Cataract Surgery and Age-Related Macular Degeneration in the 2008-2012 Korea National Health and Nutrition Examination Survey

Research

Original Investigation Cataract Surgery and Age-Related Macular Degeneration in the 2008-2012 Korea National Health and Nutrition Examination Survey

Sang Jun Park, MD, MSc; Ju Hyun Lee, MS; Soyeon Ahn, PhD; Kyu Hyung Park, MD, PhD

Invited Commentary page 627

IMPORTANCE In the past, concern has been raised that cataract surgery may be associated Supplemental content at with the incidence or progression of age-related macular degeneration (AMD); inconsistent jamaophthalmology.com findings from previous studies have puzzled clinicians. In addition, data addressing this association in Asian populations and in the era of phacoemulsification are scarce.

OBJECTIVE To determine the associations between cataract surgery and AMD in a representative Korean population.

DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used a multistage, probability-cluster survey sample to produce nationally representative estimates. Data were analyzed from the Korea National Health and Nutrition Examination Survey (KNHANES), which included results for cataract surgery status and AMD grading from 2008 to 2012. A total of 20 419 participants 40 years or older were included. Data were analyzed from February 5 to August 20, 2015.

MAIN OUTCOMES AND MEASURES The association between cataract surgery and AMD was assessed in each right and left eye using logistic regression models and in both eyes using generalized estimating equation models. Sample weights were applied to adjust for survey design, nonresponse, and stratification to generate nationally representative population-based results.

RESULTS From the 20 419 eligible individuals (11 642 women [51.9%] and 5777 men [48.1%]; mean [SE] age, 55.83 [0.14] years), 17 987 had information regarding cataract surgery status and gradable fundus photographs of at least 1 eye. A total of 34 863 eyes (17 616 right eyes and 17 247 left eyes) underwent analysis. Of these, 1264 right eyes (5.5%) and 1235 left eyes (5.4%) had cataract surgery. Of 1056 right eyes and 949 left eyes with any AMD (early or late), 167 right eyes (15.2%) and 147 left eyes (13.7%) had cataract surgery. The analyses did not show any association between cataract surgery and any form of AMD (early, late, and all) except in left eyes, where cataract surgery was associated with late AMD (odds ratio, 2.34; 95% CI, 1.13-4.85). Author Affiliations: Department of Ophthalmology, Seoul National University College of Medicine, Seoul CONCLUSIONS AND RELEVANCE The results suggest that the association between cataract National University Bundang surgery and AMD is uncertain in the current era of phacoemulsification. The association for Hospital, Seongnam, Republic of left eyes might be a chance finding. Korea(S.J.Park,K.H.Park); Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea (S. J. Park); Division of Statistics, Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea (Lee, Ahn). Corresponding Author: Kyu Hyung Park, MD, PhD, Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, JAMA Ophthalmol. 2016;134(6):621-626. doi:10.1001/jamaophthalmol.2016.0453 Gyeonggi-Do, 463-707, South Korea Published online March 31, 2016. ([email protected]).

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ataract and age-related macular degeneration (AMD) are the leading causes of visual impairment and blindness Key Points worldwide.1,2 Given the aging population, cataract and C Question Is cataract surgery associated with a risk for age-related AMD have emerged as public health concerns during the last macular degeneration (AMD) in the 2008-2012 Korea National decade.1,2 Because both conditions are quite common and of- Health and Nutrition Examination Survey (KNHANES)? ten coexist, concerns have been raised that cataract surgery Findings In this cross-sectional study of 17 987 participants with may be associated with the occurrence and progression of AMD. 34 863 eyes, analyses showed no association between cataract However, contradictory results from previous studies that have surgery and any form of AMD (early, late, and all) except in left investigated the association between cataract surgery and AMD eyes, where cataract surgery was associated with late AMD. have puzzled clinicians: early cohort and case-control stud- Meaning The association between cataract surgery and AMD in ies suggested an association,3-11 whereas other studies did not KNHANES is not clear in the current era of phacoemulsification. (Table 1).12-15 In addition, these results have been derived primarily from white populations; a paucity of data addresses the potential populations.18-20 A recent study also showed differences between association in Asian populations.16,17 In addition to inherent Asian and white patients in the genetic architecture of AMD.21 differences, such as iris color and retinal pigment epithelial Uncertainty regarding the association between cataract sur- darkness, which may influence AMD pathogenesis in relation gery and AMD specifically in Asian populations led us to con- to cataract surgery, AMD characteristics are quite different duct the present study. South Korea is a newly industrialized between Asian and white individuals. Early signs of AMD (eg, country in East Asia and one of the most populous countries drusen) are less common in Asian than in white patients, and in the world. The Korea National Health and Nutrition Exami- polypoidal choroidal vasculopathy, a distinct subtype of exuda- nation Survey (KNHANES) is a nationwide, government-led tive AMD, accounts for 20% to 55% of exudative AMD in Asian survey that can provide nationally representative estimates of populations, whereas it accounts for only 8% to 13% in white the prevalence of various health conditions.20,22-24 Using the

Table 1. Results of Previous Studies Investigating the Association Between Cataract Surgery and AMD

No. of Age Range at Source (Study Name) Design Follow-up, y Participants Baseline, y Results Studies suggesting an association Pollack et al,7 1998 Clinical trial (paired-eye 1 36 72-94 AMD progression occurred more analysis) often in the eye undergoing surgery Klein et al (BDES),3 2002 Population-based 10 3684 at 5 y 43-86 Cataract surgery increased the cohort study 2764 at 10 y risk for late AMD Wang et al (BDES and BMES),6 Population-based 5 6019 ≥43 (BDES) Cataract surgery increased the 2003 cohort study ≥49 (BMES) risk for late AMD Cugati et al (BMES),5 2006 Population-based 10 2335 at 5 y ≥49 Cataract surgery increased the cohort study 1952 at 10 y risk for late AMD Klein et al (BDES),4 2012 Population-based 20 2626 (early AMD) 43-86 Cataract surgery increased the cohort study 3329 (late AMD) risk for late AMD Freeman et al,9 2003 Cross-sectional study NA 2520 (SEE) 65-84 (SEE) Cataract surgery was associated 4774 (Proyecto ≥40 (Proyecto VER) with late AMD VER) ≥40 (BES) 4396 (BES) Kaiserman et al,8 2007 Retrospective 3 5913 74.6 (8.9) Cataract surgery was associated case-control study (mean [SD]) with increased PDT rate (presumably for subfoveal AMD) Ho et al (Rotterdam Study),11 Population-based 2.8-9.7 6032 ≥55 Cataract surgery increased the 2008 cohort study risk for dry AMD Fraser-Bell et al (LALES),10 Cross-sectional study NA 6357 ≥40 Cataract surgery was associated 2010 with advanced AMD Studies suggesting no association Armbrecht et al,12 2003 Prospective 1 40 ≥40 Cataract surgery was not case-control study associated with AMD progression Chew et al (AREDS),13 2009 Clinic-based cohort 5 4577 55-80 No clear effect of cataract study surgery on the risk for progression to advanced AMD Hooper et al,14 2009 Randomized clinical 0.5 60 ≥50 Cataract surgery was not trial associated with AMD progression Wang et al (CSAMDS),15 2012 Clinic-based cohort 3 1244 ≥65 Cataract surgery was not study (paired-eye associated with developing AMD analysis) Abbreviations: AMD, age-related macular degeneration; AREDS, Age-Related Eye Disease Study; BDES, Beaver Dam Eye Study; BES, Baltimore Eye Study; BMES, Blue Mountain Eye Study; CSAMDS, Australian Cataract Surgery and AMD Study; LALES, Los Angeles Latino Eye Study; NA, not available; PDT, photodynamic therapy; SEE, Salisbury Eye Evaluation.

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KNHANES database, we aimed to elucidate the association be- who had cataract surgery status determined by the slitlamp tween cataract surgery and AMD in the Korean population. examination and a gradable fundus photograph of at least 1 eye. Statistical analysis was performed with SAS software (ver- sion 9.2; SAS Institute Inc). Multivariate adjusted odds ratios Methods and 95% CIs were assessed separately for the right and left eyes using logistic regression models. For these analyses, KNHANES Study Design and Population sample weights were applied to adjust for survey design, non- For this study, we analyzed the 5-year (2008-2012) data from response, and stratification to generate nationally represen- the KNHANES, which included the Korean Ophthalmological tative population-based results.20,22,24,25 Similar multivariate- Society–designed 5-year ophthalmic survey. Detailed survey adjusted odd ratios and 95% CIs were assessed for right and information has been published.20,22-26 Briefly, the KNHANES left eyes combined using generalized estimating equation mod- is an ongoing population-based, cross-sectional survey in els, which address correlations of findings within the same par- South Korea conducted by the Korea Centers for Disease Con- ticipant. Statistical significance was set at P < .05. trol and Prevention and the Korean Ministry of Health and Welfare.20,22-26 For the 2008-2012 KNHANES, 3840 to 4600 Determination of Covariates households were selected randomly on an annual basis in 192 Covariates for statistical models were determined based on re- to 200 postal codes that represented the civilian, noninstitu- lated studies.20,24,25 The early AMD covariates included age, tionalized South Korean population. A rolling sample design sex, smoking status (never, former, or current smoker), equal- yielded a multistage, probability-cluster survey. The KNHANES ized gross household income (>50% or ≤50% household in- consists of health interview, health examination, and nutri- come according to equalized gross household incomes), edu- tion surveys20,22,24-26; for this study, we analyzed data from the cational level (high school or higher or middle school or lower), first 2 surveys. The institutional review board of the Seoul occupation (white collar, blue collar, or unemployed), medi- National Bundang Hospital approved this study, which was cal history of diabetes mellitus and dyslipidemia, body weight conducted in accordance with the Declaration of Helsinki.27 (body mass index [calculated as weight in kilograms divided Informed consent was waived for this survey-based study. by height in meters squared] ≥25 or <25), presence of hepatitis B surface antigens, and anemia (hemoglobin level, <13 g/dL Determining Status With Respect to Cataract Surgery and AMD in men or <12 g/dL in women [to convert to grams per liter, mul- Using structured slitlamp examinations (BQ-900; Haag-Streit tiply by 10.0]). The late AMD covariates included age, sex, AG), KNHANES ophthalmologists classified cataract status as smoking status, and body weight. The analyses for all AMD phakia and postoperative status, including pseudophakia and (early and late AMD) included all covariates for early AMD. aphakia (category 1), and as phakia, pseudophakia, and aphakia (category 2).26 Fundus photographs were taken with a non- mydriatic fundus camera (TRC-NW6S, Topcon). Grading of AMD Results was performed in participants 40 years or older. Participants were defined as having early AMD when the fundus photo- A total of 20 419 eligible individuals 40 years or younger (11 642 graph demonstrated the presence of soft indistinct or reticular women [51.9%] and 5777 men [48.1%]; mean [SE] age, 55.83 drusen or the presence of hard or soft distinct drusen with pig- [0.14]) participated in the KNHANES during the study period; mentary abnormalities (increased pigmentation or hypopig- of these participants, 17 987 had information regarding cata- mentation of the retinal pigment epithelium) in the absence late ract surgery status and gradable fundus photographs of at least AMD signs. Late AMD included the presence of signs of wet AMD 1 eye. Comparisons between participants who were included and or geographic atrophy. Wet AMD was defined as retinal pig- excluded in this study are provided in the eTable in the Supple- ment epithelial detachment or serous detachment of the sen- ment. Briefly, excluded participants tended to be older, to have sory retina, subretinal or sub–retinal pigment epithelial hem- lower income and educational levels, to be unemployed, and orrhages, and subretinal fibrous scars. Geographic atrophy was to have comorbidities including diabetes mellitus, history of defined as a discrete circular area (≥175 μm in diameter) of reti- stroke, and anemia compared with participants included in the nal depigmentation with visible choroidal vessels in the ab- analyses; the sex ratio, smoking status, history of dyslipid- sence of wet AMD signs. Each fundus photograph was graded emia, and body weight did not differ between groups. at least twice using the International Age-related Maculopathy The right eye analysis included 17 616 eyes, and the left Epidemiological Study Group protocol.26,28 Details of AMD grad- eye analysis included 17 247 eyes. Among these, 1264 right ing describing the resolution of discrepancies and interrater re- eyes (5.5%) and 1235 left eyes (5.4%) had cataract surgery, and liability have been published.20,24 The Epidemiologic Survey 1056 right eyes (5.0%) and 949 left eyes (4.5%) had signs of Committee of the Korean Ophthalmological Society verified the any AMD. Table 2 shows detailed characteristics of the partici- ophthalmic survey, including the slitlamp examination results pants included in each analysis for the right and left eyes. and AMD grading.20,23-25 Thirteen right eyes and 11 left eyes were aphakic; only 1 aphakic right eye showed early AMD, and no other aphakic eyes Statistical Analysis showed any signs of AMD. Therefore, our analysis could not Data were analyzed from February 5 to August 20, 2015. For provide results using category 2 cataract status (phakia, pseu- the present study, we included participants 40 years or older dophakia, and aphakia).

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An association between cataract surgery and late AMD was observed in the left eyes (odds ratio, 2.34; 95% CI, 1.13- Discussion 4.85) but not in the right eyes. Cataract surgery was not associated with early AMD or all AMD across all analyses con- We assessed the association between cataract surgery and ducted in the right or left eyes using logistic regression AMD in a nationwide representative sample of the Korean models. Cataract surgery was not associated with early, late, population 40 years and older. To the best of our knowl- or all AMD in both eyes combined using the generalized esti- edge, the present study is one of the largest population- mating equation models. Detailed results from category 1 based studies in Asian or Anglo-European populations. Our cataract status (phakia and postoperative status) are provided findings suggest that cataract surgery is not associated with in Table 3. AMD; 8 of 9 sets of analysis did not show any association. Although our observed association in left eyes might be Table 2. Characteristics of Participantsa owing to chance, large, well-known eye disease cohorts and Right Eyes Left Eyes case-control and cross-sectional studies have suggested that Characteristic (n = 17 616) (n = 17 247) an association between cataract surgery and late AMD exists Age, mean (SE), y 54.87 (0.14) 54.70 (0.14) (Table 1). The Beaver Dam Eye Study3,4 and the Blue Moun- Women, No. (%) 10 136 (52.1) 9967 (52.2) tains Eye Study5 reported that cataract surgery was associ- Cataract surgery, No. (%) ated with AMD progression, particularly for incidences of Pseudophakia 1251 (5.46) 1224 (5.38) late AMD, in their follow-up studies and pooled analysis.6 Aphakia 13 (0.05) 11 (0.05) Pollack et al7 reported a higher rate of progression to exuda- Early AMD tive AMD in eyes that had cataract surgery compared with No. of eyes 972 885 fellow eyes that did not undergo surgery in their nonran- Age, mean (SE), y 65.83 (0.46) 65.53 (0.45) domized clinical trial, and Kaiserman et al8 reported similar Cataract surgery, No. (%) 149 (14.7) 133 (12.9) results in a retrospective study. Late AMD Cross-sectional studies also reported the association No. of eyes 84 64 between cataract surgery and late AMD, which included the Age, mean (SE), y 66.52 (1.48) 66.51 (1.61) results of a pooled analysis of 3 cross-sectional studies (the Cataract surgery, No. (%) 18 (20.6) 14 (24.2) Salisbury Eye Evaluation, the Proyecto VER, and the Balti- more Eye Survey)9 and the Los Angeles Latino Eye Study.10 All AMD Conversely, the Rotterdam Study,11 a cohort study, found No. of eyes 1056 949 that cataract surgery increased the risk for dry AMD, unlike Age, mean (SE), y 65.89 (0.45) 65.60 (0.44) the results from the Blue Mountains Eye Study and the Cataract surgery, No. (%) 167 (15.2) 147 (13.7) Beaver Dam Eye Study. Cataracts, particularly nuclear cata- Abbreviation: AMD, age-related macular degeneration. racts, may have a protective effect on AMD develop- a Characteristics are listed according to each method of analysis of the ment29,30 based on blue light toxicity studies and may be association between AMD and cataract surgery. Percentages are weighted to one explanation for the observed different associations.31 generate nationally representative population-based results. Another explanation is that of cataract surgery–related

Table 3. Associations Between Cataract Surgery and AMDa

Right Eyesb Left Eyesb Both Eyesc AMD Type OR (95% CI) P Value OR (95% CI) P Value OR (95% CI) P Value Early Phakia 1 [Reference] NA 1 [Reference] NA 1 [Reference] NA Cataract surgery 0.92 (0.71-1.20) .35 0.77 (0.58-1.01) .06 0.98 (0.82-1.16) .80 Late Phakia 1 [Reference] NA 1 [Reference] NA 1 [Reference] NA Cataract surgery 1.27 (0.88-1.81) .20 2.34 (1.13-4.85) .02 1.42 (0.88-2.29) .19 All Phakia 1 [Reference] NA 1 [Reference] NA 1 [Reference] NA Cataract surgery 1.00 (0.78-1.29) .98 0.84 (0.65-1.10) .21 1.02 (0.87-1.21) .79 Abbreviations: AMD, age-related macular degeneration; NA, not applicable; [calculated as weight in kilograms divided by height in meters squared] Ն25 or OR, odds ratio. <25), presence of hepatitis B surface antigens, and anemia (hemoglobin level a The models for early AMD and all AMD included age, sex, smoking status <13 g/dL in men or <12 g/dL in women [to convert hemoglobin to grams per (never, former, or current smoker), equalized gross household income (>50% liter, multiply by 10.0]). The models for late AMD included age, sex, smoking or Յ50% household income according to equalized gross household status, and overweight. incomes), educational level (high school or higher or middle school or lower), b Calculated using logistic regression models. occupation (white collar, blue collar, or unemployed), medical history of c Calculated using generalized estimating equation models. diabetes mellitus and dyslipidemia, being overweight (body mass index

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inflammatory responses, which is a cornerstone of AMD and a higher proportion of polypoidal choroidal vasculopathy pathogenesis.20 in exudative AMD) might be associated with AMD pathogen- However, other studies with primarily clinic-based esis as related to cataract surgery status.18-20 patient samples have not found an association between The strengths notwithstanding, the present study has cataract surgery and AMD, as the present results suggest several limitations. First, the study design is cross-sectional (Table 1).12-14 A prospective study by Armbrecht et al12 in nature, which could not address the temporal relationship showed no increased risk for AMD progression after cataract of cataract surgery and AMD. The present results cannot be surgery among patients with AMD within 1 year. Similarly, a interpreted as a causal relationship. Second, the KNHANES randomized clinical trial by Hooper et al14 showed no included only noninstitutionalized individuals, and of these increased 6-month risk for AMD progression among patients participants, the present study included the participants who with early AMD. Recently, the Age-Related Eye Disease had cataract surgery and AMD grading. Therefore, the eligi- Study, a large, well-known disease-based cohort, could not bility criteria of the KNHANES and this study might affect the show a clear effect of cataract surgery on the risk for progres- analyses of association. Third, among eligible participants, sion to late AMD.13 In addition, the Australian Cataract Sur- those younger than 50 years were expected to have a low gery and AMD Study15 investigated this association by paired prevalence of AMD and cataract surgery, which might affect comparisons between eyes undergoing surgery and fellow the analyses of association. However, although AMD and eyes that did not in each patient, which inherently addresses cataract surgery are scarce among persons in their 40s, between-persons confounding factors; the study also numerous cohort and cross-sectional studies included the showed no increased risk for developing any AMD (early or participants 40 years or older in their analyses for the late) in eyes undergoing cataract surgery. Wang et al15 sug- association.4,9,16,17,34 In addition, the KNHANES provides gested that the discrepancies between the results of these AMD grading in participants 40 years or older so that all stud- studies may derive from differences in comorbidity distribu- ies regarding AMD epidemiology using the KNHANES data- tions between clinic-based samples and population-based base set the eligible participants to 40 years or older, as in our participants, which may be attributed to a systematic bias of present study and previous studies.20,24 Moreover, the the selected populations in these studies. In cohort studies, KNHANES classified any geographic atrophy, not central relatively low recall rates and mortality on follow-up exami- geographic atrophy, as late AMD according to the grading nations may be a threat to generalization, and in clinic-based protocol and did not provide the raw data (eg, fundus photo- studies, sampled participants may be more prone to have graphs) to the researchers. Thus, all published AMD epide- AMD than the healthy general population living in the miologic studies using the KNHANES database used the same community.15 The present study, in contrast, analyzed a AMD grading,20,23,25,26 as was the case for our analyses. nationally representative population from the KNHANES, Fourth, we estimated the association between cataract sur- which could minimize any selection bias. In addition, the gery and AMD while accounting for person-level covariates KNHANES provided comprehensive information for comor- through generalized estimating equation models. However, bidities for every participant, which helped to address the we did not implement survey weights in these models risk for bias. Therefore, the present results could not be because the standard survey procedure of the SAS software explained by these biases. does not support paired-eye analysis. Fifth, individuals with Cataract-related inflammation has decreased significantly unrecognized AMD might undergo the cataract surgery when from the era of extracapsular/intracapsular cataract surgery to incorrectly attributing decreased visual acuity to cataract. the era of phacoemulsification, and with advances in cataract This event might influence the analyses to a certain degree, surgery technique, aphakic cataract surgery has also sharply although it might not weaken the present results. Sixth, the decreased with increasing intraocular lens replacement dur- analyses could not assess the effect of aphakia because apha- ing cataract surgery. In addition, UV-blocking intraocular kic eyes were scarce in the database. However, given lenses have been used widely since the mid-1980s.32 These advances in cataract surgery techniques and intraocular changes may help to address blue light toxicity and cataract lenses, aphakic condition effects have become less impor- surgery–related inflammatory responses, which have been tant, as discussed above. used to explain the association between cataract surgery and AMD. Moreover, recent advances in diagnostic tools, espe- cially optical coherence tomography, facilitate the evaluation Conclusions of the retina in individuals with decreased visual acuity. Hence, the likelihood of cataract surgery might decrease in The association between cataract surgery and AMD was not someone with AMD mistakenly believed to have cataract. In clear in this representative Korean population. Because addition, ethnic differences may provide another biological recent studies reported that most patients with AMD had explanation, because very little is known about Asian popula- better visual function and quality of life after undergoing tions regarding the association between cataract surgery and cataract surgery,35 we expect the results of the present study AMD. Darker irises and retinal pigment epitheliums may affect to help guide cataract surgery in Asian patients with AMD. AMD progression in eyes with cataract surgery, although these Further longitudinal studies are warranted to assess the associations were not clearly confirmed.33 Moreover, clinical causal association between cataract surgery and AMD in characteristics of Asian AMD (uncommon drusen in early AMD Asian populations.

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ARTICLE INFORMATION 7. Pollack A, Bukelman A, Zalish M, Leiba H, Oliver 21. Cheng CY, Yamashiro K, Chen LJ, et al. New loci Submitted for Publication: November 17, 2015; M. The course of age-related macular degeneration and coding variants confer risk for age-related final revision received February 4, 2016; accepted following bilateral cataract surgery. Ophthalmic macular degeneration in East Asians. Nat Commun. February 8, 2016. Surg Lasers. 1998;29(4):286-294. 2015;6:6063. Published Online: March 31, 2016. 8. Kaiserman I, Kaiserman N, Elhayany A, Vinker S. 22. Kweon S, Kim Y, Jang MJ, et al. Data resource doi:10.1001/jamaophthalmol.2016.0453. Cataract surgery is associated with a higher rate of profile: the Korea National Health and Nutrition photodynamic therapy for age-related macular Examination Survey (KNHANES). Int J Epidemiol. Author Contributions: Dr S. J. Park and Ms Lee degeneration. Ophthalmology. 2007;114(2):278-282. 2014;43(1):69-77. contributed equally to this work. Drs S. J. Park and K. H. Park had full access to all the data in the study 9. Freeman EE, Munoz B, West SK, Tielsch JM, 23. Yoon KC, Mun GH, Kim SD, et al. Prevalence of and take responsibility for the integrity of the data Schein OD. Is there an association between cataract eye diseases in South Korea: data from the Korea and the accuracy of the data analysis. surgery and age-related macular degeneration? National Health and Nutrition Examination Survey Study concept and design: S. J. Park, Lee. data from three population-based studies. Am J 2008-2009. Korean J Ophthalmol. 2011;25(6):421- Acquisition, analysis, or interpretation of data: All Ophthalmol. 2003;135(6):849-856. 433. authors. 10. Fraser-Bell S, Choudhury F, Klein R, Azen S, 24. Park SJ, Lee JH, Woo SJ, Kang SW, Park KH; Drafting of the manuscript: S. J. Park, Lee. Varma R; Los Angeles Latino Eye Study Group. Epidemiologic Survey Committee of Korean Critical revision of the manuscript for important Ocular risk factors for age-related macular Ophthalmologic Society. Five heavy metallic intellectual content: All authors. degeneration: the Los Angeles Latino Eye Study. elements and age-related macular degeneration: Statistical analysis: S. J. Park, Lee, Ahn. Am J Ophthalmol. 2010;149(5):735-740. Korean National Health and Nutrition Examination Obtained funding: S. J. Park, Lee. 11. Ho L, Boekhoorn SS, Liana, et al. Cataract Survey, 2008-2011. Ophthalmology. 2015;122(1): Administrative, technical, or material support: surgery and the risk of aging macula disorder: the 129-137. S.J.Park,Lee,K.H.Park. Rotterdam Study. Invest Ophthalmol Vis Sci. 2008; 25. Park SJ, Ahn S, Woo SJ, Park KH. Extent of Study supervision: S.J.Park,Lee,K.H.Park. 49(11):4795-4800. exacerbation of chronic health conditions by visual Conflict of Interest Disclosures: All authors have 12. Armbrecht AM, Findlay C, Aspinall PA, Hill AR, impairment in terms of health-related quality of life. completed and submitted the ICMJE Form for Dhillon B. Cataract surgery in patients with JAMA Ophthalmol. 2015;133(11):1267-1275. Disclosure of Potential Conflicts of Interest and age-related macular degeneration: one-year 26. Yoon KC, Choi W, Lee HS, et al. An overview of none were reported. outcomes. J Cataract Refract Surg. 2003;29(4): ophthalmologic survey methodology in the Funding/Support: This study was supported by 686-693. 2008-2015 Korean National Health and Nutrition grant NRF-2015R1D1A1A02062194 from the 13. Chew EY, Sperduto RD, Milton RC, et al. Risk of Examination Surveys. Korean J Ophthalmol.2015; National Research Foundation of Korea, awarded by advanced age-related macular degeneration after 29(6):359-367. the Ministry of Education, Science, and Technology. cataract surgery in the Age-Related Eye Disease 27. World Medical Association. World Medical Role of the Funder/Sponsor: The funding source Study: AREDS report 25. Ophthalmology. 2009;116 Association Declaration of Helsinki: ethical had no role in the design and conduct of the study; (2):297-303. principles for medical research involving human collection, management, analysis, and 14. Hooper CY, Lamoureux EL, Lim L, et al. Cataract subjects. JAMA. 2013;310(20):2191-2194. doi:10 interpretation of the data; preparation, review, or surgery in high-risk age-related macular .1001/jama.2013.281053. approval of the manuscript; and decision to submit degeneration: a randomized controlled trial. Clin 28. Bird AC, Bressler NM, Bressler SB, et al; The the manuscript for publication. Experiment Ophthalmol. 2009;37(6):570-576. International ARM Epidemiological Study Group. An international classification and grading system for REFERENCES 15. Wang JJ, Fong CS, Rochtchina E, et al. 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