Smoking complicates the course of non-infectious uveitis

HIGH LONG-TERM DRUG-FREE REMISSION RATE FOR ACUTE VOGT-KOYANAGI-HARADA DISEASE WITH AN APPROPRIATE IMMUNOSUPPRESSIVE REGIMEN

PURPOSE

To report the clinical profile and outcomes of acute Vogt-Koyanagi-Harada disease with a strict immunosuppression regimen and investigate the risk factors for a prolonged disease course.

METHODS

A total of 101 patients with acute Vogt-Koyanagi-Harada (202 eyes) with more than 24 months of follow-up were recruited from January 2011 to June 2020. They were divided into two groups according to the interval between the onset of Vogt-Koyanagi-Harada and treatment. Oral prednisone was gradually tapered off by a diminished dose according to a relatively strict protocol. Patient responses to the treatment regimen were classified as long-term drug-free remission or chronic recurrent.

RESULTS

Ninety-six patients (95.0%) achieved long-term drug-free remission without recurrence, while 5 (5.0%) had chronic recurrence. Most patients achieved good best-corrected visual acuity (90.6% ≧20/25). A generalized estimation equation model demonstrated that time of visit, ocular complications, and cigarette smoking were independent risk factors for a longer disease course, and smokers required a higher drug dose and longer treatment course than nonsmokers.

CONCLUSION

An immunosuppressive regimen with an appropriate tapering speed can lead to long-term drug-free remission in patients with acute Vogt-Koyanagi-Harada. Cigarette smoking significantly affects ocular inflammation.

Rheumatologist's Perspective on Non-Infectious Uveitis: Patterns from Tertiary Referral Rheumatologic Clinics in Italy

Non-infectious uveitis (NIU) can be an early or even the first extra-articular manifestation of systemic rheumatic diseases, or the first one; thus, rheumatologists are often involved in the diagnostic and therapeutic assessment of NIU. We evaluated 130 patients with a diagnosis of NIU who were admitted to two Italian rheumatologic clinics (Tor Vergata University Hospital in Rome, and Federico II University in Naples) from January 2018 to December 2021. Anterior uveitis (AU) occurred in 75.4% of patients, followed by posterior uveitis (PU, 21.5%); acute (54.6%) and recurrent (35.4%) NIU were more documented than chronic NIU (10%), and a bilateral involvement was observed in 38.7% of cases. Half of NIU cases were associated with spondyloarthritis (SpA); the remaining were affected by Behçet disease (BD)-related uveitis (13.9%) and idiopathic NIU (9.2%). HLA-B27⁺ patients (34.8%) had a higher prevalence of anterior and unilateral NIU (p = 0.005) with acute course (p = 0.04) than HLA-B27^- patients. On the contrary, HLA-B51⁺ patients (19.6%) had mostly PU and bilateral NIU (p < 0.0001) and recurrent course (p = 0.04) than HLA-B51^- patients. At the first rheumatologic referral, 117 patients (90%) received systemic treatments. Findings from this study demonstrate that rheumatologic referral has a pivotal role in the diagnostic work-up of NIU and may dramatically influence NIU-treatment strategies.

Factors Associated With Adverse Outcomes in Uveitis Related to Spondyloarthritis: Development of an Outcome Score (SpA-U)

BACKGROUND

Evaluating the efficacy and refractoriness to treatment and determining factors associated with adverse outcomes in uveitis associated with spondylarthritis (SpA) are complicated by the lack of validated outcome measures.

OBJECTIVES

The aims of this study were to develop an outcome score SpA-U in patients with uveitis associated with SpA and to determine factors associated with adverse outcomes in patients with uveitis under systemic treatment.

METHODS

The outcome score SpA-U was defined by best-corrected visual acuity, anterior chamber inflammation, macular edema and inflammation of posterior chamber, global assessment, and refractoriness to treatment. Factors associated with adverse outcomes in uveitis were studied using linear regression. For categorical factors, marginal averages and their SEs are displayed together with linear regression coefficients with 95% confidence intervals. For continuous factors, averages and SDs are reported in addition to linear regression coefficients with 95% confidence interval. Two regression coefficients are reported for each variable: unadjusted and adjusted for age at diagnosis and sex.

RESULTS

One hundred ninety-seven uveitis outbreaks were included. Sixty-two uveitis outbreaks (31%) were classified as severe, 42 as moderate (21%), and 93 as mild (47%) based on the definition and construction of outcome score. The results of the linear regression model revealed that the uveitis activity was more severe in patients with smoking history ( β = 0.34), axial and peripheral involvement ( β = 0.43), Ankylosing Spondylitis Disease Activity Score >2.1 ( β = 0.45), positive HLA-B27 ( β = 0.29), female sex ( β = 0.19), patients with C-reactive protein elevation ( β = 0.002), and bilateral ocular involvement ( β = 0.32). At the same time, shorter disease evolution ( β = -0.02) was associated with less severe uveitis activity.

CONCLUSION

We have determined factors associated with adverse outcomes in patients with uveitis associated with SpA by developing an outcome score SpA-U that integrates ocular inflammatory activity, visual acuity, global assessment, and refractoriness to treatment.

Smoking and environmental tobacco smoke exposure: implications in ocular disorders

PURPOSE

This article aims to gather and review the available knowledge on several implications of smoking and environmental tobacco smoke (ETS) exposure in ocular disorders and provides pathomechanistic insights where applicable.

MATERIALS AND METHODS

PubMed and Scopus databases were searched for relevant studies on the association of smoking and ETS exposure with various ocular disorders. Studies with different evidence levels, e.g., in-vivo, case-control, cohort, and meta-analysis, were included.

RESULTS

Smoking is an established, modifiable risk factor in several ocular diseases, including cataract, age-related macular degeneration, and Graves' ophthalmopathy; smokers are subject to more severe disease courses and less favorable treatment outcomes. Uveitis is twice as likely in smokers; smoking may also delay its resolution. Smoking and ETS exposure are major risk factors for diseases of other organs, with associated ocular complications as well, such as diabetes mellitus. ETS exposure is also associated with ocular surface pathologies, including dry eye syndrome. In children, early-life ETS exposure and maternal smoking during pregnancy are strongly associated with refractive errors and strabismus. Currently, available data on potential risks attributable to ETS exposure regarding ocular diseases are scarce and, in some instances, controversial.

CONCLUSION

In addition to smoking, ETS exposure is also a significant public health concern with possible links to several ocular diseases. However, the level of education of at-risk populations in this regard does not match the strength of the evidence.

Characteristics and Outcomes of Patients with Scleritis in the IRIS® Registry (Intelligent Research in Sight) Database

PURPOSE

To report patient characteristics and factors associated with poor visual acuity and abnormal intraocular pressure (IOP) in patients with scleritis in the American Academy of Ophthalmology's IRIS® Registry (Intelligent Research in Sight).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients in the IRIS Registry with at least 3 office visits associated with an International Classification of Diseases scleritis code from 2013 through 2019.

METHODS

We evaluated demographic and clinical characteristics in scleritis and scleritis subtype cohorts. We conducted Cox proportional hazards and multiple logistic regression analyses to assess associations with poor best-corrected visual acuity (BCVA), vision loss, and IOP abnormalities.

MAIN OUTCOME MEASURES

Patient characteristics, BCVA of 0.6 logarithm of the minimum angle of resolution (logMAR) or more, BCVA worsened by more than 3 logMAR units 6 months after presentation, IOP of 30 mmHg or more, and IOP of 5 mmHg or less.

RESULTS

In this cohort of 111 314 patients with scleritis, the mean ± standard deviation age was 58.5 ± 16.6 years, 66% were women, and 30% had bilateral scleritis. Patients with scleromalacia perforans were older and more likely to have bilateral disease. Multiple logistic regression analysis identified factors with increased odds for poor presenting BCVA (older age, male sex, Black race, Hispanic ethnicity, smoking, and scleritis subtypes) and at least 3 lines of vision loss 6 months after initial scleritis diagnosis (older age, smoking, and anterior scleritis). Cox proportional hazards regression modeling of BCVA of 0.6 logMAR or more showed older age (adjusted hazard ratio [aHR] per 10-year unit, 1.11), Black race (aHR, 1.19), Hispanic ethnicity (aHR, 1.22), active smoking (aHR, 1.39), former smoking (aHR, 1.26), and certain scleritis subtypes increase the risk of poor visual acuity development (P < 0.001 for all). Older age, male sex, Black race, Hispanic ethnicity, smoking, and scleritis subtypes increased the odds of IOP abnormality.

CONCLUSIONS

Older age, Black or Hispanic ancestry, smoking, and specific scleritis subtypes are risk factors for worse visual and IOP outcomes in patients with scleritis in the IRIS Registry. Closer follow-up may be appropriate for older, Black, or Hispanic patients with scleritis; smokers should receive smoking cessation assistance.

Intermediate Uveitis: A Review

PURPOSE

This review aims to provide an update on the clinical presentation, etiologies, complications, and treatment options in intermediate uveitis (IU).

METHODS

Narrative literature review.

RESULTS

IU affects all age groups with no clear gender predominance and has varied etiologies including systemic illnesses and infectious diseases, or pars planitis. In some instances, IU may be the sole presentation of an underlying associated condition or disease. Management of IU and its complications include administration of corticosteroids, antimetabolites, T-cell inhibitors, and/or biologics, along with surgical interventions, with varying degrees of effectiveness across literature. In particular, increasing evidence of the safety and efficacy of immunomodulatory agents and biologics has seen greater adoption of these therapies in clinical practice.

CONCLUSIONS

IU is an anatomical description of uveitis, involving intraocular inflammation of the vitreous, peripheral retinal vasculature, and pars plana. Various treatment options for intermediate uveitis are currently used in practice.

Risk of inflammatory bowel disease in uveitis patients: a population-based cohort study

OBJECTIVES

To investigate the potential association between uveitis and an increased risk of developing inflammatory bowel disease (IBD).

METHODS

We conducted a retrospective cohort study by interrogating data from the Taiwan National Health Insurance Research Database entered between January 1, 2001 and December 31, 2013 to identify uveitis patients and age- and gender-matched controls. The cumulative incidence rates of subsequent IBD in the two groups were compared. The adjusted hazard ratio (HR) of IBD related to uveitis was generated by a multivariate cox regression model after adjustment for hypertension, diabetes, hyperlipidaemia, obesity and smoking. Furthermore, the HRs of the Crohn's disease (CD) and ulcerative colitis (UC) IBD subtypes were calculated separately.

RESULTS

A total of 198,923 subjects with uveitis and 397,846 controls were enroled. The mean age of the cohort was 47.7 ± 18.9 years. A significantly higher cumulative incidence of IBD was found in the uveitis group than in controls (4.13% vs. 1.48%, p < 0.0001). Under univariate cox regression analysis, uveitis patients had a significantly higher risk of IBD (HR = 1.47; 95% confidence interval (CI): 1.43-1.52, p < 0.0001). The association remained significant in the multivariate regression model, with an adjusted HR of 1.44 (95% CI: 1.39-1.49, p < 0.0001). Moreover, in subgroup analysis, uveitis was significantly associated with an increased risk of Crohn's disease (adjusted HR = 1.49; 95% CI: 1.44-1.54), but not with ulcerative colitis (adjusted HR = 1.03; 95% CI: 0.92-1.15).

CONCLUSIONS

Patients with uveitis are at significantly greater risk of developing IBD than individuals without uveitis.

The Adverse Effects of Air Pollution on the Eye: A Review

Air pollution is inevitably the result of human civilization, industrialization, and globalization. It is composed of a mixture of gases and particles at harmful levels. Particulate matter (PM), nitrogen oxides (NOx), and carbon dioxides (CO₂) are mainly generated from vehicle emissions and fuel consumption and are the main materials causing outdoor air pollution. Exposure to polluted outdoor air has been proven to be harmful to human eyes. On the other hand, indoor air pollution from environmental tobacco smoking, heating, cooking, or poor indoor ventilation is also related to several eye diseases, including conjunctivitis, glaucoma, cataracts, and age-related macular degeneration (AMD). In the past 30 years, no updated review has provided an overview of the impact of air pollution on the eye. We reviewed reports on air pollution and eye diseases in the last three decades in the PubMed database, Medline databases, and Google Scholar and discussed the effect of various outdoor and indoor pollutants on human eyes.

Epidemiology and Risk Factors in Non-infectious Uveitis: A Systematic Review

Purpose: Non-infectious uveitis is a leading cause of vision loss in the developed world. The purpose of this systematic review is to investigate the epidemiology and risk factors of non-infectious uveitis over the last 50 years.

Methods: A systematic literature search of Pubmed/MEDLINE database was performed in the 50-year period from January 1971 to January 2021, according to the PRISMA guidelines. Studies that assessed the epidemiology and risk factors for non-infectious uveitis were included.

Results: Few epidemiologic studies focus specifically on non-infectious uveitis. In the Unites States, the estimated prevalence of non-infectious uveitis is 121/100,000. The incidence and prevalence varies considerably worldwide. Females and the working age group (20–50 years) appear to be the most affected. Smoking and vitamin D deficiency are the biggest risk factors for non-infectious uveitis, while pregnancy appears to be protective. Additional risk factors include presence of other autoimmune diseases (thyroid disease, diabetes, celiac), pre-eclampsia/eclampsia, psychological stress, and certain medications (bisphosphonates, immune checkpoint inhibitors, female hormone therapy, and etanercept).

Discussion: Our systematic review summarizes the incidence and prevalence of non-infectious uveitis and associated modifiable and non-modifiable risk factors.

The burden of non-infectious intraocular inflammatory eye diseases: a systematic literature review

OBJECTIVE

Non-infectious inflammatory eye diseases (IEDs), although rare, are complex and varied and may result in detrimental effects. A systematic literature review was conducted on the clinical outcome and economic burden of IED.

METHODS

The Ovid search platform (Wolters Kluwer) was used to access scientific literature databases, including MEDLINE, Embase, Cochrane libraries, Health Technology Assessment and the NHS Economic Evaluation database. The search strategy targeted clinical and economic outcomes research in 2009-2016. Titles and abstracts resulting from inclusion criteria were screened, and two reviewers independently extracted relevant information from the selected full-text articles.

RESULTS

Thirty-nine papers met the inclusion criteria - 21 clinical trials, 7 database analyses, 6 non-systematic literature reviews with expert commentary, 3 chart reviews, and 2 surveys - which assessed steroids, immunosuppressants, implants and biologics. Patients experienced considerable morbidity, much of which was associated with corticosteroid use. The average annual healthcare costs of patients with IED were $13,728 to $32,268 in 2009 US dollars, which amounted to 3.1 to 8.3 times that of patients without IED. Steroid-releasing intraocular implants were associated with higher up-front costs, close monitoring requirements, potential for implant removal and increased rates of adverse ocular events than systemic steroids.

CONCLUSIONS

IEDs are rare and complex conditions that threaten eyesight and impose considerable morbidity as well as a substantial economic burden. This review confirms that further research is needed to more fully explore the burden of IED and treatment-related adverse events, as well as appropriate means for clinicians to intensify treatment.

Epidemiology of uveitis in a US population-based study

Background

The purpose of this study is to assess the relationship between self-reported uveitis and purported demographic and clinical risk factors, using an American adult population extracted from the National Health and Nutrition Examination Survey (NHANES) for the years 2009 and 2010. This is a cross-sectional, population-based study using a sample of 5106 subjects between 20 and 69 years old. The main outcome for our study was the self-report of a diagnosis of uveitis. The demographic analysis included age, gender, and ethnicity. Potential predictors were having a diagnosis of ankylosing spondylitis (AS), ulcerative colitis (UC), or Crohn’s disease (CD); a history of cigarette smoking; vitamin D deficiency; and different mental health measures. Univariate and multivariate analyses were conducted using RStudio.

Results

Of the 5106 participants, 27 had reported a diagnosis of uveitis, showing an adjusted prevalence of 5.4 per 1000 subjects (95% CI 3.4–8.5/1000). Increased age was associated with higher uveitis prevalence in the multivariate analysis (odds ratio [OR] = 1.04, 95% CI 1.01–1.07; p = 0.02). Positive smoking history was reported in 59.2% of patients. Multivariate analysis comparing smoking with the presence of uveitis showed an OR of 3.18 (95% CI 1.59–6.37; p = 0.003), adjusting for age and gender. Moreover, 11.1% of the participants from the uveitis group self-reported a diagnosis of AS and 11.7% informed a diagnosis of UC and 7.1% of CD. The ORs were of 16.64 (95% CI 3.64-76.09; p = 0.001), 11.34 (95% CI 2.69-47.88; p = 0.003), and 22.16 (95% CI 2.64-186.17; p = 0.007), respectively when compared with the non-uveitis group in the multivariate analysis.

Conclusions

Age, cigarette smoking, AS, UC, and CD are positively associated with self-reported uveitis. There is previous evidence that smoking and female gender are positive risk factors for uveitis, as well as evidence that HLA-B27-positive spondyloarthritides have the highest association with non-infectious uveitis in the adult population in North America and Europe. However, there are no prior studies that have utilized a representative US population-based sample to validate these findings. The present study supports smoking as a risk factor, which has clinical relevance since this is a modifiable habit.

Increasing smoking intensity is associated with increased disease activity in axial spondyloarthritis

A history of ever-smoking appears to be associated with a more severe disease phenotype in axial spondyloarthritis (axSpA). However, evidence is sparse for the effect of increased smoking exposure on disease outcomes or whether smoking reduction or cessation improves outcomes. The aim of this study was to explore whether a dose–response relationship exists between pack-years and disease activity and functional impairment in axSpA. Consecutive patients meeting ASAS criteria for axial SpA were recruited from a spondyloarthritis service. The associations between pack-years of smoking and: (1) disease activity (BASDAI/ASDAS), (2) spinal pain, (3) functional impairment (BASFI) and (4) inflammatory markers were explored using multivariable linear models, adjusted for age, gender and use of TNF inhibition (TNFi) therapy. Pack-years were categorised into four groups (<10, 11–20, 21–40, >40) and analysed with light smoking (<10) as reference. Two hundred and thirty-eight axSpA patients were recruited: 76% were male, mean age 46.4 years (SD ± 13.7), and 33% were treated with TNFi. One hundred and twelve patients reported history of ever-smoking with median pack-year 20 [IQR10-30]. Compared to light smokers, those with higher categories of smoking exposures had higher BASDAI (21–40 pack-years, β = 1.6 (95% CI 0.28, 2.95); >40, β = 2.6 (0.54, 3.56)), higher BASFI (21–40, β = 2.1 (0.42, 4.80); >40, β = 3.2 (0.76, 5.71)), and higher ASDAS (21–40, β = 0.82 (0.14, 1.51)). This cross-sectional study demonstrated that smoking is associated with increased axSpA severity markers in a dose–response manner. Particular effort should be made to restrict smoking exposure early before accruing a significant number of pack-years.

Association between Smoking and Uveitis: Results from the Pacific Ocular Inflammation Study

PURPOSE

To assess whether cigarette smoking is associated with the development of uveitis in a population-based setting.

DESIGN

Retrospective, population-based, case-control study.

PARTICIPANTS

Patients aged ≥ 18 years who were seen at a Kaiser Permanente Hawaii clinic between January 1, 2006, and December 31, 2007. Analysis included 100 confirmed incident uveitis cases, 522 randomly selected controls from the general Kaiser Hawaii population, and 528 randomly selected controls from the Kaiser Hawaii ophthalmology clinic.

METHODS

International Classification of Diseases, 9th revision (ICD-9), diagnosis codes were used to identify possible uveitis cases. A uveitis fellowship-trained ophthalmologist then conducted individual chart review to confirm case status. Multivariate logistic regression models were used to evaluate the association between smoking and uveitis, adjusting for age, sex, race, and socioeconomic status.

MAIN OUTCOME MEASURES

Development of uveitis.

RESULTS

Current smokers had a 1.63 (95% confidence interval [CI], 0.88-3.00; P = 0.12) and 2.33 (95% CI, 1.22-4.45; P = 0.01) times greater odds of developing uveitis compared with those who never smoked using the general and ophthalmology control groups, respectively. The association was even stronger with noninfectious uveitis, which yielded odds ratios of 2.10 (95% CI, 1.10-3.99; P = 0.02) and 2.96 (95% CI, 1.52-5.77; P = 0.001) using the general and ophthalmology control groups, respectively.

CONCLUSIONS

Cigarette smoking is significantly associated with new-onset uveitis within a population-based setting. The association was stronger for noninfectious uveitis. Given the well-established risks of smoking with regard to other inflammatory disorders, these results reaffirm the importance of encouraging patients to avoid or cease smoking.

Effects of chronic smoking on color vision in young subjects

AIM

To evaluate the effects of chronic smoking on color vision in young subjects.

METHODS

This study included 91 smokers and 88 non-smokers (a total of 179 volunteers) without any ophthalmologic and systemical disorders. The subjects were between 18-40 years of age with a best corrected visual acuity (BCVA) of 20/20, normal anterior and posterior segment examinations and normal intraocular pressure. The color vision of the subjects were evaluated with Farnsworth-Munsell 100 Hue test (FMHT). The total error scores and axis calculation were performed for each subject and the results correlated.

RESULTS

Mean age and the standard deviation was 28±5y in the smokers group, and 26.7±5.5y in the control group (P=0.101). Sex distribution was similar in the two groups (P=0.365). There was no significant correlation between age and FMHT total error scores (P=0.069). Median of FMHT total error scores of smokers and non-smokers were 65 and 50.50, respectively. FMHT total error scores was found significantly higher in smokers than non-smokers (P=0.004). There was no statisticaly significant difference between smoker and non-smoker groups with respect to axis ratio calculation (P=0.611). There was no significant correlation with FMHT total error scores with neither smoking duration nor number of cigarettes smoked per day (P=0.405, P=0.454, respectively).

CONCLUSION

This study suggested that chronic smoking affects the color vision of young smokers but this may not be sector selective.

Effects of smoking on ocular health

PURPOSE OF REVIEW

To review recent data on the effects of smoking on ocular health.

RECENT FINDINGS

Smoking has been associated with a myriad of negative ocular health effects including age-related macular degeneration (ARMD) and cataract. Most recently, several papers have demonstrated a connection between smoking and ocular inflammation. Smokers are both more likely to develop ocular inflammation and to have more severe disease as manifested by poorer presenting vision and a higher risk of recurrent disease compared to nonsmokers. Smoking has also been shown to enhance the effect of genetic susceptibility with regards to the presence and development of ARMD. Finally, the negative effects of smoking on ocular disease have been increasingly documented in nonwhite populations outside of the USA. However, despite the abundance of data, public awareness on the adverse consequences of smoking on vision is lacking in the USA. In contrast, Australia improved public knowledge by launching a successful antitobacco health campaign highlighting the effects of smoking on ocular health.

SUMMARY

These findings suggest that eye care professionals should discuss and offer options for smoking cessation as part of the management of patients with ocular diseases, especially in those with ocular inflammation, ARMD, lens opacities/cataract, and thyroid-associated orbitopathy. Health campaigns using existing medical data can improve public awareness on the connection between tobacco and visual impairment.

Smoking as a risk factor for choroidal neovascularization secondary to presumed ocular histoplasmosis syndrome

PURPOSE

To investigate the relationship of smoking to choroidal neovascularization (CNV) secondary to presumed ocular histoplasmosis syndrome (POHS).

DESIGN

Retrospective, case-control study.

PARTICIPANTS

A total of 568 patients 18 to 50 years of age, 142 of whom were diagnosed with CNV secondary to POHS in a private retina practice between July 1, 2000, and August 1, 2010. Four hundred twenty-six were controls selected from a private comprehensive ophthalmology practice at the same location.

METHODS

A retrospective medical record review was performed for all participants. Age, gender, zip code, CNV diagnosis date, insurance status, and smoking status at CNV diagnosis date were collected first for the POHS patients. For each of these 142 patients, 3 randomly selected comprehensive clinic patients, whose visit date fell within 3 months of the corresponding POHS patient's CNV diagnosis date, served as controls. Age, gender, zip code, visit date, reason for visit, insurance type, and smoking status were recorded. Descriptive statistics were calculated for cases and controls.

MAIN OUTCOME MEASURES

Logistic regression analyses were performed for both univariate and multivariate models, with CNV secondary to POHS as the main outcome variable and smoking as the main predictor variable, while adjusting for age, gender, insurance type, median household income, and education level.

RESULTS

The mean age of patients with CNV secondary to POHS was 39.0±7.1 years, whereas that of the control patients was 35.7±9.1 years. Of the patients with CNV secondary to POHS, 47.2% were current or former smokers (42.3% current, 4.9% former). Of the control patients, 22.5% were current or former smokers (21.8% current, 0.7% former). Age, insurance type, median income, educational attainment, and smoking status were significant in the univariate models. In the final adjusted logistic regression model, only age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.07; P = 0.001), level of educational attainment by zip code (OR, 0.95; 95% CI, 0.92-0.98; P = 0.001) and smoking status (OR, 2.83; 95% CI, 1.86-4.31; P<0.0001) were significant.

CONCLUSIONS

The odds of a smoker having CNV secondary to POHS are almost 3 times that of a nonsmoker. In this study, the odds of having CNV secondary to POHS increased with age and decreased with increasing level of educational attainment.