Das Risiko der Maculadegeneration
wird in Abhängigkeit von der
gerauchten Zigarettenmenge vervielfacht.
Auch Passivraucher haben ein
erhöhtes Risiko, durch diese
Augenerkrankung zu erblinden (siehe unten und
PNAS 2005: Zur Pathogenese der Maculadegeneration
Endokrine Orbitopathie: 70% der der Patienten sind Raucher.
Die Anzahl der Zigaretten prognostiziert die Entstehung von
Doppelbildern. Nach Tabakabstinenz kommt es zur Besserung der Symptome.
Hypothesen: Reizwirkung von Tabakrauch und Hypoxie im
Retrobulbärraum (Symptome korrelieren mit Zytokinen).
Smoking and blindness (Editorial)
BMJ 2004;328:537-538 (6 March). http://bmj.bmjjournals.com/cgi/content/full/328/7439/537
Strong evidence for the link, but public awareness lags
While most people and many patients attending eye clinics recognise
many adverse health hazards of tobacco smoking, they remain largely
of its link with blindness. Although smoking is associated with several
eye diseases, including nuclear cataract
(1,2) and thyroid eye disease (3), the most common cause of smoking
related blindness is age related macular degeneration, which results in
severe irreversible loss of central
vision. Current treatment options are of only partial benefit to
patients. Identifying modifiable risk factors to inform efforts for
A risk factor is generally judged to be a cause of disease if certain
causality criteria are fulfilled (4). Applying commonly used criteria
(4) to available evidence provides strong evidence of a causal link
tobacco smoking and age related macular degeneration. The strength of
association is confirmed in a pooled analysis of data from three cross
studies, totalling 12 468 participants, in which current smokers had a
significant threefold to fourfold increased age adjusted risk of age
related macular degeneration compared with never smokers (1). By way of
the relative risks associated with smoking for lung cancer and chronic
obstructive pulmonary disease are in excess of 20, the relative risk
for ischaemic heart disease in men is only 1.6 (5). Consistency of
effect is demonstrated as smoking was the strongest environmental risk
age related macular degeneration across these three different study
populations in Australia, North America, and Europe (2-4) A temporal
between exposure and outcome was established through long term follow
these cohorts (5-7). A dose-response relation between exposure to
age related macular degeneration is demonstrated as the risk of early
disease increases with number of pack years (6,7). Finally, this causal
association is biologically plausible, as age related macular
degeneration may reflect accumulated oxidative damage in the retina and
smoking is known to
impede the protective effects of antioxidants and to reduce macular
pigment density (8).
Owen et al estimated 214 000 UK residents to have visual impairment
(best visual acuity 6/18-3/60 Snellen) and 71 000 individuals to be
(better eye visual acuity < 3/60 Snellen) because of age related
macular degeneration (9). We estimate that 53 900 United Kingdom
than 69 years may have visual impairment because of age related macular
degeneration attributable to smoking of whom 17 800 are blind (see
table and methods on bmj.com, 1, 6, 9).
Randomised controlled trials examining whether smoking cessation
interventions reduce incidence or progression of smoking related
diseases are problematic. Observational studies show a protective
smoking cessation on the development of age related macular
former smokers have an only slightly increased risk of age related
macular degeneration compared with never smokers (1). The reversibility
of this association in smokers with age related macular degeneration in
has important implications for prevention of late macular involvement
in the second eye. In addition, continuing smoking is associated with
poorer outcome after photocoagulation with argon laser (10). Continued
could perhaps also adversely affect the long term response to newer
treatments such as photodynamic therapy.
Robust evidence indicates that smoking cessation support results in
higher abstinence rates (8). Guidelines recommend that smokers are
referred to professional smoking cessation services and should
generally be offered nicotine replacement therapy.w8 Many diabetes,
cardiac, and respiratory
NHS clinics now incorporate smoking cessation support into their
and ophthalmology or optometry services could follow likewise. The
of this intervention among eye care personnel in the United States is
high, but time and knowledge constraints may hinder implementation
Primary smoking prevention is perhaps even more important. In New
Zealand, publicity about smoking and blindness resulted in increased
calls to the national Quitline (9) and a television campaign
incorporating the (slightly modified) Australian eye advertisement
was considered more successful than other advertisements relating
smoking to stroke and heart disease (N
Wilson, personal communication, 2003). A sustained public health
campaign in the United Kingdom is warranted to increase awareness of
the ocular hazards associated with smoking, "North West Action on
Smoking and Health" (http://www.nwash.co.uk) has launched a leaflet
describing these risks alongside user friendly advice on smoking
cessation. The Royal College of
Ophthalmologists supports this initiative. More novel, varied, and
specific pack warnings of the impact of smoking on health (10),
eyesight, might help as primary prevention efforts. Warnings targeted
at specific concerns may be more effective than current general
is a major cause of blindness" has been suggested (12). The finding
smokers develop age related macular degeneration around 10 years
earlier than non-smokers (5) could also be a potent message in public
Tobacco smoking is the prime modifiable risk factor for age related
macular degeneration. Evidence indicates that more than a quarter of
age related macular degeneration with blindness or visual impairment
are attributable to current or past exposure to smoking. Patients,
health professionals, and the public will benefit from greater
this causal association. Smoking cessation advice should be introduced
and evaluated. Similarly, research examining the behaviour of smokers
as result of acquired knowledge about smoking and the risk of visual
impairment or blindness could usefully inform public health campaigns.
Policy initiatives based on these concepts are now clearly needed.
Simon P Kelly, consultant ophthalmic surgeon Bolton Hospitals NHS
Trust, Bolton BL4 0JR ( firstname.lastname@example.org
Judith Thornton, honorary research fellow, Georgios Lyratzopoulos,
lecturer in public health, Richard Edwards, senior lecturer in public
health Evidence for Population Health Unit, School of Epidemiology and
Health Sciences, University of Manchester, Manchester M13 9PT
Paul Mitchell, professor of clinical ophthalmology University of Sydney
Department of Ophthalmology, Centre for Vision Research, Westmead
Hospital, Westmead, NSW 2145, Australia
Additional references (1-10), a table, and methods appear on bmj.com
We are grateful to P McElduff, lecturer in statistics, Evidence for
Population Health Unit, University of Manchester for statistical help.
The Retinal Research Endowment Fund, Bolton Hospital NHS Trust
supported this work.
Competing interests: RE is the chair (unpaid) of North West Action on
Smoking and Health, and the Faculty of Public Health's representative
to the Royal College of Physicians Tobacco Group.
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