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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 17  |  Issue : 2  |  Page : 91-96

Prevalence of age-related macular degeneration among elderly patients attending Alexandria Main University Hospital


1 Department of Ophthalmology, Alexandria University, Alexandria, Egypt
2 Department of Community Medicine and Public Health, Alexandria University, Alexandria, Egypt

Date of Submission16-Sep-2015
Date of Acceptance04-Nov-2015
Date of Web Publication30-Aug-2016

Correspondence Address:
Maha M Zaki
19 El Moshir Ahmed Ismaiil, Sidi Gaber, 21311 Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-9173.189075

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  Abstract 

Purpose
The aim of the study was to estimate the age-specific and sex-specific prevalence of age-related macular degeneration (AMD) among elderly patients attending Alexandria Main University Hospital.
Study design
A cross-sectional survey was conducted.
Patients and methods
Patients aged 55 years or older were randomly selected from those attending different outpatient clinics at Alexandria Main University Hospital. One thousand eyes of 532 patients were included in the study. They underwent full ophthalmic examination with fundus photography. The fundus photographs were graded into early and late AMD according to the International Age-Related Macular Epidemiological Study Group Classification system. Prevalence rates were calculated.
Results
The overall prevalence of AMD was 6.6%. The prevalence of early and late AMD was 5.3 and 2.4%, respectively. There was a significantly higher prevalence of early and late AMD among those aged at least 75 years as compared with other age groups. The prevalence of AMD among male participants was 9.2% compared with only 4.1% among female participants. When potential risk factors were analyzed, smokers and those suffering from hypertension were associated with a significantly higher prevalence of AMD than were nonsmokers or those without hypertension. Diabetes mellitus was not significantly associated with AMD.
Conclusion
In this study, the prevalence of early AMD in younger age groups was lower than that found in other population-based studies in western populations. The prevalence of AMD increased with age and was significantly higher among men and smokers.

Keywords: age-related macular degeneration, drusen, geographic atrophy, neovascular age-related macular degeneration, prevalence, risk factors


How to cite this article:
Fadel AM, El Hennawi HM, Bayoumi NH, Elweshahi HM, Zaki MM. Prevalence of age-related macular degeneration among elderly patients attending Alexandria Main University Hospital. Delta J Ophthalmol 2016;17:91-6

How to cite this URL:
Fadel AM, El Hennawi HM, Bayoumi NH, Elweshahi HM, Zaki MM. Prevalence of age-related macular degeneration among elderly patients attending Alexandria Main University Hospital. Delta J Ophthalmol [serial online] 2016 [cited 2022 May 22];17:91-6. Available from: http://www.djo.eg.net/text.asp?2016/17/2/91/189075


  Introduction Top


Age-related macular degeneration (AMD) is defined as a degenerative disease of the photoreceptors and retinal pigment epithelium (RPE) in the human macula affecting elderly persons [1]. In epidemiologic studies, an age of 50 years is arbitrarily chosen as the minimum age for the diagnosis of AMD [2].

According to the WHO in 2012, AMD ranked third globally as a cause of blindness after cataract and glaucoma [3], and according to the Eye Diseases Prevalence Research Group it is the most common cause of visual impairment in individuals over the age of 55 years in developed countries [4].

Among individuals who have vision loss from AMD, 60% report significant declines in their ability to participate in valued activities as reading and driving [5]. Their quality of life is reduced as documented by clinical depression in almost one-third of those who have this condition [5].

A decade ago, AMD was largely untreatable. However, new pharmaceuticals have substantially changed the management of the disease. Currently, these treatments are associated with enormous monetary cost. Hence, accurate prevalence estimates are needed to plan for availability of healthcare services and quality of life connected with having such a condition.

In addition to treatment, major advances have been made in understanding the epidemiology, risk factors, and genetics of AMD.

Such data are also of importance in planning future studies, such as controlled clinical trials for prevention and treatment of the disease.


  Patients and methods Top


A cross-sectional survey was conducted. Individuals aged 55 years or older were randomly selected from among those attending four outpatient clinics of different specialties in Alexandria Main University Hospital — namely, internal medicine, dermatology, surgery, and cardiology. Each outpatient clinic was visited once a week at an alternative base (i.e. field work was carried out 4 days/week). Patients were selected randomly using a systematic random sampling technique. Every third patient attending the clinic, fulfilling the inclusion criteria, and willing to participate was included in the study until completion of the required sample.

Approval for this study has been obtained from the Research Ethics Committee of Alexandria Faculty of Medicine. Both verbal and written informed consent was obtained from all participants included in the study after explaining the aim and procedures of the study to them.

All participants were interviewed using a structured questionnaire that included personal data (age, sex, and occupation), smoking history, and medical history [chronic hypertension and diabetes mellitus (DM)]. Family history was taken at the beginning of the study but was later omitted as most of the participants were unaware whether their first-degree relatives suffered from AMD.

All eligible eyes were examined for best-corrected distance and near visual acuity.

Automated refraction (Topcon Corporation, Tokyo, Japan) and tonometry (using Goldmann applanation tonometer) were carried out. Anterior segment examination and stereoscopic fundus examination using a slit-lamp biomicroscope with a 78 D superfield lens (Volk Optical Inc., Mentor, Ohio, USA) were performed. The fundus examination was performed after adequate pupil dilatation with one drop of 1.0% tropicamide.

Eyes with ocular diseases or conditions and those that had undergone previous retinal surgical procedures or interventions, the presence of which may complicate the evaluation of AMD, were excluded. The eyes with sufficiently clear media to allow photographic assessment of the fundus details were enrolled in the study. One thousand eyes were included.

Colored fundus photographs were taken using a digital Topcon fundus camera (TRC-50IX; Topcon Corporation, Tokyo, Japan). They were examined and graded into early and late AMD according to the international classification proposed by the International Age-Related Macular Epidemiological Study Group [2]. Early AMD was defined by the presence of soft drusen (≥63 μm) or the presence of RPE abnormalities associated with drusen in the absence of signs of late AMD. Pigmentary abnormalities were classified into hypopigmentation or hyperpigmentation. Late AMD was classified into two types: geographic atrophy (GA) and neovascular AMD (NV-AMD). GA was defined by hypopigmentation, where the choroidal vessels of the eye are visible in an area of at least 175 μm in diameter. NV-AMD was defined by the presence of at least one of the following characteristics: RPE detachment, which may be associated with neurosensory retinal detachment; subretinal or sub-RPE neovascular membranes; subretinal hemorrhages that are not related to other retinal vascular diseases; epiretinal, intraretinal, subretinal, or subpigment epithelial scar; or glial tissue or hard exudates (lipids) within the macular area related to any of the above, and not related to other retinal vascular disease.

The coexistence of GA and NV-AMD in the same eye was categorized as NV-AMD.

Fluorescein angiography using a digital Topcon fundus camera and optical coherence tomography using Heidelberg Spectralis (Heidelberg Engineering, Heidelberg, Germany) were carried out for cases with suspected GA, grayish macular lesions, or macular scars.

Data management and analysis

Data were coded and fed into the computer using the statistical package for the social sciences program (SPSS, version 18; SPSS Inc., Chicago, Illinois, USA). Descriptive and analytic measures were used. In descriptive statistics, number and percentage were used to describe the frequency of the studied qualitative variables as well as the prevalence of both early and late AMD. Age of the participants was presented as mean and SD. In analytic statistics, comparative statistics using the c2 and Monte-Carlo tests as well as analysis of variance were used to identify factors that might be associated with the occurrence of AMD. Data were analyzed at 5% level of significance.


  Results Top


In this study, 1000 eyes of 532 participants underwent full ophthalmic examination and retinal photography. The 532 participants had gradable photographs of at least one eye, allowing the final analysis to be made on 1000 eyes. Poor-quality photographs were most often due to media opacities.

As shown in [Table 1], the age of the participants ranged from 55 to 85 years, with a mean of 61.74 ± 5.93 years. Also, women accounted for 50.9% (n = 271) and men for 49.1% (n = 261) of the study sample.
Table 1 Distribution of the study sample according to their demographic data (n = 532)

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Smokers made up 37.6% (200 patients) of the sample [Table 2]. All women were nonsmokers.
Table 2 Distribution of the study sample according to history of smoking and medical history (n = 532)

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A history of hypertension was observed in 34.2% and a history of diabetes in 12.6% of patients [Table 2].

Out of the 1000 eyes included in the study, 54 (5.4%) eyes revealed AMD (any form) [35 of 532 (6.6%) patients]. Among these 35 patients, bilateral presence of AMD was detected in 13 (37.1%).

Early AMD, which included drusen 63 μm or more with or without pigmentary abnormalities (excluding late AMD), was present in 38 eyes out of the 1000 (3.8%) examined, or in 28 of 532 (5.3%) participants. Eighteen participants had early AMD in one eye only, whereas 10 patients had bilateral early AMD.

Late AMD was present in 16 eyes out of the 1000 (1.6%) eyes examined or in 13 of 532 (2.4%) patients. It was unilateral in 10 (1.9%) patients and bilateral in three (0.6%) patients.

Among persons with unilateral late AMD, 60% had early AMD in the other eye.

Late AMD was diagnosed as GA in six eyes of six patients. Neovascular macular degeneration was found in 10 eyes of 10 patients.

The age of patients diagnosed with any form of AMD ranged from 55 to 85 years, with a mean of 72.17 ± 7.09 years. It was significantly higher than the mean age among those with no AMD (61.01 ± 5.09 years; P < 0.001). The frequency of AMD increased with age [Table 3]. There was a significantly higher percentage of patients with AMD in the 75 or more age group as compared with those free from AMD (PMC < 0.001).
Table 3 Distribution of the studied sample according to the prevalence of age-related macular degeneration and age of patients

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[Table 4] reveals the age-specific prevalence of early and late AMD. Early AMD increased in prevalence from 0% in people aged 55 to less than 60 years to 54.2% among those aged 75 years and older. Also, late AMD increased from 0.9% in the age group 55 to younger than 60 years to 16.7% in the age group 75 years or more.
Table 4 Distribution of the studied sample according to the prevalence of early and late age-related macular degeneration by age groups

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The mean age of patients with late AMD (73.73 ± 7.13) was significantly higher than the mean age among those with no AMD (61.01 ± 5.09) and among those with early AMD (69.54 ± 6.44) (P < 0.001).

As shown in [Table 5], the frequency of any AMD among male participants was 9.2% as compared with only 4.1% among female participants. This difference was statistically significant (P = 0.017).
Table 5 Distribution of the studied sample according to the prevalence of age-related macular degeneration and their personal and medical history

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Early AMD and late AMD were present in 6.1 and 3.1% of male participants, respectively, as compared with 2.2 and 1.8% in women. This was statistically significant (P = 0.047; [Table 6].
Table 6 Distribution of the studied sample according to the prevalence of early and late age-related macular degeneration and personal and clinical characteristics

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Ten percent of current smokers suffered from AMD as compared with only 4.5% of nonsmokers [Table 5]. This difference was statistically significant (P = 0.013). Although 6.5% of smokers had early AMD, only 2.7% of nonsmokers had early AMD. Only 1.8% of nonsmokers were diagnosed with late AMD as compared with 3.5% of those who are currently smokers. This difference was statistically significant (P = 0.041; [Table 6].

A significantly higher percentage of patients were diagnosed with AMD among those with a history of systemic hypertension (12.1%) than among those without hypertension (3.7%) (P < 0.001; [Table 5]. Among those with a positive history of systemic hypertension, 6.6 and 5.5% were diagnosed as having early and late AMD, respectively, as compared with only 2.9 and 0.9%, respectively. This was statistically significant (P < 0.001; [Table 6].

No statistically significant difference was found between patients with DM and those without DM as regards the prevalence of AMD (P = 0.830; Table 5). DM was not significantly associated with either category of AMD (P = 0.844; [Table 6].


  Discussion Top


Being the best study design to estimate the prevalence of diseases, a cross-sectional survey was conducted. This study aimed to know the prevalence of AMD among 1000 eyes of 532 patients attending Alexandria Main University Hospital at the outpatient clinic between June 2012 and November 2013. Out of the 1000 eyes included in the study, 54 (5.4%) eyes of 35 patients were diagnosed with AMD. In other words, 6.6% of the participants had signs of AMD in one or both eyes. Among Americans 40 years of age or older, the prevalence of any AMD in the 2005–2008 National Health and Nutrition Examination Survey (NHANES) was 6.5%, which is lower than the 9.4% prevalence reported in the 1988–1994 Third NHANES [6].

In this study, the age-specific prevalence of AMD, whether early or late, increased with age. This signifies that increase in age is a risk factor for AMD.

In this study early AMD was present in 5.3% of patients. The pooled prevalence estimate for early AMD in Asian populations aged 40–79 years was 6.8%, whereas that for the same age range in mainly white populations was slightly higher at 8.8% [7].

In the present study, early AMD increased from 0% of the study subjects in the age group 55 to less than 60 years to 54.2% of the patients aged 75 years or more. In the meta-analysis of several population-based studies in the USA, Europe, and Australia, Friedman et al. [8] found that the prevalence of large drusen increased from about 1.5% in Whites aged 40–49 years to more than 25% in those aged 80 years or more. Among Black participants in the same meta-analysis, the percentages were 3.9 and 10.5%, respectively.

In the present study, it is noted that the prevalence of early AMD in younger age groups was lower than that in many studies, but it must be taken into account that the relatively small number of participants in the highest age category caused a relatively higher prevalence in this category.

The definition of late-stage AMD is more clear-cut, making comparisons more reliable. The results of the present study (2.4%) were comparable to those in other studies. In the Blue Mountains Eye Study [9] the prevalence of late AMD was 2.06% among participants aged 50 years or more. In the Thessaloniki Eye Study [10] and in the Rotterdam Study [11], the prevalence was 2.5 and 1.9%, respectively, among participants aged 60 years or more.

The results in this study were higher than those of several other USA studies in which the prevalence ranged between 0.2 and 1.6%. This higher prevalence might be explained by the differences in the age distribution of the participants. The Atherosclerosis Risk in Communities (ARIC) Study [12] demonstrated a low prevalence rate (0.2%). In that study, the age range of participants was 48–72 years, thus excluding the oldest participants, in which the prevalence of late AMD is the highest.

In this study, those with late AMD were further subdivided into six (0.6%) eyes with GA and 10 (1%) eyes with NV-AMD; that is, neovascular disease outnumbered GA. In the Thessaloniki Eye Study [10], GA was present in 1.3% and NV-AMD in 1.4% of the participants. In the European Eye Study (EUREYE), an excess of NV-AMD (prevalence of 2.3%) was found compared with GA (prevalence of 1.2%) at a ratio of 1.9, which is similar to ratios reported in other studies [9],[11],[13].

In the present study, AMD was more common in men compared with women, whether early (6.1 vs. 2.2%) or late AMD (3.1 vs. 1.8%). In the Los Angeles Latino Eye Study [14], Latino men were at an approximately two-fold increased risk of any or early AMD. Also, the Rotterdam Study [11] reported a lower prevalence in women. Studies [15],[16],[17],[18] in Asian populations have reported higher late AMD prevalence among men compared with women and this was partly speculated to be due to the higher smoking rate in Asian men than in women [17].

In contrast, our results were inconsistent with some studies among White populations. A higher prevalence of late AMD in women was reported in the Beaver Dam Eye Study [13] and the Blue Mountains Eye Study [9].

The results in this study may be explained by the higher smoking rate among men and also the higher participation rate of men in the higher age groups. It is possible that the higher rates observed for men at older ages may reflect differential survival.

In this study, the prevalence of early AMD among smokers (6.5%) was higher than that of late AMD (3.5%) in the same group. This might have been due to the relatively small number of late AMD in this study, which is more likely related to smoking [19].

In the US Twin Study of Age-Related Macular Degeneration [20], smokers had almost a two-fold increased risk for AMD.

In the present study, 7.1 and 5.5% of those with a positive history of systemic hypertension were diagnosed as having early and late AMD, respectively, and hypertension was significantly associated with occurrence of any AMD.

Hypertension [21],[22],[23] has been significantly associated with early and advanced AMD in several studies. In the Framingham Study [21], systemic hypertension was significantly associated with AMD. In the Beaver Dam Eye Study (BDES) [22], individuals with uncontrolled hypertension had over a three-fold risk of developing exudative AMD.

In this study, out of the 67 patients with diabetes, only four had AMD. This study was unable to detect any association between DM and any AMD lesion. Similar to the present study, some population-based studies that have examined the relationship of diabetes with AMD did not detect any association [24],[25]. Only a few studies have shown that diabetes is correlated to late AMD [26],[27].

The strength of this study is the relatively large number of patients examined. Those patients were not visiting the hospital for the treatment of confirmed AMD, which may bias the estimates upward. Another point of strength was using an internationally recognized grading system and digital retinal photographs in this study.

Still, there are some limitations to the present study. The number in the oldest age group (>80 years) was very small, resulting in only 13 cases of late AMD. The oldest age group was less likely to have gradable fundus images, and this may cause reduction in the prevalence rate of AMD.

Characteristics of patients who refused to participate compared with responders may have biased the results.

Choosing all patients from a hospital leads to bias as they are mostly suffering from hypertension and/or DM.

In summary, older age, male sex, smoking, and systemic hypertension were related to AMD in this study. These relationships need to be further validated and considered when developing programs for screening and management of AMD in Egyptians.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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