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Visual Impairment, Age-Related Cataract, and Mortality
Arch Ophthalmol. 2001;119:1186-1190.
ABSTRACT
| |
Objective To explore associations between visual impairment, cataract, and mortality
in older persons after adjusting for other factors associated with mortality.
Methods A population cohort of 3654 persons aged 49 years or older (82.4% of
eligible residents in the Blue Mountains region, west of Sydney, Australia),
were examined at the Blue Mountains Eye Study baseline period (1992-1994)
and followed up 5 years later (1997-1999). Australian National Death Index
data were used to confirm persons who had died since baseline. Associations
between mortality and presence of visual impairment and cataract at baseline
were assessed using the Cox proportional hazards regression model, controlling
for age, sex, demographic and socioeconomic status, medical history, and health
risk behaviors.
Results By June 30, 1999, 604 participants (16.5%) had died. The age- and sex-standardized
7-year cumulative mortality rate was 26% among persons with any visual impairment
and 16% in persons without visual impairment. After adjusting for factors
found significantly associated with mortality, including age, male sex, low
self-rated health, low socioeconomic status, systemic medical conditions,
and negative health risk behaviors, the presence at baseline of any visual
impairment was independently associated with increased mortality risk (risk
ratio [RR], 1.7; 95% confidence interval, 1.2-2.3). The presence of age-related
cataract, either nuclear (RR, 1.5), cortical (RR, 1.3), or posterior subcapsular
cataract (RR, 1.5), was also significantly associated with increased mortality
risk. These associations remained statistically significant when visual impairment
and each type of cataract were included simultaneously in the multivariate
Cox model.
Conclusion Visual impairment and age-related cataract may be independent risk factors
for increased mortality in older persons.
INTRODUCTION
VISUAL IMPAIRMENT broadly impacts the ability of people to function
and to remain independent as they grow older.1-2
Impaired vision also severely affects quality of life,3
may be associated with depression,4 can affect
a person's self-ranking of his or her health,5
and increases the need for community support.6
Limited data are available to assess whether visual impairment is associated
with survival of older persons. Only 3 previous reports have examined this
relationship. In a small population in Melton Mobray, Leicestershire (England)
(N = 469)7 and in the Study of the Well-Being
of Older People in Cleveland (Ohio) (N = 1408),8
persons with visual impairment had a moderate increased risk of death, a difference
that was not statistically significant after adjustment. In the Beaver Dam
(Wisconsin) population (N = 4926),9 visual
impairment was statistically significantly associated with a 57% increase
in mortality after adjusting for age and sex. However, the association became
nonsignificant after adjusting for multiple systemic characteristics (eg,
history of cancer, cardiovascular disease, or diabetes; smoking; diastolic
blood pressure) found to be associated with mortality.9
Several studies have reported that cataract is associated with increased
mortality.9-13
In the Framingham Eye Study (Mass) (N = 1945), the 3 main cataract subtypes
(nuclear, cortical, and posterior subcapsular) were significantly associated
with increased mortality after adjusting for age, sex, and presence of diabetes.10 Later reports have also supported a relationship
between the presence of age-related cataract or cataract surgery and mortality
in nondiabetic populations,11-13
although a limited number of confounding variables were adjusted for in these
studies. In the Beaver Dam Eye Study, more severe nuclear cataract was significantly
associated with reduced survival in people without diabetes after adjusting
for multiple systemic characteristics.9
Any relationship between visual impairment and mortality could be mediated
via cataract as an intermediary or surrogate. Since previous studies have
not addressed this question to our knowledge, we aimed to assess whether an
association exists between visual impairment and increased mortality and,
if so, whether this is independent of the association between age-related
cataract and mortality.
METHODS
The Blue Mountains Eye Study is a population-based cohort study of vision
and common eye diseases in residents aged 49 years or older living in a defined
area west of Sydney. The population is representative of Australia's ethnic
mix and measures of socioeconomic status but is slightly older than the New
South Wales (Australia) state average.14 This
research was approved by the Western Sydney Area Human Ethics Committee and
written informed consent was obtained from all 3654 participants. Baseline
examinations were performed during 1992-1994, with a participation rate of
82.4% overall and 87.9% after excluding people who died or left the area during
the examination period.
IDENTIFICATION OF DEATHS
To identify persons who had died since the baseline examination, demographic
information was used to cross-match the 3654 participants with the Australian
National Death Index (NDI) data in late 1999. The NDI data had at that time
been updated to June 30, 1999, in most Australian states. A probabilistic
record linkage package was used, adopting a multiple-pass procedure in which
both data sets were grouped based on different characteristics (eg, date of
birth, name, sex) each time. Matches were divided into exact and nonexact.
All nonexact matched records were examined manually and accepted if there
was only 1 nonexact matched characteristic that was noncritical. Information
provided by family members during follow-up was also included if the participant
was reported to have died on or before June 30, 1999. This increased the number
of deaths by 39 persons. Among these additional deaths, most (71%) died in
the year prior to June 30, 1999, so that a lag in notification to the NDI
was presumed to be the reason this group had not been listed.
BASELINE EYE EXAMINATION
During the baseline eye examination, presenting visual acuity was measured
using a logMAR chart while the participant wore current distance glasses.
Best-corrected visual acuity was then measured after a detailed subjective
refraction.15 For each eye, visual acuity was
recorded as number of letters read correctly, from 0 (worse than 20/200) to
70 (20/10) letters. Visual impairment was defined as a visual acuity of 20/40
or worse in the better eye. Presenting visual impairment was defined as impaired
vision using current spectacles, if worn, and visual impairment after best
correction was defined as impaired vision after best refractive correction.
Those whose presenting visual impairment improved after refraction were considered
to have "correctable" visual impairment.
Cataract and past cataract surgery were diagnosed from grading of slitlamp
and retroillumination lens photographs16 using
the Wisconsin Cataract Grading System.17 Nuclear
opacities were graded by comparison with 4 standard slitlamp photographs and
nuclear cataract was defined as an opacity level of 4 or 5. Cortical cataract
was defined as opacity involving greater than or equal to 5% of the lens area,
and posterior subcapsular cataract was defined as the presence of any such
opacity. There were 71 persons without retinal photographs of both eyes, 102
without photographs for grading cortical or posterior subcapsular cataract,
and 1045 persons without gradable photographs for assessing nuclear cataract.16
Diabetic retinopathy or other retinal diseases were diagnosed during
a masked grading of the stereo retinal photographs. Grading of age-related
maculopathy photographs followed the Wisconsin Age-Related Maculopathy Grading
System.18 Open-angle glaucoma was defined as
reported previously.19 Spherical equivalent
refraction, measured in diopters, was calculated using the spherical diopter
power plus half the cylindrical power. Myopia was defined when the mean spherical
equivalent of the 2 eyes was greater than or equal to -1 diopter.
OTHER BASELINE DATA
Baseline characteristics were collected during a face-to-face interview
using a standard questionnaire. A history of systemic diseases and a detailed
history of smoking (including pack-years), alcohol consumption, and whether
participants walked regularly for exercise were recorded. Global self-rated
health was assessed by asking: "For someone of your age, how would you rate
your overall health; would you say it is excellent, good, fair or poor?" Difficulty
in walking or use of a cane, walker, or wheelchair at the clinic visit was
recorded. Height, weight, and blood pressure were measured and body mass index
calculated.
STATISTICAL ANALYSIS
Age- and sex-standardized mortality rates were directly standardized
to the whole study population. Age- and sex-adjusted survival curves were
plotted using S-Plus (Version 4.5, MathSoft Inc, Seattle, Wash). Survival
analyses, including the log-rank test and the Cox proportional hazards regression
analysis were performed using SAS software (Version 6.12, SAS Institute Inc,
Cary, NC). Survival time was calculated as days survived since baseline. Systemic
factors known to be associated with mortality were screened for associations
with mortality using age- and sex-adjusted Cox proportional hazards regression
analysis. A basic multivariate model was constructed containing factors significantly
associated with mortality after simultaneous multiple adjustment. Each eye
condition was assessed separately using age- and sex-adjusted models and then
the basic multivariate model.
RESULTS
By June 30, 1999, 604 participants had died, including 565 persons confirmed
dead by matching with NDI data (459 exact and 106 nonexact matches on only
1 noncritical variable) and 39 persons confirmed dead by reports from family
members.
Age- and sex-adjusted survival curves by presence of visual impairment
or nuclear cataract at baseline are shown in Figure 1 and
Figure 2.
The age- and sex-standardized 7-year cumulative survival rate was 74% among
persons with visual impairment after best correction at baseline compared
with 84% among persons without visual impairment. Corresponding standardized
survival rates were 78% among persons with nuclear cataract at baseline and
86% in those without nuclear cataract.
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Figure 1. Age- and sex-adjusted survival
curves of subjects with and without visual impairment after best correction
at the baseline examination.
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Figure 2. Age- and sex-adjusted survival
curves of subjects with and without nuclear cataract at the baseline examination.
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After adjusting for age and sex, persons with presenting visual impairment
(risk ratio [RR], 1.7; 95% confidence interval [CI], 1.4-2.0) or visual impairment
after best correction (RR, 1.8; 95% CI, 1.4-2.3) at baseline had a 70% to
80% higher mortality risk than persons without visual impairment. Persons
with nuclear cataract (RR, 1.4; 95% CI, 1.1-1.8), posterior subcapsular cataract
(RR, 1.4; 95% CI, 1.1-1.8), or cortical cataract (RR, 1.3; 95% CI, 1.0-1.5)
at baseline had a 30% to 40% higher mortality risk than those without cataract.
The presence of diabetic retinopathy (RR, 2.2; 95% CI, 1.5-3.3) or myopia
(RR, 1.4; 95% CI, 1.2-1.8) was also associated with a higher mortality risk.
However, presence of age-related maculopathy or glaucoma was not associated
with mortality.
Systemic factors that remained statistically significant in the basic
multivariate model are presented in Table
1. Fair (RR, 2.2) or poor (RR, 3.2) self-rated health, male sex
(RR, 1.7), presence of walking disability (RR, 1.7), current smoking (RR,
2.0), and low body mass index (<20 [RR, 1.9]), were associated with a greater
than 50% increased mortality risk.
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Table 1. Baseline Systemic Characteristics Associated With Mortality
in the Multivariate-Adjusted Cox Proportional Hazards Model*
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The association between each eye condition and mortality after adjusting
for all significant systemic factors is presented in Table 2. Presence of visual impairment at baseline was independently
associated with a 50% to 70% increased mortality risk. Any type of age-related
cataract (nuclear, posterior subcapsular, or cortical) was statistically significantly
associated with a 30% to 50% increased mortality risk. Myopia at baseline
was also associated with a 50% increased mortality risk. After excluding diabetic
subjects, the association between visual impairment after best correction
and mortality did not change, and the strength of the association between
cataract and mortality was slightly reduced (Table 2).
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Table 2. Eye Conditions Associated With Mortality in the Multivariate-Adjusted
Cox Proportional Hazards Model*
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To assess whether the association found between visual impairment and
mortality was independent of the association with cataract, we included visual
impairment and each type of cataract in the same multivariate model (Table 3). This analysis suggested that
the associations found between either visual impairment or cataract and mortality
were independent of each other. No significant interaction was found between
visual impairment and each type of cataract.
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Table 3. Associations Between Visual Impairment, Cataract, and Mortality,
Including Visual Impairment and Each Type of Cataract Simultaneously in Each
Model*
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To assess whether the association between myopia and mortality was caused
by a myopic shift in refraction associated with developing nuclear cataract,
we included nuclear cataract and myopia in the same multivariate model. In
this analysis, the hazard RR for persons with myopia weakened from an RR of
1.45 (95% CI, 1.1-1.8) to an RR of 1.35 (95% CI, 1.0-1.8).
We further assessed the association between visual impairment and mortality
using 3 categories of visual impairment: none, correctable visual impairment,
and visual impairment after best correction, in the same basic multivariate
Cox proportional hazards model. Compared with no visual impairment, the presence
of correctable visual impairment at baseline was independently associated
with a 40% increased mortality risk, and visual impairment after best correction
at baseline was associated with an 80% increased mortality risk (results not
shown).
The primary causes of bilateral visual impairment among persons with
visual impairment after best correction who died (n = 89) and who survived
(n = 76) were similar: age-related cataract (54% in those who died and 64%
in those who survived), age-related maculopathy (33% and 24%, respectively),
and glaucoma or other diseases (13% and 12%).
Cause of death was available for 429 of 604 deaths, owing to a lag in
the completion of NDI data. Comparison of causes of death in this group did
not reveal any substantial differences between persons with and without visual
impairment at baseline. Among those without visual impairment who died, rates
were as follows: heart diseases, 36%; cancer, 33%; stroke, 9%; and injury
or fractures, 2%. Corresponding rates for those with visual impairment at
baseline were 43%, 23%, 12%, and 2%, respectively.
COMMENT
These data indicate that persons with best-corrected visual acuity reduced
to 20/40 or worse in their better eye had a 70% increased mortality risk compared
with persons without visual impairment. Nuclear, posterior subcapsular, or
cortical cataract was also associated with a 30% to 50% increased mortality
risk. The visual impairment finding supports and extends the report from the
Beaver Dam Eye Study.9 In that study (467 deaths),
the age- and sex-adjusted association was not statistically significant after
adjusting for systemic factors related to mortality. In our study population
(604 deaths), the relationship between visual impairment and mortality was
maintained after adjusting for a large number of systemic factors found associated
with mortality, as well as for the presence of age-related cataract.
There are several possible explanations for an apparent relationship
between impaired vision and mortality. First, inadequate control for age and
other possible confounding variables could be partly responsible. Prevalence
of visual impairment is strongly age-related.15, 20
Although we included age in the Cox proportional hazards model, we may not
have completely adjusted for its effects. Although many diseases representing
other potential causes of death are included in the multivariate models, they
are at best a marker for an underlying etiologic factor, and so we may not
have adjusted completely for these other confounding causes of death. Second,
decreased vision may be causally associated with other factors related to
mortality in elderly persons, such as falling,21
hip fracture, and an increased likelihood of motor vehicle accidents,22 although our limited data on causes of death provided
no support for this mechanism. Third, visual impairment may contribute to
functional disability,1-3
loss of independence, and need for community support,6
as well as reduced social interaction and depression.4
Older persons with depression have been reported to have increased mortality.23
Some previous studies have suggested that age-related cataract may be
a predictor of decreased survival in older people.10-13
Our study confirms the Beaver Dam Eye Study nuclear cataract findings.9 We also found that posterior subcapsular and cortical
cataract were independently associated with decreased survival, but did not
observe a relationship between cataract surgery and mortality, possibly owing
to small numbers.
No well-established or biologically plausible theories have been offered
to explain the association between age-related cataract and decreased survival.
It has been postulated that age-related cataract may reflect the status of
systemic processes associated with aging10-11,13
and may be a marker of exposure to systemic factors producing free oxygen
radicals, which could be associated with increased physiologic aging and decreased
survival.9, 24
The association found between myopia and mortality could be partly explained
by the well-known myopic shift in refraction associated with developing nuclear
cataract, since the relationship weakened after including nuclear cataract
in the model.
In conclusion, findings from our study indicate that both visual impairment
and age-related cataract could be independent risk factors for a moderate
increase in mortality risk for older persons. These data support and extend
previous findings from the Beaver Dam Eye Study and add to the many described
impacts of visual impairment on the older population.
AUTHOR INFORMATION
Accepted for publication December 1, 2000.
This study was supported by grant 974159 from the Australian National
Health and Medical Research Council (NHMRC), Canberra, Australia, and the
Save Sight and Millennium Institutes, University of Sydney. Dr Wang held an
NHMRC Public Health Postgraduate Research Scholarship when this study was
conducted.
Corresponding author and reprints: Paul Mitchell, MD, PhD, FRACO,
FRCOphth, Department of Ophthalmology, the University of Sydney Eye Clinic,
Westmead Hospital, Hawkesbury Road, Westmead, New South Wales, Australia 2145
(e-mail: paulmi{at}westgate.wh.usyd.edu.au).
Jie J. Wang, MBBS, MMed (Epi), PhD;
Paul Mitchell, MD, PhD, FRACO, FRCOphth;
Judy M. Simpson, BSc, PhD, CStat;
Robert G. Cumming, MBBS, PhD, FAFPHM;
Wayne Smith, BMed, PhD, FAFPHM
From the Save Sight Institute, Department of Ophthalmology, University
of Sydney Eye Clinic, Westmead Hospital, Westmead (Drs Wang and Mitchell);
Departments of Public Health and Community Medicine, University of Sydney,
Sydney (Drs Simpson and Cumming); and the National Centre for Epidemiology
and Population Health, Australian National University, Canberra (Dr Smith),
Australia.
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Causes of Incident Visual Impairment: The Blue Mountains Eye Study
Foran et al.
Arch Ophthalmol 2002;120:613-619.
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