Ophthalmic Epidemiology:

A Clouded Vision
April 10, 2000
Michael B. Gorin, M.D. Ph.D.
[email protected]
 Objectives of ophthalmic
epidemiology
• Establish the incidence and prevalence of
eye disorders that cause vision impairment
and/or blindness
• Determine the societal impact (social and
economic) of vision loss
• Assess the potential and real impact of
preventive and treatment efforts for eye
problems
 Causes of Worldwide Blindness
• Cataract 17 million
• Trachoma 6.0 million
• Glaucoma 3.0 million
• Xerophthalmia 0.5 million
• Onchocerciasis 0.5 million
• AMD 1.0 million
• Diabetic retinopathy 0.25 million
• Leprosy 0.25 million
• Others 2.5 million
– 85% of blindness is in Africa and Asia
– 85% of cases are potentially treatable or preventable
• Prevalence:
– 0.125-0.25% in Western world
– 0.2-1.5% (av 0.75%) in Asia
– 0.3-3.1% (av 1.2%) in Africa
Allen Foster in Clinical Ophthalmology - Duane, ed. (1991)
 Aging and Blindness
• Prevalence (in Germany) :
– 15 % lose sight < 20 years old
– 51% lose sight >50 and <80
– 15 % lose sight > 80 years old
• Incidence:
– 50% of new cases are people over 80
• “Imbalance” due to differences in life expectancy and duration of
blindness.
– Blind < 10 years - 74%
– Blind >10 years - 26%
– Blind > 20 years - 10%
 What is vision?
• Central visual
acuity
– Uncorrected and
corrected
– Refractive error
(definition of
myopia)
– The Snellen chart
and the ETDRS
chart
What is vision?
• Contrast
sensitivity
– Pelli Robison
chart
– grating systems
 What is vision?
• Peripheral vision
– Visual Fields
• Kinetic and
static

• Manual versus
automated
 What is vision?
• Color vision
– Color plates,
color chips,
anomaloscopes

• Adaptation
– Light recovery
from bleach
– Adaptometry
 What is vision?

• Other measures of visual function

– Electrophysiology
– Ocular movements
– Visual function questionnaires - VF-14
• Initially validated for cataracts
• more extensive use in all eye studies
 What is the definition of blindness?
• 20/10 - 20/25: Normal
• 20/30 - 20/60: Near-normal
• 20/70 - 20/160 : Moderate vision impairment - eligible for education
assistance in US
• 20/200 - 20/400: Severe vision impairment - legal blindness in US
(visual field < 20 degrees)
• 20/500 - 20/1000: profound vision impairment - WHO and several
European countries definition of blindness (visual field < 10 degrees),
CF < 3m
• < 20/1000: Near-total visual impairment: used by some developing
countries as definition of blindness (visual field < 5 degrees), HM, LP
• NLP: Total visual impairment
 Ocular pathology
• Clinical examination:
– Slit lamp biomicroscopy
– Ophthalmoscopy (fundus examination)
 Ocular pathology
Grading systems:
– Ocular dryness
(use of vital dyes, rose bengal and lissamine green) -
comparison with standard photos (CSP).
– Conjunctival scarring - CSP

– Cataracts - LOCS III (CSP)

– Optic nerve- optic nerve

cupping, CSP
– Retina - disease-specific (ie
ARM, diabetes)
 Documentation of ocular pathology
• Ratings by
clinicians tend to be
poorly standardized
and inconsistent.

• Major emphasis in
recent years has
been on
photodocumentation
and the use of
Reading Centers to • The general level of photographic
grade pathology quality in the medical community is
low. For research studies, extensive
training and certification of
photographers is required.
 Documentation of ocular pathology
• Reading Centers have been very effective in studies of
diabetic retinopathy. (subjects diagnosed prior to entry)
• Reliability of graders for large numbers of patients with
mixed (and unspecified) disorders is unknown.
 Specific issues in eye research
• Is one assessing the subject or the eye?
• Relatedness between eyes of a single individual
• Research design with bilateral and monocular cases
• Use of the contralateral eye as a control
• Masking of the subject and observer

• Is one comparing the same definition of the disease among studies?

(ie AMD, myopia, glaucoma)
• Diagnostic reliability, sample bias
• 10% of cases have vision loss from 2 different conditions, though
studies often only cite the cause of the second eye.
 Causes of vision loss
• Trauma
– Recreational, work-related, military
• Systemic Disease
– Diabetes, vascular disease, hypertension
• Aging/Eye Specific
– Cataracts, age-related maculopathy, glaucoma
• Infectious
– Trachoma, onchocerciasis, immunocompromised individuals
• Congenital/Hereditary -
– Cataracts, malformations, glaucoma, retinal degenerations
• Nutritional and Toxic
– Vitamin A deficiency, methanol
• Tumors
– Metastatic, primary malignancies (children / adults)
 Infectious causes of vision loss
• Trachoma
– Affects 500 million
– Estimated 6 million are blind

• Onchocerciasis
– Endemic across equatorial Africa (99%), some areas of South and Central America
– 80 million exposed, 18 million infected, 2 million blind
– Transmitted by blackfly - filial nematode
– Treatment - vector control, ivermectin (annual dose for a minimum of 10 years)

• Other ID: leprosy, syphillis

– Estimated 10-12 million cases of leprosy
– WHO estimated that 250,000 blind from disease
Leading causes of blindness
in Western societies

Age-related macular
degeneration
• (aka: AMD, ARM, SMD)
• Dry versus Wet
• Atrophic versus Exudative
(CNVM)
• Most common cause of
blindness
• Majority of cases are “dry”
form (>80%), however 88%
of those registered as legally
blind (in Germany) from
AMD had exudative disease.
Age-related macular degeneration (AMD)
– AMD defined as macular changes and <20/30
– ARM - no vision impairment
Prevalence (%)
Age range AMD# ARM# Blindness due to AMD*
60 - 64 2.3 12.3 0.007
65 - 69 5.9 18.0 0.012
70 - 74 12.1 17.0 0.057
75 - 80 27.3 17.8 0.115

# Vinding (1989) - Denmark

* Krumpasky et al (1996) - Germany
Age-related macular degeneration (AMD)
• Risk factors:
– Smoking 2.5 fold increased risk
– positive family history
– Others - sex, diet, eye color, hypertension,
cardiovascular disease are controversial
• Unilateral CNVM - risk to other eye:
– Incidence of 12-15% per year for 60-69 year
olds
Age-related macular degeneration (AMD)
• Success of laser treatment
– Vision 2 years after randomization to treatment or
observation (subfoveal lesions)

Deterioration in vision Treated Observed

< 2 lines 33% 18%
2-3 lines 23% 17%
4-5 lines 24% 28%
> 6 lines 20% 37%
MPS 1991
Age-related macular degeneration (AMD)
• Success of laser treatment
– Vision 2 years after randomization to treatment or
observation (extrafoveal lesions)

Deterioration in vision Treated Observed

Unchanged, improved 57% 28%
Decreased 2-5 lines 28% 27%
Decreased 6-9 lines 6% 27%
Decreased > 10 lines 6% 18%

MPS 1982
Leading causes of blindness in Western societies

• Glaucoma
– Loss of vision due to progressive optic nerve damage
often (but not always) associated with increased
intraocular pressure
– Varying definitions - IOP, Visual fields, cupping
– Different types of glaucoma
• Congenital
• Open- angle
• Narrow-angle
• Syndromic
• Glaucoma
– Glaucoma affects 1.5-2.0% of population over the age of 40. Rises
with age up to 8% for those over 80
– Current prevalence is 15% of all cases of blindness (developed
nations)
– Age of onset of blindness from glaucoma
• >60 years : 79%
– Those under 65 years old
• Glaucoma-related blindness associated with other conditions -
36%
– Those greater than 65 years old
• Glaucoma-related blindness associated with other conditions -
46%
 Leading causes of blindness in Western societies

• Diabetic retinopathy
– Women greater than men:
• 56% of the younger blind diabetic individuals
• 87% of the older blind diabetic individuals
– In those under the age of 65, diabetes is the most
common cause of blindness
– However, 2/3 of diabetics do not become blind until
after the age of 60
– Blindness from DR is a poor prognosis for survival
• Diabetes mellitus
– IDDM: 0.5-1.0%
– NIDDM: large variations among countries and ethnic groups 0.7-
3.0%
– Prevalence (%) of vision impairment among diabetics - (Klein et al 1984)
Vision Young Onset Older Onset
20/40 - 20/63 3.3 7.3
20/80 - 20/160 1.4 3.0
below 20/200 3.6 1.6
– Diabetic retinopathy:
• Nonproliferative Proliferative
• Macular edema Ischemic maculopathy
 Nonproliferative Diabetic Retinopathy

Proliferative Diabetic
Retinopathy
• Diabetes mellitus
– Visual impairment in IDDM and NIDM
Age range (yrs) % of patients
Unilateral Bilateral Blindness
visual impairment
IDDM
<50 5.4 0.9 3.6
>50 18.2 8.7 12.2
NIDM
<70 7.7 2.8 2.1
>70 20.8 17.1 7.3

Nielson 1982 (Denmark)

• Diabetes mellitus
– Cumulative events of vision loss in DRS study after laser
treatment
Follow-up Cumulative rate of events (%)
(months) Control group Treated group
12 3.4 1.8
24 13.6 6.6
48 27.4 12.6
60 32.1 15.2
72 34.2 17.5
DRS 1981
 Leading causes of blindness in Western societies
• Cataract
• Congenital - major cause of infantile blindness
• Secondary to or associated with other disorders
• Age-related
– Age at onset of blindness from cataract
• Age 70 and greater : 70-85% of cases
– Risk factors
• Age, poor education, myopia, hypertension, diabetes,
glaucoma, smoking, beer drinking, certain drugs, low vital
capacity, severe diarrhea, kidney failure