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Methods
Population
The BMES baseline survey was conducted to describe the prevalence of, and risk factors associated with, vision loss and common
eye diseases in a typical older Australian sample consisting of
permanent residents 49 years of age or older residing in the Blue
ISSN 0161-6420/13/$ - see front matter
http://dx.doi.org/10.1016/j.ophtha.2013.03.032
2091
Study Procedures
The 15-year follow-up examination methods were similar to those
used at baseline.20 Participants underwent a comprehensive eye
examination after pupil dilation and completed a detailed main
questionnaire during a face-to-face interview. Additional questionnaires were completed at home by study participants.
Visual acuity was measured using a retroilluminated logarithm
of the minimum angle of resolution chart (VectorVision CSV-
2092
Denitions
Visual impairment was dened as VA worse than 20/40 (fewer
than 41 letters read), and blindness was dened as VA worse than
20/200 (0e5 letters read). The denition for VI was in keeping
with the denitions used in previous BMES reports, and it was the
Hong et al
Statistical Analysis
SAS software version 9 (SAS Inc, Cary, NC) was used for all
analyses, and age was dened as age at baseline. Cumulative
15-year incidence was calculated while considering the competing
risk of death.23 The competing risk regression model is an
adaptation of the Kaplan-Meier method that takes into account
2 competing events; in this case, the events would be either
Results
The mean age of participants at baseline was 64.5 years, and 57.9%
were female. Table 1 shows the baseline characteristics of the 2501
participants who attended at least 1 follow-up examination after
baseline with complete data for analysis. The main reasons for
not returning for follow-up examination were participant frailty
resulting from multiple comorbidities and relocation.
The overall mean decrease in number of letters read correctly
over the 15 years was similar in right and left eyes (6.9 and 6.8
letters, respectively); there was an inverse relationship between
reduction in the mean number of letters read correctly from baseline to the 15-year examination and increasing age, as shown
in Figure 2. There was no signicant gender difference in the
changes in numbers of letters read correctly in either right or left
eyes (P 0.97 and P 0.25, respectively).
The 15-year cumulative incidence of bilateral VI was 5.2%
(119 persons) and varied from 0.4% in those younger than 55 years
to 10.5% in those 75 years of age or older at baseline. The incidence of bilateral blindness was 0.9% (21 persons) and varied from
0% in those younger than 55 years to 1.7% in those 75 years of age
or older at baseline. Women were more likely than men to have
bilateral VI (6.8% vs. 3.4%; age-adjusted P 0.02) and bilateral
blindness (1.2% vs. 0.5%; age-adjusted P 0.09). The incidences
of VI and blindness were strongly age related in both men and
women (P<0.001; Table 2).
The 15-year cumulative incidence of unilateral VI was 12.3%
(293 persons) and varied from 3.4% in those younger than 55 years
to 15.4% in those 75 years of age or older at baseline. The incidence of unilateral blindness was 3.7% (95 persons) and varied
from 1% in those younger than 55 years to 6.9% in those 75 years
of age or older at baseline. Women were more likely than men to
have unilateral VI (13.3% vs. 10.8%) and blindness (4.7% vs.
2.6%); however, these differences were not statistically signicant
after adjusting for age (P 0.5 and P 0.1; Table 3).
The cumulative incidence of any VI was 17.3% (412 persons),
and incidence of blindness in any eye was 4.6% (116 persons). As
expected, women had a higher incidence of any VI (19.7% vs.
14.2%; age-adjusted P 0.06) and blindness (5.9% vs. 3.1%;
age-adjusted P 0.03) compared with men (Table 3).
Doubling of the visual angle occurred in 183 persons (6.9%)
based on the better eye, which was associated signicantly with
age in both men and women (P<0.001). Halving of the visual
angle occurred in 34 persons (1.6%) based on worse eye VA, and
there was no signicant association of halving the visual angle with
increasing age in either gender. Of these 34 persons, 20 (59%) had
undergone cataract surgery during the follow-up period.
Table 4 shows a comparison of the incidence of VI between our
study and BDES1 ndings using the modied denition of VI and
blindness, after direct standardization to the age distribution of the
BMES population. Incidences of VI were higher in the BDES
population (11.1%) compared with our population (6.4%), after
adjusting for competing risk of death. However, the incidences
of blindness were similar among the BDES population (1.2%)
2093
No.
P Value
62.8
55.1
192
157
<0.01
0.10
0.07
1558
1295
2224
1648
63.8
42.8
83.9
62.4
190
125
250
191
0.93
<0.01
<0.01
0.22
5.9
1.8
147
45
6.2
3.3
19
10
0.82
0.08
14.7
4.6
1.8
1.8
63.5
351
105
46
44
1569
8.3
3.9
1.0
1.6
58.7
24
11
3
5
176
<0.01
0.80
0.28
0.87
0.10
3.3
14.3
42.5
6.4
7.4
83
358
1063
160
186
3.0
7.8
41.8
8.5
6.2
9
24
128
26
19
0.74
<0.01
0.82
0.16
0.44
51.24
35.6
13.2
3.8
1239
860
319
91
42.5
34.6
23.0
3.8
124
101
67
11
<0.01
0.74
<0.01
0.99
%
Mean age SD at baseline (yrs)
Female gender
Education (trade certicate or higher)
Employment
High prestige (Daniels prestige scale <5)
Receiving pension
Home ownership
Currently married
Visual impairment in worse eye
Moderate (VA 6/12e6/60)
Severe (VA 6/60 or worse)
Ocular history of
Cataract
AMD
Diabetic retinopathy
Glaucoma
Recent ophthalmologist/optometrist
examination (<2 yrs)
History of
Stroke
Heart disease (AMI or angina)
Hypertension
Diabetes
Cancer
Smoking status
Nonsmoker
Previous smoker
Current smoker
Heavy drinker (4 drinks/day)
No.
57.8
60.6
1445
1445
63.5
53.4
90.9
65.9
64.38.6
60.57.8
AMD age-related macular degeneration; AMI acute myocardial infarct; SD standard deviation; VA visual acuity.
and our population (1.1%). Similar gender differences and agerelated trends in incidences also were observed in the BDES
population.
Figure 3 presents the proportions of incident cases by primary
attributable causes for any VI and blindness in any eye (either
rst or second eye). Cataract accounted for most cases (48.5%)
of any VI, followed by AMD (26.9%). However, AMD was
responsible for most blindness cases (56.9%), followed by
Discussion
Figure 2. Mean change in number of letters read correctly in right and left
eyes by age between baseline and the 15-year follow-up.
2094
Hong et al
Table 2. Incidence of Bilateral Visual Changes by Age at Baseline and by Gender in the Blue Mountains Eye Study
Visual Impairmenty
At
Risk
95%
Condence
Interval
217
564
579
375
1735
2.6
3.6
11.8
12.3
8.0
0.1e5.1
0.9e5.3
8.8e14.8
9.2e15.4
6.6e9.4
170
441
464
294
1369
1.4
5.2
6.0
8.1
5.6
0.0e3.3
2.9e7.5
3.7e8.2
5.3e10.9
4.3e6.9
387
1005
1043
669
3104
2.0
4.3
9.0
10.4
6.9
0.4e3.6
2.9e5.7
7.1e10.9
8.3e12.5
5.9e7.9
P
Value
(for
Trend)
At
Risk
Blindnessz
P
95%
Value
Condence
(for
Interval
Trend)
At
Risk
<0.01
212 0.7
541 2.1
534 11.5
238 13.6
1525 6.8
0.0e2.1
0.7e3.5
8.3e14.7
9.5e17.7
5.4e8.2
<0.01
217
559
567
338
1681
0.0
0.3
2.0
2.4
1.2
0.0e0.0
0.0e0.8
0.6e3.4
0.7e4.1
0.6e1.8
<0.01
165
427
413
195
1200
0.0
2.9
3.7
7.0
3.4
0.0e0.0
1.0e4.8
1.8e5.6
3.7e10.3
2.3e4.5
<0.01
167
434
447
264
1312
0.0
0.3
0.5
0.8
0.5
0.0e0.0
0.0e0.9
0.0e1.3
0.0e1.9
0.1e0.9
<0.01
377 0.4
968 2.5
947 7.7
433 10.5
2725 5.2
0.0e1.1
0.4e3.6
5.8e9.6
7.8e13.2
4.3e6.1
384
993
1014
602
<0.01 2993
0.0
0.3
1.3
1.7
0.9
0.0e0.0
0.0e0.7
0.5e2.1
0.6e2.8
0.5e1.3
P
95%
Value
Condence
(for
Interval
Trend)
P
Value
(for
Trend)
At
Risk
95%
Condence
Interval
<0.01
118
365
475
365
1323
2.7
1.0
1.5
1.4
1.4
0.0e5.7
0.0e2.1
0.4e2.6
0.2e2.6
0.7e2.1
0.43
<0.01
66
231
340
279
916
0.0
2.2
2.1
1.9
1.9
0.0e0.0
0.0e4.4
0.6e3.6
0.3e3.5
1.0e2.8
0.03
<0.01
184
596
815
644
2239
1.7
1.4
1.8
1.6
1.6
0.0e3.6
0.3e2.5
0.9e2.7
0.6e2.6
1.0e2.2
0.04
*Doubling of the visual angle was dened as a loss of 15 letters or more in the better eye at follow-up visits.
y
Incidence of visual impairment was dened a visual acuity of <20/40 at follow-up in the better eye when both eyes were 20/40 at baseline examination.
z
Incidence of severe visual impairment was dened as visual acuity of <20/200 at follow-up in the better eye when both eyes were 20/200 at baseline
examination.
x
Halving of the visual angle was dened as a gain of 15 letters or more in the worse eye at the follow-up visit.
2095
Any
Blindnessy
Visual Impairment*
Gender
and Age
Range
(yrs)
Female
<55
55e64
65e74
75
Total
Male
<55
55e64
65e74
75
Total
All
<55
55e64
65e74
75
Total
At
Risk
95%
Condence
Interval
212
541
534
238
1525
2.6
10.6
18.7
17.4
13.3
0.1e5.1
7.8e13.4
15.1e22.3
12.9e21.9
11.5e15.1
165
427
413
195
1200
4.4
10.1
13.3
12.7
10.8
1.0e7.8
7.0e13.2
10.0e16.6
8.5e16.9
9.0e12.6
377
968
947
433
2725
3.4
10.4
16.3
15.4
12.3
1.3e5.5
8.3e12.5
13.8e18.8
12.3e18.5
11.0e13.6
P
Value
(for
Trend)
At
Risk
95%
Condence
Interval
<0.01
217
559
567
338
1681
1.2
2.3
6.5
8.4
4.7
0.0e2.9
0.9e3.7
4.1e8.9
5.5e11.3
3.6e5.8
<0.01
167
434
447
264
1312
0.8
1.9
2.6
5.1
2.6
0.0e2.3
0.4e3.4
1.1e4.1
2.6e7.6
1.7e3.5
<0.01
384
993
1014
602
2993
1.0
2.1
4.6
6.9
3.7
0.0e2.1
1.1e3.1
3.2e6.1
4.9e8.9
3.0e4.4
Visual Impairmentz
P
Value
(for
Trend)
At
Risk
95%
Condence
Interval
<0.01
212
541
534
238
1525
3.3
12.5
29.2
30.6
19.7
0.5e6.1
9.5e15.5
25.1e33.3
25.6e35.6
0.0e4.1
<0.01
165
427
413
195
1200
4.4
12.9
16.9
19.4
14.2
1.0e7.8
9.5e16.3
13.3e20.5
14.8e24.0
12.2e16.2
<0.01
377
968
947
433
2725
3.8
12.7
23.5
25.5
17.3
1.6e6.0
10.4e15.0
20.7e26.3
22.1e29.0
15.8e18.8
Blindnessx
P
Value
(for
Trend)
95%
Condence
Interval
P
Value
(for
Trend)
At
Risk
<0.01
217
559
567
338
1681
1.2
2.5
8.5
8.7
5.9
0.0e2.9
1.0e4.0
5.8e11.2
7.6e13.8
4.6e7.2
<0.01
<0.01
167
434
447
264
1312
0.8
2.2
3.1
5.9
3.1
0.0e2.3
0.6e3.8
1.4e4.8
3.2e8.6
2.1e4.1
<0.01
<0.01
384
993
1014
602
2993
1.0
2.4
5.9
8.6
4.6
0.0e2.1
1.3e3.5
4.3e7.5
6.5e10.7
3.8e5.4
<0.01
*Incidence of unilateral visual impairment was dened as visual acuity of <20/40 at follow-up in only 1 eye (worse eye) when both eyes had visual acuity of
20/40 at baseline examination.
y
Incidence of unilateral blindness was dened as visual acuity of <20/200 at follow-up in only 1 eye (worse eye) when both eyes had visual acuity of 20/200
at baseline examination.
z
Incidence of any visual impairment was dened as having at least 1 eye at risk of developing visual impairment (visual acuity <20/40) at baseline and the at
risk eye demonstrating visual impairment at the follow-up examination.
x
Incidence of any blindness was dened as having at least 1 eye at risk of developing blindness (visual acuity <20/200) at baseline and the at-risk eye
demonstrating blindness at the follow-up examination.
2096
Hong et al
Table 4. Fifteen-Year Incidence of Visual Impairment and Blindness Accounting for the Competing Risk of Death by Age and by Gender
in the Blue Mountains Eye Study Compared with the Beaver Dam Eye Study
Visual Impairment
At
Risk
Crude
%
211
536
523
226
1496
0.7
3.1
12.6
15.7
7.8
165
424
405
182
1176
0.0
4.3
4.8
10.4
4.8
376
960
928
408
2672
0.4
3.6
8.9
13.3
6.4
Beaver Dam
Eye Study
95%
Condence
Interval
At
Risk
Crude
%
6.3e9.3
661
574
569
270
2074
1.5
5.6
18.4
29.7
10.2
3.5e6.1
586
507
436
185
1714
1.4
2.8
12.6
18.5
6.0
5.4e7.4
1247
1081
1005
455
3788
1.4
4.3
15.9
25.1
8.3
Blindness
Standardized to
Blue Mountains
Eye Study
Blue Mountains
Eye Study
% (95%
Condence
Interval)
At
Risk
Crude
%
13.1 (11.6e14.6)
217
559
565
335
1676
0.0
0.5
2.3
3.5
1.3
8.4 (7.1e9.7)
167
433
446
263
1309
0.0
0.3
0.5
1.2
0.5
11.1 (10.1e12.1)
384
992
1011
598
2985
0.0
0.4
1.5
2.5
1.1
Beaver Dam
Eye Study
Standardized to
Blue Mountains
Eye Study
95%
Condence
Interval
At Risk
Crude %
% (95%
Condence
Interval)
0.9e2.3
667
578
598
327
2170
0.2
0.2
0.9
5.0
1.0
1.4 (0.9e3.4)
0.2e1.0
588
510
447
211
1756
0.2
0.0
1.6
1.8
0.6
0.9 (0.2e0.9)
0.7e1.5
1255
1088
1045
538
3926
0.2
0.1
1.2
3.7
0.8
1.2 (0.7e2.4)
The estimated VI incidence also might have been overestimated in our population. Participants who did not return
to any follow-up examination had a lower mean age at
baseline and a lower prevalence of cataract at baseline
compared with those who attended at least 1 follow-up
examination. Our study had a relatively high proportion of
participants lost to follow-up at the 15-year examination.
Assuming losses to follow-up were not deaths, the incidence
estimates potentially could range from 4.6%, if all participants did not have incident VI, to 19%, if all participants had
2097
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Centre for Vision Research, Department of Ophthalmology and Westmead Millennium Institute, University of Sydney, Sydney, Australia.
2
Centre for Eye Research Australia, University of Melbourne, Melbourne,
Australia.
Correspondence:
Jie Jin Wang, MMed, PhD, Centre for Vision Research, Department of
Ophthalmology, University of Sydney, Westmead Hospital, Hawkesbury
Road, Westmead, New South Wales, Australia 2145. E-mail: jiejin.wang@
sydney.edu.au.
Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials
discussed in this article.
2099