Neely David C, Bray Kevin J, Huisingh Carrie E, Clark Mark E, McGwin Gerald, Owsley Cynthia
Department of Ophthalmology, School of Medicine, University of Alabama at Birmingham.
Department of Ophthalmology, School of Medicine, University of Alabama at Birmingham2Department of Epidemiology, School of Public Health, University of Alabama at Birmingham.
JAMA Ophthalmol. 2017 Jun 1;135(6):570-575. doi: 10.1001/jamaophthalmol.2017.0830.
Age-related macular degeneration (AMD) is the leading cause of irreversible vision impairment in older adults in the United States, yet little is known about whether AMD is appropriately diagnosed in primary eye care.
To examine the prevalence of eyes with AMD in patients seen in primary eye care clinics who purportedly have normal macular health per their medical record and the association of AMD with patient and physician characteristics.
DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional study of primary eye care practices in Birmingham, Alabama, 644 persons 60 years or older with normal macular health per medical record based on their most recent dilated comprehensive eye examination by a primary eye care ophthalmologist or optometrist were enrolled from May 1, 2009, through December 31, 2011. Data analysis was performed from May 1, 2016, through December 20, 2016.
Presence of AMD as defined by the Clinical Age-Related Maculopathy Staging system based on color fundus photography and a masked grader. Types of AMD-associated lesions were noted. Patient health and physician characteristics were collected.
The sample consisted of 1288 eyes from 644 participants (231 [35.9%] male and 413 [64.1%] female; mean [SD] age, 69.4 [6.1] years; 611 white [94.9%]) seen by 31 primary eye care ophthalmologists or optometrists. A total of 968 eyes (75.2%) had no AMD, in agreement with their medical record; 320 (24.8%) had AMD despite no diagnosis of AMD in the medical record. Among eyes with undiagnosed AMD, 32 (10.0%) had hyperpigmentation, 43 (13.4%) had hypopigmentation, 249 (77.8%) had small drusen, 250 (78.1%) had intermediate drusen, and 96 (30.0%) had large drusen. Undiagnosed AMD was associated with older patient age (odds ratio [OR], 1.06; 95% CI, 1.04-1.09; P < .001), male sex (age-adjusted OR, 1.39; 95% CI, 1.02-1.91; P = .04), and less than a high school education (age-adjusted OR, 2.40; 95% CI, 1.03-5.62; P = .04). Prevalence of undiagnosed AMD was not different for ophthalmologists and optometrists (age adjusted OR, 0.99; 95% CI, 0.71-1.36; P = .94).
Approximately 25.0% of eyes deemed to be normal based on dilated eye examination by primary eye care physicians had macular characteristics that indicated AMD revealed by fundus photography and trained raters. A total of 30.0% of eyes with undiagnosed AMD had AMD with large drusen that would have been treatable with nutritional supplements had it been diagnosed. Improved AMD detection strategies may be needed in primary eye care as more effective treatment strategies for early AMD become available in the coming years.
年龄相关性黄斑变性（AMD）是美国老年人不可逆视力损害的主要原因，但对于AMD在初级眼科保健中是否得到恰当诊断，人们知之甚少。
调查在初级眼科保健诊所就诊、据其病历显示黄斑健康正常的患者中AMD患眼的患病率，以及AMD与患者和医生特征之间的关联。
设计、地点和参与者：在阿拉巴马州伯明翰市对初级眼科保健机构进行的这项横断面研究中，从2009年5月1日至2011年12月31日纳入了644名60岁及以上、根据其最近由初级眼科保健眼科医生或验光师进行的散瞳全面眼科检查病历显示黄斑健康正常的人。数据分析于2016年5月1日至2016年12月20日进行。
根据临床年龄相关性黄斑病变分期系统，基于彩色眼底照片和一名盲法分级人员确定是否存在AMD。记录AMD相关病变的类型。收集患者健康状况和医生特征。
样本包括来自644名参与者的1288只眼（男性231名[35.9%]，女性413名[64.1%]；平均[标准差]年龄为69.4[6.1]岁；611名白人[94.9%]），由31名初级眼科保健眼科医生或验光师进行检查。共有968只眼（75.2%）没有AMD，与其病历一致；320只眼（24.8%）尽管病历中未诊断出AMD，但实际患有AMD。在未诊断出AMD的眼中（10.0%）有色素沉着过度，43只眼（13.4%）有色素沉着不足，249只眼（77.8%）有小玻璃膜疣，250只眼（78.1%）有中等大小玻璃膜疣，96只眼（30.0%）有大玻璃膜疣。未诊断出的AMD与患者年龄较大（比值比[OR]，1.06；95%置信区间[CI]，1.04 - 1.09；P < 0.001）、男性（年龄调整后的OR，1.39；95%CI，1.02 - 1.91；P = 0.04）以及高中以下学历（年龄调整后的OR，2.40；95%CI，1.03 - 5.62；P = 0.04）相关。眼科医生和验光师诊断未出的AMD患病率没有差异（年龄调整后的OR，0.99；95%CI，0.71 - 1.36；P = 0.94）。
在初级眼科保健医生散瞳检查后认为正常的眼中，约25.0%的眼具有通过眼底照片和经过培训的评估人员显示为AMD的黄斑特征。在未诊断出AMD的眼中，共有30.0%的眼患有伴有大玻璃膜疣的AMD，若能诊断出来，这些患者原本可以通过营养补充剂进行治疗。随着未来几年针对早期AMD的更有效治疗策略的出现，初级眼科保健中可能需要改进AMD检测策略。
