Ocular manifestations in patients with senile sensorineural deafness: Experience at Prince Rashid Bin AL-Hussien hospital

Ahmed E. Khatatbeh, MD*Samer I. Al- Alawneh, MD*Hisham A. Rashdan, MD**Khaldoun K. Al- Shugran, MD**Hala K. Haddad, MD*

ABSTRACT

Objectives: To screen patients having senile sensorineural hearing loss (presbycusis) for the presence of age- related changes in their eyes particularly age- related . Method: A prospective study conducted at prince Rashid Bin Al Hassan Military hospital, Irbid- Jordan between March 2016 and May 2016. Three- hundred and forty-five patients diagnosed with senile sensorineural hearing loss (Presbycusis) at the ENT clinic were referred to the clinic to perform comprehensive eye examination including visual acuity (VA), anterior segment examination using biomicroscope, applanation tonometry using Goldmann applanation tonometer and dilated fundus examination using non-contact 78 diopter . Results: Three- hundred and forty-five patients aged between 45 and 87 years (mean 64.4 ± 12.5 years) were included in the study. One-hundred and fifty-seven (45.8%) were females with a mean age of 62 years. The mean visual acuity was (0.6). Arcus senilis was present in (53.6%) of patients with slight male predominance. was found in (55.9%) of patients. Pseudoexfoliative material on the anterior capsule of the lens and/or pupillary margin was found in (8.3%) of patients. was found in (3.2%) of patient’s eyes. Age-related macular degeneration was found in (20.1%) of patients. Conclusion: Age related macular degeneration and pseudo exfoliation syndrome were present at higher frequency among patients with presbycusis. There was no increase in the frequency of arcus senilis, cataract and glaucoma among those patients.

Key words: Age related ocular changes, Presbycusis.

JRMS Sep 2016; 23(3):78-82/DOI: 10.12816/0029078

(1-4) Introduction syndrome (PXF). This is believed to be There is a long list of diseases which was attributed to common embryological origin and closed anatomical and histological reported to present with deafness along with (4) ophthalmic manifestations like: Cogan's features. Age- related hearing loss (Presbycusis) is considered the commonest syndrome, Alport’s syndrome, – (1) ichthyosis–deafness (KID) syndrome, sensory deficit affecting elderly. It is well Congenital Rubella and pseudoexfoliation known that a lot of age- related changes take place in the human’s eye such as: arcus From Department of: *Ophthalmology Department, Royal Medical Services department of ophthalmology, Prince Rashid Bin Al Hassan Military hospital, Irbid-Jordan. **Otolaryngology Department, Royal Medical Services, Prince Rashid Bin Al Hassan Military hospital, Irbid-Jordan. Correspondence should be addressed to:Dr. Ahmed Essa Khatatbeh Email: [email protected] Manuscript Received May 31,2016. Accepted Sep 4,2016 78 JOURNAL OF THE ROYAL MEDICAL SERVICES Vol. 23 No. 3 Sep 2016 senilis, senile cataract, glaucoma, age- related ear surgeries or trauma, history of tympanic macular degeneration (AMD). (5) The aim of membrane perforation, patients with history this study is to screen all patients having of ototoxic drugs usage and patients with Presbycusis for the presence of age- related diabetes or those who had history of steroid changes in their eyes and to compare the data treatment were all excluded from the study. obtained with the results of other studies Data was collected and analyzed using excels which evaluated the prevalence of those Microsoft office and then compared to that ocular findings among the general population. found in the general population. Ethical

approval was initially obtained through the Methods ethical committee of the Jordanian Royal This is a prospective study conducted at Medical Services. prince Rashid Bin Al Hassan Military hospital, Irbid-Jordan between March 2016 Results and May 2016. Three- hundred and forty-five Three- hundred and forty-five patients aged patients diagnosed with senile sensorineural between 45 and 87 years (mean 64.4 ± 12.5 hearing loss (Presbycusis) at the ENT clinic years) were included in the study. One- were referred to the ophthalmology clinic to hundred and fifty-seven (45.8%) were females perform comprehensive eye examination with a mean age of 62 years. Visual acuity including visual acuity (VA), anterior (VA) was assessed using Snellen chartin segment exam using slit lamp biomicroscope, Decimal; the mean VA for the patients was applanation tonometry using Goldmann (0.6); however mean VA was slightly lower in applanation tonometer and dilated fundus males (0.55) compared with females (0.66). examination using non-contact 78 diopter Table I summarized the VA among all lens. Patients with previous known ocular patients. diseases such as glaucoma, retinal disease or ocular surgery (except for cataract surgery),

Table I: Visual Acuity (VA) using Snellen chart among patients with Presbycusis. Visual acuity Number of male Number of female Total(345) patients (188) patients((157) 1.0 74 (39.4%) 71 (45.2%) 145(42.0%) 0.6-0.25 79 (42.0%) 60 (38.2%) 139(40.3%) 0.2-0.1 25 (13.3%) 10(6.4%) 35(10.1%) Less than 0.1 10 (5.3%) 16 (10.2%) 26(7.5%) Mean 0.55 0.66 0.6

patients (43.3%)) compared to males (117 Arcus senilis was present in 185 (53.6%) of patients (62.2%)). patients. However, it was found that arcus The result of the lens examination is senilis was less frequent in females (68 summarized in Table II.

Table II: The outcome of lens examination among patients with Presbycusis. Result Number of males Number of females Total (345) patients (188) patients (157) Clear lens 51 (27.1%) 44 (28.0%) 95(27.5%) Cataract 110 (58.5%) 83 (52.9%) 193(55.9%) Pseudophakia 27 (14.4%) 30 (19.1%) 57(16.5%) Pseudoexfoliation 16 (8.5%) 13 (8.2%) 29(8.4)

Cataract was cortical in (28%) of cases, (34%) of cases. Pseudoexfoliation was found nuclear in (28%) of cases, posterior in (8.4%) of patients and there was no subcapsular in (10%) of cases and mixed in

JOURNAL OF THE ROYAL MEDICAL SERVICES 79 Vol. 23 No. 3 Sep 2016 statistical significant difference between Age-related macular degeneration (AMD) males and females. was found in (21.0%) and (19.0%) of males There was no significant difference between and females, respectively. Bilateral AMD the mean IOP in males and females which was found in 33.1% of cases. Wet AMD was was around 15 mmHg. The range of IOP in found in 12% of cases and it was more males was between 8 and 30 mmHg while in common in female (ratio 3:2). females it was ranging between 12 and 24 Table IV compares the results of ocular mmHg. Primary open angle glaucoma findings found in patients with presbycusis (POAG) was found in 6 male patients (3.2%) and those found in the general population and 5 female patients (3.2%). worldwide.

Table IV: Ocular findings found in patients with presbycusis and those found in the general population worldwide. Ocular finding frequency in patients with P value Global prevalence presbycausis Arcus senilis 53.6% >0.05 47.2-66.7% Cataract including 72.5% >0.05 70.0% Pseudophakia Pseudoexfoliation 8.4% <0.05 2.3% Glaucoma 3.2% >0.05 3.4% Age-related macular 20.1% <0.05 8.69% degeneration (AMD)

Discussion cataract in males was due to the higher mean Hearing is one of the most important senses to age of males compared to females resulting in human beings since it enables us to receive higher chance to develop senile cataract with alarms especially during sleep and in dark, the increase of age. However, severe visual loss of this sensation may lead to loss of impairment was found in only (5.3%) of communication with the surroundings and males while (10.2%) of females had severe contributes to patient’s isolation, depression, , the explanation for this is and possibly dementia . (6) Hearing loss is that wet AMD which is usually associated considered the commonest sensory deficit with more decline in vision was more affecting elderly. In addition, a lot of age- frequent in females than males with a ratio of related changes may occur to the eyes as well; (3:2), this observation was also noted in other studies conducted worldwide on patients with some of those changes may interfere with (10) vision and will adversely affect the life style AMD but with variable percentages. of the patients especially if it is associated Arcus senilis was present in (53.6)% of with hearing disabilities. patients with slight male predominance which The prevalence of presbycusis varies with could be related to the higher mean age of age; it ranges between 25% in patients at 70 - males compared with that of females since the prevalence of arcus senilis increases with age. 74 years old, 50% in patients at 75-84 and (11) more than 80% at those older than 85 years. (7) Cooke investigated the significance of In this study 80% of patients were older than arcus senilis among Caucasians with different 60 years, presbycusis was more common in age groups and found that arcus senilis was present in 47.2% to 66.7% of individuals aged males than females, and this finding was (12) comparable to that found in other studies. (8,9) between 60 and 69 years. Those results Regarding visual acuity, it was slightly lower were comparable to that found in our study. in males (0.55) compared to females (0.66) The prevalence of cataract among non- operated patients in the general population .This could be related to the higher frequency (13) of cataract in males (58.5%) when compared ranges between 53% and 58%. In this study to females (52.9%. The higher frequency of cataract was found in (58.5%) and (52.9%) among males and females, respectively, and if

80 JOURNAL OF THE ROYAL MEDICAL SERVICES Vol. 23 No. 3 Sep 2016 we add the patients who already underwent hair cells, serial presbycusis those results cataract surgery and became pseudophakic we from decrease in the metabolic function of the will get (72.9%) and (72%), respectively, and cochlea, and neural presbycusis which result this is comparable to that found in other from damage of the auditory nerve. (7) In studies evaluating the prevalence of cataract addition, gene-related hereditary susceptibility among the general population. (14) However, was also found to play an important most studies reported that the prevalence of role.(22)On the other hand the exact etiology of cataract was more among females than males. AMD is still unknown but genetic factors was (15) In our study there was no significant shown to play a role in the pathogenesis of difference between the frequency of cataract AMD as well. (23) including Pseudophakia between males and The association of visual impairment and females but we still think it was more hearing loss with aging was noted and common in females at any given age; that’s investigated by researchers who thought that probably because the mean age of males in this association might be related to general our sample was higher than that of the sensory impairments which occur with aging females which will be associated with more and some of them suggested an association chance to develop cataract since the with cognitive decline. (24,25) prevalence of cataract increases with age and In spite of the small- sized sample we this will probablymake the two frequencies investigated, our study showed a higher obtained more comparable. (16) frequency of AMD and pseudo exfoliation Pseudoexfoliation was found in (8.4%) of syndrome among patients with presbycusis, patients and there was no significant and we strongly recommend a multi-center difference between males and females. This study to prove such an association and to percentage was higher when compared to that compare the results with that found among the found in the general population which is Jordanian population. In addition, we need to about 2.3%. (17)The higher frequency of conduct another study to evaluate the pseudoexfoliation among those patients might prevalence of presbycusis among patients be related to the significant association with AMD and to compare that with the between sensorineural hearing Loss and global prevalence of presbycusis to prove the pseudoexfoliation syndrome which was existence of this association. reported by several studies. (18,19) This study showed that there was no increase Conclusion in the frequency of glaucoma (3.2%) among Age- related macular degeneration and patients with presbycusis with a mean IOP of pseudo exfoliative syndrome were present at 15 mmHg when compared to that of the (20) higher frequency among patients with general population (3.4%). In addition, presbycusis. There was no increase in the there was no significant difference between frequency of arcus senilis, cataract and males and females. glaucoma among patients with presbycusis. Age-related macular degeneration was found with significant higher frequency among patients with presbycusis. It was present in References 20.1% of our patients compared to a global 1. Huang Qi., Tang J. Age-related hearing loss. European Archives of Oto-Rhino-Laryngology, 2010; prevalence of (8·69 %) in a study conducted 267:1179-1191. (21) by wang et al. on 129 664 individuals. Age- 2. Messmer E M, Kenyon K R, Rittinger O, et related macular degeneration was bilateral in al. Ocular manifestations of keratitis– ichthyosis– 33.1% of cases, 12% of cases were wet which deafness (KID) syndrome. Ophthalmology 2005; was more common in female (ratio 3:2). 112(2):1-6. These results were comparable to a study 3. Samarai V, Samarei R, Haghighi N, et al. Sensory-neural hearing loss in pseudoexfoliation performed by Garavito et al. on French syndrome. Int J Ophthalmol 2012; 5(3): 393–396. patients suffering from AMD. 4. Singham N V, Zahari M, Peyman M, et al. Presbycusis have been divided based on the Association between Ocular Pseudoexfoliation and etiology into three subtypes; Sensory Sensorineural Hearing Loss. Journal of presbycusis which is associated with loss of Ophthalmology 2014:1-4

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