The multivariate logistic regression analysis included records from 542 individuals. One hundred forty-nine (22%) participants were excluded from the multivariate analysis because of missing at least one portion of the risk assessment. The multivariate analysis identified several independent risk factors for failing the vision screening tests (Tables 4 and 5). The independent risk factors for failing the visual field test (Table 4) were sex (OR 1.5, confidence interval [CI] 1.0 to 2.3), age (OR 2.8, CI 1.6 to 5.0), African American ethnicity (OR 3.4, CI 1.5 to 7.5), Hispanic ethnicity (OR 1.9, CI 1.2 to 2.8), and persistent pain (OR 2.3, CI = 1.3 to 4.1). The independent risk factors for failing the visual acuity test (Table 5) were persistent eye pain (OR = 2.4, CI 1.4 to 4.0) and personal history of glaucoma (OR = 3.3, CI 1.3 to 8.3). There was no significant association between personal history of glaucoma and persistent eye pain in either of the vision screening tests.
Participants who failed the visual field test were also more likely to be 65 years and older and to report persistent eye pain (p < 0.01). Participants who failed the visual field test were also more likely to be female (p < 0.05) and either Hispanic or African American (p < 0.01) compared with those who did not fail. Participants who failed the visual acuity test were more likely to have a personal history of glaucoma (p < 0.05) and more likely to report persistent eye pain (p < 0.01). Diabetes was not found to be a significant risk factor for either vision screening test after adjusting for all other covariates.
We compared data from participants with complete data (n = 542, 78%) and participants with incomplete data (n = 149, 22%) to evaluate the impact of missing data on study results. Participants with complete and missing data were similar with respect to all risk factor characteristics except ethnicity (p < 0.01) and age (<65 vs. ≥65 years, p = 0.01). A larger proportion of participants with missing data were Hispanic compared to participants with complete data (66% vs. 43%). Also, a larger proportion of participants with missing data were 65 years of age or older compared with participants with complete data (25% vs. 15%). Including participants with missing data in the multivariate regression model did not affect the results (data not shown).
Rates of AREDs and VI are increasing throughout the United States and becoming a serious public health concern.17 Identifying significant risk factors for AREDs and VI is essential to providing appropriate vision screening programs. This was the first study to analyze PBA data from Nebraska to assess risk factors for developing AREDs among high-risk elderly and minority populations.
Previous studies have identified female sex, older age, and being a member of an ethnic minority as significant risk factors for developing AREDs and VI.17 Those findings are consistent with the results of our study. After adjusting for all other covariates, participants older than 65 years had significantly higher odds of failing the visual field test (OR 2.8, p < 0.01). Also, African Americans were 3.5 times more likely to fail and Hispanics were 2.4 times more likely to fail the visual field test compared to non-Hispanic whites (p < 0.01). Females were also slightly more likely to fail the visual field test (p < 0.05), which is consistent with previous studies that have found females to have an increased risk for some AREDs.
Other risk factors were associated with failing either the visual field or the visual acuity screening test. These included personal history of glaucoma and persistent eye pain. Individuals with a personal history of glaucoma had an increased odds of failing the visual acuity test (p < 0.05). Participants reporting persistent eye pain were at an increased risk of failing both vision screening tests (OR = 2.3, p < 0.01 for visual field test and OR = 2.4, p < 0.01 for visual acuity test).
Previous studies have also found diabetes to be a significant risk factor for AREDs and VI.28,35–41 In our study, although the presence of diabetes was significantly associated with failing the visual field test in the univariate model, it did not remain significant in the multivariate model. After adjusting for all other covariates, diabetes was not found to be a significant independent risk factor for failing either vision screening test. For those individuals who failed either vision screening test, diabetes was significantly associated with being older than 65 years and with eye injury. Also, when adjusting only for age, diabetes was found to be significantly associated with failing the visual field test for those participants younger than 65 years (data not shown). Thus, the high rates of failures for the vision screening tests among those with diabetes could be accounted for by other risk factors with stronger associations for failing the vision screening tests.
An important factor to consider is that URE is also associated with many of the same risk factors. Consequently, individuals may have had VI because of an URE and not because of an ARED or a more serious condition. Nonetheless, screening programs provide an opportunity to identify individuals who still need a comprehensive eye examination for vision correction and disease prevention.
This study reinforces the need to screen elderly (≥65 years) and minority populations for AREDs and VI. In addition, personal history of glaucoma and persistent eye pain may be important when identifying high-risk populations because both remained significant independent risk factors for failing vision screening tests after adjusting for other variables in the multivariate model. Although persistent pain may be a symptom of glaucoma, there was no significant association between the two variables in our study.
Study results should be considered in light of several limitations. First, potential inconsistencies in data entry and/or form completion may have occurred. Some data were missing for 22% of the participants (n = 149). Although including participants with missing data in the multivariate regression model did not affect the results, future screening studies should ascertain completion of screening forms to the best extent possible. In addition, the study population was small and fairly homogeneous with a large proportion of women and Hispanics. Therefore, the results are not generalizable to the entire Nebraska population.
Another limitation to consider is that failure of the visual acuity test could potentially be due to URE. It is crucial that screening programs follow-up on patients who are seen for VI to determine how many individuals were seen for URE compared with those for AREDs. Lastly, language barriers between PBA employees and the largely Hispanic population may have also contributed to inaccuracies.
The authors thank the staff and volunteers of Prevent Blindness Nebraska for providing the data. The Nebraska affiliate of PBA is no longer active. For more information on PBA, see http://www.preventblindness.org. The author(s) have no proprietary interest in any materials discussed in this article. Results of this study were presented as a poster at the 2011 American Public Health Association Annual Meeting in Washington, D.C. on October 31, 2011.
The author(s) have received no financial support for this research.
Received: November 12, 2012; accepted April 30, 2013.
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