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1.  Prevalence of Cataract in an Older Population in India 
Ophthalmology  2011;118(2-19):272-278.e2.
To describe the prevalence of cataract in older people in 2 areas of north and south India.
Population-based, cross-sectional study.
Randomly sampled villages were enumerated to identify people aged ≥60 years. Of 7518 enumerated people, 78% participated in a hospital-based ophthalmic examination.
The examination included visual acuity measurement, dilatation, and anterior and posterior segment examination. Digital images of the lens were taken and graded by type and severity of opacity using the Lens Opacity Classification System III (LOCS III).
Main Outcome Measures
Age- and gender-standardized prevalence of cataract and 95% confidence intervals (CIs). We defined type of cataract based on the LOCS III grade in the worse eye of: ≥4 for nuclear cataract, ≥3 for cortical cataract, and ≥2 for posterior subcapsular cataract (PSC). Any unoperated cataract was based on these criteria or ungradable dense opacities. Any cataract was defined as any unoperated or operated cataract.
The prevalence of unoperated cataract in people aged ≥60 was 58% in north India (95% CI, 56–60) and 53% (95% CI, 51–55) in south India (P = 0.01). Nuclear cataract was the most common type: 48% (95% CI, 46–50) in north India and 38% (95% CI, 37–40) in south India (P<0.0001); corresponding figures for PSC were 21% (95% CI, 20–23) and 17% (95% CI, 16–19; P = 0.003), respectively, and for cortical cataract 7.6% (95% CI, 7–9) and 10.2% (95% CI, 9–11; P<0.004). Bilateral aphakia/pseudophakia was slightly higher in the south (15.5%) than in the north (13.2%; P<0.03). The prevalence of any cataracts was similar in north (73.8%) and south India (71.8%). The prevalence of unoperated cataract increased with age and was higher in women than men (odds ratio [OR], 1.8). Aphakia/pseudophakia was also more common in women, either unilateral (OR, 1.2; P<0.02) or bilateral (OR, 1.3; P<0.002).
We found high rates of unoperated cataract in older people in north and south India. Posterior subcapsular cataract was more common than in western studies. Women had higher rates of cataract, which was not explained by differential access to surgery.
Financial Disclosure(s)
The authors have no proprietary or commercial interest in any of the materials discussed in this article.
PMCID: PMC3146699  PMID: 20801514
2.  EPHA2 Polymorphisms and Age-Related Cataract in India 
PLoS ONE  2012;7(3):e33001.
We investigated whether previously reported single nucleotide polymorphisms (SNPs) of EPHA2 in European studies are associated with cataract in India.
We carried out a population-based genetic association study. We enumerated randomly sampled villages in two areas of north and south India to identify people aged 40 and over. Participants attended a clinical examination including lens photography and provided a blood sample for genotyping. Lens images were graded by the Lens Opacification Classification System (LOCS III). Cataract was defined as a LOCS III grade of nuclear ≥4, cortical ≥3, posterior sub-capsular (PSC) ≥2, or dense opacities or aphakia/pseudophakia in either eye. We genotyped SNPs rs3754334, rs7543472 and rs11260867 on genomic DNA extracted from peripheral blood leukocytes using TaqMan assays in an ABI 7900 real-time PCR. We used logistic regression with robust standard errors to examine the association between cataract and the EPHA2 SNPs, adjusting for age, sex and location.
7418 participants had data on at least one of the SNPs investigated. Genotype frequencies of controls were in Hardy-Weinberg Equilibrium (p>0.05). There was no association of rs3754334 with cataract or type of cataract. Minor allele homozygous genotypes of rs7543472 and rs11260867 compared to the major homozygote genotype were associated with cortical cataract, Odds ratio (OR) = 1.8, 95% Confidence Interval (CI) (1.1, 3.1) p = 0.03 and 2.9 (1.2, 7.1) p = 0.01 respectively, and with PSC cataract, OR = 1.5 (1.1, 2.2) p = 0.02 and 1.8 (0.9, 3.6) p = 0.07 respectively. There was no consistent association of SNPs with nuclear cataract or a combined variable of any type of cataract including operated cataract.
Our results in the Indian population agree with previous studies of the association of EPHA2 variants with cortical cataracts. We report new findings for the association with PSC which is particularly prevalent in Indians.
PMCID: PMC3297613  PMID: 22412971
3.  Prevalence and Risk Factors for Vitamin C Deficiency in North and South India: A Two Centre Population Based Study in People Aged 60 Years and Over 
PLoS ONE  2011;6(12):e28588.
Studies from the UK and North America have reported vitamin C deficiency in around 1 in 5 men and 1 in 9 women in low income groups. There are few data on vitamin C deficiency in resource poor countries.
To investigate the prevalence of vitamin C deficiency in India.
We carried out a population-based cross-sectional survey in two areas of north and south India. Randomly sampled clusters were enumerated to identify people aged 60 and over. Participants (75% response rate) were interviewed for tobacco, alcohol, cooking fuel use, 24 hour diet recall and underwent anthropometry and blood collection. Vitamin C was measured using an enzyme-based assay in plasma stabilized with metaphosphoric acid. We categorised vitamin C status as deficient (<11 µmol/L), sub-optimal (11–28 µmol/L) and adequate (>28 µmol/L). We investigated factors associated with vitamin C deficiency using multivariable Poisson regression.
The age, sex and season standardized prevalence of vitamin C deficiency was 73.9% (95% confidence Interval, CI 70.4,77.5) in 2668 people in north India and 45.7% (95% CI 42.5,48.9) in 2970 from south India. Only 10.8% in the north and 25.9% in the south met the criteria for adequate levels. Vitamin C deficiency varied by season, and was more prevalent in men, with increasing age, users of tobacco and biomass fuels, in those with anthropometric indicators of poor nutrition and with lower intakes of dietary vitamin C.
In poor communities, such as in our study, consideration needs to be given to measures to improve the consumption of vitamin C rich foods and to discourage the use of tobacco.
PMCID: PMC3232233  PMID: 22163038
4.  Sunlight exposure, antioxidant status, and cataract in Hong Kong fishermen. 
STUDY OBJECTIVES--The aim was to test whether cataract is associated with higher lifetime exposure to sunlight, and whether antioxidants protect against cataract. DESIGN--This was a cross sectional survey of eye disease, with assessment of antioxidant status in a subgroup. SETTING--Hong Kong fishing communities in 1989. PARTICIPANTS--685 men and women aged 55 to 74 years old were included in the study, of whom 367 (54%) attended hospital for detailed examination. MEASUREMENTS AND MAIN RESULTS--At a mobile clinic visual acuity and lens opacities were assessed, and using a questionnaire, occupational history and lifetime exposure to sunlight. At hospital ophthalmic measurements were repeated and blood was taken for measurement of plasma vitamin C, vitamin E, and total carotenoids, and red cell activities of glucose-6-phosphate dehydrogenase, glutathione peroxidase, superoxide dismutase, and catalase. Higher grades of cataract (particularly nuclear cataract) tended to be more common in subjects with the most sun exposure, although not to the point of statistical significance. In contrast to earlier studies, no association was found with antioxidant status. CONCLUSIONS--The findings give some support to the hypothesis that sunlight causes cataract. The absence of a relation to antioxidant status may be because blood levels of antioxidants at one point in time do not adequately reflect a subject's past metabolic state, and particularly the past activity of antioxidants in the lens.
PMCID: PMC1059710  PMID: 8436894
5.  The need for cataract surgery: projections based on lens opacity, visual acuity, and personal concern 
AIM—To assess the projected needs for cataract surgery by lens opacity, visual acuity, and patient concern.
METHODS—Data were collected as part of the Melbourne Visual Impairment Project, a population based study of age related eye disease in a representative sample of Melbourne residents aged 40 and over. Participants were recruited by a household census and invited to attend a local screening centre. At the study sites, the following data were collected: presenting and best corrected visual acuity, visual fields, intraocular pressure, satisfaction with current vision, personal health history and habits, and a standardised eye examination and photography of the lens and fundus. Lens photographs were graded twice and adjudicated to document lens opacities. Cataract was defined as nuclear greater than or equal to standard 2, 4/16 or greater cortical opacity, or any posterior subcapsular opacities.
RESULTS—3271 (83% response) people living in their own homes were examined. The participants ranged in age from 40 to 98 years and 1511 (46.2%) were men. Previous cataract surgery had been performed in 107 (3.4%) of the participants. The overall prevalence of any type of cataract that had not been surgically corrected was 18%. If the presence of cataract as defined was considered the sole criterion for cataract surgery with no reference to visual acuity, there would be 309 cataract operations per 1000 people aged 40 and over (96 eyes of people who were not satisfied with their vision, 210 eyes of people who were satisfied with their vision, and three previous cataract operations). At a visual acuity criterion of less than 6/12 (the vision required to legally drive a car), 48 cataract operations per 1000 would occur and people would be twice as likely to report dissatisfaction with their vision.
CONCLUSIONS—Estimates of the need for cataract surgery vary dramatically by level of lens opacity, visual acuity, and patient concern. These data should be useful for the planning of health services.

 Keywords: cataract surgery; visual acuity; patient satisfaction
PMCID: PMC1722775  PMID: 10209437
6.  Prevalence of Early and Late Age-Related Macular Degeneration in India: The INDEYE Study 
This large, two-center, population-based study provides estimates of the prevalence of age-related macular degeneration in India.
To estimate the prevalence of early and late age-related macular degeneration (AMD) in India.
Of 7518 people aged 60 years and older identified from randomly sampled villages in North and South India, 5853 (78%) attended an eye examination including fundus photography. Fundus images were graded according to the Wisconsin Age-Related Maculopathy Grading System.
Fundus images were ungradable in 1587 people, mainly because of cataract. People 80 years of age and older were less likely to attend the eye examination and more likely to have ungradable images. For ages 60 to 79 years, the percent prevalence (95% confidence interval [CI]) were late AMD 1.2 (0.8–1.5); and early AMD: grade 1 (soft distinct drusen or pigmentary irregularities), 39.3 (37.2–41.5); grade 2 (soft distinct drusen with pigmentary irregularities or soft indistinct or reticular drusen), 6.7 (5.8–7.6); and grade 3 (soft indistinct or reticular drusen with pigmentary irregularities), 0.2 (0.1–0.4). For ages 80 and older, the respective percent prevalence was: late AMD, 2.5 (0.4–4.7); and early AMD: grade 1, 43.1(35.7–50.6); grade 2, 8.1 (4.3–12.0); and grade 3, 0.5 (0–1.5).
The prevalence of early AMD (grades 1 and 2) is similar to that observed in Western populations, but grade 3 appears to be lower. The prevalence of late AMD is comparable to that in Western populations in the age group 60 to 79 years. It is likely that the prevalence in the 80 and older age group is underestimated.
PMCID: PMC2868454  PMID: 19696177
7.  Fruit and vegetable intake and vitamins C and E are associated with a reduced prevalence of cataract in a Spanish Mediterranean population 
BMC Ophthalmology  2013;13:52.
Cataract is among the major causes of vision impairment and blindness worldwide. Epidemiological studies support the role of antioxidants in the etiology of cataract, but the evidence for one specific antioxidant over another is inconsistent. Few studies have examined the association of cataract with fruit and vegetable intake with inconclusive results. In the present study, the relationship between cataract and fruit and vegetable intake and dietary and blood levels of carotenoids, vitamins C and E were examined in a Spanish Mediterranean population.
The present work is an analysis of data from 599 elderly ( ≥ 65 years) participants from the Spanish segment of the EUREYE study. This is a European multi-center cross-sectional population-based study. Cataract was diagnosed using a slit-lamp examination and defined as any lens opacity in either eye or evidence of its removal (cataract extraction). Energy-adjusted intake of fruit and vegetables and antioxidant vitamins was estimated using a semi-quantitative food frequency questionnaire. Plasma concentrations of vitamin C were analyzed by a colorimetric method and carotenoids and α-tocopherol by a HPLC method. The associations between cataract and quartiles of fruit and vegetable intake and plasma antioxidants were investigated using logistic regression models.
Of the 599 elderly recruited, 433 (73%) had cataract or cataract extraction, 54% were women and 46% were men. After adjustments, increasing quartiles of combined fruit and vegetable intake were associated with decreasing reduction of odds of cataract or cataract extraction, (P for trend = 0.008). Increasing quartiles of dietary intakes from 107 mg/d of vitamin C showed a significant decreasing association with prevalence of cataract or cataract extraction (P for trend = 0.047). For vitamin E, a protective association was found from intakes from 8 mg/d, but no linear trend was observed across quartiles of intake (P for trend = 0.944).
High daily intakes of fruit and vegetables and vitamins C and E were associated with a significantly decreased of the prevalence of cataract or cataract surgery. This study reinforces the WHO recommendations on the benefits of diets rich in fruit and vegetables.
PMCID: PMC3853246  PMID: 24106773
Cataract; Fruit intake; Vegetables intake; Antioxidant vitamins; WHO recommendations
8.  A population based eye survey of older adults in Tirunelveli district of south India: blindness, cataract surgery, and visual outcomes 
Aims: To assess the prevalence of vision impairment, blindness, and cataract surgery and to evaluate visual acuity outcomes after cataract surgery in a south Indian population.
Methods: Cluster sampling was used to randomly select a cross sectional sample of people ≥50 years of age living in the Tirunelveli district of south India. Eligible subjects in 28 clusters were enumerated through a door to door household survey. Visual acuity measurements and ocular examinations were performed at a selected site within each of the clusters in early 2000. The principal cause of visual impairment was identified for eyes with presenting visual acuity <6/18. Independent replicate testing for quality assurance monitoring was performed in subjects with reduced vision and in a sample of those with normal vision for six of the study clusters.
Results: A total of 5795 people in 3986 households were enumerated and 5411 (93.37%) were examined. The prevalence of presenting and best corrected visual acuity ≥6/18 in both eyes was 59.4% and 75.7%, respectively. Presenting vision <6/60 in both eyes (the definition of blindness in India) was found in 11.0%, and in 4.6% with best correction. Presenting blindness was associated with older age, female sex, and illiteracy. Cataract was the principal cause of blindness in at least one eye in 70.6% of blind people. The prevalence of cataract surgery was 11.8%—with an estimated 56.5% of the cataract blind already operated on. Surgical coverage was inversely associated with illiteracy and with female sex in rural areas. Within the cataract operated sample, 31.7% had presenting visual acuity ≥6/18 in both eyes and 11.8% were <6/60; 40% were bilaterally operated on, with 63% pseudophakic. Presenting vision was <6/60 in 40.7% of aphakic eyes and in 5.1% of pseudophakic eyes; with best correction the percentages were 17.6% and 3.7%, respectively. Refractive error, including uncorrected aphakia, was the main cause of visual impairment in cataract operated eyes. Vision <6/18 was associated with cataract surgery in government, as opposed to that in non-governmental/private facilities. Age, sex, literacy, and area of residence were not predictors of visual outcomes.
Conclusion: Treatable blindness, particularly that associated with cataract and refractive error, remains a significant problem among older adults in south Indian populations, especially in females, the illiterate, and those living in rural areas. Further study is needed to better understand why a significant proportion of the cataract blind are not taking advantage of free of charge eye care services offered by the Aravind Eye Hospital and others in the district. While continuing to increase cataract surgical volume to reduce blindness, emphasis must also be placed on improving postoperative visual acuity outcomes.
PMCID: PMC1771133  PMID: 11973242
blindness; cataract surgery; visual acuity
9.  Risk factors associated with incident cataracts and cataract surgery in the Age Related Eye Disease Study (AREDS). AREDS Report Number 32 
Ophthalmology  2011;118(11):2113-2119.
To investigate potential risk factors associated with incident nuclear, cortical, and posterior subcapsular (PSC) cataracts and cataract surgery in participants in the Age-Related Eye Disease Study (AREDS).
Clinic-based prospective cohort study.
Persons (N=4425), aged 60 to 80 years of age enrolled in a controlled clinical trial of antioxidant vitamins and minerals, AREDS, for age-related macular degeneration (AMD) and cataract.
Lens photographs were graded centrally for nuclear, cortical, and PSC opacities using the AREDS System for Classifying Cataracts. Type-specific incident cataracts were defined as an increase in cataract grade from none or mild at baseline to a grade of moderate at follow-up, with also a grade of at least moderate at the final visit, or cataract surgery. Cox regression analyses were used to assess baseline risk factors associated with type specific opacities and cataract surgery.
Main Outcome Measures
Moderate cataract was defined as a grade of ≥4.0 for nuclear opacity, ≥10% involvement within the full visible lens for cortical opacity, and ≥5% involvement of the central 5 mm circle of the lens for PSC opacity. These were graded on baseline and annual lens photographs.
A clinic-based cohort of 4425 persons aged 55–80 years at baseline was followed for an average of 9.8 ± 2.4 years. The following associations were found: increasing age with increased risk of all types of cataract and cataract surgery; males with increased risk of PSC and decreased risk of cortical cataracts; non-whites with increased risk of cortical cataract; hyperopia with decreased risk of PSC, nuclear cataract, and cataract surgery; Centrum use with decreased risk of nuclear cataract; diabetes with increased risk of cortical, PSC cataract, and cataract surgery; higher educational level with decreased risk of cortical cataract; and smoking with increased risk of cortical cataract and cataract surgery. Estrogen replacement therapy in female participants increased the risk of cataract surgery.
Our findings are largely consistent with the results of previous studies, providing further evidence for possible modifiable risk factors for age-related cataract.
PMCID: PMC3178670  PMID: 21684602
10.  A prospective study of dietary carotenoids, vitamins C and E, and risk of cataract in women 
Archives of ophthalmology  2008;126(1):102-109.
To examine in prospective data the relation between dietary intake of carotenoids and vitamins C and E and risk of cataract in women.
Dietary intake was assessed at baseline in 1993 among 39,876 female health professionals by use of a detailed food-frequency questionnaire. A total of 35,551 of these women provided detailed information on antioxidant nutrient intake from food and supplements and were free of a diagnosis of cataract.
Main Outcome Measure
Cataract defined as an incident, age-related lens opacity, responsible for a reduction in best-corrected visual acuity to 20/30 or worse, based on self-report confirmed by medical record review.
A total of 2,031 cases of incident cataract were confirmed during an average of 10 years of follow-up. Comparing women in extreme quintiles, the multivariate relative risk of cataract was 0.82 (95% confidence interval, 0.71-0.95; P, test for trend, 0.045) for lutein/zeaxanthin, and 0.86 (95% confidence interval, 0.74-1.00; P, test for trend, 0.03) for vitamin E from food and supplements.
In these prospective observational data from a large cohort of female health professionals, higher dietary intakes of lutein/zeaxanthin and vitamin E from food and supplements were associated with significantly decreased risks of cataract.
PMCID: PMC2396535  PMID: 18195226
11.  Effect of vitamin C and E activity on surgically removed cataractous human lens epithelium cells 
Oxidative stress has been proposed as a common underlying mechanism of cataractogenesis. Experimental and observational data suggest that micronutrients like vitamin C and vitamin E with antioxidant capabilities may retard the development of age-related cataract. Effect of these factors on lens epithelium cells, center of lens metabolic activities, is not completely elucidated. The aim of present study was to examine the effect of vitamin C and E on surgically removed lens epithelium cells of patients with cataract. Capsulorhexis samples were collected from 170 patients, admitted for cataract surgery. Catalase specific activity was estimated in lens epithelium cells with and without vitamin (C or E) treatment at different concentration for different time duration. Student’s t-test was employed for data analysis. We observed that in ex-vivo condition, a) both vitamin C and E bring about a decrease in catalase activity in lens epithelial cells. b) vitamin C showed toxic effect at high concentration. c) 100μM was the optimum concentration at which both vitamins showed maximum antioxidant activity. It was concluded that both vitamin C and E has direct effect on lens epithelium cells. At optimum concentration, they can reduce oxidative stress in these cells thus can support to prevent or delay cataract development.
PMCID: PMC3453048  PMID: 23105864
Cataract; Lens epithelium; Vitamin C; Vitamin E.
12.  Antioxidant Capacity of Lenses with Age-Related Cataract 
The immediate cause of the occurrence of cataract is unknown, but oxidative damage and effects of reactive oxygen species are considered important in its etiopathogenesis. Our research was aimed at testing the nonenzyme antioxidant power of corticonuclear lens blocks, with different types and different maturity of age-related cataract. Clinical and biochemical researches were carried out in 101 patients with age-related cataract. In corticonuclear lens blocks of the patient, the concentration of nonprotein and total-SH groups and the concentration of total vitamin C and dehydroascorbic acid (DHA) were determined; the current redox balance of dehydroascorbate/ascorbate and total antioxidant power measured by ferric-reducing ability were examined. In corticonuclear lens blocks with incipient cataract a significantly higher concentration of GSH, total SH groups, concentration of total vitamin C and ascorbic acid (AA), and ferric-reducing ability were measured. The measured concentration of DHA is higher than the concentration of AA in the lenses with the incipient and mature cataract. The concentration ratio of redox couple DHA/AA is higher in lenses with mature cataract, where the measured concentration of AA was lower than in the incipient cataract. Timely removal of DHA from the lens is important because of its potential toxicity as an oxidant. An increase of the current concentration of DHA/AA redox balance can be an indicator of oxidative stress.
PMCID: PMC3272861  PMID: 22363833
13.  Cataract blindness and visual outcome of cataract surgery in a tribal area in Pakistan 
To estimate the rates of cataract blindness and cataract surgical coverage and to assess the visual outcome of cataract surgery among individuals aged ⩾50 years in Orakzai Agency, Pakistan.
1600 individuals aged ⩾50 years were selected using probability proportional to size sampling. The main outcome measure was bilateral cataract blindness which was defined as visual acuity of <3/60 in the better eye with best available correction and with obvious central lens opacities/absence of red reflex in both eyes.
A total of 1549 people were examined; the coverage rate was 96.8%. Of individuals who were examined, 958 (61.8%) were men. The overall prevalence of bilateral cataract blindness was 4.8% (95% CI: 3.8% to 5.9%). Women had a 2.1‐fold greater prevalence of bilateral cataract blindness than men (7.1% (5.0% to 9.2%) v 3.4% (2.3% to 4.6%); p = <0.0001). However, cataract surgical coverage rates were lower for women than men. The overall quality of previous cataract surgery was poor: 43.1% eyes with cataract surgery had VA <6/60. 73.3% people with bilateral cataract blindness reported they could not undergo cataract surgery because they were too poor to afford its cost.
The unacceptably high rates of cataract blindness and poor affordability and visual outcome of cataract surgery calls for the establishment, in the agency, of static cataract surgical services that are high quality, affordable, and gender sensitive.
PMCID: PMC1860172  PMID: 16424519
cataract blindness; cataract surgery; cataract surgical coverage; Pakistan
14.  The Antioxidants in Prevention of Cataracts Study: effects of antioxidant supplements on cataract progression in South India 
To determine if antioxidant supplements (β carotene and vitamins C and E) can decrease the progression of cataract in rural South India.
The Antioxidants in Prevention of Cataracts (APC) Study was a 5 year, randomised, triple masked, placebo controlled, field based clinical trial to assess the ability of interventional antioxidant supplements to slow cataract progression. The primary outcome variable was change in nuclear opalescence over time. Secondary outcome variables were cortical and posterior subcapsular opacities and nuclear colour changes; best corrected visual acuity change; myopic shift; and failure of treatment. Annual examinations were performed for each subject by three examiners, in a masked fashion. Multivariate modelling using a general estimating equation was used for analysis of results, correcting for multiple measurements over time.
Initial enrolment was 798 subjects. Treatment groups were comparable at baseline. There was high compliance with follow up and study medications. There was progression in cataracts. There was no significant difference between placebo and active treatment groups for either the primary or secondary outcome variables.
Antioxidant supplementation with β carotene, vitamins C and E did not affect cataract progression in a population with a high prevalence of cataract whose diet is generally deficient in antioxidants.
PMCID: PMC1857154  PMID: 16556618
cataract; randomised controlled trial; β carotene; ascorbic acid; vitamin E; antioxidants
15.  Risk factors for age related cataract in a rural population of southern India: the Aravind Comprehensive Eye Study 
Aim: To determine risk factors for lens opacities and age related cataract in an older rural population of southern India.
Methods: A cross sectional population based study of 5150 people aged 40 years and above from 50 clusters from three districts in southern India. The lens was graded and classified after dilation using LOCS III system at the slit lamp for cataract. Definite cataract was defined as nuclear opalescence ⩾3.0 and/or cortical cataract ⩾3.0 and/or PSC ⩾2.0.
Results: Definite cataracts were found in 2449 (47.5%) of 5150 subjects and the prevalence of cataract increased with age. The age adjusted prevalence of cataract was significantly lower in males (p = 0.0002). Demographic risk factors—increasing age and illiteracy—were common for the three subtypes of cataract; females were more likely to have cortical cataracts and nuclear cataracts. Additionally, nuclear cataracts were associated with moderate smoking (OR:1.28, 95% CI:1.01 to 1.64), lean body mass indices (OR: 1.37, 95% CI: 1.17 to 1.59) and higher waist to hip ratios (OR: 0.67, 95% CI: 0.54 to 0.82); cortical cataracts with hypertension (OR: 1.39 95% CI:1.11 to 1.72), pseudoexfoliation (OR:1.53,95% CI:1.17 to 2.01), and moderate to heavy smoking; and posterior subcapsular cataracts with diabetes (OR:1.55, 95% CI:1.12 to 2.15), lean body mass (OR:1.32, 95% CI:1.11 to 1.57), and high waist to hip ratios (OR: 0.77, 95% CI: 0.62 to 0.94).
Conclusions: Risk factors for age related cataract in this population do not appear to be different from those reported in other populations. Further studies are required to identify the reason for the high prevalence of age related cataract and to understand better the role of each risk factor for cataractogenesis in this population.
PMCID: PMC1772282  PMID: 15258010
age related cataract; India; Aravind Comprehensive Eye Study
16.  Lipid Peroxidation and the Total Antioxidant Status in the Pathogenesis of Age Related and Diabetic Cataracts: A Study on the Lens and Blood 
Background: Cataract is one of the major causes of a visual impairment, which eventually leads to blindness. An oxidative damage to the lens proteins is a major factor which leads to cataract formation. Therefore, we intended to study the relationship between the biochemical markers of oxidative stress and various forms of cataracts.
Methods: We examined the lenses and the sera of 120 subjects who were aged 50 to 80 years, who were distributed in two groups, viz. the study group (90 patients) and the control group (30 subjects). The oxidative stress was assessed by estimating the lipid peroxidation product in the form of thiobarbituric acid reactive substances (TBARS), the antioxidant status by measuring the levels of vitamin E and the total antioxidant capacity (TAC). The study group patients were further divided into those with nuclear cataracts (30 patients), cortical cataracts (30 patients), and diabetic cataracts (30 patients).
Results: In this study, it was found that the levels of TBARS in the study group were significantly high (p<0.001), whereas the TAC (p<0.001) and the vitamin E (p<0.001) levels were significantly low, both in the lenses and the blood of the study group as compared to those of the control group.
Conclusion: Thus, the present study suggests that an imbalance between the oxygen free radicals and the antioxidants may lead to lipid peroxidation in the lens. Also, the elevated levels of glucose in the diabetic cataracts lead to the auto-oxidation of glucose and a non-enzymatic glycation of the lens protein. Thereby, the high molecular weight proteins aggregate in the cataract.
PMCID: PMC3708254  PMID: 23905084
Cataract; Lens; Lipid peroxidation; Vitamin E; Protein glycation; Total antioxidant status
17.  Nuclear Cataract Shows Significant Familial Aggregation in an Older Population after Adjustment for Possible Shared Environmental Factors 
To quantify the association between siblings in age-related nuclear cataract, after adjusting for known environmental and personal risk factors.
All participants (probands) in the Salisbury Eye Evaluation (SEE) project and their locally resident siblings underwent digital slit lamp photography and were administered a questionnaire to assess risk factors for cataract including: age, gender, lifetime sun exposure, smoking and diabetes history, and use of alcohol and medications such as estrogens and steroids. In addition, blood pressure, body mass index, and serum antioxidants were measured in all participants. Lens photographs were graded by trained observers masked to the subjects' identity, using the Wilmer Cataract Grading System. The odds ratio for siblings for affectedness with nuclear cataract and the sibling correlation of nuclear cataract grade, after adjusting for covariates, were estimated with generalized estimating equations.
Among 307 probands (mean age, 77.6 ± 4.5 years) and 434 full siblings (mean age, 72.4 ± 7.4 years), the average sibship size was 2.7 per family. After adjustment for covariates, the probability of development of nuclear cataract was significantly increased (odds ratio [OR] = 2.07, 95% confidence interval [CI], 1.30–3.30) among individuals with a sibling with nuclear cataract (nuclear grade ≥ 3.0). The final fitted model indicated a magnitude of heritability for nuclear cataract of 35.6% (95% CI: 21.0%–50.3%) after adjustment for the covariates.
Findings in this study are consistent with a genetic effect for age-related nuclear cataract, a common and clinically significant form of lens opacity.
PMCID: PMC3092733  PMID: 15223793
18.  Visual Acuity Outcomes after Cataract Surgery in Patients with Age-Related Macular Degeneration: Age-Related Eye Disease Study Report No. 27 
Ophthalmology  2009;116(11):2093-2100.
To evaluate visual acuity outcomes after cataract surgery in patients with varying degrees of age-related macular degeneration (AMD).
Cohort study.
A total of 4757 participants enrolled in the Age-Related Eye Disease Study (AREDS), a prospective, multicenter, epidemiological study of the clinical course of cataract and AMD and a randomized controlled trial of antioxidants and minerals.
Standardized lens and fundus photographs, performed at baseline and annual visits, were graded by a centralized reading center using standardized protocols for severity of AMD and lens opacities. History of cataract surgery was obtained every 6 months. Analyses were conducted using multivariate logistic regression.
Main Outcome Measure
The change in best-corrected visual acuity (BCVA) after cataract surgery compared with preoperative BCVA.
Visual acuity results were analyzed for 1939 eyes that had cataract surgery during AREDS. The mean time from cataract surgery to measurement of postoperative BCVA was 6.9 months. After adjustment for age at surgery, gender, type, and severity of cataract, the mean change in visual acuity at the next study visit after the cataract surgery was as follows: Eyes without AMD gained 8.4 letters of acuity (P<0.0001), eyes with mild AMD gained 6.1 letters of visual acuity (P<0.0001), eyes with moderate AMD gained 3.9 letters (P<0.0001), and eyes with advanced AMD gained 1.9 letters (P = 0.04). The statistically significant gain in visual acuity after cataract surgery was maintained an average of 1.4 years after cataract surgery.
On average, participants with varying severity of AMD benefited from cataract surgery with an increase in visual acuity postoperatively. This average gain in visual acuity persisted for at least 18 months.
PMCID: PMC3021463  PMID: 19700198
19.  Risk factors for nuclear, cortical and posterior subcapsular cataracts in the Chinese population of Singapore: the Tanjong Pagar Survey 
The British Journal of Ophthalmology  2003;87(9):1112-1120.
Aim: To describe risk factors for nuclear, cortical, and posterior subcapsular (PSC) cataracts in Chinese Singaporeans.
Methods: A population based cross sectional study was carried out on ethnic Chinese men and women aged 40–81 years. A stratified, clustered, disproportionate (more weights to older people), random sampling procedure was used to initially select 2000 Chinese names of those aged 40–79 years from the 1996 electoral register in the Tanjong Pagar district in Singapore. Eligible subjects (n = 1717) were invited for a standardised ocular examination and interview at a centralised clinic, following which an abbreviated examination was conducted for non-respondents in their homes. Cataract was graded clinically using to the Lens Opacity Classification System (LOCS) III system. The main outcome measures were adjusted odds ratio for risk factors for specific cataract types (nuclear, cortical and PSC), any cataract and cataract surgery, examined in multiple logistic regression models.
Results: Out of the 1232 (71.8%) examined, 1206 (70.2%) provided lens data for this analysis. Increasing age was associated with all cataract types, any cataract, and cataract surgery. There was no significant sex difference in presence of any cataract, specific cataract types or cataract surgery. After controlling for age, sex, and other factors, diabetes was associated with cortical cataract (3.1; 95% CI: 1.6 to 6.1), PSC cataract (2.2; 95% CI 1.2 to 4.1), any cataract (2.0; 95% CI: 0.9 to 4.5), and cataract surgery (2.3; 95% CI: 1.3 to 4.1). Lower body mass index was associated with cortical cataract (1.8; 95% CI: 1.1 to 2.9; lowest versus highest quintile) and any cataract (2.3; 95% CI: 1.3 to 4.0). Current cigarette smoking was associated with nuclear cataract (1.7, 95% CI: 1.0 to 2.9; more than 10 cigarettes per day versus none). A non-professional occupation was associated with nuclear cataract (2.9; 95% CI: 1.5 to 5.8; for production or machine operators and 2.6; 95% CI: 1.2 to 5.5; for labourers or agricultural workers, both versus professionals). Lower education was associated with nuclear cataract (2.3; 95% CI: 1.0 to 5.2, none versus tertiary), while lower household income was associated with PSC cataract (4.7, 95% CI: 1.1 to 20.0; income S$4000).
Conclusions: Age related cataracts are associated with a variety of risk factors among Chinese people in Singapore, similar to those reported in European, Indian, and African derived populations. These data support common aetiological mechanisms for age related cataracts, irrespective of ethnic origin.
PMCID: PMC1771847  PMID: 12928278
cataracts; Chinese; Singapore
20.  Comparison of age-specific cataract prevalence in two population-based surveys 6 years apart 
BMC Ophthalmology  2006;6:17.
In this study, we aimed to compare age-specific cortical, nuclear and posterior subcapsular (PSC) cataract prevalence in two surveys 6 years apart.
The Blue Mountains Eye Study examined 3654 participants (82.4% of those eligible) in cross-section I (1992–4) and 3509 participants (75.1% of survivors and 85.2% of newly eligible) in cross-section II (1997–2000, 66.5% overlap with cross-section I). Cataract was assessed from lens photographs following the Wisconsin Cataract Grading System. Cortical cataract was defined if cortical opacity comprised ≥ 5% of lens area. Nuclear cataract was defined if nuclear opacity ≥ Wisconsin standard 4. PSC was defined if any present. Any cataract was defined to include persons who had previous cataract surgery. Weighted kappa for inter-grader reliability was 0.82, 0.55 and 0.82 for cortical, nuclear and PSC cataract, respectively. We assessed age-specific prevalence using an interval of 5 years, so that participants within each age group were independent between the two surveys.
Age and gender distributions were similar between the two populations. The age-specific prevalence of cortical (23.8% in 1st, 23.7% in 2nd) and PSC cataract (6.3%, 6.0%) was similar. The prevalence of nuclear cataract increased slightly from 18.7% to 23.9%. After age standardization, the similar prevalence of cortical (23.8%, 23.5%) and PSC cataract (6.3%, 5.9%), and the increased prevalence of nuclear cataract (18.7%, 24.2%) remained.
In two surveys of two population-based samples with similar age and gender distributions, we found a relatively stable cortical and PSC cataract prevalence over a 6-year period. The increased prevalence of nuclear cataract deserves further study.
PMCID: PMC1524813  PMID: 16623958
21.  Influence of tobacco use on cataract development 
The British Journal of Ophthalmology  2006;90(11):1374-1377.
To study the influence of tobacco use on cataract formation in a rural South Indian population.
3924 subjects from the Chennai Glaucoma Study conducted in rural south India underwent a comprehensive eye examination, including Lens Opacities Classification System II grading. Information on tobacco use, type of tobacco (smoking and smokeless), duration and quantity of use was collected.
1705 (male:female (M:F) 1106:599) people used tobacco and were significantly older (mean (standard deviation (SD)) age 55.80 (10.64) years) than non‐users (52.23 (10.51); p<0.001). 731 (M:F 730:1) people smoked, 900 (M:F 302:598) used smokeless tobacco, and 74 (M:F, 74:0) used tobacco in both forms. The unadjusted and adjusted (age and sex) odds ratio (OR) for a positive history of tobacco use and cataract was 1.72 (95% confidence interval (CI) 1.51 to 1.96) and 1.39 (95% CI 1.15 to 1.68), respectively. The unadjusted OR for smokers and smokeless tobacco users was 1.04 (95% CI 0.88 to 1.23) and 2.74 (95% CI 2.31 to 3.26), respectively. The adjusted OR was 1.19 (95% CI 0.89 to 1.59) and 1.54 (95% CI 1.22 to 1.95), respectively. No significant association was noted between smoking and any particular type of cataract. Smokeless tobacco use was found to be significantly associated with nuclear cataract even after adjusting for age and sex (OR 1.67, p = 0.067, 95% CI 1.16 to 2.39).
Tobacco use was significantly associated with cataract. Smoking was not found to be significantly associated with cataract formation; however, smokeless tobacco use was more strongly associated with cataract.
PMCID: PMC1857475  PMID: 16837540
22.  Oxidative stress and antioxidant status in older adults with early cataract 
Eye (London, England)  2008;23(6):1464-1468.
Oxidative stress and antioxidant status were determined in forty healthy men and post-menopausal women aged 50–70 y (F25, M15), who underwent concurrent eye examinations. Blood samples were collected for analyzing major well-known antioxidants by HPLC systems with UV and ECD detectors, total antioxidant performance using a fluorometry, lipid peroxidation determined by malondialdehyde using a HPLC system with a fluorescent detector and by total hydroxyoctadecadienoic acid (HODE) and F2-isoprotanes (8-iso-PGFα2) using GC-MS. Twenty-seven (F17, M10) of the 40 subjects were diagnosed to have early cataracts at the onset of the study, which were regarded as age appropriate lens opacities. There was no significant difference in plasma major antioxidants, total antioxidant performance and lipid peroxidation determined by malondialdehyde as well as 8-iso-PGFα2 between the groups with and without early cataract. However, isomers of 9- & 13-(Z,E)-HODE levels were significantly higher in subjects with early cataract as compared to those of non-cataract subjects (P<0.05). Our data suggest that subjects with early cataract are under increased systemic oxidative stress, which can be identified by a sensitive biomarker of lipid peroxidation such as isomers of HODE.
PMCID: PMC2695503  PMID: 18806766
early cataract; antioxidants; oxidative stress; lipid peroxidation; total antioxidant performance
23.  Genistein and Genistein-Containing Dietary Supplements Accelerate the Early Stages of Cataractogenesis in the Male ICR/f Rat 
Experimental eye research  2010;92(2):120-127.
Cataract-related loss of vision affects large numbers of people in today’s aging populations and presents a healthcare burden to many nations. The role of dietary supplements within the lens is largely unknown, although benefits from dietary antioxidants are expected. In this study, the effects of genistein as its aglycone, a genistein-containing dietary supplement (Novasoy®200), and a genistein-containing food (soy protein isolate, PRO-FAM 932) on the development of lens opacity were examined in the hereditary cataractous ICR/f rat. These studies were carried out in a background diet of semi-purified, isoflavone-free AIN-76A with casein as its protein source. The amount of genistein for the experimental diets was standardized to its concentration (as genistein aglycone as well as simple and complex β-glucoside conjugates) in the soy protein isolate supplement. Also tested was a high-dose genistein diet containing an 11-fold higher amount of genistein aglycone. The composition of each diet was verified by reverse-phase HPLC and blood plasma isoflavone concentrations were determined by LC-tandem mass spectrometry. The development of opacity in each lens was monitored and digitally recorded using slit-lamp examination over the course of the study. Each of the genistein-containing diets caused a significantly more rapid development of fibrous opacification in the anterior cortical region and development of apparent water clefts or vacuoles in the posterior subcapsular region than the AIN-76A control diet; however, the establishment of dense lens opacification was not significantly different between each of the diets. There was also no significant difference observed between the low-dose and high-dose genistein aglycone groups. These data suggest that genistein-containing dietary supplements accelerate the early stages of cataractogenesis in the male ICR/f rat, with no dose-dependent effects.
PMCID: PMC3034771  PMID: 21147102
Lens; Cataract; ICR/f Rat; Antioxidant; Genistein; Soy; Dietary Supplement
24.  The assessment of lens opacities in clinical practice: results of a national survey 
AIM—To investigate the examination of lens opacities in routine ophthalmic clinical practice.
METHOD—A questionnaire survey was mailed to 703 consultant ophthalmologists in the UK. The surgeons were asked which lens feature(s) they assessed in their clinics when deciding whether to offer cataract surgery.
RESULTS—489 replies were received. A broad range of lens opacities was assessed, with differences between surgeons for some opacities with high prevalences in the population, particularly cortical opacities. Many (74% of 467) surgeons assessed one or more lens opacities (anterior subcapsular cataract, vacuoles, water clefts, coronary flakes, focal dots, retrodots, fibre folds) which may be visually important but which have received relatively little attention by researchers.
CONCLUSIONS—Some classes of lens opacity which are traditionally measured by researchers may be ignored in clinical practice and opacities which are traditionally ignored by some researchers are regarded as clinically important by a substantial number of surgeons.

PMCID: PMC1723872  PMID: 11222338
25.  Cataract in childhood: photograph methods in assessment. 
The slit-lamp examination of the child's lens with cataract can yield useful prognostic signs, especially when this is supplemented by slit-image photography and measurement. A normal lens size for the subject's age is a good prognostic sign and is usually associated with a static cataract or with very slow deterioration in a developmental cataract. A small lens and absence of the anterior subcapsular clear zone are each associated with progressive cataract. Nuclear lamellar cataracts are shown to become smaller in diameter with time, which favours medical treatment with mydriasis.
PMCID: PMC1042898  PMID: 843511

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