Long-term changes in visual acuity in an older population over a 15-year period: the Blue Mountains Eye Study.

PURPOSE: To describe the change in visual acuity (VA) and incidence of visual impairment (VI) in an older population over a 15-year period. DESIGN: Population-based cohort. PARTICIPANTS: Of the 3654 participants of the Blue Mountains Eye Study (BMES) baseline examination from 1992 through 1994, 1149 were re-examined during the 15-year follow-up between 2007 and 2010. METHODS: Best-corrected VA by means of subjective refraction was measured with a logarithm of the minimum angle of resolution chart using Early Treatment Diabetic Retinopathy Study methods at each examination. MAIN OUTCOME MEASURES: Unilateral VI was defined as VA worse than 20/40 and blindness was defined as VA worse than 20/200 in the worse eye. Incident bilateral VI and blindness were determined according to VA in the better eye at the 15-year visit. Doubling of the visual angle was defined as a loss of 15 letters or more from baseline to the 15-year visit. Halving of the visual angle was defined as a VA improvement of 15 letters or more over the same period. Causes of VI were determined at examination, by photographic grading, and from medical records. RESULTS: Cumulative 15-year incidence of unilateral and bilateral VI was 12.3% (95% confidence interval [CI], 11.0-13.6) and 5.2% (95% CI, 4.3-6.1), respectively, and for unilateral and bilateral blindness, the cumulative incidence was 3.7% (95% CI, 3.0-4.4) and 0.9% (95% CI, 0.5-1.3), respectively. These incidence rates increased significantly with increasing age (P<0.01 for trend). Doubling and halving of the visual angle occurred in 6.9% (95% CI, 5.9-7.9) and 1.6% (95% CI, 1.0-2.2) of participants, respectively. Cataract accounted for 48.5% of unilateral and bilateral incident VI, followed by age-related macular degeneration (26.9%). Age-related macular degeneration accounted for 56.9% of unilateral and bilateral incident blindness cases, followed by cataract (20.7%). CONCLUSIONS: These data provide population-based estimates of long-term incidence of visual impairment among older persons. Our estimate for cumulative incidence of blindness, accounting for competing risk of death, was similar to that of the Beaver Dam Eye Study (BDES) after age standardization. However, our estimate for cumulative incidence of VI was lower compared with that observed in the BDES population. This difference may be explained in part by a higher mortality rate among our population. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Ten-year incidence and progression of age-related maculopathy: the blue Mountains Eye Study.

PURPOSE: To assess the 10-year incidence of age-related maculopathy (ARM) in an older Australian cohort. DESIGN: Population-based cohort study. PARTICIPANTS: Three thousand six hundred fifty-four Blue Mountains Eye Study participants > or =49 years old were examined during 1992 through 1994; 2335 (75% of survivors) were reexamined after 5 years (1997-1999) and 1952 (76% of survivors) after 10 years (2002-2004). METHODS: The same graders performed retinal photographic grading in all examinations, using the Wisconsin Age-Related Maculopathy Grading System. Photographs of participants with ARM lesions at any of the examinations were subsequently regraded using a side-by-side comparison method. MAIN OUTCOME MEASURES: The diagnosis of incident late ARM was given if neovascular ARM or geographic atrophy was detected at either follow-up examination in persons free of these lesions at baseline. Incident early ARM was diagnosed if early ARM (soft indistinct or reticular drusen or combined soft distinct drusen and retinal pigment abnormality) was present in persons free of early and late ARM at baseline. Age-related maculopathy incidence was calculated using Kaplan-Meier methods to incorporate information from both 5- and 10-year examinations. Discrete logistic models were used to assess the risk of incident late ARM according to various baseline factors, including early ARM lesion characteristics. RESULTS: After excluding 72 late ARM cases present at baseline, 2395 of 3582 subjects at risk of late ARM (67%) were reexamined at either follow-up time point or both follow-up time points. Over the 10-year period, 72 of 2395 subjects (3.7%) developed late ARM and 266 of 2255 subjects (14.1%) developed early ARM. After age standardization to the Beaver Dam Eye Study population, our 10-year incidences of late and early ARM were 2.8% and 10.8%, respectively. Baseline age and early ARM lesion characteristics and severity were strong predictors of late ARM incidence. CONCLUSIONS: Long-term follow-up of this older population confirms that the risk of ARM progression is related strongly to the severity of early-stage lesions. The study provides evidence-based criteria for identifying persons at high risk of developing late ARM.

Sensory impairment, use of community support services, and quality of life in aged care clients.

OBJECTIVE: To assess influences from visual or hearing impairment on use of community support services and health-related quality of life in aged care clients. METHOD: The authors sampled 284 frail elderly individuals presenting for assessment in Sydney, Australia. Moderate to severe visual impairment was defined as visual acuity <20/80 (better eye), and moderate to severe hearing loss as hearing thresholds >40 decibels (better ear). Community support services included home-delivered meals, home help, and community nurse visits. RESULTS: After adjusting for age, sex, and two or more comorbid conditions, moderate to severe visual impairment, but not moderate to severe hearing loss, was significantly associated with increased use of community services (adjusted odds ratio 2.8, 95% confidence interval = 1.0-7.8). CONCLUSION: Moderate to severe visual impairment was associated with an increased likelihood of community service utilization in this aged care client sample.

Association between vision and hearing impairments and their combined effects on quality of life.

OBJECTIVES: To assess associations between age-related vision and hearing impairments and whether combined sensory losses magnify effects on health-related quality of life. METHODS: Seventy-five percent of survivors (n = 2334) were reexamined at Blue Mountains Eye Study 5-year examinations and 86.3% (2015) attended hearing assessments. Visual impairment was defined as visual acuity less than 20/40 (better eye), and hearing impairment as average pure-tone air conduction threshold greater than 25 dB (500-4000 Hz, better ear). RESULTS: Persons with visual impairment, compared with those without visual impairment, had lower mean audiometric thresholds across all frequencies (P< or =.05). For each 1-line (5-letter) reduction in best-corrected visual acuity and presenting visual acuity, hearing loss prevalence increased by 18% and 13%, respectively. Cataract and age-related maculopathy were also associated with hearing loss (respectively, multivariate-adjusted odds ratio, 1.3 and 1.6; 95% confidence interval, 1.0-1.7 and 1.1-3.1). The association between age-related maculopathy and hearing loss was stronger at younger ages (<70 years). Combined impairments were associated with poorer health-related quality of life than were single impairments (multivariate-adjusted 36-Item Short-Form Health Survey mean physical and mental component scores; Ptrend = .001 and <.001, respectively). CONCLUSIONS: Older persons with visual impairment were also more likely to have hearing loss in this study, which suggests that these sensory impairments could share common risk factors or biologic aging markers. Combined sensory impairments also cumulatively affect health-related quality of life.

Assessment of vision-related quality of life in an older population subsample: The Blue Mountains Eye Study.

PURPOSE: To assess visual functioning and vision-specific health-related quality of life (HRQOL) in an older, community-dwelling-based population subsample, using the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25). METHODS: Three-quarters (76%, n = 892) of Extension Blue Mountains Eye Study participants (aged > or = 50 years, mean 60.8 years) completed the self-administered NEI-VFQ-25, an instrument consisting of 12 dimensions and one summary composite score, and comprehensive eye examinations, including monocular distance visual acuity. Visual impairment was defined as visual acuity < 6/12. Unilateral and bilateral visual impairment was defined by the worse eye and better eye, respectively. Correctable visual impairment was defined as that which improved, and non-correctable visual impairment as that which persisted after subjective refraction. Mild visual impairment was defined as visual acuity < 6/12 but > or = 6/24, moderate as < 6/24 but > or = 6/60, and severe as < 6/60. RESULTS: There were no significant differences in age, sex, or vision status between NEI-VFQ-25 responders and non-responders. Men had significantly better scores in three subscales than women but there were no significant differences in their overall composite scores (men 88.5+/- 0.5; women 88.1+/- 0.4). Persons aged 60-69 years had the best NEI-VFQ-25 profiles (mean composite score +/- standard error, 90.2 +/- 0.5; 50-59 years, 88.5 +/- 0.4; > or =70 years, 86.2 +/- 0.8). Presenting bilateral visual impairment (77.1 +/- 1.4) was associated with significantly poorer functioning than unilateral (87.5 +/- 0.8) or no visual impairment (89.4 +/- 0.3). Increasing levels of impairment were associated with poorer levels of visual functioning. The impact of impairment was principally from non-correctable (49.2 +/- 2.6) rather than refractive impairments (85.3 +/- 1.4), although the latter accounted for over three-quarters (77.5%) of presenting bilateral impairment. Non-correctable unilateral impairment (85.3 +/- 1.1) was associated with poorer functioning than no impairment. CONCLUSIONS: The findings from this community-dwelling older population show that the NEI-VFQ-25 differentiates well between various levels of visual impairment with regard to the magnitude of their impact on vision-specific quality of life. Greater impacts were noted among persons with bilateral compared to unilateral impairment, with increasing impacts at greater severities of visual impairment. Visual impairment from refractive errors is more frequent than from underlying pathologic disorders, but the impact of correctable visual impairment was considerably milder than the impact of non-correctable visual impairment.

Utility and validity of the self-administered SF-36: findings from an older population.

INTRODUCTION: The objectives of this study were to assess the utility and validity of the self-administered SF-36 and the effect of visual or cognitive impairment on these measures in an older population. MATERIALS AND METHODS: Attempt rates, completion rates and internal consistency (Cronbach alpha) were compared within the second cross-sectional, population-based Blue Mountains Eye Study (n = 3509, mean age 66.7 years, 57% women). RESULTS: The SF-36 was attempted by 3162 (90.1%) participants, of which 2470 (78.1%) completed all items and 2873 (90.9%) completed sufficient items for calculation of all dimensions. In a multivariate model adjusting for age, sex, and presenting visual and cognitive impairments, women (P = 0.011) and participants with visual or cognitive impairments (P < 0.0001) were less likely to attempt the questionnaire. Completion rates were significantly lower with increasing age (P < 0.0001), in men (P < or = 0.0005) and in those with cognitive impairment (P < 0.0001). A high level of internal consistency (Cronbach alpha > 0.85 for all dimensions) and construct validity was demonstrated, the latter distinguishing between those with and without medical conditions, disabilities or recent hospital admissions (P < 0.01). As the prevalence of visual or cognitive impairment was relatively low in this population, we found no apparent effect of these impairments on the validity of SF-36. CONCLUSIONS: Attempt and completion rates, but not internal consistency and construct validity, of the SF-36 were influenced by age, gender, and presenting visual and cognitive impairments. The overall high attempt and completion rates, internal consistency and construct validity suggest that the self-administered SF-36 is a suitable healthrelated quality of life (HRQOL) measure in similar older community-living populations.

Impact of bilateral visual impairment on health-related quality of life: the Blue Mountains Eye Study.

PURPOSE: To assess the impact of visual impairment on health-related quality of life (HRQOL) in an older population and compare it with the impact of major medical conditions. METHODS: Participants of the second cross-sectional Blue Mountains Eye Study (BMES; n = 3509; mean age, 66.7 years; 57% female) were asked to complete the self-administered 36-item Short-Form health survey (SF-36), a comprehensive interview, and an eye examination. Visual impairment was defined as visual acuity less than 20/40 (better eye). RESULTS: Of 3154 (89.9%) participants with complete data, 172 (5.5%) had visual impairment due to refractive errors (correctable visual impairment) and 66 (2.1%) due to eye conditions (noncorrectable visual impairment; 49 mild, 9 moderate, 8 severe). After adjustment for demographic and medical confounders, there was a trend toward lower SF-36 scores in participants with noncorrectable impairment than in those with correctable impairment (physical component score [PCS] Ptrend = 0.01 and mental component score [MCS] Ptrend = 0.02). Increasingly severe noncorrectable visual impairment was associated with significantly poorer SF-36 scores in all but two dimensions. The impact of noncorrectable visual impairment was comparable to that from major medical conditions (e.g., stroke) and had a greater impact on mental than physical domains (mean MCS = 46.2, PCS = 41). No significant differences in HRQOL were demonstrated between visual impairment cases caused by age-related maculopathy and cataract, after adjusting for severity of visual impairment. CONCLUSIONS: Noncorrectable visual impairment was associated with reduced functional status and well-being, with a magnitude comparable to major medical conditions. These data have implications for disability weights such as those developed by the Global Burden of Disease study.

Correlation between vision- and health-related quality of life scores.

PURPOSE: To examine the correlation between health-related quality of life (HRQOL) scores [assessed using the generic Short Form Health Survey (SF-36) questionnaire] and vision-related quality of life (VRQOL) scores [assessed using the National Eye Institute Visual Function Questionnaire (NEI-VFQ25)]. METHODS: Cross-sectional analytic study. All surviving participants of the Blue Mountains Eye Study (n = 1952, aged 60 years and older) were invited to attend comprehensive eye examinations 10 years after baseline examinations and were asked to complete both questionnaires. RESULTS: Complete data were available for 1436 participants. After controlling for age, sex and the presence of either unilateral or bilateral visual impairment, the number of hospital admissions, chronic medical conditions and disabilities, we found that the composite NEI-VFQ score was significantly associated with the two main domains of the SF-36 survey: the summary physical component score (P < 0.001) and the mental component score (P < 0.001). There was relatively low correlation (r < 0.3) between the NEI-VFQ25 subscales and SF-36 subscales including the physical and mental composite scores. CONCLUSION: VRQOL is influenced by both general health and HRQOL. However, there is a relatively low correlation between the individual subscales of these two quality of life questionnaires.

Hearing impairment and health-related quality of life: the Blue Mountains Hearing Study.

OBJECTIVES: To assess the association between hearing impairment and health-related quality of life (HRQOL) in an older population, using the self-administered 36-item Short-Form Health Survey (SF-36). DESIGN: Participants of the Blue Mountains Hearing Study (BMHS, N = 2956) attended a comprehensive interview and hearing examination in which both self-reported and measured hearing impairments were assessed. Hearing impairment was defined as the pure-tone average of air-conduction hearing thresholds >25 decibels hearing level (dB HL) for the four frequencies (0.5 to 4.0 kHz) in the better ear. RESULTS: Of the 2431 participants with complete data (mean age, 67.0 yr), 1347 (55.4%) did not have measured hearing loss, whereas 324 (13.3%) had unilateral (285 mild, 22 moderate, 17 severe) and 760 (31.3%) had bilateral hearing impairment (478 mild, 207 moderate, 75 severe). After adjusting for demographic and medical confounders, bilateral hearing impairment was associated with poorer SF-36 scores in both physical and mental domains (fall in physical component score, PCS of 1.4 points, p = 0.025; fall in mental component score, MCS of 1.0 point, p = 0.13), with poorer scores associated with more severe levels of impairment (PCS p(trend) = 0.04, MCS p(trend) = 0.003). Participants with bilateral hearing impairment who habitually used hearing aids had a slightly better PCS (mean, 43.1; standard error [SE], 0.9) than those with the same impairment who did not have hearing aids or who only used them occasionally (mean, 41.2; SE 0.5), although this finding was not statistically significant (p = 0.055). Persons with self-reported hearing loss had significantly poorer HRQOL than corresponding persons without, but persons with unilateral or high-frequency hearing loss did not have significantly different HRQOL scores than their corresponding counterparts. CONCLUSIONS: This study quantifies the associated disease burden of age-related hearing impairment on health-related quality of life in a population-based cohort of older persons.

Eccrine porocarcinoma of the upper eyelid.

A 75-year-old Caucasian man presented with foreign-body-type irritation of the left eye. Physical examination revealed a 12 x 10-mm nodule in his left upper eyelid, which reportedly had been present unchanged for more than 40 years. No other ophthalmological abnormalities were present. Incisional biopsy of the lesion revealed a malignant tumour that was thought to possibly represent a sebaceous carcinoma. However, a subsequent wide surgical excision showed that the tumour was an eccrine porocarcinoma, a rare sweat gland adenocarcinoma arising from the acrosyringium.

Patterns of glaucomatous visual field defects in an older population: the Blue Mountains Eye Study.

This report aims to describe the frequency of different patterns of visual field loss in open-angle glaucoma (OAG). The Blue Mountains Eye Study examined 3654 persons (aged 49+) during 1992-1994. Humphrey supra-threshold visual fields were performed in 88.9%. Those classified as glaucoma suspects had 30-2 full-threshold fields (9.2%). Of OAG cases (n = 108) with field tests in both eyes (n = 97), unilateral defects were present in 49 (50.5%) and bilateral in 48 (49.5%). Advanced field loss was found in 16 (15.4%) subjects and in 22 (10.9%) eyes, with bilateral loss present in 6 (6.2%) cases. Of all eyes of OAG cases (n = 201), 49 (24.4%) had no defects, 52 (25.9%) upper, 61 (30.3%) lower, and 17 (8.5%) had combined upper and lower loss. Of the upper and lower cases (n = 113), the types of defects included nasal step (36), arcuate (26), nasal plus arcuate (26), and hemispherical defects (25). Of subjects with fields in at least one eye (n = 104), there was a similar proportion in the worse eye of upper defects (28.8%), lower (31.7%), and combined upper and lower (24.0%). Undiagnosed OAG was more frequent in unilateral (65.3%) than bilateral (34.7%) cases (P = 0.003). This study reports the pattern of typical glaucomatous field loss in an older Australian population.

Prevalence and associations of dry eye syndrome in an older population: the Blue Mountains Eye Study.

This report describes the prevalence of self-reported dry eye syndrome and associations with systemic and ocular factors in an older Australian population. Participants of the Extension Blue Mountains Eye Study, aged 50 or older (mean age 60.8 years, n = 1174) completed a comprehensive eye examination and dry eye questionnaire. At least one dry eye symptom was reported by 57.5% of participants, with 16.6% reporting moderate to severe symptoms, more frequent in women (age-adjusted odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1-2.2). Three or more symptoms were reported by 15.3% of participants, also more frequent in women (age-adjusted OR 1.7, CI 1.2-2.4). No age-related trends or significant ocular associations were observed. After adjusting for age and sex, systemic factors significantly associated with dry eye syndrome included history of arthritis, asthma, gout, use of corticosteroids, antidepressants and hormone replacement therapy. In this older population, dry eye syndrome was common and has associations with female gender and systemic diseases.