The association of stroke with herpes zoster ophthalmicus.

BACKGROUND/OBJECTIVES: Studies have reported an association between herpes zoster ophthalmicus (HZO) and stroke. We sought to validate this association with rigorous controls for both medical comorbidities and social factors using a nationwide U.S. administrative medical claims database. SUBJECTS/METHODS: A two-step approach was taken: first a retrospective case-control study was performed, followed by a self-controlled case series (SCCS). For the case control study, cox proportional hazard regression with inverse proportional treatment weighting assessed the hazard for stroke. In the SCCS, incidence of stroke was compared prior to and after the diagnosis of HZO. RESULTS: For the case-control study, 25,720 cases and 75,924 controls met our eligibility criteria. 1712 (6.7%) and 4544 (6.0%) strokes occurred in the case and control groups respectively, conferring an 18% increased risk of stroke in the observed 1-year post-HZO period (HR = 1.18, 95% CI: 1.12-1.25, p < 0.001). SCCS analysis showed the risk for stroke was highest in the month immediately after HZO episode compared to any other time range (1-30 days after, relative risk 1.58, p < 0.001) and even higher when assessing time more distal time points prior to the HZO diagnosis (days 1-30 after HZO diagnosis had RR = 1.69 (95% CI: 1.38-2.07) and RR = 1.93 (95% CI: 1.55-2.39) compared with days -120 to -91 and -150 to -121 prior to index, respectively (p < 0.001). CONCLUSIONS: After accounting for stroke risk factors, our analysis confirms the association between HZO and stroke, with highest risk in the immediate month after an episode.

Real-world socioeconomic determinants of corneal crosslinking in a national cohort.

PURPOSE: To characterize recent socioeconomic trends in patients with keratoconus/corneal ectasias undergoing corneal crosslinking (CXL). SETTING: A deidentified administrative medical claims database comprised commercial and Medicare Advantage health claims from across the United States. DESIGN: Population-based retrospective cohort study. METHODS: This study identified 552 patients with keratoconus/corneal ectasia who underwent CXL and 2723 matched controls who did not undergo CXL based on Current Procedural Terminology coding from a U.S. national insurance claims database from 2016 to 2020. For each patient, characteristics, including sex, race, age, household net worth, education level, insurance plan type, and geographic region, were extracted. Multivariate logistic regression was conducted to determine the odds of undergoing crosslinking. RESULTS: Age 30 years or older (odds ratio [OR], 0.34, P < .001) was associated with decreased likelihood of undergoing CXL. Sex, race, education, and patient income were not associated with odds of undergoing CXL. Patients with health maintenance organization insurance had lower odds of undergoing CXL (OR, 0.64, P = .047). Geographically, patients on the east coast (OR, 0.37, P < .001) and Lower Midwest (OR, 0.31, P < .001) had statistically lower odds of undergoing crosslinking. CONCLUSIONS: This is the first study to identify socioeconomic determinants of CXL, and it highlights that geographic location and insurance type may limit accessibility to patients.

SGLT2 inhibitors and diabetic retinopathy progression.

PURPOSE: To evaluate whether sodium-glucose co-transporter 2 (SGLT2) inhibitors affect progression of non-proliferative diabetic retinopathy (NPDR) compared to standard of care. METHODS: A retrospective cohort study compared subjects enrolled in a commercial and Medicare Advantage medical claims database who filled a prescription for a SGLT2 inhibitor between 2013 and 2020 to unexposed controls, matched up to a 1:3 ratio. Patients were excluded if they were enrolled for less than 2 years in the plan, had no prior ophthalmologic exam, had no diagnosis of NPDR, had a diagnosis of diabetic macular edema (DME) or proliferative diabetic retinopathy (PDR), had received treatment for vision-threatening diabetic retinopathy (VTDR), or were younger than 18 years. To balance covariates of interest between the cohorts, an inverse probability treatment weighting (IPTW) propensity score for SGLT2 inhibitor exposure was used. Multivariate Cox proportional hazard regression modeling was employed to assess the hazard ratio (HR) for VTDR, PDR, or DME relative to SGLT2 exposure. RESULTS: A total of 6065 patients who initiated an SGLT2 inhibitor were matched to 12,890 controls. There were 734 (12%), 657 (10.8%), and 72 (1.18%) cases of VTDR, DME, and PDR, respectively, in the SGLT2 inhibitor cohort. Conversely, there were 1479 (11.4%), 1331 (10.3%), and 128 (0.99%) cases of VTDR, DME, and PDR, respectively, among controls. After IPTW, Cox regression analysis showed no difference in hazard for VTDR, PDR, or DME in the SGLT2 inhibitor-exposed cohort relative to the unexposed group [HR = 1.04, 95% CI 0.94 to 1.15 for VTDR; HR = 1.03, 95% CI 0.93 to 1.14 for DME; HR = 1.22, 95% CI 0.89 to 1.67 for PDR]. CONCLUSION: Exposure to SGLT2 inhibitor therapy was not associated with progression of NPDR compared to patients receiving other diabetic therapies.

Association of Treatment Type and Loss to Follow-up With Tractional Retinal Detachment in Proliferative Diabetic Retinopathy.

Importance: The association of proliferative diabetic retinopathy (PDR) interventions of panretinal photocoagulation (PRP) and intravitreal injections (IVIs) with tractional retinal detachment (TRD) is unclear. Objectives: To determine whether different treatment types or a 6-month or longer period of loss to follow-up (LTFU) is associated with TRD. Design, Setting, and Participants: This nested case-control study included data from January 1, 2000, to June 30, 2021, of patients with PDR. Those who progressed to TRD were matched to non-TRD controls up to a 5:1 ratio. Exclusion criteria included 2 or fewer years in the plan, history of nondiabetic retinopathy, vitreous hemorrhage, previous RD, or any other surgically indicated diagnosis. Patient data were obtained from a deidentified commercial and Medicare Advantage medical claims database. Statistical analysis was performed from January to May 2022. Exposures: Primary exposures of interest were prior treatment (PRP, IVI, both) and any period of 6 months or longer in which the patient received no eye care. Main Outcomes and Measures: Odds ratios (ORs) of IVI only compared with PRP and 6-month or longer LTFU on development of TRD. Results: After application of inclusion and exclusion criteria, a total of 214 patients (mean [SD] age, 55.6 [12.4] years; 115 female [53.7%]) with PDR and TRD were matched to 978 controls (mean [SD] age, 65.6 [11.3] years; 507 female [51.8%]) with only PDR. Among patients with TRD, 69 (32.2%) were treated with laser only, 17 (7.9%) were treated with injection only, 39 (18.2%) were treated with both, and 89 (41.6%) had no prior treatment. Among patients in the PDR-only group, 207 (21.2%) received laser only, 83 (8.5%) received injection only, 57 (5.8%) received both, and 631 (64.5%) received no treatment. After adjusted analysis, no difference in odds of TRD for patients who received injection only compared with patients who received laser only was found (adjusted OR [aOR], 0.56; 95% CI, 0.27-1.14). Patients who received both treatments had higher odds of TRD compared with those who received laser only (aOR, 2.33; 95% CI, 1.21-4.48), and patients who had no treatment had lower odds of TRD (aOR, 0.46; 95% CI, 0.29-0.71; P < .001 for treatment category). Similarly, no difference was seen in the odds of TRD between those with LTFU for 6 months or longer and those without LTFU (aOR, 0.72; 95% CI, 0.49-1.07; P = .11). Conclusions and Relevance: Results of this case-control analysis suggest that there is no increased risk of TRD associated with IVI-only treatment or with 6-month or longer periods of LTFU, which supports the findings of other investigations. Nonetheless, LTFU rates continue to remain high in patients with PDR, which can contribute to substantial vision loss regardless of treatment regimen.

Risk of non-infectious uveitis or myasthenia gravis in patients on checkpoint inhibitors in a large healthcare claims database.

AIM: To determine if checkpoint inhibitors (CPIs) confer an increased risk of non-infectious uveitis or myasthenia gravis (MG) compared to patients on non-checkpoint inhibitor (N-CPI) chemotherapy. METHODS: A retrospective cohort study was performed comparing patients in a large commercial and Medicare advantage database exposed to CPI compared to N-CPI. All patients who initiated a CPI (ipilimumab, pembrolizumab, nivolumab, atezolizumab, avelumab, cemiplimab and durvalumab) were eligible. Date of earliest CPI in the exposure group and N-CPI chemotherapy in the comparator group was considered the index date. Exclusion occurred in both cohorts for any history of uveitis or MG diagnosis and having <1 year in the insurance plan prior to the index date, and <6 months in plan following the index date. Every exposed patient was matched up to 1:10 based on demographics and index year to patients on N-CPI chemotherapy. Multivariate Cox proportional hazards regression modelling was performed. RESULTS: For evaluation of incidence of non-infectious uveitis, 26 (0.3%) of 8678 patients on CPI and 123 (0.2%) of 76 153 N-CPI comparators were found to have non-infectious uveitis. After multivariate analysis, CPIs showed an increased hazard for uveitis compared to N-CPI (HR=2.09; 95% CI 1.36 to 3.22, p=0.001). For the MG analysis, 11 (0.1%) of 9210 patients developed MG in the CPI group and 36 (0.04%) of 80 620 comparators. The CPI cohort had a higher hazard of developing MG (HR=2.60; 95% CI 1.34 to 5.07, p=0.005) compared to controls in multivariate analysis. CONCLUSIONS: Exposure to CPI confers a higher risk for non-infectious uveitis and MG compared to N-CPI chemotherapy.

Association of metformin and development of dry age-related macular degeneration in a U.S. insurance claims database.

PURPOSE: To assess whether metformin is associated with dry age-related macular degeneration (dAMD) development. METHODS: In this retrospective cohort study, patients enrolled in a nationwide U.S. medical insurance claims database from 2002 to 2016 were included if they had diabetes mellitus, were ⩾55 years old, and were enrolled for ⩾2 years without a prior AMD diagnosis. The primary exposure was metformin use analyzed as either active or prior use or cumulative metformin dosage over the study period. A time updating Cox proportional hazard regression was used to estimate the hazard ratio of dAMD incidence with metformin exposure. RESULTS: Among 1,007,226 diabetic enrollees, 53.3% were female and 66.4% were white with a mean hemoglobin A1c of 6.8%. Of eligible enrollees, 166,115 (16.5%) were taking metformin at the index date. Over the study period, 29,818 (3.0%) participants developed dAMD. In the active versus prior use of metformin model, active use conferred an increased hazard of developing dAMD (HR, 1.08; 95% CI, 1.04-1.12) while prior use had a decreased hazard (HR, 0.95; 95% CI 0.92-0.98). The cumulative metformin dosage model showed a significant trend toward increased hazard of dAMD incidence with increasing cumulative dosage (p < 0.001), with the lowest dosage quartile having decreased hazard of dAMD incidence (HR, 0.95; 95% CI, 0.91-0.99) and the highest having increased hazard (HR, 1.07; 95% CI, 1.01-1.13). CONCLUSIONS: Small, conflicting associations between metformin exposure and development of dAMD were observed depending on cumulative dosage and whether drug use was active, suggesting metformin did not substantially affect the development of dAMD.

Association of Retinal Vascular Occlusion With Women Filling a Prescription for Female Hormone Therapy.

Importance: Oral contraceptives have been associated with cardiovascular disease, ischemic stroke, venous thromboembolic disease, and breast cancer. Retinal vascular occlusions share the same risk factors as cardiovascular and cerebrovascular disease. Objective: To determine whether filling a prescription of female hormone therapy (FHT) is associated with an increased risk of retinal artery occlusion (RAO) or retinal vein occlusions (RVO). Design, Setting, and Participants: A multiple-cohort study was conducted using an administrative claims insurance database comparing women who filled a prescription for FHT with matched control individuals. Exclusion occurred for those enrolled for less than 2 years in the plan, with no prior ophthalmologic examination, with a history of a RAO/RVO, with systemic diseases/medications that affected estrogen levels, or a disease associated with an increased risk for thromboembolism. Main Outcomes and Measures: The primary outcome was the incidence of a new diagnosis of RAO or RVO. Cox proportional hazard regression modeling with inverse probability of treatment weight was used to assess the hazard ratio (HR) for a new diagnosis of RAO or RVO relative to filling prescription for FHT. Subanalyses were conducted to stratify by age, race/ethnicity, diabetes, and hypertension. Results: A total of 205 304 women who filled a prescription for FHT were matched to 755 462 control individuals. After inverse probability of treatment weight, the study cohort was a mean age of 47.2 years, 71% were White, 7% were Black, 6% were Hispanic, 3% were Asian, and 3% were unknown. There were 41 cases (0.01%) of RAO and 68 cases of RVO (0.02%) in the FHT cohort. In comparison, there were 373 cases of RAO (0.05%) and 617 cases of RVO (0.08%) in the control cohort. After inverse probability of treatment weight, Cox regression analysis showed no difference in hazard for RAO, RVO, or combined outcomes in the FHT cohort relative to the control cohort (RAO HR, 1.17; 95% CI, 0.83-1.65; P = .36; RVO HR, 1.07; 95% CI, 0.82-1.39; P = .65; combined HR, 1.10; 95% CI, 0.89-1.36; P = .37). Subanalyses that stratified by age, diabetes, and hypertension similarly showed no significant associations between the FHT prescription cohort and all outcomes. Conclusions and Relevance: These findings suggest that filling a prescription for FHT, and presumably taking FHT, does not increase the risk of RAO or RVO. Such history may not be relevant in the evaluation of an individual with an RAO or RVO nor do our results support stopping FHT in an individual who develops an RAO or RVO.

Blindness and Visual Impairment in the Medicare Population: Disparities and Association with Hip Fracture and Neuropsychiatric Outcomes.

Purpose: Vision loss has been associated with negative health outcomes, but population-level data on vision loss are lacking, and there are limited data on low vision-associated outcomes among women, minorities, and older age groups. The objective of this study was to determine the prevalence of vision loss in a nationally representative sample of older US adults and examine its association with hip fracture, depression, anxiety, and dementia. Methods: Cross-sectional analysis of Medicare claims data from 2014. Blindness and low vision, hip fracture, depression, anxiety, and dementia were identified using Chronic Condition Warehouse indicator variables based on ICD-9 and CPT codes. Multivariable logistic regression models were built to examine whether sociodemographic factors were associated with vision loss and to determine the relationships between vision loss and hip fracture and neuropsychiatric outcomes. Results: The prevalence of low vision in the Medicare population was 994/100,000 and increased significantly with age, Black (1,854/100,000) or Hispanic (2,862/100,000) race/ethnicity, female gender (1,181/100,000), and Medicaid eligibility (2,975/100,000). After adjusting for relevant comorbidities, low vision was significantly associated with hip fracture (adjusted odds ratio [AOR] 2.54, 95% CI: 2.52-2.57), depression (AOR 3.99, 95% CI: 3.97-4.01), anxiety (AOR 2.93, 95% CI: 2.91-2.95), and dementia (AOR 3.91, 95% CI: 3.88-3.93). Conclusion: Blindness and low vision are common in older Americans, especially among racial and ethnic minorities and lower income individuals, and associated with hip fracture, depression, anxiety, and dementia. The prevention and treatment of vision loss may reduce health disparities and negative health outcomes in the aging population.

Association of Hypovitaminosis D With Increased Risk of Uveitis in a Large Health Care Claims Database.

Importance: Understanding the role of vitamin D-which regulates inflammatory responses-in noninfectious uveitis (an inflammatory disease) may provide insight into treatment and prevention of this disease. Objective: To investigate whether there is an association between hypovitaminosis D and incident noninfectious uveitis. Design, Setting, and Participants: In a retrospective case-control study, data from a health care claims database containing deidentified medical claims from a large private insurer were used to identify 558 adults enrolled from January 1, 2000, to December 31, 2016, who received a diagnosis of noninfectious uveitis from an eye care clinician (with receipt of a confirmatory diagnosis within 120 days of the initial diagnosis) and who had a vitamin D level measured within 1 year before the first diagnosis. Exclusion criteria included having systemic disease or receiving medication known to lower vitamin D levels, having undergone intraocular surgery, and having infectious uveitis. Each case patient was matched with 5 controls on the basis of age, sex, race/ethnicity, and index date (2790 controls). The controls had vitamin D level determined either within 1 year before or within 6 months after receiving an eye examination with normal findings. Multiple logistic regression models were used to examine the association between hypovitaminosis D and noninfectious uveitis. Main Outcomes and Measures: The primary, prespecified analysis assessed the association of noninfectious uveitis with hypovitaminosis D (vitamin D level ≤20 ng/mL). Results: The 558 cases and 2790 controls were matched on age, and each group had a mean (SD) age of 58.9 (14.7) years. Among the cohort of 3348 patients, 2526 (75.4%) were female, and the racial/ethnic distribution in the matched samples was 2022 (60.4%) white, 552 (16.5%) black, 402 (12.0%) Hispanic, 162 (4.8%) Asian, and 210 (6.3%) unknown. Patients with normal vitamin D levels had 21% lower odds of having noninfectious uveitis than patients with low vitamin D levels (odds ratio [OR], 0.79; 95% CI, 0.62-0.99; P = .04). In a race-stratified analysis, an association between vitamin D and uveitis was found in black patients (OR, 0.49; 95% CI, 0.30-0.80; P = .004) and was qualitatively similar but nonsignificant in white patients (OR, 0.87; 95% CI, 0.62-1.21; P = .40) and Hispanic patients (OR, 0.60; 95% CI, 0.33-1.10; P = .10). Conclusions and Relevance: This and other reports have found an association between hypovitaminosis D and noninfectious uveitis. However, these studies cannot establish a causal relationship. Prospective studies are warranted to evaluate whether hypovitaminosis D causes increased risk of uveitis and the role of vitamin D supplementation in prevention and treatment of uveitis.

Accuracy of Billing Codes Used in the Therapeutic Care of Diabetic Retinopathy.

Importance: Insurance billing claim databases represent a growing field of scientific inquiry within ophthalmology. Validating the accuracy of billing claim codes used during the care of diabetic retinopathy is a necessary precursor to fully understanding the underlying data and subsequent results of these types of studies. Objective: To determine the accuracy of diagnostic, procedural, and therapeutic billing codes used in the treatment of diabetic retinopathy. Design, Setting, and Participants: This retrospective medical record review was conducted at 3 clinical practices (1 academic and 2 private). Insured patients with diabetic retinopathy were seen by the practices between 2011 and 2013. Each patient then had every visit for 2 years reviewed twice, once for billing data and the second for data from the medical record. Data were collected and analyzed from October 2015 to July 2016. Main Outcomes and Measures: The positive predictive value (PPV) and negative predictive value (NPV) for each code of interest. Sensitivity and specificity were secondary outcomes. Results: A total of 146 patients (mean [SD] age, 60.3 [12.5] years) from 11 physicians had 1072 encounters reviewed over 2 calendar years. Among the included patients, 49.3% were female (n = 72), 48.6% were white (n = 71), 37.0% were black (n = 54), and 18.5% had type 1 diabetes and a mean (SD) hemoglobin A1C level of 7.7% (1.8) (n = 27). Nearly all codes of interest that were used frequently also had a high PPV (range, 89.5%-100%) and NPV (88.6%-100%) including billing codes for intravitreal injection, focal laser, panretinal photocoagulation, laterality of procedure, ranibizumab, bevacizumab, fundus photographs, fluorescein angiography, and optical coherence tomography. Codes that were used infrequently (<20 instances) but still had a high PPV (all 100%) and NPV (99.7%-100%) were codes for aflibercept, triamcinolone, and the dexamethasone implant. Only the codes for infrequently used B-scan ultrasonography (PPV, 69.6%) and subtenon injection (PPV, 100%; NPV, 99.7%, but sensitivity of only 40%) were found to be of questionable accuracy. Other than subtenon injection (40%), all codes were also found to have a high sensitivity (range, 87.6%-100%) and a high specificity (range, 97.2%-100%). Conclusions and Relevance: These data suggest diagnostic, procedure, and therapeutic codes derived from insurance billing claims accurately reflect the medical record for patients with diabetic retinopathy.

Oral Fluoroquinolones and the Risk of Uveitis.

IMPORTANCE: Fluoroquinolones are the most commonly prescribed antibiotic class in the outpatient setting. Recent reports have implicated an association between oral fluoroquinolones and an increased risk of uveitis. OBJECTIVE: To determine the hazard of uveitis with oral fluoroquinolone use. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted using medical claims data from a large national US insurer (N = 4,387,651). Cohorts from ambulatory care centers across the United States were created including every new user of an oral fluoroquinolone or ß-lactam antibiotic prescription with at least 24 months of data prior to the date of the prescription from January 1, 2000, to January 30, 2013. Exclusion criteria consisted of any previous diagnosis of uveitis or a uveitis-associated systemic illness. Participants were censored for a new diagnosis of a uveitis-associated systemic illness, the end of an observation period, use of the other class of antibiotic, or removal from the insurance plan. Data analysis was performed from January 2 through March 15, 2015. MAIN OUTCOMES AND MEASURES: The hazard of a uveitis diagnosis after a fluoroquinolone prescription compared with a ß-lactam prescription using multivariate regression with Cox proportional hazards models. RESULTS: Of the 4,387,651 patients in the database, 843,854 individuals receiving a fluoroquinolone and 3,543,797 patients receiving a ß-lactam were included in the analysis. After controlling for age, race, and sex using multivariate analysis, no hazard for developing uveitis at the 30-, 60-, or 90-day observation windows was seen (hazard ratio [HR] range, 0.96; 95% CI, 0.82-1.13; to 1.05; 95% CI, 0.95-1.16; P > .38 for all comparisons). The 365-day observation period showed a small increase in the HR for the fluoroquinolone cohort (1.11; 95% CI, 1.05-1.17; P < .001). Moxifloxacin produced an increased hazard for uveitis at every time point (HR range, 1.47-1.75; 95% CI, 1.27-2.37; P < .001 for all comparisons). Secondary analysis demonstrated a similar hazard at 365 days for a later diagnosis of a uveitis-associated systemic illness after fluoroquinolone use (HR range, 1.46-1.96; 95% CI, 1.42-2.07; P < .001 for all comparisons). CONCLUSIONS AND RELEVANCE: These data do not support an association between oral fluoroquinolone use and uveitis. Instead, this study shows an association between oral fluoroquinolone use and the risk for uveitis-associated systemic illnesses, which is a possible source of bias that could explain the findings of previous studies.

Outcomes, impact on management, and costs of fungal eye disease consults in a tertiary care setting.

OBJECTIVE: To determine the frequency of clinical management changes resulting from inpatient ophthalmic consultations for fungemia and the associated costs. DESIGN: Retrospective case series. PARTICIPANTS: Three hundred forty-eight inpatients at a tertiary care center between 2008 and 2012 with positive fungal blood culture results, 238 of whom underwent an ophthalmologic consultation. METHODS: Inpatient charts of all fungemic patients were reviewed. Costs were standardized to the year 2014. The Student t test was used for all continuous variables and the Pearson chi-square test was used for categorical variables. MAIN OUTCOME MEASURES: Prevalence of ocular involvement, rate of change in clinical management, mortality rate of fungemic patients, and costs of ophthalmic consultation. RESULTS: Twenty-two (9.2%) of 238 consulted patients with fungemia had ocular involvement. Twenty patients had chorioretinitis and 2 had endophthalmitis. Only 9 patients (3.7%) had a change in management because of the ophthalmic consultation. One patient underwent bilateral intravitreal injections. Thirty percent of consulted patients died before discharge or were discharged to hospice. The total cost of new consults was $36 927.54 ($204.19/initial level 5 visit and $138.63/initial level 4). The cost of follow-up visits was $13 655.44 ($104.24/visit). On average, 26.4 patients were evaluated to find 1 patient needing change in management, with an average cost of $5620.33 per change in 1 patient's management. CONCLUSIONS: Clinical management changes resulting from ophthalmic consultation in fungemic patients were uncommon. Associated costs were high for these consults in a patient population with a high mortality rate. Together, these data suggest that the usefulness of routine ophthalmic consultations for all fungemic patients is likely to be low.

Role of statins in the development and progression of age-related macular degeneration.

PURPOSE: To determine if statins are associated with the development or progression of age-related macular degeneration (AMD). METHODS: A large, national insurance claims database was reviewed to identify individuals aged 60 years or older who were enrolled for ≥2 years and had ≥1 visits to an eye provider. Prescription claims for statins within a 24-month look-back period and outpatient lipid laboratory values were also reviewed. Cox regression analysis was used to determine whether statin use was associated with the development of nonexudative or exudative AMD or progressing from nonexudative to exudative AMD. RESULTS: Of the 107,007 beneficiaries eligible for the nonexudative AMD analysis, 4,647 incident cases of nonexudative AMD occurred. Seven hundred and ninety-two incident cases of exudative AMD were found among the 113,111 beneficiaries eligible for the exudative AMD analysis. Of the 10,743 beneficiaries with known nonexudative AMD eligible for the progression model, 404 progressed to exudative AMD during their time in the plan. After multivariable analysis, statin use was not associated with the development of nonexudative AMD (P > 0.05). Statin use of >12 months was associated with an increased hazard for developing exudative AMD (P < 0.005). Among those taking statins, only enrollees with the highest lipid levels had an increased hazard of developing exudative AMD (P < 0.05). CONCLUSION: In those with elevated lipid levels, >1 year of statin use was associated with an increased hazard for exudative AMD. Lipid status influences the relationship between statins and the risk of AMD. Because of a number of limitations in study design, these observations warrant further study and should not be the rationale for any changes in the use of statins to treat dyslipidemias.

Racial differences in age-related macular degeneration rates in the United States: a longitudinal analysis of a managed care network.

PURPOSE: To compare the incidence, prevalence, and hazard of nonexudative and exudative age-related macular degeneration (AMD) among different races throughout the United States. DESIGN: Retrospective longitudinal cohort study. METHODS: Billing records of all encounters for 2 259 061 beneficiaries aged ≥40 enrolled in a large, national US managed care network from 2001 through 2007 were reviewed and the incidence and prevalence of nonexudative and exudative AMD were determined and stratified by race. Cox regression analyses determined the hazard of nonexudative and exudative AMD for each race, with adjustment for confounders. RESULTS: During the study, 113 234 individuals (5.0%) were diagnosed with nonexudative and 17 181 (0.76%) with exudative AMD. After adjustment for confounders, blacks had a significantly reduced hazard of nonexudative (hazard ratio [HR]=0.75, 95% confidence interval [CI]: 0.71-0.79) and exudative AMD (HR=0.70, 95% CI: 0.59-0.83) at age 60 and a reduced hazard of nonexudative (HR=0.56, 95% CI: 0.52-0.60) and exudative AMD (HR=0.45, 95% CI: 0.37-0.54) at age 80 relative to whites. Similar comparisons for Latinos demonstrated an 18% reduced hazard for nonexudative AMD at age 80 (HR=0.82, 95% CI: 0.76-0.88) relative to whites. Asian Americans showed a 28% increased hazard for nonexudative AMD at age 60 (HR=1.28, 95% CI: 1.20-1.36) but a 46% decreased hazard for exudative AMD at age 80 (HR=0.54, 95% CI: 0.40-0.73). CONCLUSIONS: Racial minorities, including Latinos and Asian Americans, do not appear to have similar risks of developing nonexudative and exudative AMD as whites. Additional studies using other sources should be conducted to determine the generalizability of this study's findings to other groups.