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Year : 2015  |  Volume : 7  |  Issue : 1  |  Page : 1-5

Prevalence and risk factors of age-related macular degeneration in elderly patients

Department of Ophthalmology, Dr. D.Y. Patil Medical College & Research Centre, Pimpri, Pune, Maharashtra, India

Date of Web Publication17-Jun-2015

Correspondence Address:
Kavita R Bhatnagar
OPD-5, Department of Ophthalmology, Dr. D.Y. Patil Medical College, Sant Tukaram Nagar, Pimpri, Pune - 18, Maharashtra
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Source of Support: Dr. D.Y.Patil Medical College & Research Centre, Pune., Conflict of Interest: None

DOI: 10.4103/1858-540X.158988

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Purpose: To determine the prevalence of age-related macular degeneration (ARMD) in elderly patients and its correlation with systemic disease, personal and environmental factors. Design: Cross-sectional. Materials and Methods: Patients seen from July 2011 to September 2013, visiting ophthalmic OPD of a tertiary care hospital were included in the study. Visual acuity, slit lamp biomicroscopy using +90 D & +78 D, direct and indirect ophthalmoscopy were performed for all cases. The ARMD was confirmed by Fundus Fluroscein Angiography (FFA). The association of ARMD with age, sex, family history of ARMD, history of smoking, occupation, diet, BMI, hypertension, and diabetes was ascertained. Result: Out of 5000 patients screened, 76 were diagnosed with ARMD. The proportion of overall ARMD was 1.52%. The proportion of Dry and Wet ARMD was 1.42% and 0.1%. In our study, we found a significant association of increasing age (P < 0.05), males (P < 0.005), smoking (P < 0.01) and occupation (P < 0.01) with ARMD. Conclusion: The prevalence of ARMD in our population in Maharashtra was found to be low. Visual disability of blinding due to ARMD was of low magnitude. Older age group, male gender, history of smoking and occupation were significant risk factors for ARMD.

Keywords: ARMD, gender, increasing age, occupation, smoking, visual disability

How to cite this article:
Vashi JN, Bhatnagar KR, Magdum RM, Shah AP, Khanna AR, Jagani S. Prevalence and risk factors of age-related macular degeneration in elderly patients. Sudanese J Ophthalmol 2015;7:1-5

How to cite this URL:
Vashi JN, Bhatnagar KR, Magdum RM, Shah AP, Khanna AR, Jagani S. Prevalence and risk factors of age-related macular degeneration in elderly patients. Sudanese J Ophthalmol [serial online] 2015 [cited 2023 Sep 25];7:1-5. Available from: https://www.sjopthal.net/text.asp?2015/7/1/1/158988

  Introduction Top

Age-related macular degeneration (ARMD) is the leading cause of irreversible blindness worldwide. [1] The disease adversely affects quality of life and activities of daily living, [2] causing many affected individuals to loss their independence in their retirement years. Macular degenerative changes have typically been classified into two clinical forms, dry or wet, both of which can lead to visual loss. The pathogenesis of the development of CNV is largely unknown. The presence of diffuse thickening of the inner aspect of Bruch's membrane (associated with large, soft drusen clinically) predisposes Bruch's membrane to develop cracks through which ingrowth of new vessels from the choriocapillaris can occur. This hypothesis is supported by the finding of CNV in other pathologic myopia [3] and angioid streaks. [4] The causes of ARMD are thought to be multifactorial. The purpose of this study was to learn linkage between various environmental factors and epidemiology of ARMD that it may be applied to the future prevention, treatment and eventually the cure of ARMD. [5] Many prospective trials support the use of antioxidant vitamins and mineral supplements, intravitreal injection of antivascular endothelial growth factor (VEGF) agents, PDT and laser photocoagulation surgery to treat AMD.

  Materials AND METHODS Top

A total of 5000 patients above 55 years of age, attending the eye OPD, were included in this study. Patients with hazy ocular media which interfered with the detailed examination of the fundus were excluded. Informed, written consent was obtained from all the patients. Relevant history like age, gender, occupation, family history, BMI [WHO criteria (kg/m 2 ) under weight- <18.50, normal range- 18.50-24.99, over weight- ≥25.00, obese ≥30.00], history of smoking (in pack years), history of cataract surgery, diabetes [fasting capillary blood sugar level was >7 mmol/l and those already taking medicines to control diabetes were treated as diabetics] and hypertension (more than 140/90 mm Hg, WHO Classification of Hypertension) and patients who were on medication to control blood pressure were taken as hypertensive] was taken according to performa. Patients underwent check up for uncorrected visual acuity, best corrected visual acuity and pinhole improvement of vision. Anterior segment was evaluated using slit-lamp bio-microscope. Fundus was examined with Direct & Indirect Ophthalmoscope & slit-lamp bio-microscope using +90 D lens. Macula was examined using +78D lens. Patients complaining of distortion of image were examined using Amsler's grid chart. Patients were graded into following three groups based on their examination findings.

Group I- No AMD (Age Related Maculopathy), was the control group for our study and had no or few small drusen (<63 microns in diameter).

Group II- Dry ARMD included few drusen of more than 63 microns in size at macula, and geographic atrophy.

Group III- Wet ARMD included neo-vascular vessels of chorio-capillary plexus in macular area (CNVM), macular star or combination of any of these three conditions.

To confirm the diagnosis fundus fluorescein angiography was done in selected patients using 3 ml 25% sodium fluorescein dye. A separate written, informed, consent was taken prior to fundus fluorescein angiography. Based on fundus fluorescein angiography finding patients were subjected to different treatment modalities. Patients in Group I & II with No AMD and Dry ARMD were given antioxidants. Patients in Group III with Wet ARMD were subjected to photodynamic therapy (Vertiporfin) [Figure 1] and [Figure 2] and antivascular endothelial growth factor (Avastin 1.25 mg/0.5 ml) [Figure 3] and [Figure 4].
Figure 1: Subretinal neovascular membrane: Pre PDT

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Figure 2: Subretinal neovascular membrane: Post PDT

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Figure 3: Subretinal neovascular membrane: Pre Avastin injection

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Figure 4: Subretinal neovascular membrane: Post Avastin treatment

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All the patients who received treatment were followed up 1 monthly for 6 months for visual acuity and fundus examination. Data was collected, compiled and analyzed using SPSS version 17. Quantitative variable summarized using Mean ± SD and Z-test. Qualitative data was summarized using percentages. The chi-square test was applied and OR (odds-ratio) were calculated.

  Results and observation Top

Out of 5000 patients, 76 were diagnosed with ARMD, so the prevalence was 1.52%. [Table 1] shows age- and sex-wise distribution of cases. Five thousand patients were screened. Patients were distributed in different groups, as the first group was 55-64 years, had 1752 patients, out of which 4 were males and 5 were females, so the prevalence was 0.5% in this age group. The second group that is 65-74 years of age, had 1968 patients, among which 9 were males and 10 were females. The prevalence was 0.96% in this age group. In third group that is 75-84 years, had1003 patients, out of which 18 were males and 13 were females. The prevalence in this age group was 3.08%. All patients of 85 years and above were included in the forth group. In this group, 277 patients were examined, out of which 9 were males and 8 were females. The prevalence in this age group was found to be highest at 6.13%. [Table 2] shows environmental and personal factors of cases. Out of 76 patients, 7 (9.21%) had family history of ARMD and 69 (90.79%) patients had no positive family history. Twenty-six (34.21%) patients were gave history of smoking and 50 (65.79%) patients did not give. Vegetarians were 60 (73.33%) and non-vegetarians were 16 (26.67%). Fourteen (18.42%) patients had BMI <18.5 (underweight), 25 (32,89%) had BMI between 18.5 and 25 (normal), 30 (39.47%) patients had BMI between 25 and 29.9 (overweight) and 7 (9.21%) had BMI >30 (obese). Seventy-two (94.74%) patients had brown color iris, 2 (2.63%) had green, 1(1.32%) patient had blue and 1 (1.32%) had grey color of iris. History of previous cataract surgery was present in 51 (67.11%) of patients and absent in 25 (32.89%) of patients. Out of 76 ARMD patients, 31(40.79%) had hypertension and 45(59.21%) patients did not have one. DM was present in 16(26.67%) patients and absent in 60(73.33%) patients. Pie diagram 1 shows type of ARMD-wise distribution of cases. Out of 76 patients, the maximum number of patients had Dry ARMD that was 60 (78.95%), followed by 11 (14.47%) patients who had No AMD [had no or few small drusen <63 microns in diameter] and 5 (6.58%) patients had Wet ARMD.
Table 1: Age- and sex-wise distribution of cases in the study group

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Table 2: Environmental, personal factors & systemic factors wise distribution of cases in the study group

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[Table 3] shows the association between sex and ARMD. There was significant association between male gender and ARMD (P < 0.005). Males were 15 times at higher risk of developing ARMD than females in our study. Out of 40 males 39 had ARMD and only 1 male had No AMD. While out of 36 females 26 had ARMD and 10 had No AMD.
Table 3: Association between sex and ARMD in the study group

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[Table 4] shows the association between smoking and ARMD. There was a significant association between smoking and ARMD (P < 0.01). Out of 76 patients 26 were smokers and 39 were non-smokers in the ARMD group (Group I & II), 11 were non-smokers in the No AMD group (control group).
Table 4: Association between smoking and ARMD in the study group

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[Table 5] shows there is significant association between occupation and ARMD (P < 0.01). Out of 65 patients in the ARMD group (Group I & II), 25 were farmers, followed by 19 were laborers, 14 were housewives, 4 were unemployed and 3 were others. In the No AMD group (control group), 8 were housewives, 2 were laborers and 1 unemployed.
Table 5: Association between occupation and ARMD in the study group

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  Discussion Top

ARMD is a common ophthalmological disorder that can significantly impair a patient's ability to function independently and potentially have a dramatic impact on health-related quality of life. In our study, 5000 patients of 55 years and older was screened for ARMD. Out of which 76 patients were found to have ARMD. The overall proportion of ARMD in our study was 1.52%. [Dry ARMD-1.42% and Wet ARMD-0.1%]. Our results are corroborating with the study done by Kulkarni et al., where the prevalence was 1.38%. [6] The prevalence of ARMD in the Rotterdam Study, Netherland, is 1.7%. [7] The prevalence rate for ARMD increased from 0.51% in 55-64 years to 6.13% in 85 years and above age strata in our study. Males had significantly higher risk for ARMD than females in our study (P < 0.005). This was also noted in a study done in Japan. [8] BMI were not significantly associated with ARMD in our study. As far as our sample is concerned, out of 76 subjects only 7 had BMI 30 and above (P > 0.05). Similar results were noted by Yasuda et al. [8] Obese individuals were at higher risk of ARMD noted by Schaumberg et al. [9] Smoking was significantly associated with ARMD (P < 0.01) in our study. The French POLA study (Pathologies Ocularies Liees a l'Age) done in the French Mediterranean found that both current and former smokers had the highest risk for developing macular degeneration. [10] Cigarette smoking is the only risk factor other than age that has been consistently identified in numerous studies. [11],[12],[13],[14] Smoking doubles the risk of AMD, and there appears to be a dose response whereby increasing odds are associated with an increased number of pack-years smoked. [12] Smoking is the major modifiable risk factor. Nicotine in general causes a lowering of antioxidants throughout body. It also compromises the immune system. Smoking cessation was associated with a reduced risk for AMD; the risk of developing AMD in those who had not smoked for over 20 years was comparable to the risk in nonsmokers. [12] In our study, we didn't find any association between diet and ARMD. There was no significant association between family history and ARMD in our study. The incidence is found to be less in our study, maybe because most of our patients were having low education and were not really aware about the disease. In our study we did not find an association between hypertension and ARMD (P > 0.05). Age-related eye diseases study (AREDS) said that persons with hypertension were 1.5 times more likely to have wet macular degeneration compared with persons without hypertension. There was no significant relationship between diabetes mellitus and ARMD (P > 0.05) found in our study. We did not find significant association between cataract surgery and ARMD (P > 0.05) in our study, corroborating with the study done in Maharashtra by Kulkarni et al. [6] Out of 76 patients 72 (94 (94.74%). We did not find significant association of ARMD with iris color (P > 0.05) in our study. Study by Chung Hua et al. revealed that lighter iris is associated with a higher incidence of ARMD. [15] In our study, we found a significant association between occupation and ARMD (P < 0.01). Our study is corroborating with the previous study, In the Asian population, highest incidence of ARMD was seen among miners (7.98%), followed by peasants (7.33%), factory workers (4.94%) and office cadres (2.78%). [16] Farmer and laborer are more exposed to the sunlight because of the nature of their work. In the Beaver Dam Eye Study, increased time spent outdoor in the summer was associated with a twofold increased risk of advanced AMD. [17]

  Conclusion Top

The prevalence of ARMD was 1.52%, among 55 years of age and older. In our study the prevalence was increased with increasing age. We also found that Dry ARMD was much more common than Wet ARMD, and both types increased in frequency with increasing age. Incidence of ARMD was more in males than in females; males were 15 times at higher risk of developing ARMD. There was significant association of ARMD with occupation, and was more in farmers and laborers. The prevalence of ARMD was significantly associated with smokers in our study. Rest personal factors like iris color, diet, BMI, family history, cataract surgery were not associated with increased incidence of ARMD. Systemic diseases like hypertension and diabetes were not associated with ARMD. Efficacy of available treatment such as antioxidants, anti-VEGF and PDT were less and more research work needed in this regard. To sum up, it is important to focus on modifiable risk factors like smoking, occupation, diet and BMI which are found to be associated with increased risk of developing ARMD and also look into preventable aspect of the disease. Many such studies in future need to be done to establish more association and treatment of ARMD.

  References Top

National Institute for Neurological Disease and Blindness, Section on Blindness Statistics, Statistics on blindness in the model reporting area, 1969-1970.  Back to cited text no. 1
National Advisory Eye Council (US).Vision research: A national plan 1994-1998.NIH publication no.93-3186. Bethesda, MD: US Department of Health and Human Service; 1993.  Back to cited text no. 2
Gass JD. Pathogenesis of disciform detachment of neuroepithelium. VI: Disciform detachment secondary to heredodegenerative, neoplastic and traumatic lesions of the choroid. Am J Ophthalomol 1967;63:689.  Back to cited text no. 3
Lim JI, Bressler NM, Marsh MJ, Bressler SB. Laser treatment of choroidal neovascularization in patients with angioid streaks. Am J Ophhalmol 1993;116:414-23.  Back to cited text no. 4
AREDS Research Group. "Risk factors associated with age-related macular degeneration. A case-control study in the age-related eye disease study: Age-Related Eye Disease Study Report Number 3." Ophthalmology 2000;107:2224-32.  Back to cited text no. 5
Kulkarni SR, Aghashe SR, Khandekar RB, Deshpande MD. Prevalence and determinants of age related macular degeneration I n the 50 years and older population: A hospital based study in Maharashtra, India. Indian J Ophthalmol 2013;61:196-201.  Back to cited text no. 6
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Yasuda M, Kiyohara Y, Hata Y, Arakawa S, Yonemoto K, Doi Y, et al. Nine-year incidence and risk factors for age related macular degeneration in a defined Japanese population the Hisayama study. Ophthalmology 2009;116:2135-40.  Back to cited text no. 8
Schaumberg DA, Chriten WG, Hankinson SE, Glynn RJ. Body mass index and incidence of visually significant age related maculopathy in men. Arch Ophthalmol 2001;119:1259-65.  Back to cited text no. 9
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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