Visual impairment due to age-related macular degeneration during 40 years in Finland and the impact of novel therapies.

PURPOSE: To evaluate the changes in visual impairment (VI) due to age-related macular degeneration (AMD) during the past 40 years and the impact of novel therapies at population level. METHODS: In this nationwide register-based study, we assessed the incidence, prevalence, severity, and onset age of VI due to AMD based on the Finnish Register of Visual Impairment data from 1980 to 2019. Our data included 30 016 visually impaired persons with AMD as the main diagnosis for VI. The number of persons treated with intravitreal injections in Finland was obtained from hospital data kept by the Finnish Institute for Health and Welfare. RESULTS: Between the 1980s and the 2010s, the incidence of reported VI doubled; however, this increase has stagnated in the 2010s. Since 2012, the prevalence of reported VI has decreased. The number of patients treated with intravitreal injections showed a 40-fold increase during 2005-2019. The severity of reported VI has decreased whereas the mean age at the onset of reported VI has increased during the 40 years. The age-adjusted incidence and prevalence of reported VI were significantly higher in females in comparison to males in all decades. CONCLUSION: Increase in the incidence and prevalence of VI due to AMD in the past decades has stagnated and shifted to older age in the 2010s when therapies for exudative class became commonly available. Furthermore, the prognosis of VI has improved during the past 40 years. These positive trends are likely contributable to improved diagnostic tools, earlier diagnoses, and new therapy options.

Changes in Visual Impairment due to Diabetic Retinopathy During 1980-2019 Based on Nationwide Register Data.

OBJECTIVE: To evaluate changes in the incidence, prevalence, severity, and onset age of visual impairment (VI) due to diabetic retinopathy (DR) and compare these trends in the screening and treatment of diabetes during 40 years based on Finnish national register data. RESEARCH DESIGN AND METHODS: We included people with VI with nonproliferative DR (NPDR; n = 2,490, 73% women) or proliferative DR (PDR; n = 2,026, 53% women) as the main diagnosis for VI during 1980-2019 in the Finnish Register of Visual Impairment. The number of patients with treated diabetes during 1986-2019 was obtained from the Social Insurance Institution of Finland registers based on reimbursed medication data. RESULTS: The annual incidence of reported VI due to DR has decreased since it peaked in the 1990s: regarding NPDR, it decreased from 102.3 to 5.5 per 100,000 patients with treated diabetes between the 1990s and 2010s; regarding PDR, the respective change was from 39.9 to 7.4. The incidence of patients with diabetes treated for DR increased during this period. Annual prevalence of reported VI and differences between sexes steadily decreased in the 2000s and 2010s. The severity of reported VI has decreased, and the age at the onset of reported VI increased during the 40 years. CONCLUSIONS: Prevalence and incidence of VI due to DR have dramatically decreased and shifted to older age during the 40 years despite the increasing prevalence of diabetes. These positive trends highlight the successful development and effectiveness of screening and therapies for diabetes and DR.

Prevalence and 11-Year Incidence of Cataract and Cataract Surgery and the Effects of Socio-Demographic and Lifestyle Factors.

Purpose: To assess the impact of cataract in ageing population by evaluating the prevalence, incidence, and background factors of cataract and cataract surgery. Patients and Methods: Two health examination surveys representing Finnish population in 2000 and 2011 included 7380 and 5930 participants aged 30 years or older with cataract status known. An 11-year follow-up included 4840 persons who participated in both the surveys. The data include information on physician-made diagnoses, socio-demographic factors, and lifestyle factors based on self-reported assessment. Cataract diagnoses and surgeries recorded in the Finnish Care Register for Health Care were linked to the survey data. Cataract patients were compared to those without cataract using logistic regression. Differences in cataract surgery age were evaluated using linear regression. Univariable and multivariable models were included. Results: During 2000-2011, the prevalence of cataract increased from 8.8% to 13.6% and cataract surgery from 5.7% to 8.9% in a representative sample of the Finnish adult population. Cataract and cataract surgery were associated with age, smoking, and high alcohol consumption. Cataract was also associated with female gender and low income in 2000, but this association declined during the 11 years. Smoking and high alcohol consumption were associated with younger surgery age. Conclusion: The prevalence of cataract and cataract surgery is increasing with the ageing of the population. The increase in cataract surgery is likely also reflecting the improvements in eye care. The possibility to equally use health-care services throughout a country can reduce the impact of socio-demographic status. Healthy lifestyle delays the development of cataract, whereas smoking and high alcohol consumption are associated with earlier cataract development. Therefore, the availability of cataract services and promotion of healthy lifestyle will be the key to prevent the detrimental effects of cataract on patients and the society in countries where the population is rapidly ageing.

Improving health-related quality of life in glaucoma during 11 years and its association with vision loss and treatment of the disease.

PURPOSE: To evaluate the impact of glaucoma on health-related quality of life (HRQoL) and mental health in the ageing population of Finland. METHODS: Altogether 7380 and 5774 Finnish individuals aged 30 years and older with known eye disease status were studied in 2000 and 2011, respectively, in two population-based surveys, including an 11-year follow-up of 4683 participants. Data on HRQoL (EQ-5D-3L, 15D), depression (BDI), psychological distress (GHQ-12) and eye disease diagnoses were obtained from self-reported assessments. Information on glaucoma was complemented with the medication, diagnosis and eye surgery data obtained from the Finnish Health Registries. Distance visual acuity was assessed using the Snellen eye chart test. In logistic regression analyses, data were corrected for age, gender and the most common comorbidities. RESULTS: Glaucoma patients with verified diagnosis (n = 192 in 2000, n = 202 in 2011) and individuals with self-suspected glaucoma (n = 100 in 2000, n = 41 in 2011) showed a significant decrease in their HRQoL. Glaucoma was also associated with worsened overall mental health based on BDI and GHQ-12 results. Visual impairment associated with glaucoma is the major determinant of the reduced HRQoL and mental health. Neither glaucoma medication nor glaucoma surgery affected these parameters. The impact of glaucoma on HRQoL and mental health diminished between 2000 and 2011 in a cross-sectional setting. The newly diagnosed glaucoma during the 11-year follow-up had a minimal effect on them. CONCLUSION: Glaucoma patients show reduced HRQoL and mental health, which is associated with vision loss regardless of the awareness or treatment of the disease. However, this effect seems to be diminishing over time, and the newly diagnosed glaucoma did not show a significant effect on either HRQoL or mental health.

Changes in incidence and severity of visual impairment due to glaucoma during 40 years - a register-based study in Finland.

PURPOSE: To report the incidence and severity of reported visual impairment (VI) due to glaucoma and the changes in them during the past 40 years in Finland. METHODS: A register-based study, in which the data were collected from the Finnish Register of Visual Impairment between 1980 and 2019. These data included 5819 visually impaired glaucoma patients, of which 61% were female. Visual impairment (VI) was classified according to the Finnish national definitions. The number of treated glaucoma patients in Finland was calculated using glaucoma medication reimbursement data available between 1986 and 2019 from the Social Insurance Institution of Finland registers. RESULTS: The incidence of reported VI due to glaucoma per 100 000 persons had increased from 2.3 in the 1980s to 3.4 in the 2010s. During the same time period, the incidence of reported VI per 10 000 treated glaucoma patients had decreased from 32 in the 1980s to 21 in the 2010s. Primary open-angle glaucoma (45%) was the main subtype for reported VI due to glaucoma. During the 40 years, the proportion of mild VI and the age at the onset of reported VI had increased. CONCLUSION: The incidence of reported VI due to glaucoma has increased during the 40 years, but the risk of treated glaucoma patients becoming visually impaired has decreased. Visual impairment (VI) also occurs at an older age. This is likely due to the earlier diagnoses and improved therapy. To prevent the unfavourable development of VI due to glaucoma among the ageing population in the future, all attempts need to be made to improve glaucoma care.

Prevalence and 11-year incidence of common eye diseases and their relation to health-related quality of life, mental health, and visual impairment.

PURPOSE: To study the prevalence and incidence of the most common eye diseases and their relation to health-related quality of life (HRQoL), depression, psychological distress, and visual impairment in the aging population of Finland. METHODS: Our study was based on two nationwide health surveys conducted in 2000 and 2011. Eye disease status data were obtained from 7379 and 5710 individuals aged 30 + years, of whom 4620 partook in both time points. Both surveys included identical indicators of HRQoL (EuroQol-5 Dimension [EQ-5D], 15D), depression (Beck Depression Inventory [BDI]), psychological distress (General Health Questionnaire-12 [GHQ-12]), visual acuity, and self-reported eye diseases. We assessed the impact of known eye diseases on these factors, adjusted for age, gender, and co-morbidities. RESULTS: Prevalence of self-reported eye diseases was 3.1/2.7% for glaucoma, 8.1/11.4% for cataract, and 3.4/3.8% for retinal degeneration in 2000 and 2011, and the average incidence between 2000 and 2011 was 22, 109, and 35 /year/10,000 individuals, respectively. These eye diseases were associated with a significant decrease in EQ-5D and 15D index scores in both time points. BDI and GHQ-12 scores were also worsened, with some variation between different eye diseases. Impaired vision was, however, the strongest determinant of declined HRQoL. During the 11-year follow-up the effect of eye diseases on HRQoL and mental health diminished. CONCLUSION: Declined HRQoL associated with eye diseases is more related to impaired vision than the awareness of the disease itself, and this declining effect diminished during the follow-up. Therefore, information directed to the public on the risks and prevention of blindness can and should be strengthened to prevent the deleterious effects of visual impairment.

Correlation between the rate of intravitreal injections, use of aflibercept as a second-line treatment and visual impairment for wet AMD in Finland.

PURPOSE: To correlate the rate of intravitreal anti-VEGF injections and the use of aflibercept as a second-line treatment with visual impairment throughout Finland. METHODS: Information related to anti-VEGF treatment, proportions of bevacizumab and aflibercept and new visual impairments due to wet age-related macular degeneration (AMD) was gathered from 5 university hospitals and 14 central hospital districts between 2015 and 2017 covering 232 568 injections and 1172 visual impairments. RESULTS: Between 2015 and 2017, the number of annual total anti-VEGF injections increased from 60 412 to 93 589 (+24.5% annual change) and of aflibercept injections from 8299 to 20 833 (+58.7% annual change). The 3-year average for total anti-VEGF injections ranged from 9.6 to 21.1 (median 13.3) per 1000 citizens between hospital districts and for aflibercept injections from 0.8 to 4.0 (median 1.9). According to the primary protocol for wet AMD, during 2015-2017, the number of total anti-VEGF injections increased from 10.9 to 15.2 per 1000 citizens with the pro re nata (PRN) protocol and from 11.3 to 18.9 with the treat-and-extend regimen (TER). The 3-year average of aflibercept injections as a second-line treatment, but not the total number of anti-VEGF or bevacizumab injections, inversely correlated with new onset visual impairments (R = -0.505, P = 0.027) in the hospital districts. The number of visual impairments did not differ between the hospital districts according to the PRN and TER protocols (1.23 ± 0.41 and 1.14 ± 0.67, respectively, per 1000 citizens aged ≥64 years, P = 0.713). CONCLUSION: These results emphasize that the use of aflibercept injections as a second-line treatment may decrease new onset visual impairments.

Low vision status and declining vision decrease Health-Related Quality of Life: Results from a nationwide 11-year follow-up study.

PURPOSE: The impact of visual acuity (VA) on Health-Related Quality of Life (HRQoL) and the cross-sectional and longitudinal differences in HRQoL during the 11-year follow-up were investigated. The aim was to examine the impact declining vision has on HRQoL and to provide comparable data to facilitate the allocation of health-care resources. METHODS: We utilized nationwide health examination surveys carried out by the National Institute for Health and Welfare in 2000 and 2011, providing a representative sampling of the Finnish adult population aged 30 and older. VA was assessed through Snellen E test, and HRQoL scores were evaluated using EQ-5D and 15D questionnaires. Multiple imputations with Markov chain Monte Carlo method was used to utilize the data more effectively. Regression analyses were conducted to assess the impact of declining VA on HRQoL, adjusted for incident comorbidities. RESULTS: Lower VA status was associated with significantly lower HRQoL at both time points, most clearly observable below the VA level of 0.5. Declining VA resulted in statistically significant decline in HRQoL during the follow-up, greater with distance than near VA. 15D impairment associated with decline in the distance VA was also clinically meaningful and greater than that associated with any of the examined comorbidities. CONCLUSIONS: HRQoL was significantly and meaningfully impaired even before the threshold of severe vision loss or blindness was reached. The results encourage the improvement of available treatment options aiming to postpone the onset of visual impairment or declining VA, to maintain better quality of life among the population.

Pediatric ocular disorders and visual handicap in Finland - what do the registers tell?

INTRODUCTION: There is no published data from the last few years on the frequency of pediatric ocular disorders and visual handicap in Finland. METHODS: We surveyed the registers of THL (National Institute for Health and Welfare) and statistics of Kela (The Social Insurance Institution of Finland). RESULTS: The majority of visual defects are neurologic or congenital. Retinopathic lesions were reported in 11% of small premature infants. In the years from 1993 to 2011, significant abnormalities of the eye or its accessory organs were on the average registered annually in 94 liveborn infants, and the number of corresponding cancers was less than five. CONCLUSIONS: Ocular disorders in children are rare. They are significant because of the special attention required in everyday life.

Improving visual prognosis of the diabetic patients during the past 30 years based on the data of the Finnish Register of Visual Impairment.

PURPOSE: To evaluate changes in visual impairment (VI) due to diabetic retinopathy (DR) recorded in the Finnish Register of Visual Impairment (RVI) during the past 30 years. METHODS: Data from the visually impaired diabetic persons included in the RVI were analysed using three 10-year cohorts (1982-90, 1991-2000, 2001-10). Information on the age at the time of the first VI registration, severity of VI determined according to the World Health Organisation (WHO) definition, and the age at death was collected. VI due to proliferative (PDR) and non-proliferative (NPDR) DR were analysed separately. RESULTS: Data of 4080 patients whose primary cause for VI was DR were analysed. The median age at the time of notification of VI for the three cohorts was 39, 62 and 59 years in the PDR group and 71, 73 and 73 in the NPDR group, respectively. The proportion of blind persons was 42%, 22% and 15% in the PDR group and 10%, 9% and 4% in the NPDR group, respectively. The median age at death in the three cohorts was 54, 73 and 72 years in PDR group and 76, 79 and 80 years in the NPDR group, respectively. The standardized mortality ratio (SMR) compared with the general population was 8.3, 2.9 and 1.4 in persons with PDR and 3.4, 2.0 and 1.2 in those with NPDR, respectively. CONCLUSIONS: A significant change in the profile of the VI in the PDR group has taken place in Finland. It was characterized by increased age at the time of VI notification, decreased severity of VI and higher age at death. Most evidently these improvements took place in the 1990s. The profile of VI in the NPDR group has changed only modestly. Compared with the general population, SMRs improved both in NPDR and PDR groups continuously.

Suicides in Visually Impaired Persons: A Nation-Wide Register-Linked Study from Finland Based on Thirty Years of Data.

Focusing on seasonality, gender, age, and suicide methods a Finnish nation-wide cohort-based study was carried out to compare suicide data between sighted, visually-impaired (WHO impairment level I-II, i.e., visual acuity >0.05, but <0.3) and blind (WHO impairment level III-V, i.e., visual acuity <0.05) victims. Standardized mortality ratios (SMR) of age- and gender-matched populations from official 1982-2011 national registers were used. Group differences in categorical variables were assessed with Pearson's Chi-square or Fisher's Exact test and in continuous variables with Mann-Whitney U-test. Seasonality was assessed by Chi-square for multinomials; ratio of observed to expected number of suicides was calculated with 95% confidence level. Hanging, poisoning, drowning, but rarely shooting or jumping from high places, were preferred suicide methods of the blind. Mortality was significantly increased in the visually impaired (SMR = 1.3; 95% CI 1.07-1.61), but in gender-stratified analyses the increase only affected males (1.34; 95% CI = 1.06-1.70) and not females (1.24; 95% CI 0.82-1.88). Age-stratified analyses identified blind males of working age rather than older men (as in the general population) as a high risk group that requires particular attention. The statistically significant spring suicide peak in blind subjects mirrors that of sighted victims and its possible cause in the blind is discussed.

Does incidence of breast cancer and prostate cancer decrease with increasing degree of visual impairment.

OBJECTIVE: The issue of light at night and cancer continuously attracts discussion. The major hypotheses are that melatonin may decrease risk of hormone-related cancers, particularly breast cancer, or even act as a potent antioxidant and thus have a protective effect against cancer development in general. METHODS: We tested the hypothesis that blind persons are at lower risk of cancer in a follow-up study linking a cohort of 17,557 persons with visual impairment identified from the Finnish Register of Visual Impairment with cancer incidence data of the Finnish Cancer Registry for years 1983-2003. RESULTS: Breast cancer risk in females decreased by degree of visual impairment, and a similar but less consistent trend was observed for prostate cancer in males. The incidence for the remaining cancers among nearly to totally blind persons was significantly higher than in average Finnish population. CONCLUSIONS: Our findings add to the suggestive epidemiological evidence for a decreased risk of hormone-related cancers in people with visual impairment and, consequently, a relationship between visible light at night and breast cancer risk. The result is strongly against the hypothesis of a systemic protective effect related lack of visible light.