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Aims/hypothesis: This study explored the impact of ethnicity on time-to-clinic, time-to-treatment and rates of vision loss in people referred to hospital with diabetic eye disease., Methods: A survival analysis was performed on all referrals from an inner-city diabetic eye screening programme to a tertiary hospital eye service between 1 October 2013 and 31 December 2017. Exclusion criteria were failure to attend hospital, distance visual acuity in both eyes too low to quantify with the Early Treatment Diabetic Retinopathy Study (ETDRS) letter chart and treatment received prior to referral. Demographic and screening grade data were collected at the point of referral. Small-area statistics and census data were used to calculate indices of multiple deprivation. The main outcome measures were time taken from the date of referral for an individual to achieve the following: (1) attend the first hospital clinic appointment; (2) receive the first macular laser, intravitreal anti-vascular endothelial growth factor injection or pan-retinal photocoagulation treatment, in either eye; and (3) lose at least ten ETDRS letters of distance visual acuity, in either eye., Results: Of 2062 referrals, 1676 individuals were included. Mean age (± SD) was 57.6 ± 14.7 years, with 52% male sex and 86% with type 2 diabetes. The ethnicity profile was 52% Black, 30% White, 10% Asian and 9% mixed/other, with similar disease severity at the time of referral. Time-to-clinic was significantly longer for Asian people than for Black people (p = 0.03) or White people (p = 0.001). Time-to-treatment was significantly longer for Black people than for White people (p = 0.02). Social deprivation did not significantly influence time-to-treatment. There were no significant differences in the rates of vision loss between ethnic groups., Conclusions/interpretation: Black people wait longer for hospital eye treatment compared with their White counterparts. The reasons for this delay in treatment warrant further investigation.

With age-related functional deterioration, sensory impairment including vision impairment (VI), hearing impairment (HI), and dual sensory impairment (DSI) usually occurred among the elderly population, causing a decrease in functional capacity and quality of life. The study aimed to explore how sensory impairment is associated with the risk of all-cause mortality among the elderly adults in China. We prospectively investigated the association among 37,076 participants enrolled from 1998 to 2019 in the Chinese Longitudinal Healthy Longevity Survey. We also, as a sensitivity analysis, explored the association among 11,365 newly incident sensory impairment participants. Cox regression model with sensory impairment as a time-varying exposure was performed to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs). Compared with participants without sensory impairment, those with VI (HR=1.20, 95% CI: 1.15-1.24), HI (HR=1.26, 95% CI: 1.21-1.31), and DSI (HR: 1.46, 95% CI=1.41-1.52) had significant higher risk of all-cause mortality after adjusting for potential confounders. These associations were robust among subgroup analyses stratified by sex and entry age, and sensitivity analyses performed among newly incident sensory impairment participants. In conclusion, sensory impairment was associated with higher mortality risk among the elderly adults in China.

Objective: To understand the relationship between visual impairment and risk of all-cause mortality in the elderly aged 65 years and older in 8 longevity areas in China. Methods: The data of the elderly aged 65 years and older in the project in 2012 were obtained from Healthy Aging and Biomarkers Cohort Study, a sub-cohort of the Chinese Longitudinal Healthy Longevity Survey, including physical measurement and survival status, and a follow-up for survival outcomes were conducted in 2014 and 2017 respectively. Cox proportional hazard regression model was used to analyze the influence of visual impairment on mortality. Gender and age specific analysis was conducted. Results: A total of 1 736 elderly adults were included. A total of 943 deaths occurred during the 5-year follow-up period with a 5-year mortality rate of 54.3 % . The 5-year mortality rate was 76.7 % in the group with visual impairment, and 47.6 % in the group without visual impairment ( P <0.001). After adjusting for demographic information, life style and some disease factors, the risk of 5-year mortality in the group with visual impairment group was 1.30 times higher than that in the group without visual impairment ( HR =1.30, 95 %CI : 1.09-1.55). In the females, the risk for mortality in the group with visual impairment was 1.48 times higher than that in the group without visual impairment ( HR =1.48, 95 %CI :1.20-1.84). However, vision status was not associated with the risk for mortality in males ( HR =1.02, 95 %CI : 0.72-1.43). The risk for mortality in the group with visual impairment was 1.39 times higher than that in the group without visual impairment in the elderly aged over 90 years ( HR =1.39, 95 %CI : 1.13-1.70). Vision status was not associated with mortality risk in the elderly aged 65-79 years and 80-89 years ( HR =1.37, 95 %CI : 0.61-3.07; HR =0.95, 95 %CI : 0.61-1.48). Conclusion: In the elderly people in China, visual impairment is a risk factor for mortality.

The association between visual impairment and higher mortality remains unclear. In addition, evidence is lacking on the interaction between visual function and physical activity on mortality. We used data of individuals with no disability or with visual impairment among those who participated in the National Health Screening Program in Korea in 2009 or 2010. We constructed Cox proportional hazard models adjusted for potential confounders to evaluate the independent association between visual impairment and mortality. More severe visual impairment was associated with higher all-cause mortality ( p -value for trend = 0.03) and mortality due to cardiovascular diseases ( p -value for trend = 0.02) and that due to other diseases ( p -value for trend = 0.01). We found an interaction on an additive scale between visual impairment and no physical activity on all-cause mortality (relative excess risk due to interaction = 1.34, 95% confidence interval: 0.37, 2.30, p -value = 0.01). When we stratified the study population by physical activity, the association between visual impairment and mortality was only found among individuals who did not engage in regular physical activity ( p -value for trend = 0.01). We found an independent association between visual impairment and mortality and modification of this association by physical activity.

Objective: To estimate the association between (1) visual impairment (VI) and (2) eye disease and 6-year mortality risk within a cohort of elderly Kenyan people., Design, Setting and Participants: The baseline of the Nakuru Posterior Segment Eye Disease Study was formed from a population-based survey of 4318 participants aged ≥50 years, enrolled in 2007-2008. Ophthalmic and anthropometric examinations were undertaken on all participants at baseline, and a questionnaire was administered, including medical and ophthalmic history. Participants were retraced in 2013-2014 for a second examination. Vital status was recorded for all participants through information from community members. Cumulative incidence of mortality, and its relationship with baseline VI and types of eye disease was estimated. Inverse probability weighting was used to adjust for non-participation., Primary Outcome Measures: Cumulative incidence of mortality in relation to VI level at baseline., Results: Of the baseline sample, 2170 (50%) were re-examined at follow-up and 407 (10%) were known to have died (adjusted risk of 11.9% over 6 years). Compared to those with normal vision (visual acuity (VA) ≥6/12, risk=9.7%), the 6-year mortality risk was higher among people with VI (<6/18 to ≥6/60; risk=28.3%; risk ratio (RR) 1.75, 95% CI 1.28 to 2.40) or severe VI (SVI)/blindness (<6/60; risk=34.9%; RR 1.98, 95% CI 1.04 to 3.80). These associations remained after adjustment for non-communicable disease (NCD) risk factors (mortality: RR 1.56, 95% CI 1.14 to 2.15; SVI/blind: RR 1.46, 95% CI 0.80 to 2.68). Mortality risk was also associated with presence of diabetic retinopathy at baseline (RR 3.18, 95% CI 1.98 to 5.09), cataract (RR 1.26, 95% CI 0.95 to 1.66) and presence of both cataract and VI (RR 1.57, 95% CI 1.24 to 1.98). Mortality risk was higher among people with age-related macular degeneration at baseline (with or without VI), compared with those without (RR 1.42, 95% CI 0.91 to 2.22 and RR 1.34, 95% CI 0.99 to 1.81, respectively)., Conclusions: Visual acuity was related to 6-year mortality risk in this cohort of elderly Kenyan people, potentially because both VI and mortality are related to ageing and risk factors for NCD., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Study Design: A retrospective review of the Scoliosis Research Society (SRS) morbidity and mortality (M&M) database., Objective: The aim of this study was to investigate visual related complications in spinal deformity patients undergoing spine surgery., Summary of Background Data: The SRS compiles surgeon-reported complications into an M&M database, tracking postoperative complications including visual loss, neurological deficits, infections, and death. Limited literature exists on postoperative visual complications, a rare but devastating complication following spine surgery., Methods: We utilized the SRS M&M database to determine demographics, perioperative risk factors, and prognosis for visual related complications in spinal deformity patients undergoing corrective spine surgery from 2009 to 2012., Results: A total of 167,972 spinal deformity patients from 2009 to 2012 were identified with a visual acuity complication (VAC) rate of 0.01%, or 12.5 per 100,000 patients. VAC rates for patients with kyphosis were significantly higher than patients with scoliosis (0.049% vs. 0.010%, P = 0.002) and spondylolisthesis (0.049% vs. 0.005%, P = 0.001). Postoperative visual loss rates significantly decreased from 2010 to 2012 (0.022% vs. 0.004%, P = 0.029). Twenty-one patients identified with VACs had a mean age of 34.8 ± 24.3 years. Two (9.5%) patients had preoperative vision changes, two (9.5%) were diabetic, two (9.5%) had vascular disease, one (4.8%) had a history of thromboembolic disease, and five (23.8%) had hypertension. Extent of VAC was bilateral-partial in four (19.0%), bilateral-total in five (23.8%), unilateral-partial in eight (38.1%), and unilateral-total in three (14.3%) patients. Four (19.0%) patients developed anterior ischemic optic neuropathy, four (19.0%) had posterior ischemic optic neuropathy (PION), five (23.8%) had central retinal artery occlusion, and five (23.8%) developed cortical blindness (CB). Greater than 50% of the VACs occurred on, or before, the first postoperative day. Ten (47.6%) patients recovered complete vision and four (19.0%) improved. All patients with CB and 50% with posterior ischemic optic neuropathy experienced complete resolution., Conclusion: VACs occur in approximately 12.5 per 100,000 deformity patients, with a rate five times higher in patients with kyphosis. More than 50% of these complications occur within 24 hours postoperatively. Nearly half of these complications resolve completely, and another 19% improve postoperatively., Level of Evidence: 4.

Objectives: We aimed to investigate the impact of visual field defects (VFD) on mortality in ischemic stroke patients., Materials and Methods: All patients with acute infarction and a clinically detected VFD from February 2006 to December 2013 in the NORSTROKE Registry (n = 506) were included and compared with ischemic stroke patients with normal visual fields (n = 2041). A record of patients who had died per ultimo April 2015 was obtained from the central registry at Haukeland University Hospital., Results: Patients with VFD were significantly older (75.0 vs 69.8, P < .001) than patients with normal visual fields. The majority of patients with VFD was male, had higher cardiovascular morbidity prestroke, and were more likely to have shorter median time from symptom onset to admission (1.7 hours vs 2.7 hours, P < .001). Baseline National Institute of Health Stroke Scale (NIHSS) score was higher (12.7 vs 3.5, P < .001) as was modified Rankin Scale (mRS) score (3.5 vs 1.9, P < .001) and Barthel Index was lower (51.9 vs 84.8, P < .001) day 7. VFD was associated with increased mortality on Kaplan-Meier plots. Hazard ratio was significantly higher for patients with VFD after adjusting for age, sex, employment prior to infarction, married prior to infarction, institutionalization prior to infarction, prior myocardial infarction, atrial fibrillation, smoking, Barthel Index score and i.v. thrombolysis with Cox regression (hazard ratios [HR] 1.30, CI 1.07-1.56, P = .007)., Conclusions: Having a visual field defect after ischemic stroke is independently associated with increased mortality. This should be addressed when selecting candidates for thrombolysis and in the rehabilitation process., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background and aims We examined the neurological manifestations, treatment and outcomes of a subset of 25 patients within the largest ever outbreak of wound botulism in Europe. Methods and results All 25 cases were intravenous drug users. The most common presenting symptom was dysarthria in 19/25 (76%), followed by dysphagia in 12/25 (48%), blurred vision in 10/25 (40%) and double vision in 8/25 (32%). Microbiological analysis confirmed the diagnosis in nine cases (36%). Duration of admission positively correlated with time to antitoxin, time to wound debridement and female sex. Conclusion As the outbreak continued, hospital stays shortened, reflecting growing awareness of the outbreak and quicker treatment initiation.

Objective: The endoscopic extended transsphenoidal approach for suprasellar craniopharyngiomas may be a really alternative to the transcranial approach in many cases. The authors present their experience with this technique in 136 patients with craniopharyngiomas., Methods: From the past 7 years 204 patients with different purely supradiaphragmatic tumors underwent removal by extended endoscopic transsphenoidal transtuberculum transplanum approach. Most of the patients (136) had craniopharyngiomas (suprasellar, intra-extraventricular). The patients were analyzed according to age, sex, tumor size, growth and tumor structure, and clinical symptoms. Twenty-five patients had undergone a previous surgery. The mean follow-up was 42 months (range, 4-120 months). The operation is always performed with the bilateral endoscopic endonasal anterior extended transsphenoidal approach., Results: A gross-total removal was completed in 72%. Improvement of vision or absence of visual deterioration after operation was observed in 89% of patients; 11% had worsening vision after surgery. Endocrine dysfunction did not improve after surgery, new hypotalamopituitary dysfunction (anterior pituitary dysfunction or diabetes insipidus) or worsening of it was observed in 42.6%. Other main complications included transient new mental disorder in 11%, temporary neurological postoperative deficits in 3.7%, bacterial meningitis in 16%, cerebrospinal fluid leaks in 8.8%. The recurrence rate was 20% and the lethality was 5.8%., Conclusions: Resection of suprasellar craniopharyngiomas using the extended endoscopic approach is a more effective and less traumatic technology, able to provide resection of the tumor along with high quality of life after surgery, and relatively rare postoperative complications and mortality., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: It is unknown whether sudden vision loss (SVL) is an independent marker for future cardiovascular disease (CVD) events in African Americans. We examined the hazard of future stroke or myocardial infarction (MI) and mortality associated with self-reported SVL lasting 24 hours or longer in a cohort of African Americans enrolled in the Jackson Heart Study (JHS)., Methods: The study sample comprised 4670 African Americans aged 20-95 years enrolled in the JHS without previous coronary heart disease or stroke at baseline. All participants who responded to the question "Have you ever had any sudden loss of vision or blurring, lasting 24 hours or longer?" on the baseline stroke questionnaire were included in the study. Ten years of follow-up data was used. Cox proportional hazards modeling was used to examine the association between SVL (n = 142) and risk of future stroke/MI and mortality., Results: In age- and sex-adjusted Cox models, SVL was significantly associated with higher hazards of future stroke/MI (hazard ratio, HR, 2.08, 95% confidence interval, CI, 1.09-3.96) and mortality (HR 1.73, 95% CI 1.07-2.78). After adjusting for diabetes mellitus, total/high-density lipoprotein cholesterol ratio, smoking, hypertension and income, the relationships between SVL and future stroke/MI (adjusted HR 1.51, 95% CI 0.78-2.90) or mortality (adjusted HR 1.29, 95% CI 0.78-2.11) were no longer significant., Conclusions: Self-reported SVL lasting 24 hours or longer was significantly associated with future stroke/MI and mortality, but its effect is likely a surrogate for underlying CVD risk factors rather than being an independent predictor.

Background: The findings from prospective studies on visual impairment (VI) and the risk of mortality are not consistent., Objective: A meta-analysis of prospective studies was conducted to quantitatively summarise the evidence about the association between VI and the risk of mortality., Methods: Pertinent studies were identified by a search of PubMed, Web of Science and the Chinese National Knowledge Infrastructure and Wanfang databases up to December 2015. The random-effect model was used to combine study-specific relative risks (RRs) and 95% CIs. Meta-regression and subgroup analysis were conducted to explore potential sources of heterogeneity. Publication bias was estimated by Egger's test and the funnel plot. Dose-response relationship was assessed by restricted cubic spline functions., Results: This meta-analysis contained 29 prospective studies including 269 839 participants and 67 061 deaths. Compared to the no VI, the highest VI level was significantly associated with an increased risk of mortality (RR: 1.36, 95% CI 1.25 to 1.46). The association remained significant in participants older than 65 years (RR: 1.28, 95% CI 1.18 to 1.39), and a significant association was also observed in men (RR: 1.29, 95% CI 1.07 to 1.54) and women (RR: 1.39, 95% CI 1.14 to 1.70), respectively. For dose-response analysis, a linear relation was found between visual acuity (VA) and the risk of mortality. For every 0.1 Logarithm of the Minimum Angle of Resolution (LogMAR) increment, the risk of mortality increased by 4% (RR: 1.04, 95% CI 1.01 to 1.06)., Conclusions: VI was significantly associated with an increased risk of mortality., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Vision and hearing impairments among elders are common, and cognitive impairment is a concern. This study assessed the association of vision and hearing impairments with cognitive impairment and mortality among long-term care recipients., Methods: Data of 1754 adults aged 65 or older were included in analysis from the Gujo City Long-Term Care Insurance Database in Japan for a mean follow-up period of 4.7 years. Trained and certified investigators assessed sensory impairments and cognitive impairment using a national assessment tool. Five-level scales were used to measure vision and hearing impairments. Cognitive performance was assessed on two dimensions, namely communication/cognition and problem behaviors. We performed logistic regression analysis to estimate odd ratios (ORs) and 95 % confidence intervals (CIs) for the association of vision and hearing impairments with cognitive impairment. Using Cox proportional hazard regression models, we obtained hazard ratios (HRs) for mortality., Results: Of 1754 elders, 773 (44.0 %) had normal sensory function, 252 (14.4 %) vision impairment, 409 (23.3 %) hearing impairment, and 320 (18.2 %) dual sensory impairment. After adjusting for potential cofounders, ORs of cognitive impairment were 1.46 (95 % CI 1.07-1.98) in individuals with vision impairment, 1.47 (95 % CI 1.13-1.92) in those with hearing impairment, and 1.97 (95 % CI 1.46-2.65) in those with dual sensory impairment compared to individuals with normal sensory function. The adjusted HR of overall mortality was 1.29 (95 % CI 1.01-1.65) in individuals with dual sensory impairment and cognitive impairment relative to normal sensory and cognitive functions., Conclusions: Cognitive impairment was most common in individuals with dual sensory impairment, and those with dual sensory impairment and cognitive impairment had increased mortality.

Background: Concurrent vision and hearing impairment, known as dual sensory impairment (DSI), is associated with increased mortality. We aimed to examine individual and joint associations of DSI and involvement in activities with mortality in a large European nursing home study., Methods: In total, 2,851 nursing home residents in 59 facilities in eight countries were followed for 1 year in the Services and Health for Elderly in Long TERm Care study. Vision and hearing impairment and average time of involvement in activities were assessed by trained research staff using the interRAI Long Term Care Facilities. Association between DSI and 1-year all-cause mortality was examined using Cox proportional hazards models adjusted for age, sex, facility, diagnoses of coronary heart disease and diabetes mellitus, self-rated health, end-stage disease, and functional and cognitive status. The modifying effect of involvement in activities on the association was investigated by the additive hazard model., Results: DSI, defined as moderate to severe impairment in both senses, was independently associated with a 35% increased risk of 1-year mortality compared with non-DSI. Residents with DSI who were involved in activities did not have higher mortality, while residents with DSI who were not involved in activities had 51% higher mortality than non-DSI residents who were involved in activities, equivalent to approximately 209 additional deaths per 1,000 person-years (p = .012) due to the interaction between DSI and no involvement in activities., Conclusions: DSI is associated with increased mortality at nursing homes when combined with no involvement in activities., (© The Author 2015. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To assess 10-year mortality in people who had undergone cataract surgery with no residual visual impairment (VI) and those who had persistent VI due to cataract using a population-based cohort., Methods: The Liwan Eye Study is a 10-year longitudinal study commenced in 2003. According to the World Health Organization, presenting VI was defined as visual acuity less than 20/63 in the better-seeing eye. History of cataract surgery was defined as cataract surgery performed on either eye. Information on the date of surgery was recorded. Dates of death occurring between baseline and April 30, 2014 were obtained from the National Death Index data. Information on socioeconomic factors was obtained from questionnaire interviews. Cox proportional hazards regression models were used to assess the hazard ratios (HRs) and 95% confidence intervals (CIs)., Results: Fifty-nine participants had undergone cataract surgery without residual VI and 67 participants had persistent cataract-related VI. The 10-year mortality rate for participants who had undergone cataract surgery without residual VI was statistically significant lower than that in participants who had VI due to cataract based on log-rank test (32.2% vs. 64.2%; P = 0.002). This finding remained significant in the unadjusted Cox proportional hazards model (HR, 0.43; 95% CI, 0.25-0.74; P = 0.002). After adjusting for age, sex, history of diabetes, and hypertension, body mass index (BMI), education level, and personal income, participants with cataract surgery and no residual VI did not have a higher chance of survival than participants with persistent VI due to cataract (HR, 0.56; 95% CI, 0.26-1.20; P = 0.136)., Conclusions: Cataract-related VI corrected by cataract surgery was not associated with better survival after adjusting for a number of possible confounders. Given our sample size is relatively small and limited power, further studies with larger sample are needed.

We investigated the relationship of visual impairment (VI) and age-related eye diseases with mortality in a prospective, population-based cohort study of 3,280 Malay adults aged 40-80 years between 2004-2006. Participants underwent a full ophthalmic examination and standardized lens and fundus photographic grading. Visual acuity was measured using logMAR chart. VI was defined as presenting (PVA) and best-corrected (BCVA) visual acuity worse than 0.30 logMAR in the better-seeing eye. Participants were linked with mortality records until 2012. During follow-up (median 7.24 years), 398 (12.2%) persons died. In Cox proportional-hazards models adjusting for relevant factors, participants with VI (PVA) had higher all-cause mortality (hazard ratio[HR], 1.57; 95% confidence interval[CI], 1.25-1.96) and cardiovascular (CVD) mortality (HR 1.75; 95% CI, 1.24-2.49) than participants without. Diabetic retinopathy (DR) was associated with increased all-cause (HR 1.70; 95% CI, 1.25-2.36) and CVD mortality (HR 1.57; 95% CI, 1.05-2.43). Retinal vein occlusion (RVO) was associated with increased CVD mortality (HR 3.14; 95% CI, 1.26-7.73). No significant associations were observed between cataract, glaucoma and age-related macular degeneration with mortality. We conclude that persons with VI were more likely to die than persons without. DR and RVO are markers of CVD mortality.

Background: The association between visual impairment and mortality has been controversial. Moreover, literature on the relationship was very limited in the Asian population. The purpose of this study was to investigate whether visual impairment increases the 3-year risk of mortality in a cohort of urban Chinese elderly individuals., Methods: Participants in the Shihpai Eye Study, who were aged ≥65 years, with a baseline examination conducted between July 1, 1999 and December 31, 2000, were recruited for the current study. The total number of possible participants identified was 4750. Of those, 3746 persons were eligible, and 2045 persons were randomly selected to be invited to participate in the study. Of those 2045 individuals, 1361 (66.6%) participated in both the questionnaire and eye examination. A follow-up of a fixed cohort was also conducted after 3 years. The death of any participants was confirmed through the household registration system., Results: Of the 1361 participants included at baseline, 54 (3.97%) died before the 3-year follow-up. Multiple logistic regression analysis showed that mortality was significantly associated with a fall history [relative risk (RR): 2.12; 95% confidence intervals (CI): 1.08-3.98] and a history of diabetes (RR: 2.06; 95% CI: 1.03-3.95). Visual impairment was not a significant predictor of mortality after adjustment for confounders., Conclusion: After adjustments were made for age, sex, education, marital status, lifestyle factors, depression symptoms, fall history, and history of systemic diseases, visual impairment was not a significant predictor of 3-year mortality in elderly persons., (Copyright © 2014. Published by Elsevier Taiwan.)

Importance: Determination of the mechanisms by which visual loss increases mortality risk is important for developing interventional strategies., Objective: To evaluate the direct and indirect effects of loss of visual acuity (VA) on mortality risk through functional status changes among aging adults., Design, Setting, and Participants: Prospective longitudinal study of a population-based sample of 2520 noninstitutionalized adults aged 65 to 84 years from September 16, 1993, through July 26, 2003, in the greater Salisbury area of Maryland. Participants underwent reassessment 2, 6, and 8 years after baseline. Mortality status was ascertained from linkage with the National Death Index through 2009., Exposures: Results of VA testing and self-reported functional status based on activities of daily living (ADL) and instrumental ADL (IADL)., Main Outcomes and Measure: Mortality., Results: Worse VA levels at baseline were associated with an increased the risk for mortality (hazard ratio [HR], 1.16 [95% CI, 1.04-1.28]; P < .01) through their effect on lower IADL levels at baseline. Declines in VA over time were associated with increased mortality risk (HR, 1.78 [95% CI, 1.27-2.51]; P < .001) by way of decreasing IADL levels over time. Participants experiencing the mean linear decline in VA of 1 letter on the Early Treatment Diabetic Retinopathy Study acuity chart per year are expected to have a 16% increase in mortality risk during the 8-year study exclusively through associated declines in IADL levels., Conclusions and Relevance: In this longitudinal study of older adults, VA loss adversely affected IADL levels, which subsequently increased the risk for mortality. Prevention of disabling ocular conditions, treatment of correctable visual impairment, and interventions designed to prevent the effect of visual impairment on IADL declines may all reduce mortality risk in aging adults.

Background: The aims of this study were to evaluate visual function outcomes in idiopathic intracranial hypertension (IIH) patients who underwent ventriculoperitoneal (VP) shunt for visual loss and to determine a VP shunt survival curve over time., Methods: A retrospective medical record review was performed of all new IIH patients first evaluated at our institution who underwent VP shunt placement over a 7-year period (2004-2010). There were 2 primary outcome measures: the first being visual acuity (VA) and the second being shunt survival. Patients who received VP shunt for visual loss were included in the visual outcome analysis, and all patients who received VP shunt for any reason were included in the shunt survival analysis., Results: Of the 338 new patients with IIH, 19 patients (6%) met the inclusion criteria and 17 underwent VP shunt for visual loss and 2 for headaches. Average follow-up was 21.2 months (range, 5-1,342 days). Of the 17 patients who had VP shunt for visual loss, 5 patients had optic nerve sheath fenestration (ONSF) surgery before VP shunt, and 1 patient had bilateral ONSF surgery after VP shunt. Median VA before shunt was 20/200 in the worse eye (range, 20/20 to NLP) and 20/40 in the better eye (20/20 to HM). Median VA after shunt was 20/60 in the worse eye (20/20 to lumboperitoneal) and 20/30 in the better eye (20/20 to 20/800). The improvement in VA was statistically significant in both worse eyes (P = 0.002, Wilcoxon signed-rank test) and better eyes (P = 0.028). The mean automated visual field (AVF) mean deviation (MD) of available AVFs before shunt was 223.36 dB (range, 233.38 to 27.01 dB) for the worse eye (n = 11) and 219.66 dB (230.11 to 25.91 dB) for the better eye (n = 11). Mean AVF MD deviation of available AVFs after shunt was 220.68 dB (232.13 to 23.97 dB) for the worse eye (n = 11) and 216.35 dB (232.13 to 21.00 dB) for the better eye (n = 11): this improvement was not significant (P = 0.27, P = 0.26, respectively). Independent masked record reviews by 3 neuro-ophthalmologists showed that 9 (53%) patients improved, 5 (29%) unchanged, 1 (6%) worsened, and 2 (12%) were indeterminate. Kaplan-Meier analysis showed a persistent steady decrease of functioning VP shunts over the entire period of 36 months with 80%, 65%, and 48% of VP shunts functioning without replacement, removal, or revision at 12, 24, and 36 months, respectively., Conclusion: VP shunts improve or stabilize most IIH patients presenting with severe progressive visual loss or those with visual loss refractive to medical treatment and ONSF. Survival analysis shows persistent decrease of functioning shunts over time.

Background: Due to the devastating late effects associated with cranial irradiation in young children with central nervous system (CNS) tumors, treatment for these patients has evolved to include the use of intensive chemotherapy to either avoid or postpone irradiation. While survival outcomes have improved, late effects data in survivors treated on such regimens are needed., Objective: This multi-institutional study comprehensively describes late effects in survivors treated on the Head Start I/II protocols., Methods: Survivors of CNS tumors treated on Head Start I/II protocols were enrolled. Late effects data were collected using a validated parent-report questionnaire. Social, emotional, and behavioral functioning and quality of life were assessed using parent-report on the BASC-2 and CHQ-PF50 questionnaires., Results: Twenty-one survivors (medulloblastoma = 13, sPNET = 4, ATRT = 1, ependymoma = 3) were enrolled. Ten (48%) were irradiation-free. Late effects (frequency; median time of onset since diagnosis) included ≥ grade III hearing loss (67%; 3.9 years), vision (67%; 4.1 years), hypothyroidism (33%; 4 years), growth hormone (GH) deficiency (48%; 4.7 years), dental (52%; 7.1 years), and no cases of secondary leukemia. Irradiation-free (vs. irradiated) survivors reported low rates of hypothyroidism (0/10 vs. 7/11; P = 0.004) and GH deficiency (2/10 vs. 8/11; P = 0.03). The BASC-2 and CHQPF-50 mean composite scores were within average ranges relative to healthy comparison norms. Neither age at diagnosis nor irradiation was associated with these scores., Conclusions: Irradiation-free Head Start survivors have lower risk of hypothyroidism and GH deficiency. Secondary leukemias are not reported. With extended follow-up, survivors demonstrate quality of life, social, emotional, and behavioral functioning within average ranges., (© 2014 Wiley Periodicals, Inc.)

Objective: to examine the relationships between impairments in hearing and vision and mortality from all-causes and cardiovascular disease (CVD) among older people., Design: population-based cohort study., Participants: the study population included 4,926 Icelandic individuals, aged ≥67 years, 43.4% male, who completed vision and hearing examinations between 2002 and 2006 in the Age, Gene/Environment Susceptibility-Reykjavik Study (AGES-RS) and were followed prospectively for mortality through 2009., Methods: participants were classified as having 'moderate or greater' degree of impairment for vision only (VI), hearing only (HI), and both vision and hearing (dual sensory impairment, DSI). Cox proportional hazard regression, with age as the time scale, was used to calculate hazard ratios (HR) associated with impairment and mortality due to all-causes and specifically CVD after a median follow-up of 5.3 years., Results: the prevalence of HI, VI and DSI were 25.4, 9.2 and 7.0%, respectively. After adjusting for age, significantly (P < 0.01) increased mortality from all causes, and CVD was observed for HI and DSI, especially among men. After further adjustment for established mortality risk factors, people with HI remained at higher risk for CVD mortality [HR: 1.70 (1.27-2.27)], whereas people with DSI remained at higher risk of all-cause mortality [HR: 1.43 (1.11-1.85)] and CVD mortality [HR: 1.78 (1.18-2.69)]. Mortality rates were significantly higher in men with HI and DSI and were elevated, although not significantly, among women with HI., Conclusions: older men with HI or DSI had a greater risk of dying from any cause and particularly cardiovascular causes within a median 5-year follow-up. Women with hearing impairment had a non-significantly elevated risk. Vision impairment alone was not associated with increased mortality.

Purpose: To compare mortality risk between cataract surgical patients with corrected and persistent visual impairment., Design: Cohort study., Methods: A total of 1864 consecutive patients, aged ≥64 years, undergoing phacoemulsification surgery at Westmead Hospital were followed annually for 5 years postoperatively. Visual impairment status in the surgical eye was categorized as none (presenting visual acuity [VA], ≥20/40), mild (VA <20/40-20/60), or moderate-severe (VA <20/60). All-cause mortality was obtained from the Australian National Death Index., Results: Of 901 patients with moderate-severe visual impairment before surgery, 60.4% (n = 544), 15.5% (n = 140), and 24.1% (n = 217) had no, mild, or moderate-severe visual impairment in the surgical eye, respectively, 1 month postoperatively. Age-standardized 5-year mortality rates were nonsignificantly lower in patients with either mild (24.7%, 95% confidence interval [CI] 16.5%-32.9%) or no visual impairment (24.1%, 95% CI 19.9%-28.4%) post surgery compared to that in patients whose moderate-severe visual impairment persisted (30.6%, 95% CI 23.3%-37.9%). After adjusting for age, sex, smoking, body mass index, and individual comorbid conditions, such as hypertension, diabetes, angina, myocardial infarction, stroke, transient ischemic attack, and kidney disease, patients with no visual impairment 1 month postoperatively had a lower mortality risk (HR 0.73, 95% CI 0.52-1.01) compared to those with persistent moderate-severe visual impairment after surgery. This finding was significant (HR 0.71, 95% CI 0.51-0.99) after additional adjustment for number of medications taken (continuous variable) and number (≥3 vs <3) of comorbid conditions., Conclusion: Correcting moderate-severe visual impairment in older patients with phacoemulsification surgery was associated with a lower mortality risk, compared to surgical patients whose visual impairment persisted postoperatively., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: A large-scale prevalence survey of blindness and visual impairment (The Andhra Pradesh Eye Diseases Study [APEDS1]) was conducted between 1996-2000 on 10,293 individuals of all ages in three rural and one urban clusters in Andhra Pradesh, Southern India. More than a decade later (June 2009-March 2010), APEDS1 participants in rural clusters were traced (termed APEDS2) to determine ocular risk factors for mortality in this longitudinal cohort., Methods and Findings: Mortality hazard ratio (HR) analysis was performed for those aged >30 years at APEDS1, using Cox proportional hazard regression models to identify associations between ocular exposures and risk of mortality. Blindness and visual impairment (VI) were defined using Indian definitions. 799/4,188 (19.1%) participants had died and 308 (7.3%) had migrated. Mortality was higher in males than females (p<0.001). In multivariable analysis, after adjusting for age, gender, diabetes, hypertension, body mass index, smoking and education status the mortality HR was 1.9 (95% CI: 1.5-2.5) for blindness; 1.4 (95% CI: 1.2-1.7) for VI; 1.8 (95% CI: 1.4-2.3) for pure nuclear cataract, 1.5 (95% CI: 1.1-2.1) for pure cortical cataract; 1.96 (95% CI: 1.6-2.4) for mixed cataract, 2.0 (95% CI: 1.4-2.9) for history of cataract surgery, and 1.58 (95% CI: 1.3-1.9) for any cataract. When all these factors were included in the model, the HRs were attenuated, being 1.5 (95% CI: 1.1-2.0) for blindness and 1.2 (95% CI: 0.9-1.5) for VI. For lens type, the HRs were as follows: pure nuclear cataract, 1.6 (95% CI: 1.3-2.1); pure cortical cataract, 1.5 (95% CI: 1.1-2.1); mixed cataract, 1.8 (95% CI: 1.4-2.2), and history of previous cataract surgery, 1.8 (95% CI: 1.3-2.6)., Conclusions: All types of cataract, history of cataract surgery and VI had an increased risk of mortality that further suggests that these could be potential markers of ageing.

Background: In various contexts, the identification of insurants with geriatric conditions (GC) can offer new approaches for specific medical services. GC can be determined from diagnoses data of insurants retrieved from different care sectors, and supplemented with other relevant claims data, e.g., long-term care levels and pharmaceutical data., Methods: Part 3 of this study is based on a systematic sample of 957,447 AOK insurants (age ≥ 60 years). Prevalence of 15 GC was investigated using anonymous claims data of diagnoses from physicians in the ambulant care setting and diagnoses from hospital settings in 2008. In addition the potential relationships of GC with mortality, nursing home admission, need for long-term care and hospital utilization in the following year were examined. All results were standardized by gender and age based on the general population aged ≥ 60 years in Germany., Results: Pain and impairment of vision or hearing was the most common GC (> 25%) followed by high risk of complications, fall risk/dizziness, and cognitive deficit (8-14%). Delayed convalescence, frailty, medication problems, immobility and malnutrition occurred in < 1% of the insurants. Almost all GC occurred more often with increasing age. Only 37% insurants in the sample showed no GC, while for 31% exactly one, for 17% two, and for 15% three or more GC were observed. With the exception of pain and impairment of vision or hearing all of the GC had a significant positive association with mortality, nursing home admission, increasing need of care, and hospital utilization in the following year., Conclusions: The applied operational approach proved to be generally practicable and successful with few adaptations. The GC pain and impairment of vision or hearing, however, do not contribute sufficiently to the identification of geriatric multimorbidity based on claims data. These GC should be therefore disregarded from such identification processes. To enhance the reliability of an identified geriatric multimorbidity, the requirements on the specificity and number of individual GC (two, three, or more) can be adapted.

Objective: We assessed whether correction of visual impairment (VI) by cataract surgery was associated with improved long-term survival in an older Australian population., Design: Population-based cohort study., Participants: In the Blue Mountains Eye Study, 354 participants, aged ≥ 49 years, had both cataract and VI or had undergone cataract surgery before baseline examinations. They were subsequently examined after 5- and 10-year follow-ups., Methods: Associations between the mortality risk and the surgical correction of VI (visual acuity [VA] <20/40, attributable to cataract) were assessed in Cox proportional hazard regression models, after multivariate adjustment, using time-dependent variables for the study factor., Main Outcome Measures: All-cause mortality., Results: The 15-year crude mortality of participants who had undergone cataract surgery at baseline with no subsequent VI (71.8%) was relatively similar to that in participants with cataract-related VI who had not yet undergone surgery (79.4%). However, after adjusting for age and sex, participants who underwent cataract surgery before baseline or during follow-up and no longer had VI had significantly lower long-term mortality risk (hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.46-0.77) than participants with VI due to cataract who had not undergone cataract surgery. This lower mortality risk in the group with surgically corrected VI (HR, 0.54; 95% CI, 0.41-0.73) persisted after further adjustment for smoking, body mass index, home ownership, qualifications, poor self-rated health, the presence of poor mobility, hypertension, diabetes, self-reported history of angina, myocardial infarction, stroke, cancer, asthma, and arthritis. This finding remained significant (HR, 0.55; 95% CI, 0.41-0.73) after additional adjustment for the number of medications taken (continuous variable) and the number (≥ 5 vs. <5) of comorbid conditions (poor mobility, hypertension, diabetes, angina, myocardial infarction, stroke, cancer, asthma, or arthritis) as indicators of frailty., Conclusions: Surgical correction of VI due to cataract was associated with significantly better long-term survival of older persons after accounting for known cataract and mortality risk factors, and indicators of general health. Whether some uncontrolled factors (frailty or general health) could have influenced decisions not to perform cataract surgery in some participants is unknown. However, this finding strongly supports many previous reports linking VI with poor survival., Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references., (Copyright © 2013 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: To provide instructive information on death and neurodevelopmental outcomes of infants born at 22 and 23 weeks' gestational age., Methods: The study cohort consisted of 1057 infants born at 22 to 25 weeks in the Neonatal Research Network, Japan. Neurodevelopmental impairment (NDI) at 36 to 42 months' chronological age was defined as any of the following: cerebral palsy, hearing impairment, visual impairment, and a developmental quotient <70. A systematic review was performed by using databases of publications of cohort studies with neonatal and neurodevelopmental outcomes at 22 and 23 weeks., Results: Numbers and incidences (%) of infants with death or NDI were 60 (80%) at 22 weeks and 156 (64%) at 23 weeks. In logistic regression analysis, gestational ages of 22 weeks (odds ratio [OR]: 5.40; 95% confidence interval [CI]: 2.48-11.76) and 23 weeks (OR: 2.14; 95% CI: 1.38-3.32) were associated with increased risk of death or NDI compared with 24 weeks, but a gestational age of 25 weeks (OR: 0.65; 95% CI: 0.45-0.95) was associated with decreased risk of death or NDI. In the systematic review, the medians (range) of the incidence of death or NDI in 8 cohorts were 99% (90%-100%) at 22 weeks and 98% (67%-100%) at 23 weeks., Conclusions: Infants born at 22 and 23 weeks' gestation were at higher risk of death or NDI than infants at born at 24 weeks. However, outcomes were improved compared with those in previous studies. There is a need for additional discussions on interventions for infants born at 22 or 23 weeks' gestation.

Retinoblastoma affects approximately 40 children in Germany per year. Most children are diagnosed early with localized intraocular disease, and the overall survival rate exceeds 95%. However, the prognosis of metastasized retinoblastoma remains poor. In 40% of the patients, retinoblastoma occurs bilaterally and, especially for these children, the salvage of the eye and visual function is of major importance. The variety of conservative treatment options for localized retinoblastoma includes laser coagulation, thermotherapy, cryotherapy, brachytherapy and chemotherapy. While systemic chemotherapy has nearly completely replaced external beam radiotherapy in the primary treatment of intraocular retinoblastoma, intra-arterial, intravitreal and periocular application of chemotherapy was also shown to be effective in treating intraocular retinoblastoma in case series. Genetic testing is an integral part of the routine diagnostics of all patients. Available tumor material should be analyzed to detect mutational mosaicism, that affects >10% of children with unilateral retinoblastoma. Genetic testing also identifies children with heritable (50% of patients) retinoblastoma. These children have a genetic predisposition for second malignancies. For this reason, late effects are an increasing concern and the care of patients with retinoblastoma requires a multidisciplinary approach to tailor therapy and long-term follow-up. Multicenter clinical trials are being developed to evaluate evidence-based treatment concepts for localized and metastasized retinoblastoma to improve survival rates and quality of life of children with retinoblastoma., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Mechanisms by which visual impairment (VI) increases mortality risk are poorly understood. We estimated the direct and indirect effects of self-rated VI on risk of mortality through mental well-being and preventive care practice mechanisms., Methods: Using complete data from 12,987 adult participants of the 2000 Medical Expenditure Panel Survey with mortality linkage through 2006, we undertook structural equation modeling using two latent variables representing mental well-being and poor preventive care to examine multiple effect pathways of self-rated VI on all-cause mortality. Generalized linear structural equation modeling was used to simultaneously estimate pathways including the latent variables and Cox regression model, with adjustment for controls and the complex sample survey design., Results: VI increased the risk of mortality directly after adjusting for mental well-being and other covariates (hazard ratio [HR] = 1.25 [95% confidence interval: 1.01, 1.55]). Poor preventive care practices were unrelated to VI and to mortality. Mental well-being decreased mortality risk (HR = 0.68 [0.64, 0.74], P < 0.001). VI adversely affected mental well-being (β = -0.54 [-0.65, -0.43]; P < 0.001). VI also increased mortality risk indirectly through mental well-being (HR = 1.23 [1.16, 1.30]). The total effect of VI on mortality including its influence through mental well-being was HR 1.53 [1.24, 1.90]. Similar but slightly stronger patterns of association were found when examining cardiovascular disease-related mortality, but not cancer-related mortality., Conclusions: VI increases the risk of mortality directly and indirectly through its adverse impact on mental well-being. Prevention of disabling ocular conditions remains a public health priority along with more aggressive diagnosis and treatment of depression and other mental health conditions in those living with VI.

The underlying structure of National Institutes of Health Stroke Scale (NIHSS) as the most widely used scale in clinical trials has been the focus of little attention. The aim of the current study was to elucidate the clustering pattern of NIHSS items in ischemic stroke patients. A series of 152 consecutive patients with first-ever ischemic strokes admitted to a university affiliated hospital were enrolled. NIHSS score was estimated on admission and correlation coefficients between its items were calculated. Further, exploratory factor analysis was used to study the clustering pattern of NIHSS items. Extinction neglect, visual field, and facial palsy were weakly associated with other NIHSS items. Factor analysis led to a four-factor structure. Factors 1 and 3 were determined by left brain function as items of right arm and leg motor, language and dysarthria loaded on both of them. By contrast, factor 2 reflected right brain involvement. Since visual field and ataxia loaded on factor 4, this factor was primarily associated with posterior strokes. Our study shows that a four-factor structure model is plausible for NIHSS. Further, for the first time, a single distinct factor is identified for posterior strokes.

Purpose: To evaluate the association between visual acuity (VA) and 4-year mortality in an older population-based cohort., Methods: Five thousand and fifty-seven persons aged 50 to 96 years (91.0% of the eligible population) residents of the Southern Harbin, Heilongjiang Provence, China participated in the study. At baseline (2006), the main ocular diseases were diagnosed from a basic ocular examination including presenting and best-corrected VA. Of the 5,057 participants in the baseline survey, those who died after the study were identified and the death certificate was checked. The physicians in charge of the health of the village population were asked for the presumed cause of death. The rate of death was determined in the follow-up survey in 2010. We evaluated the association of visual impairment (VI) and mortality using multiple logistic regression., Results: Between the baseline examination and the censoring cutpoint study, a total of 214 subjects (4.2%) were dead. Females with VI were less likely to have died relative to male gender with VI (P<0.05). Compared with participants who reported better presenting VA (VA ≥ 20/60), the risk of mortality was significantly higher for those reporting moderate VI (20/400 ≤ VA < 20/60) (Odds Ratio [OR], 2.1; 95% confidence interval [CI],1-4.1) and those reporting severe VI (VA < 20/400) (OR,3.6; 95% CI, 2.0-6.6). Similar associations were obtained for best-corrected VA in the better eye (OR, 3.1; 95% CI: 1.5-6.4 and 3.9; 95%CI: 2.1-7.2, respectively)., Conclusion: In this Chinese population-based cohort we found that visual impairment predicted a significantly elevated mortality.

Purpose: To determine which vision tests predict mortality within 10 years in a community-based elderly sample., Methods: Nine hundred residents of Marin County, California 58 to 101 years of age (mean 75 years at baseline), underwent a battery of tests, including high contrast acuity, low contrast acuity, low contrast/low luminance acuity, acuity in glare, contrast sensitivity, color vision, stereopsis, standard and attentional fields. The association between the vision tests and mortality within 10 years of baseline was assessed with Cox Proportional Hazards models controlling for age, sex, education level, depression, cognitive status and self-reported medical conditions., Results: Forty-three percent of the sample died within 10 years of baseline. When controlling for mortality-related covariates, impairment in any of the vision measures was associated with increased risk of death. However, non-standard vision measures (ie, impairment in low contrast/low luminance acuity, standard field integrity and the impact of the attentional task on field integrity) were more highly associated with mortality than standard high contrast acuity., Conclusions: In agreement with other studies, we find that visual impairment is a significant predictor of death. However, the strongest relationship was found for measures other than high contrast acuity. These results suggest that non-standard vision measures may be more sensitive indicators of generalized aging in the most elderly.

Objective: To investigate pathways from visual impairment to increased all-cause mortality in older persons., Methods: The Blue Mountains Eye Study examined 3654 persons 49 years and older (82.4% response) during 1992-1994 and after 5 and 10 years. Australian National Death Index data confirmed deaths until 2005. Visual impairment was defined as presenting, correctable, and noncorrectable, using better-eye visual acuity. Associations between visual impairment and mortality risk were estimated using Cox regression and structural equation modeling., Results: After 13 years, 1273 participants had died. Adjusting for mortality risk markers, higher mortality was associated with noncorrectable visual impairment (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.04-1.75). This association was stronger for ages younger than 75 years (HR, 2.58; 95% CI, 1.42-4.69). Structural equation modeling revealed greater effects of noncorrectable visual impairment on mortality risk (HR, 5.25; 95% CI, 1.97-14.01 for baseline ages <75 years), with both direct (HR, 2.16; 95% CI, 1.11-4.23) and indirect (HR, 2.43; 95% CI, 1.17-5.03) effects. Of mortality risk markers examined, only disability in walking demonstrated a significant indirect pathway for the link between visual impairment and mortality., Conclusions: Visual impairment predicted mortality by both direct and indirect pathways, particularly for persons younger than 75 years with noncorrectable visual impairment. Disability in walking, which can substantially influence general health, represented a major indirect pathway.

Purpose: To estimate the direct effects of self-reported visual impairment (VI) on health, disability, and mortality and to estimate the indirect effects of VI on mortality through health and disability mediators., Methods: The National Health Interview Survey (NHIS) is a population-based annual survey designed to be representative of the U.S. civilian noninstitutionalized population. The National Death Index of 135,581 NHIS adult participants, 18 years of age and older, from 1986 to 1996 provided the mortality linkage through 2002. A generalized linear structural equation model (GSEM) with latent variable was used to estimate the results of a system of equations with various outcomes. Standard errors and test statistics were corrected for weighting, clustering, and stratification., Results: VI affects mortality, when direct adjustment was made for the covariates. Severe VI increases the hazard rate by a factor of 1.28 (95% CI: 1.07-1.53) compared with no VI, and some VI increases the hazard by a factor of 1.13 (95% CI: 1.07-1.20). VI also affects mortality indirectly through self-rated health and disability. The total effects (direct effects plus mediated effects) on the hazard of mortality of severe VI and some VI relative to no VI are hazard ratio (HR) 1.54 (95% CI: 1.28-1.86) and HR 1.23 (95% CI: 1.16-1.31), respectively., Conclusions: In addition to the direct link between VI and mortality, the effects of VI on general health and disability contribute to an increased risk of death. Ignoring the latter may lead to an underestimation of the substantive impact of VI on mortality.

Objective: To examine the relationship between reported visual impairment and suicide mortality., Methods: From 1986 through 1996, annual cross-sectional multistage area probability surveys of the US civilian noninstitutionalized population living at addressed dwellings were conducted by the National Center for Health Statistics. We performed mortality linkage through 2002 with the National Death Index of 137,479 adults 18 years and older. The relationships between reported visual impairment and suicide were examined using structural equation modeling., Results: The mean duration of follow-up was 11.0 years, and 200 suicide deaths were identified. After controlling for survey design, age, sex, race, marital status, number of nonocular health conditions, and self-rated health, the direct effect of visual impairment on death from suicide was elevated but not significant (hazard ratio, 1.50; 95% confidence interval, 0.90-2.49). The approximate indirect effect of visual impairment on death from suicide via poorer self-rated health (1.05; 1.02-1.08) or number of nonocular health conditions (1.12; 1.01-1.24) was significant. The total effect of visual impairment on death from suicide was elevated but not significant (1.64; 0.99-2.72)., Conclusions: Visual impairment may be associated with an increased risk of suicide through its effect on poor health. This suggests that improved treatment of visual impairment and factors causing poor health may potentially reduce suicide risk.

Objective: To examine the relationship between visual acuity and mortality in a Chinese population., Design: Population-based cohort study., Participants: Chinese persons in Singapore ages 40 to 79 years at baseline examination., Methods: The Tanjong Pagar Study in Singapore examined 1232 persons (response rate, 71.8%) at the baseline examination in 1997 and 1998. Participants had measurements of presenting and best-corrected visual acuity (VA) using standardized protocols. Mortality data were obtained from the National Death Registry, which linked subjects who had died since the baseline examination. Cause of death was determined from the International Classification of Diseases 9 codes. Analysis was performed on 1225 (99.4%) participants with VA data., Main Outcome Measure: All-cause mortality., Results: By December 31, 2004 (median follow-up, 6.8 years), 126 persons had died. Participants with presenting VA in the better eye worse than 20/40 (logarithm of the minimum angle of resolution [logMAR] score, 0.3) had a significantly higher mortality rate (hazard ratio [HR], 2.9; 95% confidence interval [CI], 1.4-6.3, adjusting for age, gender, hypertension, diabetes, smoking, heart attack, stroke, and income) as compared with participants with VA of 20/20 (logMAR, 0.0). Associations were similar for best-corrected VA in the better eye (HR, 2.7; 95% CI, 1.4-5.5). Among clinic participants with logMAR VA measurements, each 1-line difference in presenting VA (logMAR gain, 0.10) was associated with a 4-fold increased risk of mortality (HR, 4.4; 95% CI, 1.9-10.2)., Conclusions: In this Chinese population in Singapore, visual impairment was associated independently with an increased risk of mortality.

Objective: To evaluate the relationship between open-angle glaucoma (OAG) and mortality in a black population at 9-years' follow-up., Design: Population-based cohort study of 4092 black participants (aged 40-84 years at baseline) in the Barbados Eye Studies. Open-angle glaucoma was defined by visual field defects and optic disc damage, based on standardized examinations and photograph gradings. Ocular hypertension was defined by an intraocular pressure greater than 21 mm Hg or treatment, without OAG damage. Mortality was ascertained from death certificates. Cox proportional hazards regression analyses determined associations with mortality., Results: After 9 years, 764 (19%) participants were deceased. Mortality was unrelated to overall OAG at baseline (n = 300) after adjustment for confounders. However, cardiovascular mortality tended to increase in persons with previously diagnosed/treated OAG (n = 141; relative risk [RR], 1.38, P = .07) and was significantly higher with treatment involving timolol maleate (RR, 1.91, P = .04). Cardiovascular deaths also tended to increase in persons with ocular hypertension at baseline (n = 498; RR, 1.28, P = .06)., Conclusions: In this black population, cardiovascular mortality tended to increase in persons with previously diagnosed/treated OAG and ocular hypertension. The excess mortality associated with timolol maleate treatment of OAG, also found in a white population, warrants further investigation.

Purpose: To assess the effect of visual impairment (VI) on the risk of depression or death in the community-dwelling elderly population., Methods: A population-based, retrospective fixed cohort study was conducted in the community-dwelling elderly (age > or = 65 years) outpatient population of Quebec. The cohort was assembled through the Quebec medical services database and consisted of the 5063 patients aged > or = 65 years who received a diagnosis of VI during the years 2000-2004. The reference cohort consisted of 16 932 elderly subjects who were randomly selected among members of the public drug programme. The outcome variables were depression and death. The main independent variable was VI and covariates included age, gender, chronic disease score, fracture and diabetes., Results: Controlling for covariates, VI was associated with an increased risk of depression although the effect was not modified by severity (hazard ratio [HR] = 1.35, 95% confidence interval [CI] 1.10-1.66 for severe VI; HR = 1.35, 95% CI 1.09-1.69 for moderate VI). Visual impairment was associated with an increased risk of mortality; patients with moderate vision loss had a higher risk of death (HR = 1.70, 95% CI 1.55-1.87) than those with severe vision loss (HR = 1.34, 95% CI 1.21-1.48)., Conclusions: Given the ageing of the population, VI in elderly subjects is becoming a public health concern. These findings enhance the need to detect and treat VI in order to improve the quality of life and to prevent premature mortality in the elderly population.

Objectives: To determine the mortality within ten years of diagnosis of chronic open angle glaucoma and the visual field progression amongst survivors of a group of patients who were followed for 10 years., Patients and Methods: Of the 436 patients seen in a glaucoma case-finding clinic between July 1994 and December 1995 a diagnosis of chronic open angle glaucoma was made in 65. Ten years after diagnosis the outcome of the 57 patients who were treated at the Oxford Eye Hospital was determined. The causes of death were obtained from the general practitioner records and from the official death certificates. The probability of death was analysed using a Kaplan-Meier survival curve. The visual field of each eye of survivors was graded using a nine-stage severity scale. The visual outcome was analysed at the 10-year follow up visit., Findings: Seventeen patients (29.8%) died during the 10-year period, including nine from cardiovascular disease. The mean (SD) age at presentation of those that died was 76.4 years (9.7) compared with 69.5 years (10.9) for survivors (p = 0.029). Using a nine-stage grading system, 42 eyes (52.5%) did not deteriorate, 30 eyes (37.5%) deteriorated by one stage, seven eyes (8.75%) two stages and one eye (1.25%) three stages over the 10-year period. The average time to first deterioration by one stage was 8.51 years (CI 7.92 to 9.10). The mean (SD) intraocular pressure was 25.6 mmHg (5.8 mmHg) on presentation and 15.7 mmHg (3.0 mmHg) at the end of 10 years., Conclusion: Approximately two thirds of patients will still be under care 10 years after presentation. In older, white patients with glaucoma the overall goal of preventing visual handicap is achievable for most patients 10 years after diagnosis.

Background: Gamma knife radiosurgery (GKR) is an adjuvant treatment for acromegaly if surgery fails to normalize GH hypersecretion., Objective: To examine the effect of GKR on tumor growth and hypersecretion, and to characterize the adverse effect of this treatment., Design: Cross-sectional follow-up study. First, retrospective data pre- and post-GKR were collected. PATIENTS then underwent a predefined survey including radiological, endocrinological, ophthalmological, and neurosurgical evaluation., Setting: Norwegian National Center for gamma knife treatment., Patients: Sixty-one patients treated with GKR for acromegaly. Out of 55, 53 living patients underwent a detailed survey. The mean follow-up was 5.5 years. No patient was lost to follow-up., Results: Tumor growth was stopped in all patients. At 3, 5, and 10 years after GKR, 45, 58, and 86% of patients had normal IGF-I levels. Consecutive hormone value analysis showed that patients receiving GH-suppressive medication had a more rapid decline in hypersecretion than those who did not receive such medication. Evaluated by survey baseline values alone, non-elevated IGF-I and GH levels below 5 mIU/l were found in 38%. GH-suppressive medication was terminated in 16 out of 40 patients following GKR. Nine out of 53 surveyed patients (17%) had normal IGF-I and GH nadir below 2.6 mIU/l at glucose tolerance tests, while not on hormone-suppressive medication. Two patients developed minor visual field defects. Eight patients started hormone substitution therapy during the follow-up period., Conclusion: GKR is an effective adjuvant treatment for residual acromegaly, carrying few side effects.

Purpose: Visual impairment and, to a lesser extent, hearing impairment are independent predictors of reduced survival in selected studies of community-residing adults. To date, the association of severity of concurrent impairment and mortality has not been examined., Method: The National Health Interview Survey is a continuous, multistage, area probability survey of the U.S. civilian noninstitutionalized population. Mortality linkage with the National Death Index of 116,796 adult participants from 1986 to 1994 with complete impairment data was performed through 1997., Results: Findings indicate that moderate to severe concurrent hearing and visual impairment in women is associated with significantly increased risk of mortality. More modest mortality associations are evident for men and for adults with less severe impairments, irrespective of gender., Discussion: Prevention of severe visual and hearing impairment should be a national public health priority, especially given the aging of the U.S. population.

Purpose: To estimate the association between self-reported visual impairment and mortality., Methods: Two national surveys in community and institutionalized populations were combined. First, 2,075 institutions for children with impairments, adults with impairments aged persons, and psychiatric patients were selected randomly. The sample comprised 15,403 subjects of whom 14,603 (94.9%) were interviewed. Second, a random, stratified sample of 21,760 persons living in the community was selected, and 16,945 (77.9%) were interviewed. Types of impairment were identified by face-to-face interviews. Two years later, 14,497 subjects in institutions and 15,648 in the community were revisited. Data on death were obtained from either the National Register or households. Death rates were related to age, gender, and impairment. A logistic regression was performed including impairments, activities of daily living, age, gender, type of residence, and geographical area., Results: Strong, independent associations were found between particular impairments, institutional residence, activities of daily living, age, gender, and risk of death. Associations between mortality and type of impairment could be ranked as follows: motor (OR = 1.235), brain (OR = 1.552), low vision (OR = 1.681), speech (OR = 2.090), visceral (OR = 2.233) and blindness (OR = 2.262)., Conclusions: Self-reported visual impairment is an independent factor associated with mortality.

Objective: Tuberculum sellae meningiomas present a special challenge because of their proximity to arteries of the anterior circulation, anterior visual pathways, and the hypothalamus. The authors report on the clinical outcome after surgical treatment of tuberculum sellae meningiomas in our neurosurgical department., Methods: A retrospective study was conducted analyzing the charts of the patients, including surgical records, discharge letters, histological records, follow-up records, and imaging studies. Patients with associated neurofibromatosis Type 2 were excluded from the study., Results: One thousand eight hundred meningiomas were operated on between 1978 and 2002. Seventy-two of these patients had tuberculum sellae meningiomas; four had undergone previous surgical procedures in outside hospitals. Fifty-five patients were women; 17 were men. Their mean age was 54.3 years (range, 30-86 yr). All patients had visual disturbances at presentation. Tumors were operated through the bifrontal approach (n = 21, from 1978 through 1995), the pterional/frontotemporal approach (n = 21, from 1982 through 2002), and the frontolateral approach (n = 30, from 1984 through 2002). Total tumor removal was achieved in most patients (Simpson 1 + 2, 91.7%). The perioperative mortality rate was 2.8% (two out of 72 patients). Immediate postoperative improvement of visual disturbance was observed in 65% of patients. Visual improvement was dependent on the duration of preoperative visual symptoms, but not on preoperative visual acuity or tumor size. The visual improvement rate was significantly better in patients who underwent frontolateral tumor resection (77.8%) compared with those who underwent bifrontal craniotomy (46.2%). The overall recurrence rate was 2.8% (two out of 72 patients). The mean follow-up time for all patients was 4 to 238 months (mean, 45.3 mo [3.8 yr])., Conclusion: From 1978 through 2002, tuberculum sellae meningiomas were removed microsurgically using three different surgical approaches. Considering the operative morbidity and mortality, the frontolateral and pterional approach provided remarkable improvement compared with the bifrontal approach. These approaches allowed quick access to the tumor and were minimally invasive with less brain exposure, but still engendered high rates of total tumor removal. By comparison, the frontolateral approach provided the best results concerning visual outcome while representing the least invasive surgical approach.

Objective: To investigate the relationship of age-related maculopathy, cataract, glaucoma, visual impairment, and diabetic retinopathy to survival during a 14-year period., Methods: Persons ranging in age from 43 to 84 years in the period from September 15, 1987, to May 4, 1988, participated in the baseline examination of the population-based Beaver Dam Eye Study (n = 4926). Standardized protocols, including photography, were used to determine the presence of ocular disease. Survival was followed using standardized protocols., Results: As of December 31, 2002, 32% of the baseline population had died (median follow-up, 13.2 years). After adjusting for age, sex, and systemic and lifestyle factors, poorer survival was associated with cortical cataract (hazard ratio [HR], 1.21; 95% confidence interval [CI], 1.06-1.37), any cataract (HR, 1.16; 95% CI, 1.03-1.32), diabetic retinopathy (HR per 1-step increase in 4-level severity, 1.36; 95% CI, 1.14-1.63), and visual impairment (HR, 1.24; 95% CI, 1.04-1.48) and marginally associated with increasing severity of nuclear sclerosis (HR, 1.07; 95% CI, 0.99-1.16). Age-related maculopathy and glaucoma were not associated with poorer survival. Associations tended to be slightly stronger in men than women., Conclusions: Cataract, diabetic retinopathy, and visual impairment were associated with poorer survival and not explained by traditional risk factors for mortality. These ocular conditions may serve as markers for mortality in the general population.

Purpose: Several studies indicate an increased mortality rate in older adults who have visual impairment, but few have attempted to address a potential causal mechanism. The goals of this study are to determine whether visual acuity loss increases the risk of dying and to examine whether depressive symptoms act as a mediator in this relationship., Methods: Data were derived from the 2520 older adults who participated in the Salisbury Eye Evaluation project, a population-based prospective 8-year cohort study. Presenting binocular visual acuity was measured with the Early Treatment Diabetic Retinopathy Study [ETDRS] eye chart and depressive symptoms with the General Health Questionnaire Part D subscale. Mortality data were collected by staff follow-up. Analyses were performed with the Cox proportional hazards regression., Results: Worse baseline acuity was associated with a higher mortality rate (hazard ratio [HR] = 1.05; 95% confidence interval [CI], 1.01-1.09). Also, those who gained two or more lines of visual acuity over 2 years had a lower adjusted risk of dying (HR = 0.47; 95% CI, 0.23-0.95). An interaction was detected, in that women who lost > or =3 lines of visual acuity over a 2-year period had a higher adjusted risk of dying (HR = 3.97; 95% CI, 2.21-7.15), whereas men did not (HR = 1.32; 95% CI, 0.66-2.63). Depressive symptoms did not mediate these relationships., Conclusions: If the relationship between visual acuity and mortality is indeed causal, it most likely acts via numerous pathways through a variety of intervening variables. The identification of these intervening variables could give additional targets for intervention if acuity cannot be restored.

Objective: To assess the association between mortality and cause-specific visual impairment in older people., Methods: Visual acuity and causes of visual impairment were collected in 13 569 participants 75 years and older participating in a randomized trial of health screening. Participants were followed up for mortality for a median of 6.1 years., Results: Compared with those with 6/6 (or 20/20 Snellen) or better visual acuity, the age- and sex-adjusted rate ratio for visually impaired people (binocular visual acuity <6/18 or <20/60 Snellen) was 1.60 (95% confidence interval, 1.47-1.74), which was markedly attenuated (rate ratio, 1.17; 95% confidence interval, 1.07-1.27) after adjustment for confounding factors. People whose visual impairment was due to cataract or age-related macular degeneration had excess risks of all-cause and cardiovascular mortality, which disappeared after adjustment. People with refractive error remained at small risk, despite adjustment, probably owing to residual confounding from factors associated with minimal use of eye services rather than underlying eye disease. There were no associations with cancer mortality., Conclusion: Associations reported for visual impairment and mortality or for specific causes of visual impairment reflect confounding by comorbidities, risk factors, and other factors related to susceptibility to death rather than an independent biological association of vision problems or specific eye diseases.

Vision impairment in the elderly is significantly related to increased morbidity as well as mortality rates. Recent studies suggest the true costs associated with visual impairment and blindness to be much higher than reported previously. Without successful interventions the number of visually impaired or blind people world-wide will double within the next 20 years. The lack of a significant world-wide reduction in avoidable visual impairment and blindness would have substantial social as well as economical consequences. In contrast, three-quarters of all visual impairments are avoidable and therefore unnecessary. In summary, vision Impairment deserves a higher degree of attention by the public as well as from governments.

The article presents the analysis of the occurrence of diabetes mellitus-linked sight impairment and proliferative retinopathy after data of National Diabetes Population Register among patients receiving insulin therapy. The number of women with above mentioned impairments has been found to prevail significantly over that of men. This tendency is also observed among the patients aged to 50 y. o., although in this age group the number of men with diabetes mellitus prevails over that of women. This discrepancy can be explained through higher death rate linked with diabetes mellitus among men as compared with women. Death rate statistics concerning patients with diabetes mellitus complicated with sight impairment for 2003 y. confirms this supposition.

Objective: To assess the association of ocular disorders and high doses of antioxidants or zinc with mortality in the Age-Related Eye Disease Study (AREDS)., Methods: Baseline fundus and lens photographs were used to grade the macular and lens status of AREDS participants. Participants were randomly assigned to receive oral supplements of high-dose antioxidants, zinc, antioxidants plus zinc, or placebo. Risk of all-cause and cause-specific mortality was assessed using adjusted Cox proportional hazards models., Results: During median follow-up of 6.5 years, 534 (11%) of 4753 AREDS participants died. In fully adjusted models, participants with advanced age-related macular degeneration (AMD) compared with participants with few, if any, drusen had increased mortality (relative risk [RR], 1.41; 95% confidence interval [CI], 1.08-1.86). Advanced AMD was associated with cardiovascular deaths. Compared with participants having good acuity in both eyes, those with visual acuity worse than 20/40 in 1 eye had increased mortality (RR, 1.36; 95% CI, 1.12-1.65). Nuclear opacity (RR, 1.40; 95% CI, 1.12-1.75) and cataract surgery (RR, 1.55; 95% CI, 1.18-2.05) were associated with increased all-cause mortality and with cancer deaths. Participants randomly assigned to receive zinc had lower mortality than those not taking zinc (RR, 0.73; 95% CI, 0.61-0.89)., Conclusions: The decreased survival of AREDS participants with AMD and cataract suggests that these conditions may reflect systemic rather than only local processes. The improved survival in individuals randomly assigned to receive zinc requires further study.

Purpose: To examine the relationship between reported visual impairment and unintentional injury mortality., Design: Mortality linkage study of a population-based survey., Methods: Mortality linkage through 1997 of 116,796 adult participants, aged 18 years and older, from the 1986 to 1994 National Health Interview Survey was analyzed with respect to reported visual impairment using Cox regression models. The average follow-up was 7.0 years, and 295 unintentional injury deaths were identified. After controlling for survey design, age, sex, and the presence and number of eye diseases, participants with severe, bilateral visual impairment were at increased risk of death relative to participants without visual impairment (hazard ratio: 7.4; 95% confidence interval: 3.0-17.8)., Conclusions: Our data provide evidence that severe, bilateral visual impairment is associated with an increased risk of unintentional mortality among adults in the United States.