced in ocular tissues. Sex hormones can have a neuroprotective action on the retina and modulate ocular blood flow. There are differences between the male and the female retina; moreover, sex hormones can influence the development (or not) of certain disorders. For example, exposure to endogenous estrogens, depending on age at menarche and menopause and number of pregnancies, and exposure to exogenous estrogens, as in hormone replacement therapy and use of oral contraceptives, appear to protect against age-related macular degeneration (both drusenoid and neurovascular types), whereas exogenous testosterone therapy is a risk factor for central serous chorioretinopathy. Macular hole is more common among women than men, particularly in postmenopausal women probably owing to the sudden drop in estrogen production in later middle age. Progestin therapy appears to ameliorate the course of retinitis pigmentosa. Diabetic retinopathy, a complication of diabetes, may be more common among men than women.

CONCLUSION

We observed a correlation between many retinopathies and sex, probably as a result of the protective effect some gonadal hormones may exert against the development of certain disorders. This may have ramifications for the use of hormone therapy in the treatment of eye disease and of retinal disorders in particular.

The tipping point: Tamoxifen toxicity, central serous chorioretinopathy, and the role of estrogen and its receptors

Purpose

To describe a case of tamoxifen toxicity superimposed on central serous chorioretinopathy (CSCR). We review the role of estrogen and the effect of tamoxifen on ocular tissues.

Observations

A 32-year-old Hispanic female with infiltrating ductal carcinoma of the left breast (T2N1M0, triple-positive), status post chemotherapy and bilateral mastectomy, presented with complaint of a floater and decreased central vision of the right eye (OD). Symptoms began three weeks after initiating tamoxifen and five months after the last cycle of chemotherapy and dexamethasone. Visual acuity (VA) was 20/30 OD at presentation. Clinical examination and multimodal imaging revealed subretinal fluid (SRF) and pigment epithelial detachment (PED) suggestive of CSCR. After one month of monitoring, VA improved to 20/20; there was SRF resolution, small PED, and focal ellipsoid zone (EZ) band loss. Two weeks later, after undergoing surgery and starting a topical steroid, she returned with count fingers (CF) VA and large SRF OD. Steroid cessation improved SRF after one month, but VA was unchanged. Tamoxifen was discontinued, and VA improved to 20/100 with near-complete resolution of SRF at three weeks, and significant reduction in choroidal thickness at two months. At final follow-up, VA was 20/200, and there was focal EZ band loss sub-foveally, minimal SRF, and small PED.

Conclusions and Importance

Treatment with tamoxifen may lead to ocular toxicity and can complicate the recovery course of patients affected with CSCR. Variations in levels of the estrogen receptor-alpha (ER-α) and treatment with tamoxifen (ER-α partial agonist) may lead to loss of the protective effect of estrogen in the retinal pigment epithelial cells in premenopausal women. Furthermore, tamoxifen toxicity can lead to focal photoreceptor loss. Treatment in these cases should be coordinated together with the oncologist.

Age-related eye disease and gender

Worldwide, the prevalence of moderate to severe visual impairment and blindness is 285 millions, with 65% of visually impaired and 82% of all blind people being 50 years and older. Meta-analyses have shown that two out of three blind people are women, a gender discrepancy that holds true for both developed and developing countries. Cataract accounts for more than half of all blindness globally and gender inequity in access to cataract surgery is the major cause of the higher prevalence of blindness in women. In addition to gender differences in cataract surgical coverage, population-based studies on the prevalence of lens opacities indicate that women have a higher risk of developing cataract. Laboratory as well as epidemiologic studies suggest that estrogen may confer antioxidative protection against cataractogenesis, but the withdrawal effect of estrogen in menopause leads to increased risk of cataract in women. For the other major age-related eye diseases; glaucoma, age-related macular degeneration (AMD) and diabetic retinopathy, data are inconclusive. Due to anatomic factors, angle closure glaucoma is more common in women, whereas the dominating glaucoma type; primary open-angle glaucoma (POAG), is more prevalent in men. Diabetic retinopathy also has a male predominance and vascular/circulatory factors have been implied both in diabetic retinopathy and in POAG. For AMD, data on gender differences are conflicting although some studies indicate increased prevalence of drusen and neovascular AMD in women. To conclude, both biologic and socioeconomic factors must be considered when investigating causes of gender differences in the prevalence of age-related eye disease.

Ocular biometric characteristics during the menstrual cycle

Purpose

To determine the ocular biometric characteristics during the menstrual cycle using the optical low-coherence reflectometry (OLCR) biometry.

Methods

Twenty-two healthy women between the ages of 19 and 36 years with regular menstrual cycles were enrolled in this prospective study. Subjects with irregular menstrual cycles, those taking contraceptive pills, those with a history of ocular surgery or trauma, and women unable to cooperate with the ocular biometry device were excluded from this study. A complete ophthalmic examination was performed between 8.30 and 10.30 am for all participants. Also, central corneal thickness, axial length, anterior chamber depth, lens thickness, and keratometric measurements were made at the same time using the OLCR device. Measurements were taken at the beginning of the cycle (1–3 days), at ovulation (12–16 days), and at the end of the cycle (26–32 days).

Results

The mean age of the participants was 22.86±4.22 (range: 18–36) years. The difference in central corneal thickness, axial length, anterior chamber depth, lens thickness, and keratometry values were not statistically significant during the menstrual cycle.

Conclusion

The ocular biometric parameters did not significantly vary during the menstrual cycle according to the OLCR biometry.

Long-term health consequences of premature or early menopause and considerations for management

AIM

To review the current evidence concerning the long-term harmful effects of premature or early menopause, and to discuss some of the clinical implications.

MATERIAL AND METHODS

Narrative review of the literature.

RESULTS

Women undergoing premature or early menopause, either following bilateral salpingo-oophorectomy or because of primary ovarian insufficiency, experience the early loss of estrogen and other ovarian hormones. The long-term consequences of premature or early menopause include adverse effects on cognition, mood, cardiovascular, bone, and sexual health, as well as an increased risk of early mortality. The use of hormone therapy has been shown to lessen some, although not all of these risks. Therefore, multiple medical societies recommend providing hormone therapy at least until the natural age of menopause. It is important to individualize hormone therapy for women with early estrogen deficiency, and higher dosages may be needed to approximate physiological concentrations found in premenopausal women. It is also important to address the psychological impact of early menopause and to review the options for fertility and the potential need for contraception, if the ovaries are intact.

CONCLUSIONS

Women who undergo premature or early menopause should receive individualized hormone therapy and counseling.

Gender specific issues in hereditary ocular disorders

This review is intended to summarize the current knowledge from basic science and clinical medical literature cited within PubMed that pertain to gender-related factors and affect those individuals with hereditary ocular disorders. We consider gender-related biological factors that (a) affect disease onset and progression, (b) gender differences for major X-linked ocular disorders, (c) gender-specific conditions, (d) medications that may influence genetic eye disorders, and finally, (e) gender-related issues that influence the management and quality of life of these patients. Several studies have demonstrated the manner in which sex-related hormones in animal models are capable of influencing cell pathway and survival that are likely to affect hereditary eye disorders. There are very few clinical studies that provide compelling evidence for gender differences in human ocular conditions, other than for a number of X-linked disorders. Disease expression for X-linked disorders may be impacted by genetic mechanisms such as lyonization or uniparental disomy. Clinical evidence regarding the impact of gender-related medical conditions and therapies on eye conditions is extremely limited and primarily based on anecdotal evidence. Gender-specific factors may play a major role in the underlying biological pathways that influence the onset, rate of progression, and clinical findings associated with ocular genetic conditions. Clinicians need to be aware of the variable phenotypes observed in female carriers of X-linked disorders of gender specific issues, many of which are inadequately addressed in the current literature. Clinicians need to be sensitive to gender differences in social, cultural, and religious systems and they should also be aware of how their own gender biases may influence how they counsel patients. Finally, it is clear that the lack of effective clinical studies in this area creates an opportunity for future research that will have real benefits for these patients.

Estrogen signalling in the pathogenesis of age-related macular degeneration

Age-related macular degeneration (AMD) is a multifactorial eye disease that is associated with aging, family history, smoking, obesity, cataract surgery, arteriosclerosis, hypertension, hypercholesterolemia and unhealthy diet. Gender has commonly been classified as a weak or inconsistent risk factor for AMD. This disease is characterized by degeneration of retinal pigment epithelial (RPE) cells, Bruch's membrane, and choriocapillaris, which secondarily lead to damage and death of photoreceptor cells and central visual loss. Pathogenesis of AMD involves constant oxidative stress, chronic inflammation, and increased accumulation of lipofuscin and drusen. Estrogen has both anti-oxidative and anti-inflammatory capacity and it regulates signaling pathways that are involved in the pathogenesis of AMD. In this review, we discuss potential cellular signaling targets of estrogen in retinal cells and AMD pathology.

Changes in the retina in induced hypoestrogenia (according to optical coherent tomography data)

Ultrastructural changes in the retina under conditions of experimental hypoestrogenia were studied. Hypoestrogenic status was induced in female rabbits by extirpation of both uterine horns with appendages. Clinical status of the eyes was evaluated after 9 months by ophthalmoscopy and optical coherent tomography. Changes in the retinal layers under conditions of experimental estrogenia were detected: thickened retinal pigmented epithelium layer, a lesser layer of nerve fibrils, and thinning of the choriocapillary layer. A relationship between thinning of the choroid and thickening of the pigmented epithelium of the retina was detected.

Differential effects of the estrogen receptor agonist estradiol on toxicity induced by enzymatically-derived or autoxidation-derived oxysterols in human ARPE-19 cells

PURPOSE/AIM OF THE STUDY

Disturbances in cholesterol metabolism and increased levels of cholesterol oxidation products (oxysterols) in retina may contribute to age-related macular degeneration (AMD). The role of oxysterols or of their target receptors liver X receptors (LXRs) and estrogen receptors (ERs) in the pathogenesis of MD is ill-known. The purpose of this study is to determine the extent to which the oxysterols 27-hydroxycholesterol (27-OHC), 25-hydroxycholesterol (25-OHC) and 7-ketocholesterol (7-KC) affect the transcriptional activity of LXR and ER.

MATERIALS AND METHODS

ARPE-19 cells, untreated or incubated with 27-OHC, 25-OHC or 7-KC for 24 h were harvested. We used Western blot analyses for detecting ERs and LXRs expression, dual luciferase assays for measuring LXRs and ERs transcriptional activity, cytotox-ONE homogeneous membrane integrity assay for measuring cytotoxicity, JC-1 method for measuring mitochondrial membrane potential changes and ELISA for measuring cytokine levels.

RESULTS

Both LXRs and ERs are expressed and are transcriptionally active in ARPE-19 cells. 27-OHC, 25-OHC and 7-KC inhibited ER-mediated transcriptional activity, whereas 27-OHC and 25-OHC increased LXR-mediated transcription. E2 reduced 25-OHC and 27-OHC-induced cytotoxicity, mitochondrial permeability potential decline, and cytokine secretion. The LXR agonist GW3965 or the LXR antagonist 5α-6α-epoxycholesterol-3-sulfate (ECHS) did not offer protection against either 27-OHC and 25-OHC or 7-KC.

CONCLUSIONS

Increased levels of oxysterols can decrease ER and increase LXR signaling. ER agonists can offer protection against cytotoxic effects of 27-OHC and 25-OHC, two oxysterols derived by enzymatic reactions. Although they exert similar toxicity, the cellular mechanisms involved in the toxic effects of oxysterols whether derived by enzymatic or autoxidation reactions appear to be different.

Neuroprotective effects of nonfeminizing estrogens in retinal photoreceptor neurons

PURPOSE

Retinal diseases such as macular degeneration and glaucoma are disorders that target specific retinal neurons that can ultimately lead to vision loss. Under these conditions and pathologies, retinal neurons can die via apoptosis that may be due to increased oxidative stress. The neuroprotective effects of 17β-estradiol (E2) and three synthetic nonfeminizing estrogen analogs (ZYC-26, ZYC-23, and ZYC-3) were investigated to examine their abilities to protect retinal neurons against glutamate toxicity.

METHODS

Using an in vitro model of glutamate-induced cell death in 661W cells, a mouse cone photoreceptor cell line, shown to express both estrogen receptors (ERs) via immunoblotting, was pretreated with E2 and its analogs and cell viability were assessed.

RESULTS

It was observed that E2 and estrogen analogs, ZYC-26 and ZYC-3, were protective against a 5 mM glutamate insult in 661W cells. The neuroprotective abilities of ZYC-26 and ZYC-3 were autonomous of estrogen receptor-α (ERα) and ERβ demonstrated by their ability to protect in the presence of ICI 182780, a pan-ER antagonist with a high affinity for the estrogen receptor. Treatment with PPT and DPN, ERα- and ERβ-specific agonists, respectively, did not protect the 661W cells from the glutamate insult. Studying the membrane ER (mER) or GPR30 did show that activation of the receptor by G1 protected the retinal neuron from insult, whereas G15, an antagonist of the mER was not able to antagonize the protection previously seen.

CONCLUSIONS

These data demonstrate that nonfeminizing estrogens may emerge as useful compounds for neuroprotection of retinal cells.

Increased Latency of Visual Evoked Potentials in Healthy Women during Menstruation

PURPOSE

To evaluate the latency of visual evoked potentials (VEPs) in healthy women during and after menstruation.

METHODS

Pattern and flash VEPs were performed in 15 healthy women aged 18 to 25 years on the maximum bleeding day (luteal phase) and 7 days after the menstrual cycle (follicular phase).

RESULTS

Mean latency was 119.6 msec on the maximum bleeding day and 100.8 msec one week after menstruation on pattern VEP (P < 0.001). Corresponding values for flash VEP were 124.5 msec and 112.7 msec, respectively (P < 0.001).

CONCLUSION

Prolonged VEP latency on the maximum bleeding day indicates that high progesterone levels may have an inhibitory effect on optic nerve conduction velocity.

Risk factors for age-related maculopathy

Age-related maculopathy (ARM) is the leading cause of blindness in the elderly. Although beneficial therapeutic strategies have recently begun to emerge, much remains unclear regarding the etiopathogenesis of this disorder. Epidemiologic studies have enhanced our understanding of ARM, but the data, often conflicting, has led to difficulties with drawing firm conclusions with respect to risk for this condition. As a consequence, we saw a need to assimilate the published findings with respect to risk factors for ARM, through a review of the literature appraising results from published cross-sectional studies, prospective cohort studies, case series, and case control studies investigating risk for this condition. Our review shows that, to date, and across a spectrum of epidemiologic study designs, only age, cigarette smoking, and family history of ARM have been consistently demonstrated to represent risk for this condition. In addition, genetic studies have recently implicated many genes in the pathogenesis of age-related maculopathy, including Complement Factor H, PLEKHA 1, and LOC387715/HTRA1, demonstrating that environmental and genetic factors are important for the development of ARM suggesting that gene-environment interaction plays an important role in the pathogenesis of this condition.

Postmenopausal hormone therapy and age-related maculopathy in older women

PURPOSE

To examine the association between postmenopausal hormone therapy and Age-Related Maculopathy (ARM) in older women and to determine if these associations vary by smoking status.

METHODS

A cross-sectional analysis of 1065 women of European origin aged > or = 74 years attending the year-10 examination of the Study of Osteoporotic Fractures was performed. Fundus photographs were graded for ARM using a modification of the Wisconsin Age-Related Maculopathy Grading System used in NHANES III. Multiple imputation methods were used to examine the associations of type and duration of postmenopausal hormone therapy use with early and late ARM as well as interactions with smoking history.

RESULTS

Compared to never users, Neither estrogen alone (E), Estrogen plus progestin (E+P), nor duration of use was significantly associated with early ARM [odds ratio (OR) E = 1.01, 95% confidence interval (CI) 0.77-1.34; OR E+P = 0.85, 95% CI 0.55-1.35; OR < or = 3 years use = 1.04, 95% CI 0.74-1.47; OR > 3-12 years use = 0.93, 95% CI 0.64-1.35; OR > 12 years use = 0.95, 95% CI 0.65-1.37] or late ARM (OR any E/E+P = 0.59, 95% CI 0.29-1.19; OR < or = 3 years use = 0.73, 95% CI 0.30-1.77; OR > 3 years of use = 0.51, 95% CI 0.22-1.17), though power for late ARM was limited. Tests for smoking interactions were not significant.

CONCLUSIONS

This study found no evidence to support an association between use of E, E+P, or duration of use and ARM risk.

Elective oophorectomy for benign gynecological disorders

OBJECTIVE

To review the risks and benefits of elective oophorectomy and to make a clinical recommendation for an appropriate age when benefits of this procedure outweigh the risks.

DESIGN

The risks and benefits of oophorectomy as detailed in published articles are reviewed with regard to quality-of-life issues and mortality outcomes in oophorectomized versus non-oophorectomized women from five diseases linked to ovarian hormones (coronary heart disease, ovarian cancer, breast cancer, stroke, and hip fracture).

RESULTS

Numerous reports link oophorectomy to higher rates of cardiovascular disease, osteoporosis, hip fractures, dementia, short-term memory impairment, decline in sexual function, decreased positive psychological well-being, adverse skin and body composition changes, and adverse ocular changes, as well as more severe hot flushes and urogenital atrophy. The potential benefits associated with oophorectomy include prevention of ovarian cancer, a decline in breast cancer risk, and a reduced risk of pelvic pain and subsequent ovarian surgery. In our study of long-term mortality after oophorectomy using Markov modeling, preservation of ovaries until women are at least aged 65 years was associated with higher survival rates. For women between ages 50 and 54 with hysterectomy and ovarian preservation, the probability of surviving to age 80 was 62% versus 54% if oophorectomy was performed. This 8% difference in survival is primarily due to fewer women dying from cardiovascular heart disease and/or hip fracture. This survival advantage far outweighs the 0.47% increased mortality rate from ovarian cancer prevented by oophorectomy. If surgery occurred between ages 55 and 59, the survival advantage was 4%. After age 64 there were no significant differences in survival rates. Prior literature supports our conclusion of a benefit over risk for ovarian conservation.

CONCLUSIONS

Elective oophorectomy is associated with short-and long-term health consequences that merit serious consideration. For women with an average risk of ovarian cancer, ovarian conservation until at least age 65 seems to benefit long-term survival.

Smoking, alcohol intake, estrogen use, and age-related macular degeneration in Latinos: the Los Angeles Latino Eye Study

PURPOSE

To assess the association between smoking, alcohol intake, estrogen use, and both early age-related macular degeneration (AMD) (soft indistinct drusen, retinal pigment abnormalities) and advanced AMD (exudative AMD, geographic atrophy) in the Latino community.

DESIGN

Population-based, cross-sectional study.

METHODS

Complete ophthalmic examination included stereoscopic macular photographs graded with a modified Wisconsin Age-related Maculopathy Grading System. A history of smoking, alcohol intake, and exogenous estrogen use was obtained by interview. Logistic regression was performed, and odds ratios (OR) were calculated with each AMD lesion as a dependent variable.

RESULTS

There were 5875 participants (92.4%) with gradable photographs. Having ever smoked was associated with a higher risk of having advanced AMD (OR, 2.4). Heavy consumption of alcohol (>5 drinks per session) was significantly associated with a greater risk of having exudative AMD (OR, 5.8) and geographic atrophy (OR, 12.7) Beer drinking was associated with a higher risk of having advanced AMD (OR, 2.9), whereas wine drinking appeared to be protective for increased retinal pigment (OR, 0.7). Exogenous estrogen use also appeared to be protective from soft indistinct drusen (OR, 0.5) and increased retinal pigment (OR, 0.6), but power was limited in the assessment of its association with advanced AMD.

CONCLUSION

Smoking and heavy alcohol consumption, particularly beer, was associated with a greater risk of having advanced AMD; exogenous estrogen use appeared to have a weak protective effect in Latino participants. Similar modifiable risk factors have been identified previously in non-Hispanic white patients, which suggests that common pathogenic mechanisms may be associated with AMD in persons of different ethnicities.

Protection against hydrogen peroxide-induced cell death in cultured human retinal pigment epithelial cells by 17β-estradiol: A differential gene expression profile

It has been demonstrated that estrogen receptors are present in the retinal pigment epithelium (RPE)-choroids complex regardless of sex. This suggests that estrogen could play a functional role in the outer retina, especially the RPE. To gain further insights on the molecular mechanisms differentially activated by 17beta-estradiol (betaE2) in RPE cells, we investigated gene expression changes in response to betaE2 in cultured RPE cells using cDNA microarray technology. A total of 47 genes among 21,329 human genes are significantly altered in response to betaE2 treatment in RPE cells. Among these 47 altered genes, 34 are up-regulated and 13 are down-regulated by betaE2. The products of 34 genes have a known or suspected function. These functions belong to various categories, including caspases; extracellular matrix proteins; metabolism pathway components; GTP/GDP exchangers and G-protein GTPase activity modulators; transcription activators and repressors. Six genes which may contribute to the unique functions of the RPE cells have been validated by both quantitative real-time reverse transcription (RT)-PCR and semi-quantitative RT-PCR. In addition, we also demonstrated that betaE2 quenches H2O2-induced up-regulation of apoptosis-related protein, and protects RPE cell degeneration. These results indicate that estrogen regulates functions of RPE cells and is involved in the maintaining and survival of RPE cells during oxidative stress, and its deficiency during menopause period may be a factor contributing to the development of age-related macular degeneration in elderly women.

Biomarkers of cardiovascular disease as risk factors for age-related macular degeneration

PURPOSE

To measure and contrast 2 biomarkers of cardiovascular disease, C-reactive protein (CRP) and plasma homocysteine, in individuals with age-related macular degeneration (AMD) and control individuals without AMD.

DESIGN

Case-control study.

PARTICIPANTS

Seventy-nine affected individuals and 77 unaffected individuals from the AMD Genetic Study Group returned to obtain CRP and homocysteine levels.

METHODS

Both affected and unaffected individuals underwent testing for CRP and homocysteine. A detailed cardiovascular history was taken.

MAIN OUTCOME MEASURES

Mean CRP and homocysteine levels in affected and unaffected individuals.

RESULTS

Mean CRP levels for affected and unaffected individuals were 3.42 and 2.30 mg/l, respectively (P = 0.03). Mean homocysteine levels for affected and unaffected individuals were 11.72 and 8.88 micromol/l, respectively (P<0.0001). In logistic regression models, older age, higher CRP, and higher homocysteine were risk factors for AMD. There were no significant differences between cases and controls in terms of gender, diabetes, hypertension, use of statin drugs, and smoking. The control group was significantly younger and had a lower rate of vitamin usage than the affected group.

CONCLUSIONS

Elevated CRP and homocysteine levels are associated with AMD and implicate the role of chronic inflammation and atherosclerosis.

Sex hormone receptors in the human eye

Dissimilarities in ocular physiopathology exist between human males and females. These differences can be observed in the lacrimal and other eye-associated glands, the ocular surface, the crystalline lens, and the retinochoroid complexes. Literature on the subject revealed that because of sex steroid hormone (estrogen, progesterone, and androgen) actions, various physiological conditions, such as age, menstrual cycles, pregnancy, and menopause or andropause, where the hormone milieu changes, affect vision. Well-designed scientific studies are lacking on the subject, although such studies hold much potential value. This review analyzes the relatively new area of hormones and vision.

Hormone replacement therapy, reproductive factors, and age-related macular degeneration: the Salisbury Eye Evaluation Project

PURPOSE

To evaluate a potential relationship between hormone replacement therapy (HRT), reproductive factors and age-related macular degeneration (AMD).

METHODS

1,458 female participants (age 65-84) from the Salisbury Eye Evaluation study were available for this cross-sectional analysis. AMD outcomes were identified by reading center assessment of fundus photographs.

RESULTS

Women who currently used HRT had a lower adjusted odds of large drusen (> 125 microm) (OR = 0.5, 95% CI 0.2-1.0). Use of HRT was not statistically significantly associated with the prevalence of early AMD or advanced AMD, although the odds ratios were all much less than 1. Women who had had an increased number of births had a greater prevalence of large drusen (test of linear trend, p = 0.03).

CONCLUSIONS

Current use of HRT was associated with a lower odds of large drusen, which may be predictive of advanced AMD. No statistically significant correlations were found between HRT or reproductive factors and early or advanced AMD.

Effect of the menstrual cycle on standard achromatic and blue-on-yellow visual field analysis of women with migraine

BACKGROUND

It has been postulated that migraine and glaucoma may have common vascular causative factors. Significant sex-based differences in the incidence of many important ocular conditions raise the possibility that estrogens may have direct effects on the eye. We performed a study to determine the effect of the menstrual cycle on standard achromatic automated perimetry (SAP) and short-wavelength automated perimetry (SWAP) (blue-on-yellow perimetry) of women with migraine.

METHODS

Both eyes of 73 normally menstruating women (31 subjects with migraine and 42 healthy control subjects) were included in the study. Subjects underwent a complete ocular examination including SAP and SWAP in both the follicular phase (12th to 13th day of the cycle) and the luteal phase (1 to 2 days before the onset of bleeding) of two consecutive menstrual cycles.We performed visual field analysis using the Humphrey Field Analyzer II with the full-threshold central 30-2 program. Mean sensitivity was calculated for the superior temporal, inferior temporal, superior nasal and inferior nasal regions separately.

RESULTS

Thirteen subjects were lost to follow-up (5 in the migraine group and 8 in the control group), leaving 26 subjects and 34 subjects respectively. There was no significant difference in mean age between the two groups (33.9 years [standard deviation (SD) 3.4 years] vs. 35.1 years [SD 3.3 years]). The mean duration of migraine was 7.6 (SD 3.1) years (range 3-14 years). In both groups, serum estradiol levels were significantly lower (p = 0.001) and serum progesterone levels were significantly higher (p < 0.001) in the luteal phase than in the follicular phase. In the control group, the mean sensitivity values with SWAP were significantly lower in the luteal phase than in the follicular phase (p = 0.04). A similar decrease was observed for the subjects with migraine with both SAP and SWAP (p = 0.01). There was no difference in regional mean sensitivity between the two phases with either perimetric test in the control group. For the subjects with migraine, there was no difference in regional mean sensitivity between the two phases with SAP. However, with SWAP, the mean sensitivity for the nasal visual field locations was significantly lower in the luteal phase than in the follicular phase (p = 0.01).

INTERPRETATION

Our study provides further evidence of an effect of sex hormones on the visual field of women with migraine. In addition to assessment of intraocular pressure, menstrual cycle phases should be considered in women with migraine at risk for glaucomatous optic neuropathy.

Age-related maculopathy: A risk indicator for poorer survival in women

PURPOSE

To examine patient survival in age-related maculopathy in a 14-year follow-up study.

DESIGN

Population-based 14-year cohort study.

PARTICIPANTS

Nine hundred forty-six residents, aged 60 to 80 years, living in the Osterbro district of Copenhagen, Denmark, participated in the first examination conducted from 1986 to 1988. These participants were followed until death or until May 1, 2002, whichever came first.

METHODS

Participants underwent an extensive ophthalmologic examination at Rigshospitalet, the National University Hospital of Copenhagen. Standardized protocols for physical examination, blood samples, and data from the National Central Person Register, the National Death Register, and the National Patient Register were used.

MAIN OUTCOME MEASURES

Mortality and age-related maculopathy.

RESULTS

By May 1, 2002, 60.9% (577 of 946) of the participants of the baseline study cohort had died. The adjusted 14-year cumulative mortality hazard ratio for subjects with early and late age-related maculopathy at baseline was 1.26 (95% confidence interval [CI], 1.06-1.51). We identified a strong correlation between mortality and age-related maculopathy among women (relative risk, 1.59; 95% CI, 1.23-2.07) but not among men.

CONCLUSIONS

When adjusting for survival-related factors, age-related maculopathy is a significant risk indicator for poorer survival in women and may be a marker of underlying serious systemic factors or aging processes specific to women.

Sociodemographic factors and age-related macular degeneration in Latinos: the Los Angeles Latino Eye Study

PURPOSE

To assess the association of various sociodemographic factors and early and advanced (geographic atrophy, exudative) age-related macular degeneration (AMD) in Latinos.

DESIGN

Population-based, cross-sectional study

METHODS

The study population included Latinos (primarily Mexican-American) aged 40 years and older living in La Puente, California. Sociodemographic factors, obtained from an interviewer-administered questionnaire, included age, sex, Native American ancestry, acculturation, country of birth, employment, income, marital status, health insurance, and education level. All participants underwent complete ophthalmic examination. AMD was diagnosed from stereoscopic macular photographs. Univariate and multivariable logistic regression was used to assess associations between sociodemographic factors and AMD.

RESULTS

Gradable retinal photographs from 5875 participants were included. Mean participant age was 54.9 years, 42% were male, and 5% had Native American ancestry. Stepwise logistic regression analyses indicated that age, sex, and being born in the United States were associated with early AMD (odds ratio [OR] = 1.8, 1.8, and 0.80, respectively). Native American ancestry was the associated with any advanced AMD and geographic atrophy (OR = 3.8 and 16.4, respectively). Family history of AMD was also associated with geographic atrophy (OR = 28.1). Acculturation was not associated with AMD.

CONCLUSION

Independent risk indicators for the various types of AMD include older age, male sex, being born outside of the United States, Native American ancestry, and a family history of AMD. These risk factors were independent of other possible behavioral factors such as smoking and alcohol consumption.

Epidemiology of age-related maculopathy: a review

Age-related maculopathy (ARM) is a degenerative disease of the retina and the leading cause of incurable blindness and visual impairment in industrialized countries. By definition, ARM is confined to the age-category above 50 years. The aetiology of ARM is still unknown, despite intensive research on many fronts. In this paper, we provide a review of the epidemiology of ARM. The most prominent findings were an exponential increase in frequency with age, a significant familial and genetic component, and a strong association with smoking. Other risk factors that were found less consistently were atherosclerosis, low intake of antioxidant nutrients, and cataract extraction. Future studies, both observational and experimental, will hopefully identify more risk factors that are amenable to prevention.

The effect of hormone therapy on the risk for age-related maculopathy in postmenopausal women

OBJECTIVE

To evaluate the effect of postmenopausal hormone therapy (HT) as well as the use of oral contraceptives and lifetime endogenous hormone exposure on the risk for age-related maculopathy (ARM) in postmenopausal women.

DESIGN

This was a cross-sectional, controlled study. A total of 102 women from 60 to 80 years of age who were receiving HT and 100 controls underwent a detailed clinical funduscopic evaluation and stereoscopic fundus photography for the presence and grading of ARM. All participants completed a standardized questionnaire regarding vascular risk factors, HT, and lifetime exogenous and endogenous estrogen and progesterone exposure. Statistical analysis was performed using Student's t test, chi2 test, and a multivariate logistic regression model.

RESULTS

The HT and the non-HT groups did not differ in terms of early (11% v 15%), late (6% v 6%), or wet (2% v 2%) ARM prevalence rates. Women with ARM were significantly older than controls (69 v 66 years; P = 0.001, 95% CI = 0.008 - 0.027) and were more likely to have ischemic heart disease (21% v 9%; OR = 2.86, P = 0.03, 95% CI = 0.020 - 0.360). Lifetime exogenous and endogenous hormone exposures and other cardiovascular risk factors were not significantly different among women with ARM as compared with controls.

CONCLUSION

Postmenopausal HT may not affect the risk for either early or late ARM in women aged 60 to 80 years. The risk for both entities is not necessarily affected by either exogenous or endogenous lifetime hormone exposure. A history of ischemic heart disease may be associated with an increased risk for ARM.

Association between reproductive and hormonal factors and age-related maculopathy in postmenopausal women

PURPOSE

The relationships between reproductive risk factors, including use of hormone replacement therapy and oral contraceptives and severity of age-related maculopathy (ARM) among postmenopausal women were evaluated. We hypothesized that exposure to endogenous or exogenous estrogens would be associated with a reduced risk of advanced ARM.

DESIGN

Cross-sectional study.

METHODS

The 394 subjects were postmenopausal women with ARM. Logistic regression analysis was used to compare the effects of several reproductive factors across two groups: 193 subjects with nonadvanced ARM and 201 subjects with advanced ARM.

RESULTS

Women with ARM who had used postmenopausal estrogen therapy in the past had significantly lower odds of advanced ARM than nonusers, after controlling for other known and potential risk factors (odds ratio [OR] = 0.5, 95% confidence interval [CI] = 0.30 to 0.98). Older age at menarche was associated with increased odds of advanced ARM (OR = 1.16, 95% CI = 1.00 to 1.35).

CONCLUSIONS

These findings suggest that exposure to exogenous estrogens may have a beneficial effect of reducing the risk of advanced types of ARM in postmenopausal women with ARM. Few therapeutic or preventive measures currently exist for ARM; therefore, these results deserve further evaluation.

Use of vitamin and zinc supplements and age-related maculopathy: the Blue Mountains Eye Study

PURPOSE

To investigate relationships between vitamin and zinc supplement use and age-related maculopathy in a population-based sample.

METHODS

We studied 2873 (79%) of the 3654 participants aged 49- 97 years who attended the cross-sectional Blue Mountains Eye Study and completed a detailed food frequency questionnaire, including type, dose and duration of supplement use. ARM was assessed during a masked grading of macular photographs. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression.

RESULTS

After adjusting for multiple confounders, we found that no vitamin or zinc supplements were significantly associated with reduced prevalence of any ARM lesions in either eye. The OR for use of any vitamin supplement was 1.3 (CI 0.9-1.7, p = 0.11) for individuals with any retinal pigment changes. It was 1.1 (CI 0.8-1.5, p = 0.59) for those with any soft (large) drusen and 1.5 (CI 0.7-3.0, p = 0.31) for those with late ARM lesions. The lack of association between supplement intake and ARM persisted regardless of their duration of use, dose or the smoking status of participants. The Breslow-Day test for heterogeneity was 0.24 with an OR for early ARM lesions among smokers of 0.7 (CI 0.4-1.3, p = 0.27), and 1.2 (CI 0.9-1.5, p = 0.24) among non-smokers.

CONCLUSION

This cross-sectional population-based study investigated associations between vitamin and zinc supplement use and the prevalence of ARM lesions. Our findings provide no support for a protective association between vitamin and zinc supplement use and lesions indicating early ARM. The small numbers of subjects with late ARM lesions precluded any detailed investigation of benefits from supplement use on the prevalence of these lesions.

Risk factors for age-related macular degeneration: an update

Age-related macular degeneration (AMD) is the leading cause of irreversible vision loss in the United States and other western nations. Limited treatment is available, and there are no established means of prevention. The detection of modifiable risk factors is important to suggest preventive behaviors that can reduce disease occurrence or prevent the progression to the late stages of AMD. Results of recent studies suggest that the etiology and pathogenesis of AMD are a complex interaction of genetic and external factors. Although a number of factors seem promising, only age and cigarette smoking are confirmed as increasing AMD risk. Other factors that most likely play a significant role in AMD are nutritional factors, e.g., antioxidants, and hypertension or other underlying atherosclerotic disease processes. The results of the Age-Related Eye Disease Study suggest a moderate beneficial effect of antioxidant, vitamin, and zinc supplementation in reducing progression to severe AMD.

The genetics of age-related macular degeneration

AIM: To review the genetics of age-related macular degeneration (AMD). The pathogenesis of AMD, the leading cause of severe visual disability and blindness in our community, remains unknown. However, AMD is regarded as a genetic disease where family history of AMD is a significant risk factor for the disease. Understanding the genetic factors associated with AMD offers the greatest chance for understanding the underlying disease processes. METHODS: Through a review of the literature and the use of original research findings, the current knowledge of the genetics of AMD is explored. CONCLUSION: AMD is increasing in prevalence and remains a major challenge for eye heath providers. Finding the genes that are associated with AMD offers the greatest chance for the development of preventative strategies and treatments.

Presence of oestrogen receptor type beta in human retina

BACKGROUND/AIMS

Recent studies have demonstrated the existence of two oestrogen receptor subtypes alpha (ORalpha) and beta (ORbeta) with significant differences of expression among organs. Since important pathologies of human eye could be linked to hormonal status, the expression of ORbeta in ocular posterior segment was sought.

METHODS

Immunohistochemical localisation of ORbeta and ORalpha protein and detection of OR mRNAs by reverse transcription-polymerase chain reaction (RT-PCR) were performed in macular and extramacular regions of the retina and in the choroid on male and female donors eyes.

RESULTS

ORbeta protein was localised in the ganglion cell layer and in the choroid. At the transcriptional level, mRNA for ORbeta and for ORalpha were both present. Local differences in the expression level were observed, however, suggesting the possibility of variation in the ratio of ORalpha v ORbeta.

CONCLUSIONS

The coexistence of two oestrogen receptor subtypes in the human ocular posterior segment raises acute questions about their potential physiological role, but offers a perspective for preferential targeting of a specific receptor subtype.

Risk factors for age-related macular degeneration

There is an increasing body of evidence as to the risk factors for age-related macular degeneration. Age and genetic make-up are the most important risk factors identified to date. Over the next decade, the different genes that are involved in the development of age-related macular degeneration will be identified. There is reasonably consistent evidence that smoking cigarettes results in increased risk of the disease. The question as to whether antioxidant vitamin and mineral supplementation prevents or delays the development of the disease will be resolved as the results of large ongoing trials become available in the next few years. Currently, there is conflicting evidence as to their benefits and some indication as to possible harm. Other risk factors such as alcohol consumption, oestrogen replacement and lifetime light exposure require further study. The study of the epidemiology of age-related macular degeneration would be facilitated by a greater standardization of methods. Studies with large numbers of late stage disease are needed in order to provide the power to investigate moderate risks. This may either be achieved by adding on macular degeneration studies to large cohort studies already in place, or by pooling data from smaller studies.

Hormone replacement therapy: reassessing the risks and benefits

Although the association between postmenopausal hormone use and breast cancer has not been clarified, there is nothing indefinite about the survival advantage conferred by hormone replacement therapy. Cardiovascular and fracture-related deaths so outnumber breast cancer deaths that even women with family histories of the latter are likely to benefit from low-potency estrogen replacement.

Do age-related macular degeneration and cardiovascular disease share common antecedents?

Age-related macular degeneration (AMD) is the leading cause of irreversible vision loss and blindness in elderly Americans. The etiology of this condition remains unknown and treatment options are limited. Some epidemiological findings point to a cardiovascular risk profile among persons with AMD. Documented risk factors for cardiovascular disease (such as age, smoking, hypertension, hypercholesterolemia, post-menopausal estrogen use, diabetes, and dietary intake of fats, alcohol and antioxidants) have also been associated with AMD in some studies. This raises the possibility that the causal pathways for cardiovascular disease and AMD may share similar risk factors. Future research on this hypothesis could lead to important insights into etiologic factors for AMD. Research could also identify modifiable risk factors and suggest new treatment options which could prevent AMD, slow its progression, or reduce visual loss. Susceptible individuals could then be targeted for improved health promotion and disease prevention measures for this disabling and highly prevalent disorder.

Bilateral involvement by age related maculopathy lesions in a population

AIMS

To describe the influences of age and sex on the frequency of bilateral age related macular degeneration (AMD) and age related maculopathy (ARM) lesions.

METHODS

The Blue Mountains Eye Study examined 3654 older Australians, 82% of permanent residents living in an area west of Sydney. Stereo macular photographs were graded for AMD (neovascular maculopathy and geographic atrophy) and early ARM lesions (soft drusen, reticular drusen, hyperpigmentation, and hypopigmentation).

RESULTS

Among 230 gradable cases of AMD or early ARM, 183 (80%) were bilateral. For AMD, 39/69 cases (57%) were bilateral, while for early ARM, 123/161 cases (77%) had signs in both eyes. Of the individual lesions, reticular drusen (91%) and indistinct soft drusen (79%) were most frequently present in both eyes. Geographic atrophy was bilateral in 56%, neovascular AMD in 40%, and distinct soft drusen in 47%, while hyperpigmentation was bilateral in 38% and hypopigmentation in only 28% of cases. A consistent age related increase in bilateral distribution was observed for most lesions. After adjusting for effects of age, current smoking, and AMD family history AMD and ARM component lesions, except for soft drusen, were more frequently bilateral in women. This sex difference was significant only for neovascular AMD, odds ratio 7.7 (95% confidence intervals 1.3-46.7). An AMD family history was more frequently reported in cases with bilateral involvement.

CONCLUSIONS

This study has documented differences in the age related bilaterality of individual ARM components with higher bilateral rates for reticular or indistinct soft drusen compared with other lesions. The increased bilaterality of most ARM lesions among women is likely to contribute to the increased age adjusted risk of AMD blindness found in women.

Amenorrhea induced by adjuvant chemotherapy in early breast cancer patients: prognostic role and clinical implications

BACKGROUND

The role of amenorrhea induced by chemotherapy in premenopausal women with early breast cancer is very controversial. Analyses by various authors of the effect of drug-induced amenorrhea (DIA) on treatment outcome have yielded conflicting results. In order to gain insight into the role of DIA, we reviewed all published data addressing the issue of DIA as a prognostic factor.

METHODS

Computerised and manual searches were conducted of relevant studies published from 1966 to 1995.

RESULTS

Thirteen studies involving 3929 patients were selected. In two papers, the prognostic role of DIA was analysed in three and two different groups of patients, respectively. Overall, 16 groups of patients were evaluated. With 12 groups, a higher disease free survival was observed in patients developing DIA compared to those who did not. This difference was statistically significant in eight groups. Data on overall survival, reported in only five studies, indicated that it was always improved in patients who became amenorrheic.

CONCLUSIONS

Available data on the role of DIA support its importance as a favorable prognostic factor for early breast cancer patients. However, due to the possible biases of this type of evaluation, this result should be interpreted with caution.