Ultraviolet Light Exposure and Lens
Opacities: The Beaver Dam Eye Study
Karen J. Cruickshanks, PhD, Barbara E. K Klein, MD, MPH, and
Ronald Klein, MD, MPH
Introduction
While cataract is a common health
problem in aging populationsl-5 and a
leading cause of vision impairment,6 little
is known about its etiology. Exposure to
ultraviolet (UV) light may be an important
risk factor through thermal or photochem-
ical effects.7-9 Some studies have sug-
gested that cataracts are more common in
regions with high UV levels"'-13 and in
persons more exposed to sunlight or ul-
traviolet-B (UVB),'4-2' while others have
found no association.22-24 One recent re-
port found an inverse association between
working outdoors and nuclear sclerosis.25
These varied findings may be due to meth-
odological differences in selection criteria,
in measurements of exposure and opaci-
ties, and in the definitions of cataract.
As part of the population-based
Beaver Dam Eye Study, we examined the
relationship between ambient UVB light
and nuclear sclerosis, cortical opacities,
and posterior subcapsular (PSC) opaci-
ties.
Methods
The methods for the Beaver Dam
Eye Study, a study of age-related eye dis-
eases in persons aged 43 to 84 years re-
siding in Beaver Dam, Wisconsin, have
been reported previously.",2629 Of the
5925 eligible persons, 83.1% (n = 4926)
participated, 4.5% (n = 269) were inter-
viewed only, 3.8% (n = 225) died prior to
examination, 1.5% (n = 91) moved, 0.4%
(n = 23) could not be located, and 6.6%
(n = 391) refused. Nonparticipants were
more likely to be older and female.27
Photographs were taken of the lens of
each eye through dilated pupils. 129 A Top-
con SL5 Photoslit lamp camera was used
to take photographs that were graded for
nuclear sclerosis on five levels. Anterior
and posterior retroillumination photo-
graphs of the lens were taken with a Neitz
CR-T camera and graded for cortical and
PSC opacities. Details of the standardized
grading systems have been reported pre-
viously.",29 Data for the worse eye were
used. Of the 4926 participants, 198 per-
sons (4%), who did not have gradable pho-
tographs or who were aphakic or enucle-
ated, were excluded from the analyses.
The average percentage of the sur-
face area of the lens with cortical opacities
was grouped into three levels: less than
5%, 5% to 24%, and 25% or more. PSC
opacities were present if 5% or more of the
surface area of the lens was involved.
In addition to the examination, a
standardized interview was administered.
Participants were asked about residential
history; time spent outdoors during leisure
and work; and use of hats, sunglasses, and
eyeglasses for distance vision. The resi-
dential history was used to construct a
measure of the average annual ambient
UVB light exposure for each individual,
using an adaptation of the technique em-
ployed by the Maryland Watermen
Study.2?'30 Each year spent in another re-
gion was weighted by the ratio of the total
ambient UVB light present in that area to
the level of such light present for 1 year in
Wisconsin (Wisconsin sun year [WISYJ).3
One WISY is equivalent to the total am-
bient UVB irradiance of a horizontal sur-
The authors are with the Department of Oph-
thalmology at the University of Wisconsin in
Madison.
Requests for reprints should be sent to
Karen J. Cruickshanks, PhD, 610 N Walnut St,
403 WARF, Madison, WI 53705-2397.
This paper was submitted to the Journal
December 5, 1991, and accepted with revisions
May 22, 1992.
December 1992, Vol. 82, No. 12
face in Wisconsin over l year. The cumu-
lative ambient UVB light exposure was INtl
computed and divided by the participant's .|
age to compute the average annual ambi xeS SS_S_______-f
-.... f
ent UVB light exposure. Because most
participants had spent most of their lives......-----------
in Wisconsin, this variable was catego- .f........

rized into two groups (less than 1.01 S

WISY and 1.01 or more WISY). Use of m. .e.

nwascom
andsuhats inabined .......................................

weighted fashion into levels of increasn

protection from UVB light.
The SAS programs were used to
compute x2 statistics, t tests, tests of
trend, and logiStiC regesion modelS.3132
For nuclea sclerois andcorticalopacite
ties, ordinal logistic regression models70
were used to compute odds ratios, which
represent the cumulative probability of
having a more severe level of opacity.~33-4

nuclear sclerosis (Table 1). There was no

Rfuk
......i....
-- ---- --

levlsthnmen.odr hnme n

2). For ach masurae

sunelighlytexosurve eposur
.otoieachofcataacitie end 1 I*
scerrei noblsignifican wassnoi
pont.cThere
e ofmethe light exposure-
tiofrns betweenmn
any

more likelunytofhv PSC opacities. (odds

95honfiener inmote
wrati [OR] dif1.79;es #74 740 81.*....
of ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.............
protection
levels
bflgtefposre (agle2
Mftenwhoaworelses

Fo 4.
40 (Tabl men ahos pe tmre leixpsure,
timenotor nwne
were less
likely
haelwr
to up--------

(ORel tha0.1m5en. .6,10)thneg

thoses who spenatiolittleo leisur tmeaue outf~
dioors. Mewenwith higther eshteimatedurB

light exposure were 1.4 times more likely X

to have more severe cortical opacities
(P .02)than those with lower esimated
exposure. No

i)ecemDer 1lowfl YJ oL,

ivvL, vol. ?mI 11)
RI) 1nU. Amenican Journal of Pubhic Health 1659
Cnidcshanks et aL
To determine ifthe average estimated
annual ambient UVB light exposure was
associated with lens opacities after con-
trolling for the potential attenuating effects
ofother light exposure variables and other
1660 American Journal of Public Health
potential risk factors (diabetes, smoking,
and heavy alcohol consumption),35 logis-
tic regression models were constructed in
a stepwise fashion for each cataract end-
point. The final models included only
UVB light exposure and those other vari-
ables associated (P < .10) with the spe-
cific outcome (Table 5).
Estimated UVB exposure level was
not associated with nuclear sclerosis or
PSC opacities in either sex. In men only,
however, the average annual ambient es-
timated UVB light exposure level was sig-
nificantly associated with more severe
cortical opacities after adjusting for other
factors (OR = 1.36; 95% CI = 1.02, 1.79)
(Table 5). Men who wore eyeglasses be-
fore age 21 were less likely to have cortical
opacities (OR = 0.67; 95% CI = 0.45,
1.01). Wearing eyeglasses when younger
was inversely associated with the severity
of nuclear sclerosis in men (OR = 0.78;
95% CI = 0.62, 0.98), as were the leisure
time spent outdoors inwinter (OR = 0.72;
95% CI = 0.54, 0.96) and thejob time spent
outdoors (OR = 0.82; 95% CI = 0.66,
1.01). Winter leisure time outdoors was
also associated with a decreased risk of
having PSC opacities in men (OR = 0.48;
95% CI = 0.24, 0.96). In women, there
were no significant associations between
any of the light exposure variables and any
of the cataract endpoints.
Because certain segments ofthe lens
may be more exposed to UVB light than
others because of the shading effects of
the lids, the nose, and the brow, and/or
because of pupil constriction, we also ex-
amined for men the distribution of the
lens segment with the greatest percentage
of area affected by cortical opacities,
according to the level of UVB light ex-
posure. There was no difference in the
distribution of segments by level of ex-
posure (Figure 1).
Diwussnion
In this study, we found an association
between estimated exposure to UVB light
and cortical opacities that was significant
in men only. We failed to find any asso-
ciation between estimated ambient UVB
light levels and nuclear sclerosis or poste-
rior subcapsular opacities. Although our
measure of relative exposure is based on
residential history and represents the av-
erage potential exposure rather than the
actual ocular exposure, our findings are
consistent with the Maryland Watermen
Study, which used a detailed assessment
of ocular UVB light exposure.20 In that
study, men with higher estimated levels of
exposure to UVB lightwere more likely to
have cortical opacities.20 No associations
were found in their study between cata-
ract and ultraviolet-A, all visible light, or
blue light.?6
December 1992, Vol. 82, No. 12
 U vi Lght and Lens Opaddes
In men, wearing eyeglasses for dis-
tance vision at younger ages appeared to
be associated with a decreased risk of hav-
ing more severe cortical opacities and nu-
dear sclerosis, perhaps because of the at-
tenuating effects of eyeglasses on the
transmission of UV light to the eye.37 One
study has reported an association between
early use of eyeglasses and decreased risk
of nuclear sclerosis,38 whereas another
has found an increased risk of mixed cat-
aract.25 Some authors have suggested that
myopia may be a protective factor in the
development of cataract,22=39 whereas one
report has found early myopia to be asso-
ciated with an increased risk ofhaving cat-
aract extraction.40
The negative relationships seen in
men between time spent outdoors in win-
ter and nuclear sclerosis and PSC opac-
ities may reflect the cross-sectional na-
ture of this study. Persons were asked
about their usual practice at the time of
the examination. Those with more severe
opacities may have altered their behavior
over time and may currently spend less
time outdoors. Similarly, the increased
odds of PSC opacities in women who fre-
quently use hats and sunglasses may re-
flect current habits influenced by the
presence of these opacities rather than
habits that existed during etiologically
more importantyears. Other studies have
also reported an inverse association be-
tween work time outdoors and nuclear
sclerosis,25 and a positive association be-
tween a history of hat use and an in-
creased risk of having PSC, cortical, or
mixed opacities.17 Clearly, longitudinal
studies are needed to distinguish the tem-
poral associations of these factors with
lens opacities.
While this study is cross-sectional
and does not lead to firm conclusions
about the etiological signifcance of light
exposure, these data suggest that expo-
sure to higher levels of UVB light may be
associated with increased severity of cor-
tical opacities in men. Although few stud-
ies have examined differences among men
and women in the association of UV light
exposure with opacities, one report from
Nepal has found a signifcant interaction
between sunlight exposure and gender.'9
In that study, the association of sunlight
with the prevalence of cataract was much
weaker in women than in men, yet women
were more likely than men to have cata-
racts.
Studies that focus only on highly ex-
posed groups may overestimate the rel-
ative importance of UV light in detennin-
ing who develops cortical opacities. In

December 1992, Vol. 82, No. 12 American Joumal of Public Health 1661
Cniicshanks et aL
Beaver Dam, Wisconsin, women were
more likely than men to have cortical
opacities in spite of having less exposure
to UVB light. Thus, our data suggest that
other, as yet unknown factors may be
more important in identifying persons at
increased risk of cortical opacities. Fur-
ther studies of gender differences will
help to elucidate the relative contribu-
tions of potential risk factors in the etiol-
ogy of lens opacities. El
Acknowledgments
This research was supported by a grant from
the National Institutes of Health, National Eye
Institute U10 EY06594.
These data were presented, in part, at the
24th Annual Meeting of the Society for Epide-
miologic Research, June 1991, in Buffalo, NY.
The authors wish to thank the Beaver
Dam Scientific Advisory Board (Frederick Fer-
ris III, MD, Leslie Hyman, PhD, Natalie
Kurinij, PhD, Robert Sperduto, MD, Robert
Wallace, MD, and Sheila West, PhD) for their
thoughtful comments and suggestions, and Lu-
ann Soule for manuscript preparation.
References
1. Klein BEK, Klein R, Linton KLP. Preva-
lence of age-related lens opacities in a pop-
ulation: the Beaver Dam Eye Study. Oph-
thabnology. 1992;99:546-552.
2. World Health Orpnization Program Ad-
visoxy Group. Repo'n of the Eighth Meet-
ing of the WHO Proramme Advisory
Group on the Prevention of Blindness.
Geneva, Switzerland: World Health Orga-
nization; 1989. WHO publication 89.17.
3. Kupfer C. The conquest of cataract: a
global challenge. Trans Ophthalmol Soc
UK 1984;104:1-10.
4. Klein BE, Klein R. Cataracts and macular
degeneration in older Americans. Arch
OphthalmoL 1982;100:571-573.
5. Sperduto RD, Seigel D. Senile lens and se-
nile macular changes on a population-based
sample. AmJ OphthalmoL 1980;98:86-91.
6. Kahn HA, Moorhead HB. Statistics on
blindness in the Model Reporting Area,
1969-1970. Washington, DC: US Dept of
Health, Education, and Welfare; 1973.
PHS publication NIH 73-427.
7. Young RW. Age-Related Cataract. New
York, NY: Oxford University Press, Inc;
1991.
8. Zigman S, Yulo T, Schultz J. Cataract in-
1662 American Journal of Public Health
duction in mice exposed to near UV light.
Ophthablic Res. 1974;6:259-270.
9. Zigman S. Photobiology of the lens. In:
Maisel H, ed. 7he OcularLens. NewYork,
NY: Marcel Dekker; 1985:301-347.
10. Hu TS, Zhen Q, Sperduto RD, et al. Age-
related cataract in the Tibet Eye Study.
Arch OphthabnoL 1989;107:666-669.
11. Hollows F, Moran D. Cataract-the ultra-
violet risk factor. Lancet. 1981;ii:1249-
1250.
12. Taylor HR. The enviromnent and the lens.
BrJ OphthabnoL 1980;64:303-310.
13. Brilliant LB, Grasset NC, Pokhrel RP, et
al. Associations among cataract preva-
lence, sunlight hours, and altitude in the
Himalayas. Am J Epidemiol. 1983;118:
250-264.
14. Hiller RL, Giacometti L, Yuen K. Sunlight
and cataract: an epidemiologic investiga-
tion. Am J EpidemoL 1977;105:450-459.
15. Hiller R, Sperduto RD, Ederer F. Epide-
miologic associations with nuclear, corti-
cal, and posterior subcapsular cataracts.
Am JEpidemioL 1986;124:916-925.
16. Kharmar BK, Rawal UM. Sunlight-its
etiological role in cataract formation. In-
dian J OphthabnoL 1983;31:842-843.
17. Italian-American Cataract Study Group.
Risk factors for age-related cortical, nu-
clear and posterior subcapsular cataracts.
Am JEpidemnioL 1991;133:541-553.
18. Mohan M, Sperduto RD, Angra SK, et al.
India-US case-control study of age-related
cataracts.Arch OphthabnoL 1989;107:670-
676.
19. Mitchell BD, Lepkowski JM. The epide-
miology of cataract in Nepal. Hwn Biol
1986;58:975-990.
20. Taylor HR. West SK, Rosenthal FS, et al.
Effect of ultraviolet radiation on cataract
formation. N Engi JMed 1988;319:1429-
1433.
21. BochowTW, West SK, AzarA, Munoz B,
Sommer A, Taylor HR. Ultaviolet light
exposure and risk of posterior subcapsular
cataracts.Arch OphthabnoL 1989;107:369-
372.
22. Dolezal JM, Perkins ES, Wallace RB. Sun-
light, skin sensitivity, and senile cataract.
Am JEpidemioL 1989;129:559-568.
23. Coflman GW, Shore DL, Shy CM, Check-
oway H, Luria AS. Sunlight and other risk
factors for cataracts: an epidemiologic
study.Am JPublic Health. 1988;78:1459-
1462.
24. Crabbe MJC. Low incidence of cataract in
Hawaii despite high exposure to sunlight.
Lancet. 1983;i:649.
25. Leske MC, ChylackLT, Wu S-Y, the Lens
Opacities Case-Control Study Group. The
lens opacities case-control study: risk fac-
tors of cataract. Arch OphthanmoL 1991;
109:244-251.
26. Campbell JA, Palit CD. Total digit dialing
for a small area census by phone. In: Pr-
ceedings ofthe Swvey Research Methods
Section, Ameian StatisticalAssociation,
1988:549-551.
27. Klein R, Klein BEK, Linton LP, DeMets
DL. The Beaver Dam Eye Study: visual
acuity. Ophthalmology. 1991;98:1310-
1315.
28. Linton KLP, Klein BEK, Klein R. The va-
lidity of self-reported and surrogate-re-
ported cataract and age-related macular de-
generation in the Beaver Dam Eye Study.
Am JEpidemioL 1991;134:1438-1446.
29. Klein BEK, Magli Y, Neider MW, Klein
R. Wisconsin system for classification of
cataract from photographs. Springfield,
Va: National Technical Information Ser-
vice; 1990. US Dept of Commerce NTIS
Accession PB 90-138306.
30. Rosenthal FS, West SK, Munoz B, Em-
mett EA, Strickland PT, Taylor HR. Ocu-
lar and facial skin exposure to ultraviolet
radiation in sunlight: a personal exposure
model with application to a worker popu-
lation. Health Phys. 1991;61:77-86.
31. SAS User's Guide: Statisics. Version 5.
Caxy, NC: SAS Institute Inc; 1985.
32. SUGISupplewntalLibrwy User's Guide.
Version 5. Cary, NC: SAS Institute Inc;
1986.
33. Agresti A.Analysis of Ordinal Categoncal
Data. New York, NY: John Wiley and
Sons; 1984:113-131.
34. McCullagh P. Regression models for ordi-
nal data. JR Stat Soc B. 1980;42:109-142.
35. Ritter LL, Klein BEK, Klein R, Mares-
Perlman JA. Alcohol use and lens opacities
in the Beaver Dam Eye Study. Arch Oph-
thalmoL In press.
36. Taylor HR, West S, Munioz B, Rosenthal
FS, Bressler SB, Bressler NM. The long-
term effects of visible light on the eye.Arch
OphthabnoL 1992;110:99-104.
37. Rosenthal FS, Bakalian AE, Taylor HR.
The effect of prescription eyewear on oc-
ular exposure to ultraviolet radiation.AmJ
Public Healh. 1986;76:1216-1220.
38. Wojno T, Singer D, Schultz RO. Ultravi-
olet light, cataracts, and spectacle wear.
Ann OphthabnoL 1983;15:729-732.
39. Belkin M, Jacobs DR, Jackson SM, Zwick
H. Senile cataracts and myopia.Ann Oph-
thabnoL 1982;14:49-50.
40. Van Heyningen R, Harding JJ. A case-
control study of cataract in Oxfordshire:
some risk factors. BrJ OphthabnoL 1988;
72:8044808.
December 1992, Vol. 82, No. 12