[Downloaded free from http://www.sjopthal.net on Wednesday, December 16, 2015, IP: 202.62.16.

168]

Original Article

Prevalence and risk factors of age-related

macular degeneration in elderly patients
Jagruti N. Vashi, Kavita R. Bhatnagar, Renu M. Magdum, Akash P. Shah, Aman R. Khanna, Somil Jagani
Department of Ophthalmology, Dr. D.Y. Patil Medical College & Research Centre, Pimpri, Pune, Maharashtra, India
Address for correspondence: Dr. Kavita Bhatnagar, OPD-5, Department of Ophthalmology, Dr. D.Y. Patil Medical College, Sant Tukaram Nagar, Pimpri, Pune - 18, Maharashtra, India.
E-mail address rajankavita12@rediffmail.com

ABSTRACT
Purpose: To determine the prevalence of age-related macular degeneration (ARMD) in elderly patients
and its correlation with systemic disease, personal and environmental factors. Design: Cross-sectional.
Materials and Methods: Patients seen from July 2011 to September 2013, visiting ophthalmic OPD of a tertiary
care hospital were included in the study. Visual acuity, slit lamp biomicroscopy using +90 D & +78 D, direct and
indirect ophthalmoscopy were performed for all cases. The ARMD was confirmed by Fundus Fluroscein Angiography
(FFA). The association of ARMD with age, sex, family history of ARMD, history of smoking, occupation, diet, BMI,
hypertension, and diabetes was ascertained. Result: Out of 5000 patients screened, 76 were diagnosed with ARMD.
The proportion of overall ARMD was 1.52%. The proportion of Dry and Wet ARMD was 1.42% and 0.1%. In our
study, we found a significant association of increasing age (P < 0.05), males (P < 0.005), smoking (P < 0.01) and
occupation (P < 0.01) with ARMD. Conclusion: The prevalence of ARMD in our population in Maharashtra was
found to be low. Visual disability of blinding due to ARMD was of low magnitude. Older age group, male gender,
history of smoking and occupation were significant risk factors for ARMD.
Key words: ARMD, gender, increasing age, occupation, smoking, visual disability

INTRODUCTION
Age-related macular degeneration (ARMD) is the
leading cause of irreversible blindness worldwide.[1] The
disease adversely affects quality of life and activities
of daily living,[2] causing many affected individuals
to loss their independence in their retirement years.
Macular degenerative changes have typically been
classified into two clinical forms, dry or wet, both
of which can lead to visual loss. The pathogenesis
of the development of CNV is largely unknown. The
presence of diffuse thickening of the inner aspect of
Bruchs membrane (associated with large, soft drusen
Access this article online
Quick Response Code

Website:
www.sjopthal.net

DOI:
10.4103/1858-540X.158988

Sudanese Journal of Ophthalmology Vol. 7 Issue 1 Jan-Jun 2015

clinically) predisposes Bruchs membrane to develop

cracks through which ingrowth of new vessels from the
choriocapillaris can occur. This hypothesis is supported
by the finding of CNV in other pathologic myopia[3] and
angioid streaks.[4] The causes of ARMD are thought
to be multifactorial. The purpose of this study was to
learn linkage between various environmental factors
and epidemiology of ARMD that it may be applied to
the future prevention, treatment and eventually the
cure of ARMD.[5] Many prospective trials support the
use of antioxidant vitamins and mineral supplements,
intravitreal injection of antivascular endothelial growth
factor (VEGF) agents, PDT and laser photocoagulation
surgery to treat AMD.

MATERIALS AND METHODS

A total of 5000 patients above 55 years of age,
attending the eye OPD, were included in this study.
Patients with hazy ocular media which interfered
with the detailed examination of the fundus were
excluded. Informed, written consent was obtained
from all the patients. Relevant history like age,
1

[Downloaded free from http://www.sjopthal.net on Wednesday, December 16, 2015, IP: 202.62.16.168]
Vashi, et al.: Age related macular degeneration

gender, occupation, family history, BMI [WHO

criteria (kg/m2) under weight- <18.50, normal range18.50-24.99, over weight- 25.00, obese 30.00],
history of smoking (in pack years), history of cataract
surgery, diabetes [fasting capillary blood sugar level
was >7 mmol/l and those already taking medicines
to control diabetes were treated as diabetics] and
hypertension (more than 140/90 mm Hg, WHO
Classification of Hypertension) and patients who
were on medication to control blood pressure
were taken as hypertensive] was taken according
to performa. Patients underwent check up for
uncorrected visual acuity, best corrected visual
acuity and pinhole improvement of vision. Anterior
segment was evaluated using slit-lamp biomicroscope. Fundus was examined with Direct &
Indirect Ophthalmoscope & slit-lamp bio-microscope
using +90 D lens. Macula was examined using +78D
lens. Patients complaining of distortion of image
were examined using Amslers grid chart. Patients
were graded into following three groups based on
their examination findings.

Group I- No AMD (Age Related Maculopathy), was the

control group for our study and had no or few small
drusen (<63 microns in diameter).

Figure 1: Subretinal neovascular membrane: Pre PDT

Figure 2: Subretinal neovascular membrane: Post PDT

Figure 3: Subretinal neovascular membrane: Pre Avastin injection

Figure 4: Subretinal neovascular membrane: Post Avastin treatment

Group II- Dry ARMD included few drusen of more than

63 microns in size at macula, and geographic atrophy.
Group III- Wet ARMD included neo-vascular vessels of
chorio-capillary plexus in macular area (CNVM), macular
star or combination of any of these three conditions.
To confirm the diagnosis fundus fluorescein
angiography was done in selected patients using
3 ml 25% sodium fluorescein dye. A separate
written, informed, consent was taken prior to fundus
fluorescein angiography. Based on fundus fluorescein
angiography finding patients were subjected to
different treatment modalities. Patients in Group I & II
with No AMD and Dry ARMD were given antioxidants.
Patients in Group III with Wet ARMD were subjected to
photodynamic therapy (Vertiporfin) [Figures 1 and 2]
and antivascular endothelial growth factor (Avastin
1.25 mg/0.5 ml) [Figures 3 and 4].

Sudanese Journal of Ophthalmology Vol. 7 Issue 1 Jan-Jun 2015

[Downloaded free from http://www.sjopthal.net on Wednesday, December 16, 2015, IP: 202.62.16.168]
Vashi, et al.: Age related macular degeneration

All the patients who received treatment were followed

up 1 monthly for 6 months for visual acuity and
fundus examination. Data was collected, compiled
and analyzed using SPSS version 17. Quantitative
variable summarized using Mean SD and Z-test.
Qualitative data was summarized using percentages.
The chi-square test was applied and OR (odds-ratio)
were calculated.

RESULTS AND OBSERVATION

Out of 5000 patients, 76 were diagnosed with ARMD,
so the prevalence was 1.52%. Table 1 shows ageand sex-wise distribution of cases. Five thousand
patients were screened. Patients were distributed in
different groups, as the first group was 55-64 years,
had 1752 patients, out of which 4 were males and 5
were females, so the prevalence was 0.5% in this age
group. The second group that is 65-74 years of age,
had 1968 patients, among which 9 were males and
10 were females. The prevalence was 0.96% in this
age group. In third group that is 75-84 years, had1003
patients, out of which 18 were males and 13 were
females. The prevalence in this age group was 3.08%.
All patients of 85 years and above were included in the
forth group. In this group, 277 patients were examined,
out of which 9 were males and 8 were females. The
prevalence in this age group was found to be highest
at 6.13%. Table 2 shows environmental and personal
factors of cases. Out of 76 patients, 7 (9.21%) had
family history of ARMD and 69 (90.79%) patients had
no positive family history. Twenty-six (34.21%) patients
were gave history of smoking and 50 (65.79%) patients
did not give. Vegetarians were 60 (73.33%) and nonvegetarians were 16 (26.67%). Fourteen (18.42%)
patients had BMI <18.5 (underweight), 25 (32,89%)
had BMI between 18.5 and 25 (normal), 30 (39.47%)
patients had BMI between 25 and 29.9 (overweight)
and 7 (9.21%) had BMI >30 (obese). Seventy-two
(94.74%) patients had brown color iris, 2 (2.63%)
had green, 1(1.32%) patient had blue and 1 (1.32%)
had grey color of iris. History of previous cataract
surgery was present in 51 (67.11%) of patients and
absent in 25 (32.89%) of patients. Out of 76 ARMD
patients, 31(40.79%) had hypertension and 45(59.21%)
patients did not have one. DM was present in
16(26.67%) patients and absent in 60(73.33%) patients.
Pie diagram 1 shows type of ARMD-wise distribution
of cases. Out of 76 patients, the maximum number of
patients had Dry ARMD that was 60 (78.95%), followed
by 11 (14.47%) patients who had No AMD [had no
or few small drusen <63 microns in diameter] and 5
(6.58%) patients had Wet ARMD.
Table 3 shows the association between sex and ARMD.
There was significant association between male gender
Sudanese Journal of Ophthalmology Vol. 7 Issue 1 Jan-Jun 2015

and ARMD (P < 0.005). Males were 15 times at higher

risk of developing ARMD than females in our study.
Out of 40 males 39 had ARMD and only 1 male had
No AMD. While out of 36 females 26 had ARMD and
10 had No AMD.
Table 4 shows the association between smoking and
ARMD. There was a significant association between
smoking and ARMD (P < 0.01). Out of 76 patients 26
were smokers and 39 were non-smokers in the ARMD
Table 1: Age- and sex-wise distribution of cases in the
study group

Table 2: Environmental, personal factors & systemic

factors wise distribution of cases in the study group

Pie diagram 1: Showing type of ARMD wise distribution of cases in study

group
3

[Downloaded free from http://www.sjopthal.net on Wednesday, December 16, 2015, IP: 202.62.16.168]
Vashi, et al.: Age related macular degeneration

group (Group I & II), 11 were non-smokers in the No

AMD group (control group).
Table 5 shows there is significant association between
occupation and ARMD (P < 0.01). Out of 65 patients
in the ARMD group (Group I & II), 25 were farmers,
followed by 19 were laborers, 14 were housewives, 4
were unemployed and 3 were others. In the No AMD
group (control group), 8 were housewives, 2 were
laborers and 1 unemployed.

DISCUSSION
ARMD is a common ophthalmological disorder that
can significantly impair a patients ability to function
independently and potentially have a dramatic impact
on health-related quality of life. In our study, 5000
patients of 55 years and older was screened for
ARMD. Out of which 76 patients were found to have
ARMD. The overall proportion of ARMD in our study
was 1.52%. [Dry ARMD-1.42% and Wet ARMD-0.1%].
Our results are corroborating with the study done by
Table 3: Association between sex and ARMD in the
study group

Table 4: Association between smoking and ARMD in the

study group

Table 5: Association between occupation and ARMD in

the study group

Kulkarni et al., where the prevalence was 1.38%.[6]

The prevalence of ARMD in the Rotterdam Study,
Netherland, is 1.7%.[7] The prevalence rate for ARMD
increased from 0.51% in 55-64 years to 6.13% in 85
years and above age strata in our study. Males had
significantly higher risk for ARMD than females in
our study (P < 0.005). This was also noted in a study
done in Japan.[8] BMI were not significantly associated
with ARMD in our study. As far as our sample is
concerned, out of 76 subjects only 7 had BMI 30
and above (P > 0.05). Similar results were noted by
Yasuda et al.[8] Obese individuals were at higher risk
of ARMD noted by Schaumberg et al.[9] Smoking was
significantly associated with ARMD (P < 0.01) in our
study. The French POLA study (Pathologies Ocularies
Liees a lAge) done in the French Mediterranean found
that both current and former smokers had the highest
risk for developing macular degeneration.[10] Cigarette
smoking is the only risk factor other than age that has
been consistently identified in numerous studies.[11-14]
Smoking doubles the risk of AMD, and there appears
to be a dose response whereby increasing odds are
associated with an increased number of pack-years
smoked.[12] Smoking is the major modifiable risk factor.
Nicotine in general causes a lowering of antioxidants
throughout body. It also compromises the immune
system. Smoking cessation was associated with a
reduced risk for AMD; the risk of developing AMD
in those who had not smoked for over 20 years was
comparable to the risk in nonsmokers.[12] In our study,
we didnt find any association between diet and
ARMD. There was no significant association between
family history and ARMD in our study. The incidence
is found to be less in our study, maybe because most
of our patients were having low education and were
not really aware about the disease. In our study we
did not find an association between hypertension and
ARMD (P > 0.05). Age-related eye diseases study
(AREDS) said that persons with hypertension were 1.5
times more likely to have wet macular degeneration
compared with persons without hypertension. There
was no significant relationship between diabetes
mellitus and ARMD (P > 0.05) found in our study.
We did not find significant association between
cataract surgery and ARMD (P > 0.05) in our study,
corroborating with the study done in Maharashtra by
Kulkarni et al.[6] Out of 76 patients 72 (94 (94.74%).
We did not find significant association of ARMD with
iris color (P > 0.05) in our study. Study by Chung Hua
et al. revealed that lighter iris is associated with a
higher incidence of ARMD.[15] In our study, we found
a significant association between occupation and
ARMD (P < 0.01). Our study is corroborating with
the previous study, In the Asian population, highest
incidence of ARMD was seen among miners (7.98%),
followed by peasants (7.33%), factory workers
Sudanese Journal of Ophthalmology Vol. 7 Issue 1 Jan-Jun 2015

[Downloaded free from http://www.sjopthal.net on Wednesday, December 16, 2015, IP: 202.62.16.168]
Vashi, et al.: Age related macular degeneration

(4.94%) and office cadres (2.78%).[16] Farmer and

laborer are more exposed to the sunlight because
of the nature of their work. In the Beaver Dam Eye
Study, increased time spent outdoor in the summer
was associated with a twofold increased risk of
advanced AMD.[17]

4.
5.

6.

CONCLUSION
The prevalence of ARMD was 1.52%, among 55 years
of age and older. In our study the prevalence was
increased with increasing age. We also found that
Dry ARMD was much more common than Wet
ARMD, and both types increased in frequency with
increasing age. Incidence of ARMD was more in males
than in females; males were 15 times at higher risk of
developing ARMD. There was significant association of
ARMD with occupation, and was more in farmers and
laborers. The prevalence of ARMD was significantly
associated with smokers in our study. Rest personal
factors like iris color, diet, BMI, family history, cataract
surgery were not associated with increased incidence
of ARMD. Systemic diseases like hypertension and
diabetes were not associated with ARMD. Efficacy of
available treatment such as antioxidants, anti-VEGF
and PDT were less and more research work needed
in this regard. To sum up, it is important to focus
on modifiable risk factors like smoking, occupation,
diet and BMI which are found to be associated with
increased risk of developing ARMD and also look into
preventable aspect of the disease. Many such studies
in future need to be done to establish more association
and treatment of ARMD.

REFERENCES
1.
2.
3.

National Institute for Neurological Disease and Blindness, Section on

Blindness Statistics, Statistics on blindness in the model reporting area,
1969-1970.
National Advisory Eye Council (US).Vision research: A national plan
1994-1998.NIH publication no.93-3186. Bethesda, MD: US Department
of Health and Human Service; 1993.
Gass JD. Pathogenesis of disciform detachment of neuroepithelium.
VI: Disciform detachment secondary to heredodegenerative,
neoplastic and traumatic lesions of the choroid. Am J Ophthalomol
1967;63:689.

Sudanese Journal of Ophthalmology Vol. 7 Issue 1 Jan-Jun 2015

7.
8.

9.
10.
11.
12.

13.

14.

15.
16.
17.

Lim JI, Bressler NM, Marsh MJ, Bressler SB. Laser treatment of choroidal
neovascularization in patients with angioid streaks. Am J Ophhalmol
1993;116:414-23.
AREDS Research Group. Risk factors associated with age-related
macular degeneration. A case-control study in the age-related eye
disease study: Age-Related Eye Disease Study Report Number 3.
Ophthalmology 2000;107:2224-32.
Kulkarni SR, Aghashe SR, Khandekar RB, Deshpande MD. Prevalence
and determinants of age related macular degeneration I n the 50 years
and older population: A hospital based study in Maharashtra, India.
Indian J Ophthalmol 2013;61:196-201.
Vingerling JR1, Dielemans I, Hofman A, Grobbee DE, Hijmering M,
Kramer CF, et al. The prevalence of age related maculopathy in the
Rotterdam Study. Ophthalmology 1995;102:205-10.
Yasuda M, Kiyohara Y, Hata Y, Arakawa S, Yonemoto K, Doi Y, et al. Nineyear incidence and risk factors for age related macular degeneration
in a defined Japanese population the Hisayama study. Ophthalmology
2009;116:2135-40.
Schaumberg DA, Chriten WG, Hankinson SE, Glynn RJ. Body mass index
and incidence of visually significant age related maculopathy in men.
Arch Ophthalmol 2001;119:1259-65.
Delcourt C, Diaz JL, Ponton-Sanchez A, Papoz L. Smoking and age
related macular degeneration. The POLA Study. Pathologies Ocularies
Liees a lAge. Arch Ophthalmol 1998;116:1031-5.
Thornton J, Edwards R, Mitchell P, Harrison RA, Buchan I, Kelly SP.
Smoking and age related macular degeneration: A review of association.
Eye 2005;19:935-44.
Khan JC, Thurlby DA, Shahid H, Clayton DG, Yates JR, Bradley M, et al.
Smoking and age related macular degeneration: The number of pack
years of cigarette smoking is a major determinant of risk for both
geographic atrophy and choroidal neovascularization. Br J Ophthalmol
2006;90:75-80.
Seddon JM, George S, Rosner B. Cigarette smoking, fish consumption,
omega-3 fatty acid intake, and association with age related macular
degeneration: The US Twin Study of Age Related Macular Degeneration.
Arch Ophthalmol 2006;124:995-1001.
Clemons TE, Milton RC, Klein R, Seddon JM, Ferris FL 3rd; Age-Related
Eye Disease Study Research Group. Risk factors for the incidence of
advanced age related macular degeneration in the Age Related Eye
Disease Study (AREDS). AREDS report number 19. Ophthalmology
2005;112:533-9.
Frank RN, Puklin JE, Stock C, Canter LA. Race, iris color, and age-related
macular degeneration. Trans Am Opthalmol Soc 2000;98:109-15.
Wu ZQ. Epidemiologic survey of senile macular degeneration. Chung
Hua Yen Ko Tsa Chih 1992;28:246-7.
Crruikshanks KJ, Klein R, Klein BE. Sunlight and age-related macular
degeneration: The Beaver Dam Eye Study. Arch Ophthalmol 1993;111:514-8.

How to cite this article: Vashi JN, Bhatnagar KR, Magdum RM, Shah AP,
Khanna AR, Jagani S. Prevalence and risk factors of age-related macular
degeneration in elderly patients. Sudanese J Ophthalmol 2015;7:1-5.

Source of Support: Dr. D.Y.Patil Medical College & Research Centre,

Pune. Conflict of Interest: None declared