Contents
6.1 Introduction 103
6.2 Regional Prevalence and Relationship of Morbidity to Age and Gender 104 6.2.1 Population-Based Studies 105 6.2.2 Clinical Review Studies 106 6.2.3 The Relationship of Morbidity
to Age and Gender 107
6.3 Prevalence of ‘Wet’ and ‘Dry’ AMD 107 6.4 Visual Acuity in AMD 107
6.5 Risk Factors of AMD in China 107 6.5.1 Race/Ethnicity 109
6.5.2 Light Exposures/Occupation 109 6.5.3 Smoking 109
6.5.4 Drinking 110 6.5.5 Systemic Diseases 111 6.6 Conclusions 111
References 111
With the improvement of economic conditions in China, the most common causes of blindness such as cataract, corneal diseases, trachoma and glaucoma have been largely controlled. To- day, AMD has an increased prevalence, now be- ing fourth on the list of causes of blindness in the age group of 60 years and older, and draws more and more attention from ophthalmolo- gists, medical researchers, and society (Sun 1999). Epidemiological study of AMD in China has shown that 6.98% of the people 65 years and over have AMD (National Bureau of Statis- tics of China 2000). The rate increases to 17.6%
in persons 70 years or older (Wang and Hu 2001). Considering the large population of Chi- na, it has been estimated that AMD currently affects at least 20 million individuals.
According to WHO statistics published in October 2003, China has a total population of 1.292 billion, of whom 130 million people are over 60 years of age (WHO 2000). The life ex- pectancy of Chinese people in 2003 was 69.8 years for men and 72.7 years for women (WHO 2003). Studies also show that the population is aging, and three stages of the aging of China’s population have been identified. The first stage, from 1990 to 2003, is considered as one of
“preaging of the population”; during this peri- od, the number of persons aged over 60 years in China increased from 97,190,000 (8.6% of the population) to 136,000,000 (10.2%). The second stage is the “developing stage” (from 2003 to 2020). During this period, the proportion of the population over 60 years will increase from 10.2% to 15.6%. In the third, “peak stage”(from 2020 to 2050), the proportion of people in China
Prevalence and Risk Factors for Age-Related Macular 6
Degeneration in China
Zheng Qin Yin, Meidong Zhu, Wen Shan Jiang
6.1
Introduction
Racial/ethnic differences in the incidence and prevalence of age-related macular degenera- tion (AMD) in China compared with Western countries have been noted in previous studies (Gregor and Joffe 1978; Wu 1987; Klein et al.
1999; see also Chap. 5). Despite this, in China AMD is still considered one of the most impor- tant causes of blindness in the population older than 50 years of age (Wu 1987; National Bureau of Statistics of China 2000; Wang and Hu 2001).
over 60 years will increase to 27.4% and reach 240 million people (Sun 1999; WHO 2003). At that stage, AMD is expected to be a much more severe problem in China than at present.
There have been few published studies de- scribing the incidence and prevalence of AMD from large population-based cohorts of older people in China. The purpose of this chapter is to review and examine the prevalence of AMD in China for the past 20 years based on popula- tion-based studies. The investigation covers eight regions, representing the eastern, west- ern, northern, southern, and central areas of China (Fig. 6.1). More than 250 million Orien- tal/Asian persons, including Tibetans, Mos- lems, and Hans (Chinese) have been involved in
those studies. The risk factors for AMD and their impacts in China have also been investi- gated and analyzed.
6.2
Regional Prevalence and Relationship of Morbidity to Age and Gender
The diagnoses of AMD reported below have been made according to criteria established by the National Academic Group of Fundus Dis- ease of China (Table 6.1; National Academic Group of Fundus Disease of China 1987) com- bined with the visual criteria of the Framing- ham Eye Study (Leibowitz et al. 1980).
Fig. 6.1.The investigated provinces and areas of China
6.2.1
Population-Based Studies
Population-based studies have been carried out in six provinces/areas of China, including Guangdong, Hunan, Zhejiang and Gansu prov- inces, Tibet, and Shunyi – a county of Beijing. In all cases the examinations were almost identi- cal. After randomized clustering sampling, all selected individuals were enumerated accord- ing to work places or the village residence reg- ister. Personal and family histories including nationality, occupation, smoking and drinking habits, and ocular and systemic diseases were collected. Visual acuity was measured, and a comprehensive ophthalmic examination of eyelid, cornea, lens, and fundus with dilated pu- pils were also carried out.
6.2.1.1
Guangdong Province
Guangdong province is located in the south- eastern coastal area of China, with a population of about 70.5 million. The investigation was carried out in two different areas, including Guangzhou (a modern city) and Doumen County (a rural area). A sample of 6,745 people,
aged from 40 to 93 years old, were investigated (Wu et al. 1987; Guan et al. 1989; He et al. 1998).
In rural Doumen County, 5,342 people (2,421 men and 2,921 women), 50 years or older were examined in 1997 (He et al. 1998). The overall prevalence of AMD in the group is 8.4%, with prevalence increasing with age; 2.9%, 7.8%, and 12.9% in the age groups 50–59, 60–69, and 70 years or older (respectively). Prevalence is sim- ilar in men and women (8.5% and 8.4%, respec- tively). Of the eyes diagnosed with AMD, 5% are legally blind (visual acuity equal or less than 20/400) and 49% had low vision.
In Guangzhou city, two studies were con- ducted in 1987 (Guan et al. 1989; Wu et al. 1987).
In the first, 1,091 people, including 666 men and 425 women, were investigated. Participants were divided into four age groups: 40–49, 50–59, 60–69, and 70–93 years of age. Overall prevalence in Guangzhou is 4.95% and there is a steady increase in prevalence with age (0.87%, 5.05%, 7.77%, and 15.33% in the four groups, re- spectively). Again, the prevalence of AMD in men and women is similar (4.95% and 4.94%, respectively; Guan et al. 1987).
In the second study, 312 Guangzhou citizens, including 224 men and 88 women, were exam- ined (Wu et al. 1987). Prevalence in this study is
Table 6.1.The clinical diagnostic criteria of AMD
Nonexudative (dry) type Exudative (wet) type
Age Over age 45 years Over age 45 years
Eye Two eyes affected Two eyes affected, one after another
Visual acuity Decreases slowly Decreases fast
Fundus findings Earlier period: pigment dispersed and Earlier period: pigment dispersed and proliferation throughout the macular; proliferation throughout the macular;
light reflex of the fovea is unclear or light reflex of the fovea is unclear or disappeared; discrete drusen are the disappeared; drusen are often fused most typical features
Late stage: gold foil appearance in Metaphase: serous and/or hemorrhagic detach- macula, geographic pigment epithelial ment of macula, subretinal hemorrhage, intra- atrophy, macular cystoid degeneration retinal hemorrhage and vitreous hemorrhage or lamellar hole are present can been seen in serious patients
Late stage: scar formation
FFA Transmitted fluorescence or low Subretinal neovascularization in macular area, fluorescence in macular area, no fluorescence leakage, hemorrhage obstructs fluorescence leakage fluorescence
6.41%, with a slightly higher proportion of women affected (6.82% women compared with 6.25% men). Prevalence in the age groups 50–59, 60–69, and over 70 years were 5.79%, 5.28%, and 15.00%, respectively.
6.2.1.2
Hunan Province
Hunan province is located in the middle south area of China with a population of approxi- mately 63.1 million. The investigation, carried out in the province from December 1986 to March 1987, covered five basic sampling units, including city, lake, hilly land, low mountain, and mountain areas (Huang et al. 1992). After randomized clustering 11,182 citizens were identified; of these 9,902 were examined, of whom 1,589 subjects were 50 years or older. In the sample group, the overall prevalence of AMD is 1.46%. However, in the age groups 50–59, 60–69, and over 70 years, prevalence of AMD is 4.30%, 11.20%, and 17.63%, respectively.
6.2.1.3
Zhejiang Province
This province is located in the eastern coastal region of China and has a population of ap- proximately 42.7 million. The investigation was carried out in three areas in 1989, and 730 peo- ple, whose ages ranged from 50 to 92 years, were examined (Xuan et al. 1994). The sample in- cludes 342 men and 388 women. The overall prevalence of AMD is 7.4%, with 8.18% men and 6.70% women affected. Prevalence in the age groups 50–59, 60–69, 70–79, and 80 years and over is 3.39%, 6.25%, 13.51%, and 13.64%, respec- tively.
6.2.1.4 Gansu Province
Gansu Province is located in the northwest of China with a population of 23.8 million. A total of 7,563 residents, including 598 Tibetan, 886 Moslem, and 6,079 Han, were investigated in 2001 (Tian et al. 1980). Of these 4,128 are men and 3,435 women, and ages range between 45 and 89 years. The overall prevalence of AMD is
7.66%; prevalence in men is 8.09% and in wom- en, 7.13%. Prevalence in the age groups 45–55, 56–65, 66–75, and over 75 is 5.48%, 6.09%, 10.85%, and 18.89%, respectively.
6.2.1.5 Tibet
The capital city of Tibet, Lhasa, is located more than 3,700 m above sea level. A sample popula- tion of 186 Tibetans from Lhasa, aged between 50 and 90 years old, were investigated in 1987 (Wu 1987; Wu et al. 1987). Overall prevalence of AMD in Lhasa Tibetans is 15.59% and increases from 9.88% in the sixth decade to 13.70%, and 34.38% in the seventh and eighth decades, re- spectively.
6.2.1.6 Beijing
Shunyi County is located in north area of China (30 km north of Beijing) with a population of about 560,000. After randomized clustering sampling of the whole population, 10,854 citi- zens were selected and 10,414 people were ex- amined (Hu et al. 1988). Only 40 subjects, com- prising 20 men and 20 women, have been diag- nosed with AMD, an overall prevalence in the population of 0.38%.
6.2.2
Clinical Review Studies
Clinical review studies have been conducted in Chongqing city and Anhui province.
6.2.2.1 Chongqing
Chongqing city is located in the southwest of China and has a population about 30 million people. The review study was carried out on pa- tients who were examined using fluorescence angiography (FFA) in Southwest Eye Hospital between January 1998 and the end of May 2003 (Meng et al. 2003). During this period 183,274 patients were registered as outpatients of Southwest Eye Hospital of whom 5,410 had FFA
examination. Of those, 240 AMD cases have been diagnosed in 3,361 patients who had FFA and are 40 years or older. The detected rate of AMD among the outpatient is 0.13%. The prev- alence of AMD among FFA-examined patients is 4.4% and is 7.14% in the patients of 40 years or more. In the age groups 40–49, 50–59, 60–69, and 70 or more, the prevalence of AMD is 1.82%, 5.61%, 10.22%, and 18.65%, respectively.
6.2.2.2 Anhui Province
Anhui province is located in the east of China with a population of about 59.86 million. The clinical review study was carried out in the De- partment of Ophthalmology, Fengtai Hospital (Fang et al. 2000). Between January 1997 and December 1998, 2,798 patients were registered in the outpatient clinic. Of these, 158 have been diagnosed with AMD, according to the diagno- sis criteria referred to (National Academic Group of Fundus Disease of China 1987). The prevalence of AMD in the registered patients is 1.13% and in the age groups 40–49, 50–59, 60–69, and 70 or more is 0.90%, 3.66%, 6.04%, and 16.23%, respectively.
The prevalence of AMD in the different age groups in the regions of China discussed is list- ed in Table 6.2. The data indicate that AMD morbidity is the highest (15.59%) in the capital city of Tibet, Lhasa. The average prevalence over the eight regions is 7.60%.
6.2.3
The Relationship of Morbidity to Age and Gender
The data in Table 6.2 also indicate that the prev- alence of AMD in China is strongly associated with age. The prevalence reaches from 13.09%
(Guangdong province) to 34.38% (Lhasa city) in the 70 years or older group. There is no sig- nificantly statistical difference of prevalence between men and women. Overall, the findings are similar to those of the US Beaver Dam Eye Study and the Australian Blue Mountains Eye Study (reviewed in Chap. 5). The risk factors in relation to higher prevalence in different re- gions of China are discussed below.
6.3
Prevalence of ‘Wet’ and ‘Dry’ AMD
Epidemiological findings of the relative inci- dence of the ‘wet’ and ‘dry’ forms of AMD are summarized in Table 6.3 (Wu 1987; Wu et al.
1987; Zhao et al. 1987; Hu et al. 1988; Guan et al.
1989; Huang et al. 1992; Wu et al. 1992; Xuan et al. 1994; Fang et al. 2000; Tian et al. 2002; Meng et al. 2003). The data indicate that a higher pro- portion of patients suffer from atrophic (dry) AMD than those who suffer from the exudative (wet) AMD in China. The overall ratio of the two types in China is 5.33 : 1. In Gansu province the ratio of dry to wet is the highest (114.8 : 1), and it is lowest in Chongqing city (1.38 : 1). It is likely that the low ratio of dry to wet AMD found in clinical review data-groups (including Chongqing) is due to patients being selected for FFA examination, since patients with wet AMD are more likely to require FFA.
6.4
Visual Acuity in AMD
The AMD visual acuity data are summarized in Table 6.4. (Wu 1987; Wu et al. 1987; Zhao et al.
1987; Hu et al. 1988; Guan et al. 1989; Wu et al.
1992; He et al. 1998; Fang et al. 2000; Meng et al.
2003). The table shows that 60.76% of AMD pa- tients have decreased visual acuity (between 20/60 and 20/30). 32.96% of patients are in the low-vision range and 6.28% patients, legally blind. It appears that, because of the rather high prevalence of atrophic AMD in China, the pro- portion of blindness associated with AMD is lower in China than in Australia (Blue Moun- tains Eye Study) and the USA (Beaver Dam Study).
6.5
Risk Factors of AMD in China
There are a variety of risk factors associated with AMD. The only factors consistently found to be associated with AMD are age and a family history (see Chap. 5). Epidemiological data of
Table 6.2.Prevalence of AMD in China
Region Age No. of subjects No. of cases Detected rate
Guangdong province 40–49 years 462 4 0.87%
50–59 years 2,017 72 3.57%
60–69 years 2,035 157 7.71%
>70 years 2,231 292 13.09%
Total 6,745 525 7.78%
Hunan province 50–59 years 768 33 4.30%
60–69 years 509 57 11.20%
>70 years 312 55 17.63%
Total 1,589 145 9.13%
Zhejiang province 50–59 years 177 6 3.39%
60–69 years 368 23 6.25%
>70 years 185 25 13.51%
Total 730 54 7.40%
Gansu province 45–55 years 3,614 198 5.48%
56–65 years 2,151 131 6.09%
66–75 years 1,115 121 10.85%
>75 years 683 129 18.89%
Total 7,563 579 7.66%
Capital city of Tibet (Lhasa) 50–59 years 81 8 9.88%
60–69 years 73 10 13.70%
>70 years 32 11 34.38%
Total 186 29 15.59%
Shunyi county of Beijing Natural population 10,414 40 0.38%
Chongqing citya 40–49 years 1,042 19 1.82%
50–59 years 1,052 59 5.61%
60–69 years 881 90 10.22%
>70 years 386 72 18.65%
Total 3,361 240 7.14%
Anhui provincea 45–49 years 666 6 0.90%
50–59 years 819 30 3.66%
60–69 years 894 54 6.04%
>70 years 419 68 16.23%
Total 2,798 158 5.65%
aClinical review studies
Table 6.3.The incidence/prevalence of two types of AMD in China
Region Dry AMD Wet AMD Total Rate of dry/wet
Guangdong province 72 2 74 36 : 1
Capital city of Tibet 28 1 29 28 : 1
Hunan province 399 54 453 7.39 : 1
Gansu province 574 5 579 114.8 : 1
Chongqing citya 207 150 357 1.38 : 1
Anhui provincea 143 55 198 2.6 : 1
Total 1,423 267 1,690 5.33 : 1
aClinical review studies
family history of AMD in China were not avail- able in the cases reviewed here. Other risk fac- tors which may impact the prevalence of AMD in China, including race/ethnicity, occupation, light exposure, smoking, alcohol intake, and systemic diseases are reviewed below.
6.5.1
Race/Ethnicity
China is a multiracial/ethnic country. Little published population-based data are available regarding the prevalence of AMD in different racial and ethnic groups. Table 6.5 summarizes data showing the prevalence of AMD in three racial/ethnic groups (Wu et al. 1987; Tian et al.
2002). The data show a prevalence of 13.39%, 8.01% and 7.07% in Tibetan, Moslem, and Han ethnic groups, respectively. The prevalence of AMD in Tibetans is significantly higher than in Moslem and Han ethnic groups. Although all three groups are Oriental/Asian, their environ- ments, dietary intake, and living habits are each quite different. Tibet has been considered to be a hypoxic environment, with high levels of ultraviolet radiation that may contribute the high prevalence of AMD amongst Tibetans (Wu 1987; Wu et al. 1987).
6.5.2
Light Exposures/Occupation
Guan et al. (1989) and Xuan et al. (1994) have di- vided occupations of their AMD patients into two ‘light exposure’ groups: direct and nondi- rect light exposure. Direct light exposure occu- pations are defined to include agricultural workers, fishermen, welders, and other groups who work outdoors. Nondirect light exposure occupations include clerks, persons with household duties, and others working indoors.
Table 6.6 lists the prevalence of AMD in two dif- ferent sample populations with direct and non- direct occupations in China. In both sample populations, the incidence of AMD is higher in direct light exposure occupations than in non- direct light exposure occupations. The data im- ply that the chronic light damage is one of the important risk factors of AMD.
Wu et al. (1992) have investigated the preva- lence of AMD in different occupations, includ- ing miners, agricultural workers, and clerks in Chenzhou District of Hunan province. The results (Table 6.7) show light intensities that workers in different occupations are exposed to along with the prevalence of AMD. Except in the cases of miners, the prevalence of AMD cor- relates positively with intensity of light expo- sure (regression analysis, P<0.05). The high prevalence of AMD in miners may be related to other risk factors which need further investiga- tion.
Other reports, however, have revealed differ- ent results. Table 6.8 shows light impact on prevalence of AMD in Hunan and Anhui prov- inces (Huang et al. 1992; Fang et al. 2000). The data show the highest prevalence of AMD asso- ciated with household duties, while agricultural populations have the lowest prevalence (signif- icant, P<0.05). The specific reasons for the re- sults are unknown.
6.5.3 Smoking
It has been suggested that, in addition to age, cigarette smoking is a risk factor associated with AMD and is most pronounced for the dry
Table 6.4.The visual acuity of AMD patients in China Visual <20/400 20/400– >20/60– Total
acuity 20/60 20/60
Eyes 156 819 1,510 2,485
Rate 6.28% 32.96% 60.76% 100
Table 6.5. The prevalence of AMD in different ra- cial/ethnic groups in China
Racial/Ethnic Subjects AMD Detected Group (n) cases (n) rate
Tibetans 784 105 13.39%
Moslems 886 71 8.01%
Hans (Chinese) 6,391 452 7.07%
form of AMD (Guan et al. 1989; Klein et al. 1993;
Smith et al. 1996; Mitchell et al. 1999; see also Chap. 5). Smoking is known to depress serum antioxidant levels and to reduce choroidal blood flow. Studies indicate that around 70% of men and 20–30% of women in China smoke, and a recent investigation has reported that there is an increase in female smokers, especial- ly in the younger age groups. The relationship between smoking and AMD in China have been analyzed by Wu (1987) and Guan et al. (1989) and the results are shown in Table 6.9. In Guan’s study, the prevalence of AMD in smokers is higher than in nonsmokers (Guan et al. 1989).
However, the results from Wu et al. (1987) do not show a difference.
6.5.4 Drinking
Some studies have examined the association of alcohol consumption with the prevalence of AMD. It has been reported that heavy drinkers
Table 6.6.The impact of light exposure to AMD
Guangzhou Zhejiang
AMD Non-AMD Total Detected AMD Non-AMD Total Detected
rate rate
Direct light exposure 17 163 180 9.44% 22 177 199 11.06%
occupations
Nondirect light exposure 37 874 911 4.06% 32 499 531 6.03%
occupations
P P<0.005 P<0.05
Table 6.7.The prevalence of AMD with intensity of light (Wu et al. 1992)
Group Intensity Incidence
of light of AMD
Miners 0–520 lx 7.89%
Agricultural workers 100,000 lx 7.33%
Workers 80–2,600 lx 4.94%
Clerks 80–1,800 lx 2.78%
Table 6.8.Prevalence of AMD with light exposure in Hu- nan and Anhui provinces
Occupation Subjects Cases Detected (n) (n) rate
Workers 2,525 62 2.46%
Agricultural 10,714 105 0.98%
workers
Clerks 2,721 80 2.94%
Household-duties 997 53 5.32%
workers
Others 3,070 8 0.26%
Table 6.9.The relationship between smoking and AMD Guan et al. 1989 Wu et al. 1987 AMD Non- AMD Non-
AMD AMD
Smoking Yes 28 362 8 44
No 26 657 20 104
P P<0.05 P>0.05
Table 6.10.The relationship between drinking and AMD Guan et al. 1989 Wu et al. 1987 AMD Non- AMD Non-
AMD AMD
Drinking Yes 9 113 15 84
No 45 924 12 62
P P>0.05 P>0.05
at baseline are more likely to develop late AMD than those who have never been heavy drinkers (Klein et al. 2002; see also Chap. 5), and there may be an association of alcohol consumption with early AMD (Smith and Mitchell 1996). It has also been suggested (Obisesan et al. 1998) that moderate wine consumption may be pro- tective for AMD due to the high concentration of antioxidant phenolic compounds found in red wine. However, data from population-based studies in China, (Table 6.10) suggest that drinking is not a risk factor for AMD in that population (Wu et al. 1987; Guan et al. 1989).
6.5.5
Systemic Diseases
Guan et al. (1989) have analyzed the relation- ship between hypertension, heart disease, res- piratory systemic disease, and AMD in China, while Xuan et al. (1994) has reported the rela- tionship between hypertension, chronic bron- chitis, and AMD. The data indicate (Table 6.11) that hypertension is significantly correlated with AMD and that chronic bronchitis might also be a risk factor for AMD (Guan et al. 1989;
Xuan et al. 1994). These results are similar to the results observed in other studies (Hyman et al.
2000; Klein et al. 2003; see also Chap. 5).
6.6
Conclusions
Epidemiological studies carried out over the past 20 years in China show that the prevalence of AMD is similar in most areas of China, ex- cept in Lhasa, where prevalence is much higher.
As expected, the prevalence of AMD is found to increase with age; there are no significant dif- ferences with gender. Also in China the preva- lence of ‘dry’ AMD is higher than ‘wet’ AMD.
Chronic light damage, smoking, hypertension, and chronic bronchitis might also be risk fac- tors for AMD in China.
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