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This article is intended for primary care clinicians, ophthalmologists, geriatricians, and other specialists who care for patients at risk for age-related macular degeneration.
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CME Released: 12/28/2011
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According to the current study by Klein and colleagues, age-related macular degeneration (AMD) remains a leading cause of blindness despite advances in effective treatment, and identifying individuals at risk for progression to advanced AMD threatening vision would improve decision-making about therapy and preventive measures. Risk models have been developed for cardiovascular disease and diabetes and, in ophthalmology, have focused on open-angle glaucoma. There is potential value in use of demographic, environmental, and phenotypic factors to predict AMD progression.
This trial of the Age-Related Eye Disease Study (AREDS) cohort develops a validated risk-assessment model for practicing clinicians to predict AMD progression.
A new risk-assessment model is available for online use to help practitioners identify patients with age-related macular degeneration (AMD; dry or wet) who are at highest risk for progressing to visual loss. This tool, described in an article published online August 8 and in the December print issue of the Archives of Ophthalmology, promises to be especially valuable in light of the several new treatments available for AMD.
Michael L. Klein, MD, from the Casey Eye Institute, Oregon Health & Science University, Portland, and colleagues evaluated longitudinal data from 2846 participants in AREDS and validated the findings using 297 participants in the Complications of Age-Related Macular Degeneration Prevention Trial (CAPT).
The study population presented with all levels of pathology at baseline, and follow-up averaged 9.3 years. Independent variables evaluated included age, smoking history, family history of AMD, phenotype (based on a modified AREDS simple scale score), and polymorphisms of both the CFH gene (Y402H) and the ARMS2 gene (A69S). Many past studies have identified risk factors such as severity of signs present (drusen size, abnormal pigment patterns, and area of involvement), age, sex, family history (first-degree relative), lifestyle factors, environmental exposures, and comorbidities.
The model performed well for discrimination (C statistic, 0.872) and calibration (Brier scores at 2, 5, and 10 years of 0.05, 0.08, and 0.095, respectively). The most important factors to emerge in evaluating risk for progression to visual loss from AMD were age, smoking history, severity of early AMD, and having either or both of the genetic variants, although genetics added only slightly to the overall risk, the researchers point out.
"Knowing the severity of the lesions of AMD that are already present coupled with knowledge of the important lifestyle factors (eg, smoking history) gives most of the important information about risk of progression," write Ronald Klein, MD, MPH, Barbara Klein, BD, MPH, and Chelsea Myers, MStat, from the Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, in an editorial.
A limitation of the model is that it was developed using a clinical population. Indeed, when the editorial writers applied the model to 1575 people aged 55 to 80 years at baseline in the population-based Beaver Dam Eye Study, they found that the model predicted a greater risk for progression than actually happened, possibly because the clinical population on which the model is based had more advanced disease. The editorial writers also suggest that the model should include nutritional supplement use.
The study was supported by the Casey Eye Institute Macular Degeneration Fund; Research to Prevent Blindness, New York City; Bea Arveson Macular Degeneration Fund; and Foundation Fighting Blindness, Owings Mills, Maryland. One article author is one of the inventors of a patented nutritional supplement to treat AMD that is owned by Bausch and Lomb, for which he receives government compensation. The work of 2 of the editorialists is supported by the National Eye Institute of the National Institutes of Health The editorialists have disclosed no relevant financial relationships.
Arch Ophthalmol. 2011;129:1543-1550. Full text
