Parapapillary drusen of the retinal pigment epithelium

PURPOSE

To describe the occurrence, morphology and associations of parapapillary drusen of the retinal pigment epithelium (RPE-drusen).

METHODS

Using light microscopy, we histomorphometrically examined enucleated human eyes.

RESULTS

The study included 83 eyes (axial length: 25.9 ± 3.2 mm; range: 20.0-35.0 mm). Eyes with parapapillary RPE-drusen (n = 29 (35%) eyes) as compared to those without drusen had a significantly shorter axial length (24.0 ± 1.8 mm vs 27.0 ± 3.3 mm; p < 0.001), higher prevalence (27/29 vs 12/54; p < 0.001) and longer width (213 ± 125 μm vs 96 ± 282 μm; p < 0.0001) of parapapillary alpha zone, and thicker BM in parapapillary beta zone (8.4 ± 2.7 μm vs 3.9 ± 2.0 μm; p < 0.001) and alpha zone (6.6 ± 3.9 μm vs 4.4 ± 1.5 μm; p = 0.02). Prevalence of parapapillary RPE-drusen was 27 (69%) out of 39 eyes with alpha zone. Beneath the RPE-drusen and in total alpha zone, choriocapillaris was open, while it was closed in the central part of parapapillary beta zone. BM thickness was thicker (p = 0.001) in alpha zone than beta zone, where it was thicker (p < 0.001) than in the region outside of alpha/beta zone. BM thickness outside of alpha/beta zone was not correlated with prevalence of parapapillary RPE-drusen (p = 0.47) or axial length (p = 0.31). RPE cell density was higher in alpha zone than in the region adjacent to alpha zone (22.7 ± 7.3 cells/240 μm vs 18.3 ± 4.1 cells/240 μm; p < 0.001). In the parapapillary RPE-drusen, RPE cells were connected with a PAS-positive basal membrane.

CONCLUSIONS

Parapapillary RPE-drusen as fibrous pseudo-metaplasia of the RPE were associated with shorter axial length, higher prevalence and larger size of alpha zone, and thicker BM in alpha zone and beta zone. The RPE-drusen may be helpful to differentiate glaucomatous parapapillary beta zone from myopic beta zone.

Advanced age-related macular degeneration and risk factors in eyes with pachydrusen

The risk of progression to advanced age-related macular degeneration (AMD) varies depending on the type of drusen. This retrospective longitudinal study included 248 eyes of 156 patients with pachydrusen without advanced AMD at baseline. Macular neovascularization (MNV) and geographic atrophy (GA) were evaluated. Risk factors for progression to advanced AMD were determined using multivariate Cox regression analysis. The mean age at baseline was 65.4 ± 9.1 years, and the mean follow-up duration was 6.40 ± 3.58 years. The mean total number of pachydrusen and macular pachydrusen were 4.10 ± 2.85 and 2.27 ± 1.81 per eye, respectively. Pachydrusen was accompanied by other types of drusen in 4.8% (12 eyes) of eyes at baseline. During follow-up, MNVs occurred in 2.8% (seven eyes), including polypoidal choroidal vasculopathy (PCV six eyes); however, no GA occurred. Regarding risk factors for progression to neovascular AMD, age (p = 0.023) and macular pigmentary changes (p = 0.014) were significantly associated with MNV development. The cumulative incidence of MNV was significantly higher in the group with macular pigmentary changes (17.39% vs. 0.57% at 10 years; p = 0.0005). The number of macular pachydrusen and the presence of MNV in the fellow eye did not show a statistically significant relationship with MNV development. Age and macular pigmentary changes are risk factors for MNV development in the eyes with pachydrusen. Eyes with pachydrusen appear to have a risk profile for advanced AMD that is different from that of AMD eyes with drusen or drusenoid deposits other than pachydrusen.

Macular lesions associated with age-related macular degeneration in pachydrusen eyes

BACKGROUND

To investigate the prevalence of macular lesions associated with age-related macular degeneration (AMD) in eyes with pachydrusen.

METHODS

Clinical records and multimodal imaging data of patients over 50 years old with drusen or drusenoid deposits were retrospectively assessed, and eyes with pachydrusen were included in this study. The presence of AMD features, including drusen or drusenoid deposits, macular pigmentary abnormalities, geographic atrophy (GA), and macular neovascularization (MNV), were evaluated.

RESULTS

Out of 967 eyes of 494 patients with drusen or drusenoid deposits, 330 eyes of 183 patients had pachydrusen (34.1%). The mean age was 66.1 ± 9.3 years, and the subfoveal choroidal thickness (SFCT) was 292.7 ± 100.1 μm. The mean number of pachydrusen per eye was 2.22 ± 1.73. The majority of eyes with pachydrusen had no other drusen or drusenoid deposits (95.2%). Only 16 eyes (4.8%) had other deposits, including soft drusen (10 eyes, 3.0%), cuticular drusen (3 eyes, 0.9%), and reticular pseudodrusen (RPD; 3 eyes, 0.9%). Macular pigmentary abnormalities accompanied pachydrusen in 68 eyes (27.4%). None of the eyes had GA, and 82 eyes (24.8%) had MNV. The majority of MNV was polypoidal choroidal vasculopathy (PCV; 65 eyes, 19.7%), followed by type 1 (10 eyes, 3.0%), type 2 (5 eyes, 1.5%), and type 3 MNV (2 eyes, 0.6%).

CONCLUSIONS

Eyes with pachydrusen in Korean population have several characteristic AMD lesions in low frequencies. These findings indicate that pachydrusen might have diagnostic and prognostic values that are different from those of other drusen or drusenoid deposits.

Prevalence and determinants of subretinal drusenoid deposits in patients' first-degree relatives

PURPOSE

Subretinal drusenoid deposits (SDDs) are distinct extracellular alteration anterior to the retinal pigment epithelium (RPE). Given their commonly uniform phenotype, a hereditary predisposition seems likely. Hence, we aim to investigate prevalence and determinants in patients' first-degree relatives.

METHODS

We recruited SDD outpatients at their visits to our clinic and invited their relatives. We performed a full ophthalmic examination including spectral domain-optical coherence tomography (SD-OCT) and graded presence, disease stage of SDD as well as percentage of infrared (IR) en face area affected by SDD. Moreover, we performed genetic sequencing and calculated a polygenic risk score (PRS) for AMD. We conducted multivariable regression models to assess potential determinants of SDD and associations of SDD with PRS.

RESULTS

We included 195 participants, 123 patients (mean age 81.4 ± 7.2 years) and 72 relatives (mean age 52.2 ± 14.2 years), of which 7 presented SDD, resulting in a prevalence of 9.7%. We found older age to be associated with SDD presence and area in the total cohort and a borderline association of higher body mass index (BMI) with SDD presence in the relatives. Individuals with SDD tended to have a higher PRS, which, however, was not statistically significant in the multivariable regression.

CONCLUSION

Our study indicates a potential hereditary aspect of SDD and confirms the strong association with age. Based on our results, relatives of SDD patients ought to be closely monitored for retinal alterations, particularly at an older age. Further longitudinal studies with larger sample size and older relatives are needed to confirm or refute our findings.

Epidemiology of geographic atrophy and its precursor features of intermediate age-related macular degeneration

Globally age-related macular degeneration (AMD) is a leading cause of blindness with a significant impact on quality of life. Geographic atrophy (GA) is the atrophic late form of AMD and its prevalence increases markedly with age with around 1 in 5 persons aged 85 and above having GA in at least one eye. Bilateral GA leads to severe visual impairment thus posing a significant burden on patients, careers and health providers. The incidence and prevalence of GA varies across different geographic regions, with the highest rates in those of European ancestry. Although heterogeneity in definitions of GA and reporting strategy can explain some of the discrepancies, the data overall are consistent in showing a lower prevalence in other ethnicities such as those of Asian heritage. This is at present unexplained but thought to be due to the existence of protective factors such as differences in eye pigmentation, diet, environmental exposures and genetic variability. This review covers key aspects of the prevalence and incidence of the ocular precursor features of GA (large drusen, pigmentary abnormalities and reticular pseudo-drusen), the late stage of GA and factors that have been known to be associated with modifying risk including systemic, demographic, environment, genetic and ocular. Understanding the global epidemiology scenario is crucial for the prevention of and management of patients with GA.

Prevalence and risk factors for age-related macular degeneration in a population-based cohort study of older adults in Northern Ireland using multimodal imaging: NICOLA Study

PURPOSE

To report prevalence and risk factor associations for age-related macular degeneration (AMD) and AMD features from multimodal retinal grading in a multidisciplinary longitudinal population-based study of aging in Northern Ireland.

STUDY DESIGN

Population-based longitudinal cohort study.

METHODS

Retinal imaging at the Norther Ireland Cohort for the Longitudinal Aging Study health assessment included stereo Colour Fundus Photography (CFP) (Canon CX-1, Tokyo, Japan) and Spectral-Domain Optical Coherence Tomography (SD-OCT) ((Heidelberg Retinal Angopgraph (HRA)+OCT; Heidelberg Engineering, Heidelberg, Germany). Medical history and demographic information was obtained during a home interview. Descriptive statistics were used to describe the prevalence of AMD and individual AMD features. Multiple imputation followed by multiple regression modelling was used to explore risk factor associations including relationships with AMD genetic risk score.

RESULTS

Retinal images from 3386 participants were available for analysis. Mean age of the sample was 63.4 (SD 9.01, range: 36-99). Population weighted prevalence of AMD using colour grading in those over 55 years was: no drusen: 6 0.4%; drusen <63 μm: 15.9%; drusen 63-125 µm: 13.7%; drusen >125 µm or pigmentary changes: 8.3%; late AMD: 1.6%. Prevalence of AMD features in those over 55 years was: OCT drusen 27.5%, complete outer retinal pigment epithelium and outer retinal atrophy (cRORA) on OCT was 4.3%, reticular drusen 3.2% and subretinal drusenoid deposits 25.7%. The genetic risk score was significantly associated with drusen and cRORA but less so for SDD alone and non-significant for hyperpigmentation or vitelliform lesions.

CONCLUSIONS

Multimodal imaging-based classification has provided evidence of some divergence of genetic risk associations between classical drusen and SDD. Our findings support an urgent review of current AMD severity classification systems.

Multimodal Imaging of Reticular Pseudodrusen in Turkish Patients

Objectives

To investigate the presence and prevalence of reticular pseudodrusen (RPD) in patients with age-related macular degeneration using multiple imaging modalities and to compare the sensitivity and specificity of these modalities in the detection of RPD.

Materials and Methods

Images from a total of 198 consecutive patients were analyzed prospectively. Color fundus photography, red-free imaging, spectral domain optical coherence tomography (SD-OCT), infrared and blue reflectance (BR) imaging, fundus autofluorescence (FAF), enhanced-depth imaging OCT (EDI-OCT), fundus fluorescein angiography (FFA) and indocyanine green angiography were performed. RPD was diagnosed in the presence of relevant findings in at least two of the imaging methods used.

Results

RPD were detected in 149 eyes (37.6%). In the detection of RPD, color fundus photography, red-free photography, SD-OCT, infrared, FAF, BR, and FFA imaging had sensitivity values of 50%, 57.7%, 91.6%, 95%, 74.6%, 65.7%, and 28.2% and specificity values of 99.6%, 100%, 98.4%, 94.6%, 100%, 99.6%, and 69.8%, respectively.

Conclusion

Infrared imaging had the highest sensitivity. SD-OCT combined with infrared imaging was the most sensitive imaging technique for detecting RPD. The high specificity of FAF, red-free, and BR imaging may be useful to confirm a diagnosis of RPD.

Clinical Characteristics and Progression of Geographic Atrophy in a Japanese Population

PURPOSE

To elucidate the clinical characteristics and progression rate of geographic atrophy (GA) associated with age-related macular degeneration (AMD) in a Japanese population.

DESIGN

Retrospective, multicenter, observational study.

PARTICIPANTS

A total of 173 eyes from 173 patients from 6 university hospitals in Japan were included. Of 173 study eyes, 101 eyes from 101 patients were included in the follow-up group. All patients were Japanese, aged ≥ 50 years and had definite GA associated with AMD in at least 1 eye.

METHODS

The GA area was measured semiautomatically using fundus autofluorescence (FAF) images. In the follow-up group followed for > 6 months with FAF images, the GA progression rate was calculated by 2 methods: mm2 per year and mm per year using the square-root transformation (SQRT) strategy. Simple and multiple linear regression analyses were used to identify the baseline factors associated with the GA progression rate.

MAIN OUTCOME MEASURES

Clinical characteristics of GA and the GA progression rate.

RESULTS

The mean age was 76.8 ± 8.8 years, and 109 (63.0%) were males. Sixty-two (35.8%) patients had bilateral GA. The mean GA area was 3.06 ± 4.00 mm2 (1.44 ± 1.00 mm [SQRT]). Thirty-eight eyes (22.0%) were classified as having pachychoroid GA. Drusen and reticular pseudodrusen were detected in 115 (66.5%) and 73 (42.2%) eyes, respectively. The mean subfoveal choroidal thickness was 194.7 ± 105.5 μm. In the follow-up group (follow-up period: 46.2 ± 28.9 months), the mean GA progression rate was 1.01 ± 1.09 mm2 per year (0.23 ± 0.18 mm/year [SQRT]). In the multivariable analysis, the baseline GA area (SQRT; P = 0.002) and the presence of reticular pseudodrusen (P < 0.001) were significantly associated with a greater GA progression rate (SQRT).

CONCLUSIONS

Certain clinical characteristics of GA in Asian populations may differ from those in White populations. Asian patients with GA showed male dominance and relatively thicker choroid than White patients. There was a group with GA without drusen but with features of pachychoroid. The GA progression rate in this Asian population was relatively lower than that in White populations. Large GA and reticular pseudodrusen were associated with a greater GA progression rate.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Reticular Pseudodrusen Status, ARMS2/HTRA1 Genotype, and Geographic Atrophy Enlargement: Age-Related Eye Disease Study 2 Report 32

PURPOSE

To determine whether reticular pseudodrusen (RPD) status, ARMS2/HTRA1 genotype, or both are associated with altered geographic atrophy (GA) enlargement rate and to analyze potential mediation of genetic effects by RPD status.

DESIGN

Post hoc analysis of an Age-Related Eye Disease Study 2 cohort.

PARTICIPANTS

Eyes with GA: n = 771 from 563 participants.

METHODS

Geographic atrophy area was measured from fundus photographs at annual visits. Reticular pseudodrusen presence was graded from fundus autofluorescence images. Mixed-model regression of square root of GA area was performed by RPD status, ARMS2 genotype, or both.

MAIN OUTCOME MEASURES

Change in square root of GA area.

RESULTS

Geographic atrophy enlargement was significantly faster in eyes with RPD (P < 0.0001): 0.379 mm/year (95% confidence interval [CI], 0.329-0.430 mm/year) versus 0.273 mm/year (95% CI, 0.256-0.289 mm/year). Enlargement was also significantly faster in individuals carrying ARMS2 risk alleles (P < 0.0001): 0.224 mm/year (95% CI, 0.198-0.250 mm/year), 0.287 mm/year (95% CI, 0.263-0.310 mm/year), and 0.307 mm/year (95% CI, 0.273-0.341 mm/year) for 0, 1, and 2, respectively. In mediation analysis, the direct effect of ARMS2 genotype was 0.074 mm/year (95% CI, 0.009-0.139 mm/year), whereas the indirect effect of ARMS2 genotype via RPD status was 0.002 mm/year (95% CI, -0.006 to 0.009 mm/year). In eyes with incident GA, RPD presence was not associated with an altered likelihood of central involvement (P = 0.29) or multifocality (P = 0.16) at incidence. In eyes with incident noncentral GA, RPD presence was associated with faster GA progression to the central macula (P = 0.009): 157 μm/year (95% CI, 126-188 μm/year) versus 111 μm/year (95% CI, 97-125 μm/year). Similar findings were observed in the Age-Related Eye Disease Study.

CONCLUSIONS

Geographic atrophy enlargement is faster in eyes with RPD and in individuals carrying ARMS2/HTRA1 risk alleles. However, RPD status does not mediate the association between ARMS2/HTRA1 genotype and faster enlargement. Reticular pseudodrusen presence and ARMS2/HTRA1 genotype are relatively independent risk factors, operating by distinct mechanisms. Reticular pseudodrusen presence does not predict central involvement or multifocality at GA incidence but is associated with faster progression toward the central macula. Reticular pseudodrusen status should be considered for improved predictions of enlargement rate.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Extramacular Drusen and Progression of Age-Related Macular Degeneration: Age Related Eye Disease Study 2 Report 30

PURPOSE

To identify the prevalence of extramacular drusen and their role in the progression of age-related macular degeneration (AMD).

DESIGN

Retrospective analysis of a prospective cohort study.

PARTICIPANTS

The study was conducted in 4168 eyes (2998 participants) with intermediate AMD in one or both eyes enrolled in the Age-Related Eye Disease Study 2 (AREDS2), a 5-year multicenter study of nutritional supplements.

METHODS

Baseline 3-field 30-degree color photographs were evaluated for drusen characteristics outside the macular grid, including size, area, and location. The characteristics of extramacular drusen were compared with those of drusen within the macula.

MAIN OUTCOME MEASURES

Progression rates to late AMD.

RESULTS

Although extramacular drusen were observed in 3624 (86.9%) eyes, they represented a small area (< 0.5 mm2) in 50.3% of eyes, with only 17.5% exhibiting an area of > 1 disc area. Eyes with extramacular drusen exhibited larger macular drusen size and area than eyes without extramacular drusen (P < 0.001). Extramacular drusen were not associated with progression to late AMD. The hazard ratio adjusted for baseline age, sex, smoking, AMD severity level, and reticular pseudodrusen for 4043 eyes at risk of developing late AMD over 5 years was 1.17 (95% confidence interval [CI], 0.88-1.54; P = 0.27) for geographic atrophy and 0.96 (95% CI, 0.76-1.2; P = 0.7) for neovascular AMD.

CONCLUSIONS

Extramacular drusen are commonly observed in eyes with AMD and are more frequent with an increasing drusen burden within the macula. In eyes with intermediate AMD, extramacular drusen do not confer additional risk to previously identified risk factors in progression to late AMD.

Characteristics and Spatial Distribution of Structural Features in Age-Related Macular Degeneration: A MACUSTAR Study Report

PURPOSE

To report the prevalence and topographic distribution of structural characteristics in study participants with age-related macular degeneration (AMD) and controls in the cross-sectional study part of the MACUSTAR study (ClinicalTrials.gov Identifier: NCT03349801).

DESIGN

European, multicenter cohort study.

SUBJECTS

Overall, 301 eyes of 301 subjects with early (n = 34), intermediate (n = 168), and late AMD (n = 43), as well as eyes without any AMD features (n = 56).

METHODS

In study eyes with intermediate AMD (iAMD), the presence of structural AMD biomarkers, including pigmentary abnormalities (PAs), pigment epithelium detachment (PED), refractile deposits, reticular pseudodrusen (RPD), hyperreflective foci (HRF), incomplete/complete retinal pigment epithelium (RPE), and outer retinal atrophy (i/cRORA), and quiescent choroidal neovascularization (qCNV) was systematically determined in the prospectively acquired multimodal retinal imaging cross-sectional data set of MACUSTAR. Retinal layer thicknesses and the RPE drusen complex (RPEDC) volume were determined for the total study cohort in spectral-domain (SD) OCT imaging using a deep-learning-based algorithm.

MAIN OUTCOME MEASURES

Prevalence and topographic distribution of structural iAMD features.

RESULTS

A total of 301 study eyes of 301 subjects with a mean (± standard deviation) age of 71.2 ± 7.20 years (63.1% women) were included. Besides large drusen, the most prevalent structural feature in iAMD study eyes were PA (57.1%), followed by HRF (51.8%) and RPD (22.0%). Pigment epithelium detachment lesions were observed in 4.8%, vitelliform lesions in 4.2%, refractile deposits in 3.0%, and qCNV in 2.4%. Direct precursor lesions for manifest retinal atrophy were detected in 10.7% (iRORA) and 4.2% (cRORA) in iAMD eyes. Overall, the highest RPEDC volume with a median of 98.92 × 10^-4 mm³ was found in iAMD study eyes. Spatial analysis demonstrated a predominant distribution of RPD in the superior and temporal subfields at a foveal eccentricity of 1.5 to 2 mm, whereas HRF and large drusen had a distinct topographic distribution involving the foveal center.

CONCLUSIONS

Detailed knowledge of the prevalence and distribution of structural iAMD biomarkers is vital to identify reliable outcome measure for disease progression. Longitudinal analyses are needed to evaluate their prognostic value for conversion to advanced disease stages.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Heritability and risk factors of incident small and large drusen in the Copenhagen Twin Cohort Eye Study: a 20-year follow-up

INTRODUCTION

The transition from a normal fundus to one with early drusen (≥ 20 small hard drusen) to age-related macular degeneration (AMD) in the form of drusen ≥ 63 µm in diameter is of interest, because small hard drusen may be precursors of large drusen. Study of AMD precursors lesions may provide valuable insight into factors that initiate AMD. Here, the progression of drusen was studied over an interval of 20 years in a population-based twin cohort.

METHODS

Single-center, 20-year follow-up of 138 twins, including biometry, fundus optical coherence tomography, and fundus photography. Macular characteristics were hierarchically classified as (per eye) 1) < 20 small hard drusen, 2) ≥ 20 small hard drusen, 3) drusen ≥ 63 µm, or 4) ≥ 20 small hard drusen combined with drusen ≥ 63 µm. Additive and dominant genetic effects as well as shared and non-shared environmental effects were analyzed in a bivariate biprobit model with a classic liability-threshold approach and polygenic modeling with random effects.

RESULTS

Median participant age was 59 (range 41 - 66) years. Of 25 (18%) cases of incident macular drusen, 7 had ≥ 20 small hard drusen, and 18 had drusen ≥ 63 µm at follow-up, whereas no participant had developed both traits simultaneously. Smoking was associated with incident ≥ 20 small hard drusen (p = 0.04) and incident drusen ≥ 63 µm (p = 0.003). Having ≥ 20 small hard drusen at baseline was associated with incident drusen ≥ 63 µm at follow-up (p = 0.02). Development of drusen ≥ 63 µm was attributable to 49% genetic effects and 51% environmental effects.

CONCLUSION

The risk of progressing from 0-19 small hard macular drusen per eye to having ≥ 20 small hard drusen or drusen ≥ 63 µm at follow-up was associated with smoking and genetic predisposition. Having ≥ 20 small hard drusen in the absence of drusen ≥ 63 µm at baseline was associated with incident drusen ≥ 63 µm when examined 20 years later. The study confirms that small hard macular drusen is a forewarning of AMD and that progression to AMD may be hindered by avoidance of smoking.

Drusen ooze: Predictor for progression of dry age-related macular degeneration

BACKGROUND

To evaluate natural history of drusen ooze and its role as a predictor for progression of dry age-related macular degeneration (AMD) longitudinally.

METHODS

Multi-centric retrospective observational case series of 72 eyes (72 patients) with dry AMD with a minimum follow-up of 4 years. Drusen types were identified on volume scans on optical coherence tomography (OCT) and were characterized for occurrence of drusen ooze at baseline until last visit. Drusen ooze was defined as hyperreflective dots overlying a collapsing drusen or pseudodrusen, or hyperreflective RPE above drusen or isoreflective dots at the level of outer nuclear layer. The consequent incidence of incomplete retinal pigment epithelium and outer retinal atrophy (iRORA), complete retinal pigment epithelium and outer retinal atrophy (cRORA), and neovascular AMD (nAMD) were evaluated statistically.

RESULTS

In total, 72 eyes with a mean follow-up of 68.89 (± 25.57 months) were studied. At presentation, 11 eyes (15.3%) had a single drusen type, whereas 61 eyes (84.7%) had mixed drusen. Reticular pseudodrusen were most common (84.7%) followed by soft drusen (66.6%). Drusen ooze was seen in 47 eyes (65.2%) at presentation. The presence of drusen ooze at baseline (p < 0.01) and baseline best corrected visual acuity (BCVA) (p = 0.04) significantly correlated with development of iRORA and cRORA. In total, 14 eyes progressed from iRORA to cRORA over a mean follow up of 29.14 (± 24.33) months. Odds of progression to iRORA or cRORA were 20.3 times greater for eyes with drusen ooze at baseline (95% C.I., 4.4-94.2).

CONCLUSIONS

In dry AMD, drusen ooze is a useful sign for predicting progression to iRORA and cRORA over time.

Reticular Pseudodrusen Characteristics and Associations in the Carotenoids in Age-Related Eye Disease Study 2 (CAREDS2), an Ancillary Study of the Women's Health Initiative

PURPOSE

To determine the prevalence and morphologic features of reticular pseudodrusen (RPD) and their association with participant demographics and age-related macular degeneration (AMD) status in the Carotenoids in Age-Related Eye Disease Study 2 (CAREDS2) sample, an ancillary study of the Women's Health Initiative Observational Study.

DESIGN

Cross-sectional, multicenter, natural history study.

PARTICIPANTS

Nine hundred and twenty-seven eyes from 466 postmenopausal women 69 to 101 years of age.

METHODS

Multimodal imaging, including spectral-domain (SD) OCT and infrared reflectance (IR), were used to identify RPD characteristics, including location (within or outside the 6-mm diameter circle centered at the macula), presence of peripapillary RPD, pattern of RPD, and RPD area. Age-related macular degeneration features from SD OCT, IR, and color photographs also were assessed and AMD severity was categorized.

MAIN OUTCOME MEASURES

Reticular pseudodrusen prevalence using SD OCT and IR imaging and AMD status.

RESULTS

Reticular pseudodrusen were present in 130 eyes (14% of eyes, 16% of participants), with increasing prevalence with age: 7% in those younger than 78 years, 14% in those 78 to 83 years of age, and 30% in those older than 83 years. Using clinical classification of AMD with color photography, RPD were seen in 2.4% of eyes with no AMD or aging changes, 11.5% in early AMD, 25.1% in intermediate AMD, and 51.1% in late AMD. Mean RPD area was 17.4 mm² (standard deviation, 14.7 mm²). Ribbon morphologic RPD (53%) was more common than dot morphologic RPD (36%). Reticular pseudodrusen mostly were located both within and outside the 6-mm circle with primarily superior retinal distribution. Reticular pseudodrusen were visualized with corresponding color fundus photography in only 38 eyes (4% of total eyes). Participants with and without RPD had a visual acuity±standard error of 77.9 ± 1.4 letters and 81.3 ± 0.4 letters, respectively (P = 0.02).

CONCLUSIONS

The prevalence of RPD in CAREDS2 increased with age and was associated with AMD severity. Reticular pseudodrusen were detected in eyes without other features of AMD and could represent an earlier disease state. Multimodal imaging with SD OCT and IR has significantly greater sensitivity for visualizing RPD than color fundus photography.

Subretinal Deposits in Pre-eclampsia and Malignant Hypertension: Implications for Age-Related Macular Degeneration

PURPOSE

To describe the incidence of subretinal deposits that are similar in structure and stage on OCT imaging to subretinal drusenoid deposits (SDDs) in age-related macular degeneration (AMD) in patients with hypertensive choroidopathy secondary to severe pre-eclampsia and malignant hypertension (MHT) and the implications of this ischemic choroidopathy for the pathophysiologic characteristics of SDDs in AMD.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Thirty-three pre-eclampsia patients and 25 MHT patients with serous retinal detachment (SRD) in at least 1 eye were included.

METHODS

Serial multimodal images, including enhanced depth imaging spectral-domain OCT of eyes with hypertensive choroidopathy secondary to pre-eclampsia and MHT, were reviewed at 2 time points, the acute phase (within 4 weeks of initial hypertensive insult) and the recovery phase (beyond 4 weeks).

MAIN OUTCOME MEASURES

Incidence of SDD-like lesions in patients with hypertensive choroidopathy secondary to pre-eclampsia and MHT.

RESULTS

Subretinal drusenoid deposit-like lesions were observed exclusively in eyes with SRD. Serous retinal detachment occurred in 87.87% of eyes of pre-eclampsia patients and in 94% of eyes of MHT patients. Subretinal drusenoid deposit-like lesions occurred in 28.57% of all eyes with SRD, in 32.76% of eyes with SRD from the pre-eclampsia group, and in 23.40% of eyes with SRD from the MHT group. Vascular imaging suggested underlying choroidal ischemia in all patients (12 eyes) in which it was performed.

CONCLUSIONS

Choroidal ischemia may be the underlying mechanism of SDD-like lesions in patients with pre-eclampsia and MHT choroidopathy. These findings potentially are of utmost importance in understanding the mechanism of the reticular macular disease subtype of AMD. Reticular macular disease is characterized by the known association of choroidal insufficiency and SDD, with choroidal insufficiency postulated, but not proven, to be causative. Pre-eclampsia and MHT choroidopathy seems to be a model for lesions similar to SDD in AMD developing based on choroidal insufficiency and, as such, may offer further insights into the pathoetiologic features of SDD in AMD.

Response to photodynamic therapy combined with intravitreal aflibercept for polypoidal choroidal vasculopathy depending on fellow-eye condition:2-year results

We investigated whether response to photodynamic therapy (PDT) with intravitreal aflibercept injection (IAI) for polypoidal choroidal vasculopathy (PCV) differs depending on fellow eye condition. A retrospective review was conducted for consecutive 60 eyes with PCV treated with PDT combined with IAI as well as 2-years of follow-up data. Fellow eyes were divided into 4 groups; Group 0: no drusen, Group 1; pachydrusen, Group 2; soft drusen, Group 3: PCV/fibrovascular scarring. Best-corrected visual acuity improved at 24-months irrespective of groups and there were no significant differences in visual improvement among treated eyes among the 4 groups. Within 2-years, 35 (58.3%) required the retreatment. The need for retreatment including additional injection and the combination therapy was significantly less in Group 1(12.5%) compared to the others (P = 0.0038) and mean number of additional IAI was also less in Group 1 compared to the others (P = 0.017). The retreatment-free period from the initial combination therapy was longest in Group 1 (23.6±1.1 months) (P = 0.0055, Group 0: 19.1±6.9, Group 2: 12.8±7.9, Group 3: 11.5±9.9). The need for retreatment was significantly different according to fellow-eye condition. Among PCV patients, pachydrusen in fellow eyes appear to be a predictive characteristic for a decreased treatment burden at 2 years.

CUTICULAR DRUSEN: Risk of Geographic Atrophy and Macular Neovascularization

PURPOSE

Cuticular drusen (CD) have been associated with manifestations of age-related macular degeneration such as atrophy and neovascularization in the macula. In this study, eyes with CD were followed and investigated for the estimated 5-year risk of progression to sequelae of age-related macular degeneration such as geographic atrophy (GA) and macular neovascularization (MNV).

METHODS

A consecutive series of patients with CD were followed for the development of GA and MNV. Whenever possible, they were also studied retrospectively. The patients with CD were categorized into three phenotypic groups. Phenotype 1: eyes had concentrated, densely populated CD in the macular and paramacular area, Phenotype 2: eyes showed scattered CD in the posterior fundus, and Phenotype 3: involved eyes with CD mixed with large drusen (>200 µm). The 5-year incidence of progression was then estimated using a Kaplan-Meier estimator.

RESULTS

A total of 63 eyes from 38 patients (35 women with a mean age at presentation of 58.9 ± 14.2 years) were studied and followed for a mean of 40 ± 18 months. Thirteen patients had single eyes with GA (84.5%; 11/13) or MNV (15.5%; 2/13) in one eye at presentation and were subsequently excluded. Geographic atrophy developed in 19.0% (12/63) of eyes and MNV in 4.8% (3/63) of eyes. The cumulative estimated 5-year risk of GA and MNV was 28.4% and 8.7%, respectively. The estimated 5-year incidence of MNV or GA was 12.6%, 50.0%, and 51.6% in Phenotype 1, Phenotype 2, and Phenotype 3, respectively (P = 0.0015, log-rank test). No difference in risk was found in the development of GA or MNV (P = 0.11) between the subgroup of patients presenting with GA or MNV in their fellow eye and those with both eyes included.

CONCLUSION

When patients with CD are followed longitudinally, there was a significant risk of progression to GA or MNV for Phenotype 2 and Phenotype 3. Patients with CD are commonly first diagnosed in the fifth decade of life, and there is a female predominance. Clinicians should use multimodal imaging to detect and be aware of the risk of progression to manifestations of GA and MNV. These risks of GA and MNV suggest that patients with CD may be part of the overall spectrum of age-related macular degeneration.

Prevalence of reticular pseudodrusen in an elderly UK Caucasian population-The Bridlington Eye Assessment Project (BEAP): a cross-sectional study (2002-2006)

AIMS

To determine prevalence, associations, and risk factors for reticular pseudodrusen (RPD) in a UK population.

METHODS

Cross-sectional study of Bridlington residents aged ≥65 years. Masked grading of colour fundus photographs from 3549 participants. RPD presence, phenotype, and topography were recorded, demographic details were analysed, and prevalence was calculated.

RESULTS

RPD was detected in 281 eyes (176 individuals) of 3476 participants (5.06%) with gradable images, and bilateral in 76.6%. Digital enhancement increased detection by 15.7%. Prevalence increased significantly with age from 1.18% (65-69 years) to 27.27% (≥90 years) (mean age 81.1, SD 6.01; OR 1.18, 95% CI 1.15-1.21, p value <0.001), was higher in females (5.9% vs 4.0%; OR 1.52, 95% CI 1.09-2.13, p = 0.014), and associated with diabetes (OR 1.97, CI 1.20-3.17, p = 0.005). History of antihypertension treatment appeared protective (OR 0.64, 95% CI 0.46-0.90, p = 0.009). RPD subtypes were dot in 18.5%, ribbon in 36.7%, and mixed in 36.3%. RPD were located outside the ETDRS grid in 88%, and most commonly in the outer superior subfield. Central grid involvement occurred in 12.1% of right and 14.3% of left eyes. RPD occurred in 25.9% of participants with grade 4 AMD in at least one eye. RPD was associated with visual dissatisfaction after controlling for age (OR 0.63, 95% CI 0.45-0.88, p = 0.007).

CONCLUSION

RPD occur more commonly than previously reported, most frequently in the upper-outer macular subfield, but also within the central subfield, albeit with reduced frequency and altered morphology. RPD may be associated with visual dissatisfaction and diabetes, but are less frequent in persons receiving antihypertension therapy.

Drusen-like Deposits in Young Adults Diagnosed With Systemic Lupus Erythematosus

PURPOSE

To determine the prevalence of drusen-like deposits (DLDs) and choroidal changes in patients with systemic lupus erythematosus (SLE), with or without glomerulonephritis; and to correlate ocular findings with systemic features.

DESIGN

Case-control study.

METHODS

Sixty patients with SLE (age, 18-55 years; 30 with and 30 without SLE-related glomerulonephritis) and 60 age- and sex-matched healthy controls were enrolled. All patients underwent noninvasive multimodal imaging that included fundus photography, near-infrared reflectance, blue autofluorescence, blue reflectance, and spectral-domain optical coherence tomography (SDOCT). Images were analyzed for the prevalence of DLDs. Distribution, size, and number of DLDs were measured. Correlations between ocular findings and systemic features were analyzed. Subfoveal choroidal thickness (SCT) was measured using the SDOCT.

RESULTS

Drusen-like deposits were detected in 40% of SLE subjects and 3.33% of controls (P < .0001). Compared with other techniques, SDOCT detected the largest number of affected subjects. In eyes with DLDs, small, medium, and large lesions were found in 75%, 50%, and 42% of cases, respectively. Drusen-like deposits were located in the nasal, temporal, inferior, superior, and central regions of the posterior pole in 83%, 75%, 67%, 54%, and 25% of eyes, respectively. The prevalence of DLDs in patients with SLE was similar regardless of renal involvement, but patients with glomerulonephritis had more DLDs per eye, larger deposits, and DLDs in >3 quadrants (P < .001, P = .03, P = .009, respectively). Subfoveal choroidal thickness was greater in patients with SLE (P = .002).

CONCLUSIONS

Drusen-like deposits in patients with SLE were independent of renal disease and were best detected with SDOCT. Lupus-related glomerulonephritis was associated with more fundus abnormalities and a screening SDOCT should be considered in all patients with SLE. Drusen-like deposits in the absence of glomerulonephritis may support the recent proposal that complement alteration is the primary cause of these lesions.

Pseudodrusen in the Fellow Eye of Patients with Unilateral Neovascular Age-Related Macular Degeneration: A Meta-Analysis

Importance

The fellow eye of patients with unilateral neovascular age-related degeneration (nAMD) is at increased risk of developing late AMD. Several cohort studies have evaluated the prevalence of pseudodrusen and the association between pseudodrusen and late AMD in the fellow eye of patients with unilateral nAMD. However, these studies have limited sample sizes and their results are inconsistent.

Objective

To evaluate the prevalence rate of pseudodrusen, and the association between pseudodrusen and incidence of late AMD (nAMD and geographic atrophy (GA)) in the fellow eye of patients with unilateral nAMD.

Data Sources

The PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched up to July 2015, as well as other systematic reviews.

Study Selection

All cohort studies for pseudodrusen with late AMD in the fellow eye of patients with unilateral nAMD.

Data Extraction and Synthesis

The numbers of patients with and without pseudodrusen at baseline and the numbers of incident nAMD and GA during follow up among patients with and without pseudodrusen were independently extracted by 2 authors. The results were pooled using random-effects meta-analysis. Heterogeneity was assessed using the I² test.

Main Outcome Measures

Prevalence rate of pseudodrusen, risk ratios (RRs) and their 95% confidence intervals (95% CIs) for associations between pseudodrusen and the incidence of nAMD and GA in the fellow eye.

Results

Five cohort studies (N = 677 patients) from 8 countries across 4 continents were included. The pooled prevalence rate of pseudodrusen in the fellow eye was 48.1% (95% Cl: 36.7–59.5%, I² = 87%). Pseudodrusen were associated with an increased risk of nAMD (RR = 1.54, 95% Cl: 1.10–2.16, I² = 42%), GA (RR = 4.70, 95% Cl: 1.22–18.1, I² = 64%), and late AMD (RR = 2.03, 95% Cl: 1.35–3.06, I² = 60%).

Conclusions

For patients with unilateral nAMD, pseudodrusen were present in about half of the fellow eyes. The presence of pseudodrusen was associated with a 1.5 times higher risk of developing nAMD, a 4.7 times higher risk of developing GA, and a 2 times higher risk of developing late AMD. Pseudodrusen should be considered in evaluating the risk of late AMD development; however, due to considerable heterogeneity across these studies, a larger study is needed to validate these findings.

AGE-RELATED MACULAR DEGENERATION

OBJECTIVES

The objective of our study was to review the current knowledge on Age- Related Macular Degeneration, including pathogenesis, ocular manifestations, diagnosis and ancillary testing.

SYSTEMATIC REVIEW METHODOLOGY

Relevant publications on Age-Related Macular Degeneration that were published until 2014.

CONCLUSIONS

Age-related macular degeneration (AMD) is a common macular disease affecting elderly people in the Western world. It is characterized by the appearance of drusen in the macula, accompanied by choroidal neovascularization (CNV) or geographic atrophy.

Association between dietary glycemic index and age-related macular degeneration in nondiabetic participants in the Age-Related Eye Disease Study

BACKGROUND

Age-related macular degeneration (AMD) is the major cause of irreversible blindness. AMD appears to share several carbohydrate-related mechanisms and risk factors with diabetes-related diseases, including retinopathy and cardiovascular disease (CVD); however, to date, only one small study has addressed this issue.

OBJECTIVE

The objective was to test the hypothesis that dietary glycemic index (dGI), which has been related to the risk of diabetes and CVD, is associated with the risk and severity of AMD in nondiabetic elderly populations.

DESIGN

Dietary information was obtained from 4099 participants aged 55-80 y (56% women) in the Age-Related Eye Disease Study (AREDS). A total of 8125 eligible eyes at baseline were classified into 1 of 5 AMD groups according to the size and extent of drusen, the presence of geographic atrophy, and neovascular changes. We used a generalized estimating approach to evaluate the relations between dGI and risk and severity of AMD with eyes as the unit of analysis.

RESULTS

Compared with eyes in the first quintile of dGI, eyes in the fourth and fifth quintiles had a significantly or suggestively higher risk of large drusen, geographic atrophy, and neovascularization. The multivariate-adjusted odds ratios (95% CIs) for the highest quintile were 1.42 (1.09, 1.84), 1.78 (0.81, 3.90), and 1.41 (0.95, 2.08), respectively, of which only the odds ratio for large drusen was significant. A significant positive relation between dGI and severity of AMD was also noted (P for trend < 0.001). There was a 49% increase in the risk of advanced AMD (geographic atrophy plus neovascularization) for persons with a dGI higher than the sex median (women: >or=77.9; men: >or=79.3). This result indicated that 20% of prevalent cases of AMD would have been eliminated if the AREDS participants consumed diets with a dGI below the median.

CONCLUSION

The association between dGI and AMD from the AREDS cross-sectional analysis at baseline suggests that a reduction in the dGI, a modifiable risk factor, may provide a means of diminishing the risk of AMD.

Heredity of small hard drusen in twins aged 20-46 years

PURPOSE

To examine the prevalence and heredity of small hard drusen in 220 healthy twins aged 20-46 years.

METHODS

Grayscale digital fundus photography, four-field 50 degrees nonstereoscopic, in red-free illumination was performed in 58 pairs of monozygotic (MZ) twins and 52 pairs of dizygotic (DZ) twins as part of a detailed biometric characterization. Small hard drusen (diameters, <63 microm) were counted and graded by distribution type.

RESULTS

Small hard drusen were present in 212 of the 220 subjects. Five or more drusen per eye were found in 89 subjects, in three patterns of distribution: scattered drusen (66 subjects), macular drusen (18 subjects), and stippled, innumerable drusen (5 subjects). When analyzed as a continuous trait, the heritability of small hard drusen was 63% (95% confidence interval [CI], 43% to 77%). More than 20 drusen per eye were found in 26 subjects, and the heritability of this phenotype was 99% (95% CI, 82% to 100%).

CONCLUSIONS

Hard drusen are prevalent in young adults, and having more than 20 drusen per eye is a highly hereditary feature. Additional research is needed to determine whether the presence of small hard drusen correlates with the development of age-related macular degeneration later in life and to explore the relation to AMD genotypes.

Fifteen-Year Cumulative Incidence of Age-Related Macular Degeneration

PURPOSE

To describe the 15-year cumulative incidence of signs of early and late age-related macular degeneration (AMD).

DESIGN

Population-based cohort study.

PARTICIPANTS

We included 3917 persons, 43 to 86 years of age at the time of a baseline examination in 1988 through 1990 and with information collected in follow-up in 1993 through 1995, and/or 1998 through 2000, and/or 2003 through 2005.

METHODS

Grading of stereoscopic fundus photographs using the Wisconsin Age-Related Maculopathy Grading System.

MAIN OUTCOME MEASURES

Cumulative incidence of drusen type and size, pigmentary abnormalities, geographic atrophy, and exudative AMD accounting for competing risk of death.

RESULTS

The 15-year cumulative incidence was 14.3% for early AMD (the presence of either soft indistinct drusen or the presence of pigmentary abnormalities together with any type of drusen) and 3.1% for late AMD (presence of exudative AMD or geographic atrophy). There was an increased incidence of AMD lesions with age (P<0.05). Individuals > or = 75 years of age at baseline had significantly (P<0.01) higher 15-year incidences of the following characteristics than people 43 to 54 years of age: larger drusen (125 mum in diameter, 24.1% vs 10.6%), soft indistinct drusen (18.7% vs 6.5%), retinal pigmentary abnormalities (20.2% vs 3.7%), exudative macular degeneration (4.4% vs 0.4%), and pure geographic atrophy (3.2% vs 0%). Controlling for age, compared with those with small numbers of only small hard drusen (1-2), those with large numbers of only hard drusen (> or =8) had an increased 15-year age-adjusted incidence of both soft indistinct drusen (16.3% vs 4.7%) and pigmentary abnormalities (10.6% vs 2.7%). Eyes with soft indistinct drusen or pigmentary abnormalities at baseline were more likely to develop late AMD at follow-up than eyes without these lesions (17.8% vs 1.2% and 12.9% vs 1.7%, respectively).

CONCLUSIONS

We document the long-term incidence of signs of AMD and a continuum from small hard drusen to late AMD in older persons in the population. The 15-year cumulative incidence of late AMD in people > or = 75 years of age (8%) indicates a public health problem of significant proportions because the United States population this age is expected to increase by 54% between 2005 and 2025.

Characteristics of Highly Myopic Eyes

OBJECTIVE

To evaluate factors associated with high myopia (defined as a myopic refractive error exceeding -8 diopters) in a population-based study.

DESIGN

Population-based prevalence study.

PARTICIPANTS

The Beijing Eye Study included 4439 participants from among 5324 individuals from a rural area and an urban region of Greater Beijing, > or =40 years old and invited to participate (response rate, 83.4%).

METHODS

Interview and detailed ophthalmic examination.

MAIN OUTCOME MEASURES

Refractive error, microvascular retinal abnormalities, optic disc morphometry, amount of cataract, and age-related macular changes.

RESULTS

Fundus photographs and data for refractive error were available for 4319 participants (97.3%; 8484 eyes). In binary logistic regression analysis, prevalence of high myopia was significantly associated with low best-corrected visual acuity (P<0.001; 95% confidence interval [CI], 0.15-0.40), large optic disc size (P<0.001; 95% CI, 1.64-2.25), large size of beta zone (P = 0.31; 95% CI, 1.45-1.75) and alpha zone of peripapillary atrophy (P<0.001; 95% CI, 1.20-1.58), and lower macular drusen count (P = 0.020; 95% CI, 0.81-0.98). The highly myopic group had a smaller mean size of macular drusen (P = 0.03; 95% CI, 0.02-0.26) and a smaller area covered by drusen (P = 0.01; 95% CI, 0.03-0.22). In the highly myopic group, the predominant drusen type was significantly (P = 0.01; 95% CI, 0.05-0.41) more often the hard distinct drusen type than the soft drusen type, and visual field defects were significantly more common (P<0.001; odds ratio [OR], 24.0; 95% CI, 13.9-41.4) and larger (P<0.001; 95% CI, -1.67 to -1.13). The frequencies of early macular degeneration (P = 0.03; OR, 3.0; 95% CI, 1.21-7.51) and late macular degeneration (P<0.001; OR, 6.33) were significantly lower in the highly myopic group than in the non-highly myopic group. High myopia was not significantly associated with gender (P = 0.18; 95% CI, 0.76-1.05), focal arteriolar thinning (P>0.35), arteriolar sheathing (P>0.45), arteriovenous crossing abnormalities (P>0.20), self-reported diagnosis of diabetes mellitus (P = 0.54; OR, 1.36; 95% CI, 0.48-3.80), or arterial hypertension (P = 0.34; OR, 0.66; 95% CI, 0.32-1.34).

CONCLUSIONS

In the adult Chinese population, high myopia is associated with a lower number, smaller, size and less advanced type of macular drusen, a larger optic nerve head, and decreased best-corrected visual acuity. The risk of early and late macular degeneration was lower for highly myopic participants than for non-highly myopic participants.

Prevalence of reticular pseudodrusen in age-related macular degeneration with newly diagnosed choroidal neovascularisation

AIM

To investigate the prevalence of reticular pseudodrusen (RPD) in eyes of patients presenting with newly diagnosed choroidal neovascularisation (CNV) in age-related macular degeneration (AMD), and to analyse the association between RPD, age-related maculopathy (ARM) and AMD.

METHOD

Two observational consecutive prospective series. In series 1, patients with AMD with newly diagnosed CNV were sampled to determine the incidence of RPD. Eyes with and without RPD were compared by the Mann-Whitney non-parametric test and Fisher's exact test for age, sex of patients, the eye involved and type of CNV. Series 2 comprised 100 patients referred for fundus photography, fluorescein and/or indocyanine green angiography, for whom pictures showed RPD. This second cohort was then selected from a larger group of patients.

RESULTS

Patients with newly diagnosed CNV in series 1 comprised 67 women and 33 men, aged 57-96 years (mean 79.5). CNV was "classic" (32 eyes), "occult" (41) or exhibited vascularised pigment epithelial detachment (PED, 11), retinal angiomatous proliferation (RAP) with or without PED (13), or haemorrhagic or fibrovascular scarring (3). In all, 24 (24%) eyes had RPD. The prevalence of RAP was significantly higher in eyes with RPD than in those without (p = 0.0128), despite the small number of patients with RAP. In series 2, 100 patients with RPD were enrolled in 3 months, and corresponded to 8% of the overall cases referred to our centre (Centre Ophtalmologique d'Imagerie et de Laser, Paris, France). There were 77 women and 23 men, aged 54-93 years (mean 79.2). Eyes with RPD (n = 155) usually exhibited signs of ARM or AMD, including soft drusen (101 eyes) and/or retinal pigment epithelium abnormalities (70), geographical atrophy (27) and/or CNV (61). In both studies, examination of blue-light fundus pictures was extremely helpful in diagnosing RPD.

CONCLUSION

RPD have a high prevalence among patients with AMD with newly diagnosed CNV (24% of cases). RPD were commonly associated with ARM or AMD. This study suggests that eyes with RPD could be classified as a phenotype of ARM.

Risk factors for five-year incident age-related macular degeneration: the Reykjavik Eye Study

PURPOSE

To establish risk factors for five-year incidence of age-related macular degeneration (AMD).

DESIGN

Population-based, prospective cohort study, and risk analysis.

METHODS

A random sample from the Reykjavik Population Census for individuals 50 years and older was selected. We took fundus stereo color photographs and used standard grading system to study the five-year incidence of drusen, pigmentary abnormalities, and AMD and to examine possible risk factors. A questionnaire including information on disease, medication, diet, and lifestyle from the Reykjavik Eye Study database provided additional information.

RESULTS

Current alcohol consumption decreased the risk for drusen. Being married rather than divorced or widowed decreased the risk for soft drusen; being single decreased the risk of hypopigmentation as compared with being divorced or married. Both consuming dietary fiber-rich vegetables and meat and meat products once a week or less frequently was a risk factor for developing soft drusen and decreased the risk of pigmentary abnormalities. Those who had smoked 20 pack-years or more as compared with nonsmokers had decreased survival rate over the five years (odds ratio (OR) 0.46, 95% confidence interval (CI) 0.27 to 0.80; P = .006).

CONCLUSIONS

Risk factors for drusen appear to differ from risk factors for pigmentary abnormalities. The effect of smoking on developing AMD is partly masked by selective mortality.

Dietary glycemic index and carbohydrate in relation to early age-related macular degeneration

BACKGROUND

Several dietary factors have been linked to age-related maculopathy (ARM), the early form of age-related macular degeneration, and there is reason to think that dietary carbohydrate may play a role in the development of ARM.

OBJECTIVE

The purpose of the present study was to examine the relation between dietary carbohydrate quality, as measured by dietary glycemic index (GI) or total carbohydrate intake, and ARM.

DESIGN

From the Nurses' Health Study, 1036 eyes from 526 Boston-area participants without a previous ARM diagnosis were included in the present study. The presence and degree of ARM were classified by the Age-Related Eye Diseases Study system. Long-term dietary information was based on data from an average of 4 food-frequency questionnaires collected over a 10-y period before the assessment of ARM. With eyes as the unit of analysis, we used a generalized estimating approach to logistic regression to estimate the odds ratios for ARM in a manner that accounted for the lack of independence between the 2 eyes from the same subject.

RESULTS

After multivariate adjustment, dietary GI was related to ARM (specifically to retinal pigmentary abnormalities), whereas total carbohydrate intake was not. The odds ratio for ARM being in the highest tertile of dietary GI (> or =77.0) versus the lowest (<74.6) was 2.71 (95% CI: 1.24, 5.93; P for trend = 0.01). Neither dietary GI nor total carbohydrate intake was related to drusen.

CONCLUSION

Our results suggest that dietary GI may be an independent risk factor for ARM.

Early age-related maculopathy in eyes after cataract surgery

PURPOSE

To assess age-related maculopathy (ARM) in eyes of patients who had undergone cataract surgery for at least a year.

METHODS

Consecutive patients aged 60+ years who had undergone cataract surgery at Westmead Hospital, Sydney, Australia, during 2001-2003 were examined in 2004. Interview using standardized questionnaires and stereo retinal photography was performed. Retinal photographs were graded using the Wisconsin ARM grading system. The proportions with ARM were compared between surgical and nonsurgical eyes, and between this surgical cohort and the Blue Mountains Eye Study (BMES) population.

RESULTS

Of the 622 eligible patients, 454 (73%) were re-examined, with a mean follow-period of 2.8 years. Surgical eyes had a higher proportion of early ARM compared to nonsurgical eyes (15.2 vs10.3%, P=0.07) and to the early ARM prevalence found in BMES participants of similar age (14.5 vs6.9%, P<0.01), which persisted after age standardization to the BMES population (9.7 vs6.9%, P<0.05).

CONCLUSIONS

We found an increased prevalence of early ARM in surgical eyes of patients 1-3 years after cataract surgery. Whether this increased early ARM prevalence leads to an increased prevalence of late ARM in the long-term warrants further investigation.

14-Year Incidence, Progression, and Visual Morbidity of Age-Related MaculopathyThe Copenhagen City Eye Study

PURPOSE

To describe the 14-year incidence of age-related maculopathy (ARM) lesions and the related visual loss.

DESIGN

Population-based cohort study.

PARTICIPANTS

Nine hundred forty-six residents (age range, 60-80 years) of Copenhagen participated in the study from 1986 through 1988. Excluding participants who had died since baseline, 359 persons (97.3% of survivors) were reexamined from 2000 through 2002.

METHODS

Participants underwent extensive ophthalmologic examinations. Age-related maculopathy lesions were determined by grading color fundus photographs from the examinations using a modified Wisconsin Age-Related Maculopathy Grading System.

MAIN OUTCOME MEASURES

Incidence of drusen type and size, pigmentary abnormalities, pure geographic atrophy, exudative ARM, visual impairment, and blindness.

RESULTS

The 14-year incidences of early and late ARM were 31.5% and 14.8%, respectively. Individuals 75 to 80 years of age at baseline had significantly (P< or =0.05) higher 14-year incidences of the following lesions than those aged 60 to 64 years: medium or large drusen (> or =125 microm; 34.2% vs. 12.8%, respectively), soft drusen (45.2% vs. 21.4%), pigmentary abnormalities (31.4% vs. 17.0%), pure geographic atrophy (17.4% vs. 1.0%), and exudative ARM (23.3% vs. 5.7%). Severe drusen type, large drusen, and retinal pigmentary abnormalities at baseline were important predictors of incident late ARM. The 14-year incidences of visual impairment (<20/40 but >20/200) or legal blindness from late ARM were 6.0% and 3.4%, respectively. Late ARM caused 35.7% of all visual impairment and 66.7% of all blindness.

CONCLUSIONS

There is a high incidence of ARM lesions in this elderly white population. Severe drusen type and size or a combination of drusen and pigmentary abnormalities significantly increases the risk of developing late ARM, the most frequent cause of legal blindness in this population.

Association of emphysema, gout, and inflammatory markers with long-term incidence of age-related maculopathy

OBJECTIVE

To examine the relationship of 2 diseases associated with systemic inflammatory response, emphysema and gout, and selected markers of systemic inflammation with the 10-year incidence of age-related maculopathy.

DESIGN

Population-based cohort study.

PARTICIPANTS

We included persons aged 43 to 86 years at baseline examination from 1988 to 1990 living in Beaver Dam, Wis, of whom 3684 subjects participated in a 5-year follow-up examination and 2764 participated in a 10-year follow-up.

METHODS

Standardized protocols for physical examination, blood collection, administration of a questionnaire, and stereoscopic color fundus photography to determine the presence of age-related maculopathy. Standard univariate and multivariate analyses were performed.

MAIN OUTCOME MEASURES

Incidence and progression of age-related maculopathy.

RESULTS

While controlling for age, sex, and other factors (history of heavy drinking or smoking, systolic blood pressure, and vitamin use), a higher white blood cell count at baseline was associated with the 10-year incidence of drusen 125 microm or greater in diameter (risk ratio [RR] per 10(6)/ microL = 1.10; 95% confidence interval [CI], 1.03-1.17), retinal pigment epithelial depigmentation (RR = 2.08; 95% CI, 1.01-1.16), and progression of age-related maculopathy (RR = 1.09; 95% CI, 1.03-1.15). A lower serum albumin level was associated with the incidence of exudative macular degeneration (RR per grams per deciliter = 0.31; 95% CI, 0.13-0.76). A history of emphysema at baseline was associated with the incidence of retinal pigment epithelial depigmentation (RR = 2.84; 95% CI, 1.40-5.78), increased retinal pigment (RR = 2.20; 95% CI, 1.11-4.35), and exudative macular degeneration (RR = 5.12; 95% CI, 1.63-16.06); a history of gout was associated with the incidence of pure geographic atrophy (RR = 3.48; 95% CI, 1.27-9.53).

CONCLUSIONS

These findings indicate modest relationships between both increased white blood cell count and emphysema and the increased 10-year incidence of lesions defining early and late age-related maculopathy. Further investigation of these relationships in other studies is needed.

Risk of age-related macular degeneration in eyes with macular drusen or hyperpigmentation: the Blue Mountains Eye Study cohort

OBJECTIVE

To quantify the 5-year risk of age-related macular degeneration (AMD) in eyes with different macular drusen characteristics (ie, size, type, location, and total area) or hyperpigmentation in a population-based cohort.

METHODS

The Blue Mountains Eye Study examined 3654 residents during 1992-1994; 2335 (75.1% of survivors) were reexamined during 1997-1999. Retinal photographs were graded using the Wisconsin Age-Related Maculopathy Grading System. Incident AMD lesions were defined by development of neovascular AMD or geographic atrophy in eyes without these lesions at baseline (eyes at risk). Age-adjusted relative risks (RRs) were determined. Generalized estimating equation models were used to estimate odds ratios, adjusting for the correlation between eyes and other AMD risk factors. Main Outcome Measure Incidence of AMD.

RESULTS

Of the 4634 eyes at risk, 52 (1.1%) developed neovascular or atrophic AMD lesions over 5 years. In right eyes, presence vs absence of the following macular signs predicted AMD: drusen that were 125 micro m or larger (13.9 vs 0.6%; age-adjusted RR, 5.7; 95% confidence interval [CI], 3.6-9.0), indistinct soft or reticular drusen (23.2% vs 0.4%; RR, 9.9; 95% CI, 6.4-15.4), total drusen area of half the disc area or more (31.4% vs 0.6%; RR, 13.5; 95% CI, 8.0-22.8), and hyperpigmentation (14.4% vs 0.5%; RR, 8.0; 95% CI, 5.4-11.9). After adjusting for age, sex, and smoking status, eyes with these signs at baseline had a high likelihood of developing AMD. Eyes with Age-Related Eye Disease Study categories 3 and 4 were 5 times more likely to develop AMD compared with eyes in categories 1 and 2.

CONCLUSION

This study quantifies the 5-year risk of AMD in eyes with macular drusen and hyperpigmentation.

Ten-year incidence and progression of age-related maculopathy: The Beaver Dam eye study

PURPOSE

The aim of the study was to describe the 10-year incidence and progression of retinal drusen, retinal pigmentary abnormalities, and signs of late age-related maculopathy.

DESIGN

Population-based cohort study.

PARTICIPANTS

The study included 4926 persons, 43 to 86 years of age at the time of a baseline examination from 1988 through 1990, living in Beaver Dam, Wisconsin, of whom 3684 participated in a 5-year follow-up examination and 2764 participated in a 10-year follow-up.

METHODS

Characteristics of drusen and other lesions typical of age-related maculopathy were determined by grading stereoscopic color fundus photographs using the Wisconsin Age-Related Maculopathy Grading System.

MAIN OUTCOMES MEASURES

Incidence of drusen type and size, pigmentary abnormalities, geographic atrophy, and exudative degeneration.

RESULTS

The 10-year incidence of early age-related maculopathy was 12.1% and of late age-related maculopathy it was 2.1%. There was a statistically significant increased incidence of age-related maculopathy lesions with age (P < 0.05). Individuals 75 years of age or older at baseline had significantly (P < 0.01) higher 10-year incidences of the following characteristics than people 43 to 54 years of age: larger sized drusen (125 micro m-249 micro m, 26.3% vs. 3.3%; > or =250 micro m, 16.2% vs. 1.0%), soft indistinct drusen (22.2% vs. 2.2%), retinal pigment abnormalities (19.5% vs. 0.8%), exudative macular degeneration (4.1% vs. 0%), and pure geographic atrophy (3.1% vs. 0%). Compared with those with small numbers of only small, hard drusen (1-2), those with large numbers of only hard drusen (8 or more) had an increased 10-year incidence of both soft drusen (12.3% vs. 6.7%) and pigmentary abnormalities (4.9% vs. 1.7%). Eyes with soft indistinct drusen or retinal pigmentary abnormalities at baseline, were more likely to develop late age-related macular degeneration at follow-up than eyes without these lesions (15.1% vs. 0.4% and 20.0% vs. 0.8%, respectively).

CONCLUSIONS

These population-based estimates document the high incidence of signs of age-related maculopathy in people 75 years of age or older. Our findings demonstrate that large numbers of hard drusen predict the incidence of soft drusen and pigmentary abnormalities and that the presence of the latter lesions significantly increases the risk for the development of geographic atrophy and exudative macular degeneration.

[Prevalence of drusen in homes for the elderly]

PURPOSE

To establish the prevalence of drusen in a population of over-65 year subjects residing in institutions.

MATERIAL AND METHOD

A medical interview, ophthalmological examinations and midriatic retinography were performed in 392 older-than-65 year subjects living in homes for the elder (784 eyes). Each eye was reviewed by means of the Wissconsin Age-Related Maculopathy Grading System, in order to determine drusen frequency.

RESULTS

Druses frequency totalled 33.3%. A great trend to symmetry was observed; bilateral in 23% of patients. The most frequent finding was multiple units (40 to 59 per eye), well defined soft drusen of 125 micrometer in size, which showed very little tendency to confluence. Twelve to 24% of macular area was affected by drusen. Subjects between ages of 65 to 74, presented the highest frequence. Drusen decreased with age from 75 years upwards.

CONCLUSION

The observed drusen frequency found appear lower than those described in other studies outside our country, perhaps due to higher prevalence of media opacities. Midriatic retinography can be a good screening method for the detection of drusen.

Long-term drusen study

PURPOSE

To determine the yearly incidence of visual loss in the fellow eyes of patients with unilateral neovascular age-related macular degeneration (ARMD) and to assess the drusen characteristics portending the greatest risk for this outcome.

METHODS

A total of 101 patients with unilateral exudative ARMD and drusen only in the fellow eye were entered into the study and prospectively followed up to 9 years. Visual acuity, color fundus photography, fluorescein angiography, and grading of drusen characteristics were obtained for each patient on entry into the study. Patients were followed at annual intervals with color fundus photography. The study endpoint was the development of choroidal neovascularization (CNV) or geographic atrophy (GA) in the fellow eye.

RESULTS

Yearly incidence rates for the development of an endpoint lesion were between 5 and 14%. The risk of CNV peaked at 4 years and dissipated thereafter. Longer follow-up was associated with a slightly increased incidence of GA. Greater drusen number was most highly associated with the development of an endpoint lesion. Drusen size and confluence were also significant.

CONCLUSIONS

The risk of CNV in patients with ARMD is heralded by an increase in the number, size, and confluence of drusen. This risk eventually declines and is followed by later increased risk of GA.

The VECAT study: methodology and statistical power for measurement of age-related macular features. Vitamin E, Cataract, and Age-related Maculopathy Study

PURPOSES

(1) To develop the methodology for the grading of macular one-frame stereoslides and to assess the reliability of the system. (2) To determine the prevalence of soft drusen (> 63 microm) and pigment abnormalities synonymous with age-related maculopathy (ARM) at baseline, in a clinical trial of volunteers aged between 55 and 80 years of age. (3) To ascertain the power of the study to detect the 4-year incidence and progression of ARM in vitamin E versus placebo treated participants, given the baseline prevalence.

METHODS

The 1204 participants enrolled in the Vitamin E, Cataract, and Age-related Maculopathy Study (VECAT) had colour stereoslides of their fundus taken using the Nidek 3-DX mydriatic fundus camera. The stereoslides were graded by two masked graders according to the "International Classification System for ARM and AMD". Assessment of inter- and intra-observer reliability was carried out on a regular basis on 15% of randomly selected slides. Anticipated rates of incidence and progression were based on results reported by the Beaver Dam Eye Study and the Chesapeake Bay Waterman Study. Power estimations were determined using the "nQuery Advisor" software program. Analyses were carried out on the worse affected eye.

RESULTS

Inter-observer reliability was moderate to substantial (Kappa 0.5-0.88) whilst intra-observer agreement was high (0.6-1.0). The prevalence of any soft drusen was 32%. Significant associations were found between soft large indistinct drusen, hypopigmentation, hyperpigmentation and age (p = 0.0001, 0.024 and 0.0001, respectively). The study has at least 87% power to detect an odds ratio equal to two for the progression of soft distinct, soft indistinct, hyperpigmentation and hypopigmentation.

CONCLUSIONS

The VECAT study methodology appears to be highly reliable and to have sufficient power to detect the differences in the four-year progression of soft distinct and indistinct drusen and pigment abnormalities between the treatment groups.

Alcohol consumption and the 5-year incidence of age-related maculopathy: the Beaver Dam eye study

OBJECTIVE

This study evaluated alcohol consumption as a risk factor for incidence of age-related maculopathy (ARM).

DESIGN

Persons aged 43 to 86 years in 1988 in Beaver Dam, Wisconsin, were examined from 1988 through 1990 and 1993 through 1995, n = 3684. The presence and severity of ARM at both examinations were determined from gradings of stereoscopic fundus photographs using the Wisconsin Age-related Maculopathy Classification System. Alcohol consumption was determined by self-report.

RESULTS

Men drinking at least 78 g/week of alcohol from beer had a higher 5-year age-adjusted incidence of early ARM (10.6%) than did men who did not drink beer (6.9%), but the test for trend was only borderline significant (P = 0.08). However, incidence of soft indistinct drusen (P = 0.01), increased drusen area (P < 0.01), and confluent drusen (P = 0.02) are all associated with beer drinking in men. Increased retinal pigment and retinal pigment epithelial depigmentation are not associated with beer drinking in men or women nor are any lesions associated with total alcohol consumption or consumption from liquor or wine in either men or women.

CONCLUSIONS

Except for an association of beer drinking with retinal drusen in men, consumption of alcoholic beverages is not likely to be an important risk factor for incidence of ARM.

[Age-related macular degeneration]

Age-related macular degeneration (ARMD) is the leading cause of blindness in the occidental world. Patients suffering this process have an important reduction on their quality of life being handicapped to read, to write, to recognise faces of their friends, or even to watch the television. One of the main problems of that disease is the absence of an effective treatment able to revert the process. Laser treatment is only useful in a limited number of patients, and even in these cases recurrent lesions are frequent. These facts and the progressive ageing of our society establish the ARMD as one of the biggest aim of medical investigations for the next century, and currently is focus of attention in the most industrialised countries. One of the most promising pieces of research is focused in the investigation of the risk factors associated with the age-related macular degeneration, in order to achieve a prophylactic treatment avoiding its appearance. Diet elements such as fat ingestion or reduced antioxidant intakes are being investigated as some of these factors, what open a new possibility for a prophylactic treatment. Finally, research is looking for new therapeutic modalities such as selective radiotherapy in order to improve or maintain the vision of these patients.

Seven year follow-up of age-related maculopathy in an elderly British population

Despite age-related macular degeneration (AMD) being the commonest cause of blindness amongst the elderly in Western society, the incidence of new lesions is poorly documented and the natural history of existing disease remains ill understood.

PURPOSE

To document in an elderly population the incidence of new AMD lesions and the progression of pre-existing AMD over time.

METHOD

Baseline ophthalmic examinations were performed on a geographically defined random population sample of elderly people in 1982-4, and retinal photographs taken. The present study re-examined and re-photographed survivors after approximately 7 years using the same fundus camera. Photographs were randomly encoded, and independently graded for AMD features by two masked observers using the Wisconsin AMD grading system. Disagreements were resolved by review to reach a consensus.

RESULTS

Eighty-two of the 88 participating survivors had photographs of gradable quality on both occasions in at least one eye. Mean age at follow-up was 87 years (range 84-97 years) and 70.7% of subjects were female. Paired photographs were available on 158 eyes, and showed important differences in drusen type, drusen area and characteristics of the retinal pigment epithelium (RPE) between initial and subsequent examinations. The 7 year incidence (and regression) of lesions was: drusen 30.6% (20.0%), RPE degeneration 54.5% (8.8%), increased pigment 11.6% (64.7%), subretinal haemorrhage 1.3%, subretinal scar/fibrin 1.3% and geographic study 1.3%.

CONCLUSION

These unique population-based results provide new insight into the natural history of AMD in an elderly population.

Prevalence of age-related maculopathy at two points in time in an elderly British population

As the demography of Western society changes, the population prevalence of diseases such as age-related macular degeneration (AMD) is expected to rise. Despite this, there remains a paucity of quality data concerning the population prevalence of AMD, the commonest cause of blindness in the elderly.

PURPOSE

To report the prevalence of AMD at two points in time in an elderly population.

METHOD

A geographically defined random population sample of elderly people was defined in 1980, and studied in 1982-4. In 1990, a cohort of survivors was identified. Participants underwent full ophthalmic examination with fundus photography using the same camera on each occasion. Photographs were randomly encoded and graded by two independent masked observers using the Wisconsin Age-related Maculopathy Grading System. Disagreements were resolved by consensus.

RESULTS

Eighty-eight survivors participated in the follow-up examinations. Of these, 82 subjects had gradable retinal photographs for both examination points in at least one eye. There were 158 pairs of images (initial and subsequent) available for analysis. The mean age was 80 years (range 77-90 years) at the initial examination, and 87 years (range 84-97 years) at the subsequent examination; 70.7% of subjects were female. Prevalence rates for the initial examination were: drusen 72.8%, drusen confluence 37.3%, degeneration of the retinal pigment epithelium (RPE) 51.3%, increased pigment 22.2%, exudative AMD 1.9% and geographic atrophy 1.9%. Rates at second examination were: drusen 62.7% drusen confluence 41.8%, RPE degeneration 72.8%, increased pigment 16.5%, exudative AMD 3.8% and geographic atrophy 3.2%.

CONCLUSION

This 'double' prevalence study provides detailed data on AMD lesions at two points in time in a population-based group of elderly people.

The five-year incidence and progression of age-related maculopathy: the Beaver Dam Eye Study

PURPOSE

The aim of the study was to describe the incidence and progression of retinal drusen, retinal pigmentary abnormalities, and signs of late age-related maculopathy.

POPULATION

A population of 3583 adults (range, 43-86 years of age at baseline) living in Beaver Dam, Wisconsin, was studied during a 5-year period.

METHODS

Characteristics of drusen and other lesions typical of age-related maculopathy were determined by grading stereoscopic color fundus photographs using the Wisconsin Age-Related Maculopathy Grading System.

RESULTS

There was a statistically significant increased incidence of age-related maculopathy lesions with age (P < 0.05). Individuals 75 years of age or older had a significantly (P < 0.01) higher 5-year incidence of the following characteristics than people 43 to 54 years of age: larger sized drusen (125-249 microm, 17.6% vs. 2.1%; > or = 250 microm, 6.5% vs. 0.2%), soft indistinct drusen (16.3% vs. 1.8%), retinal pigment abnormalities (12.9% vs. 0.9%), exudative macular degeneration (1.8% vs. 0%), and pure geographic atrophy (1.7% vs. 0%). After adjusting for age, the incidence of early age-related maculopathy was 2.2 times (95% confidence interval 1.6, 3.2) as likely in women 75 years of age or older compared with men this age. At follow-up, late age-related macular degeneration was more likely to develop in eyes with soft indistinct drusen (6.5% vs. 0.1%) or retinal pigmentary abnormalities (7.1% vs. 0.1%) at baseline than in eyes without these lesions.

CONCLUSIONS

These population-based estimates document the high incidence of signs of age-related maculopathy in people 75 years of age or older, and in women compared with men that age. The findings demonstrate that the presence of soft drusen and pigmentary abnormalities significantly increases the risk for the development of geographic atrophy and exudative macular degeneration.

Alcohol intake and age-related maculopathy

PURPOSE

To assess associations between alcohol intake and age-related maculopathy.

METHODS

A population-based study of 3,654 subjects identified cases of late age-related macular degeneration, early age-related maculopathy, and any large drusen (larger than 125 microns) by examination and grading of retinal photographs. Interviewer-administered questionnaires provided data on alcohol intake.

RESULTS

Neither total alcohol intake nor intake of beer specifically was significantly associated with age-related maculopathy, although a significant positive association was found between consumption of spirits and early age-related maculopathy.

CONCLUSIONS

These findings provide little evidence that alcohol is causally associated with age-related maculopathy.

Pattern of age-related maculopathy in the macular area. The Beaver Dam Eye Study

PURPOSE

To describe the distribution of lesions associated with age-related maculopathy by location in the macula in a population of adult Americans.

METHODS

Four thousand nine hundred twenty-six persons ranging in age from 43 to 84 years and living in Beaver Dam, Wisconsin, at the time of a census (1987-1988) were examined from 1988 to 1990. Lesions typical of age-related maculopathy were determined by masked grading of stereoscopic color fundus photographs using the Wisconsin Age-Related Maculopathy Grading System. The extent and prevalence of different types of lesions were determined for each of nine macular subfield regions: central, inner superior, inner nasal, inner inferior, inner temporal, outer superior, outer nasal, outer inferior, and outer temporal.

RESULTS

Lesions associated with early age-related maculopathy were distributed in specific patterns. Soft indistinct drusen were more prevalent in the temporal and superior quadrants than in the nasal and inferior quadrants, whereas pigmentary abnormalities associated with age-related maculopathy were more prevalent in the superior or nasal quadrants than in the inferior or temporal quadrants. After weighting for subfield area, all types of lesions were most prevalent in the central macular region.

CONCLUSION

Various lesions associated with early age-related maculopathy were located in specific patterns in the macula. It is not known whether these patterns resulted from environmental, anatomic, or physiologic factors.

Five-year incidence and disappearance of drusen and retinal pigment epithelial abnormalities. Waterman study

PURPOSE

To obtain 5-year longitudinal data on age-related macular degeneration (AMD) that might be useful for disease prognosis, public health planning, and clinical trial development.

PATIENTS AND METHODS

Baseline (1985) and 5-year follow-up (1990) fundus photographs of 483 watermen over 30 years of age who participated in a cohort study conducted on the eastern shore of Maryland were graded independently in a reliable, standardized fashion. Eyes in which AMD appeared or disappeared also were graded in a side-by-side fashion.

RESULTS

Development of definite choroidal neovascularization and/or disciform scarring occurred in one of 50 participants over 70 years of age, specifically one of 15 participants over 70 years of age with AMD-3 (defined as large or confluent drusen focal hyperpigmentation of the retinal pigment epithelium [RPE], and/or nongeographic atrophy of the RPE). Appearance of large drusen, focal hyperpigmentation, or AMD-3 was age related, occurring in 5%, 1%, and 7%, respectively, of participants aged 50 to 59 years; 17%, 3%, and 14%, respectively, of participants aged 60 to 69 years; and 17%, 9%, and 26%, respectively, of participants aged 70 years or more. Disappearance of large drusen, hyperpigmentation, or AMD-3 occurred in 16 (34%) of 47 participants, 11 (58%) of 19 participants, and 17 (28%) of 61 participants, respectively, who had each feature photographically present in 1985. Among the 47 eyes identified in which AMD-3 developed by independent gradings, 38 cases of AMD-3 (81%) were confirmed on side-by-side grading. Among the 16 eyes identified as having AMD-3 that disappeared, nine disappearances (56%) were confirmed. Borderline differences in appearance of pigment, drusen size, drusen location, or photographic quality may have accounted for disappearance in seven cases (44%).

CONCLUSIONS

Prospective studies on the nonneovascular features of AMD (including large drusen and abnormalities of the RPE) must account for the appearance and disappearance of these features and support the idea that side-by-side gradings can complement independent gradings identifying appearance or disappearance of features of AMD.

The prevalence of age-related maculopathy in the Rotterdam Study

PURPOSE

To determine the prevalence of age-related maculopathy in an elderly population in The Netherlands.

METHODS

Fundus photographs of 6251 participants of the Rotterdam Study, a single-center prospective follow-up study in persons 55 to 98 years of age, were reviewed for the presence of drusen, pigmentary abnormalities, and atrophic or neovascular age-related macular degeneration.

RESULTS

The prevalence of at least one drusen of 63 microns or larger increased from 40.8% in persons 55 to 64 years of age to 52.6% in those 85 years of age or older. Similarly, the prevalence of the following abnormalities increased significantly in these age categories: drusen of 125 microns or larger from 4.8% to 17.5%, retinal pigment epithelial hypopigmentations from 3.5% to 9.0%, and increased retinal pigment from 3.7% to 15.3%. Atrophic or neovascular age-related macular degeneration was present in 1.7% of the total population. Atrophic age-related macular degeneration increased from 0.1% in persons 55 to 64 years of age to 3.7% in those 85 years of age or older. Neovascular age-related macular degeneration increased from 0.1% to 7.4% in these age groups. No sex differences were observed for these lesions.

CONCLUSIONS

The prevalence of atrophic or neovascular age-related macular degeneration is 1.7%. In those 55 years of age or older, the prevalence increases strongly with age and it is similar in men and women. Neovascular age-related macular degeneration was twice as common as atrophic age-related macular degeneration. These findings suggest that age-related maculopathy may be less common in this European population than in similar populations in the United States.

Prevalence of age-related maculopathy. The Beaver Dam Eye Study

PURPOSE

The relationships of retinal drusen, retinal pigmentary abnormalities, and macular degeneration to age and sex were studied in 4926 people between the ages of 43 and 86 years who participated in the Beaver Dam Eye Study.

METHODS

The presence and severity of various characteristics of drusen and other lesions typical of age-related maculopathy were determined by grading stereoscopic color fundus photographs using the Wisconsin Age-Related Maculopathy Grading System.

RESULTS

One or more drusen were present in the macular area of at least 1 eye in 95.5% of the population. People 75 years of age or older had significantly higher frequencies (P less than 0.01) of the following characteristics than people 43 to 54 years of age: larger sized drusen (greater than or equal to 125 microns, 24.0% versus 1.9%), soft indistinct drusen (23.0% versus 2.1%), retinal pigment abnormalities (26.6% versus 7.3%), exudative macular degeneration (5.2% versus 0.1%), and geographic atrophy (2.0% versus 0%).

CONCLUSION

These data indicate signs of age-related maculopathy are common in people 75 years of age or older and may pose a substantial public health problem.

Occurrence of drusen, pigmentary changes and exudative changes in the macula with reference to age-related macular degeneration. An epidemiological study of 1000 aged individuals

Macular changes in 60 to 80-year-old people i.e. drusen (DR), pigmentary changes (PC) and exudative changes (EXC) are assessed by fundoscopy in a random and age stratified population with 924 of the participants examined in both maculae (1848 eyes). DR, PC and EXC were found in 18.4%, 12.9% and 2.1% of all eyes with a rising frequency associated with increasing age. A separation was made between changes implying a visual acuity of 6/9 or less as criteria of age-related macular degeneration (AMD) and age related macular changes without visual impairment (AMCW). The occurrence of DR, PC and EXC from eyes with AMD showed an age related rise which was also found for DR, contrary to PC and EXC deriving from eyes with AMCW. The basic forms of AMD, atrophic and exudative, were represented in 78.6% and 21.4% of individuals or 80.9% and 19.1% of eyes with AMD. The predominant findings in AMD eyes were DR + PC in combination represented in 60.7% of atrophic and 66.8% of exudative AMD eyes, while in atrophic AMCW eyes DR as only finding was leading with 59.2%. It is concluded that in eyes with atrophic macular changes, DR, respectively PC as only finding involves no visual deterioration in 80.6%, respectively 72.6%, while DR + PC in combination, as well as the appearance of EXC, are found to be the most likely expression of AMD as long as a visual impairment of 6/9 or worse is included in the definition of AMD.