Changes in Visual Acuity in a

Population
The Beaver Dam Eye Study
Ronald Klein, MD, Barbara E. K. Klein, MD, Kristine E. Lee, MS
Purpose: To describe the change in visual acuity over a 5-year period in persons
participating in a large population-based study.
Methods: Best-corrected visual acuity was measured, after refraction, with 10gMAR
charts using a modification of the Early Treatment Diabetic Retinopathy Study protocol
in 3684 persons living in Beaver Dam, Wisconsin, who ranged in age from 43 to 86
years at the time of a baseline examination from 1988 to 1990, and at a follow-up
examination from 1993 to 1995.
Results: The change in the number of letters read correctly over the 5-year period
varied from 0.4 4.9 (mean standard deviation) in people between 43 and 54 years
of age to -5.2 15.4 in people 75 years of age or older at baseline. Over the 5-year
period, vision became impaired (20/40 or worse in the better eye) in 2.9% of the population and severely impaired (20/200 or worse in the better eye) in 0.3%. The visual
angle doubled in 1.7% of the population, and 2.4% had improved vision. People 75
years of age or older at baseline were 12.5 times (95% confidence interval [CI], 8.618.2; P < 0.001) more likely to have impaired vision, 9.7 times (95% CI, 5.9-16.0; P <
0.001) more likely to have doubling of the visual angle, and 78 times more likely (95%
CI, 9.9-614.1; P < 0.001) to have severe visual impairment than people younger
than 75 years of age at baseline. People 75 years of age or older who were living in
nursing homes or group homes were 3.8 times more likely to have impaired vision,
3.3 times more likely to have severely impaired viSion, and 5.7 times more likely to
have a doubling of the visual angle than those not residing in a nursing home or a
group home.
Conclusion: These data provide precise population-based estimates of incidence
of visual loss over a wide spectrum of ages and show that decreased visual acuity in
people 75 years of age is a common finding, especially in those who are in nursing
homes or group homes. Ophthalmology 1996; 103: 1169-1178

Originally received: November 27. 1995.

Revision accepted: May I. 1996.
From the Department of Ophthalmology and Visual Sciences. University
of Wisconsin Medical School. Madison.
Supported by National Institutes of Health grant EY06594 (Drs. R Klein
and BEK Klein). Bethesda. Maryland. and. in part. by the Research to
Prevent Blindness (Dr. R Klein) Senior Scientific Investigator Award.
New York. New York.
Each author states that he/she has no proprietary interest in any aspect
of this work.
Reprint requests to Ronald Klein. MD. MPH. Department ofOphthalmology and Visual Sciences. University of Wisconsin-Madison. 610
North Walnut St. 460 WARF. Madison. WI 53705-2397.

Recent population-based studies have provided data on

the prevalence and severity ofloss of vision in the United
States. I- 3 These data show a significant increase in the
prevalence of impaired vision with increasing age, especially in those 75 years of age or older. However, estimates of the incidence of loss of vision are few and are
limited by the small size or the select nature of the groups
studied and by the lack of objective data. 4 - 7 Reliable incidence rates ofloss of vision have important public health
implications, including the ability to project needs for services and costs, defining etiologic relations, and assessing
the effect of treatment. The purpose of this report is to

1169

Ophthalmology

Volume 103, Number 8, August 1996

describe the change in visual acuity over a 5-year period

in persons participating in the Beaver Dam Eye Study, a
population-based study of older adults.

Methods
Population
Methods used to identify the population and descriptions
of the population have appeared in previous reports. 38.9
In brief, a private census of the population of Beaver Dam,
Wisconsin, was performed from September 15, 1987, to
May 4, 1988. Eligibility requirements for entry into the
study included living in the city or township of Beaver
Dam and being 43 to 84 years of age at the time of the
census. A total of 5924 individuals, both institutionalized
and noninstitutionalized, were eligible for inclusion in
the study. Of these individuals, 4926 participated in the
examination phase between March 1, 1988, and September 14, 1990. Ninety-nine percent of the population was
white. Of those who did not participate, 227 (3.8%) had
died before the examination, 99 (1.7%) had moved out
of the area, 18 (0.3%) could not be located, 276 (4.7%)
permitted an interview only, and 378 (6.4%) refused to
participate. Comparisons between participants and nonparticipants at the time of the baseline examination have
appeared elsewhere. 3
The members of the cohort who were eligible to participate at baseline had been divided randomly into ten
groups to be examined sequentially over the course of the
study. Surviving members of the cohort were invited to
participate in a 5-year follow-up examination in the same
order as at baseline examination. Of the 4926 people who
participated at the baseline examination, 385 (7.8%) died
before March 1, 1993, the beginning of the 5-year followup examination. Of the 4541 surviving persons who had,
participated in the baseline examination, 3684 (81.1 %)
participated in the follow-up examination from March 1,
1993, through June 14, 1995. One hundred seventy-one
(3.8%) died after the start of the follow-up but before examination. Four could not be located. Two hundred fiftynine (5.7%) permitted an interview only (48 of whom
moved out of the area) and 423 (9.3%) refused to participate (44 of whom moved out of the area). Both the mean
and median times between the baseline and 5-year followup examinations were 4.8 years (standard deviation, 0.4
years).
Of the 3684 people examined at baseline and at followup, 92 were living in a nursing home or a group home at
follow-up. Of these people, 24 were in a nursing home or
a group home at baseline. One person was in a nursing
home at baseline but moved home by follow-up.
Comparisons between participants and nonparticipants
at follow-up are presented in Table 1. The 686 nonparticipants who were alive at follow-up were more likely to
be older than the participants (Table 1). After controlling
for age at baseline, these nonparticipants were.more likely
at baseline to have retired and had fewer years of education
completed, a history of never drinking alcohol, lower in-

1170

come, poorer visual acuity, a history of cardiovascular

disease, more packyears smoked, a higher serum cholesterollevel, and higher systolic and diastolic blood pressure
than persons who participated. There were no statistically
significant differences in the presence of age-related maculopathy at baseline between participants and nonparticipants.

Procedures
Similar procedures were used at both the baseline and
follow-up examinations. Letters from primary care physicians or from the principal investigators, if no primary
care physician was identified, were sent to those who were
eligible. The letters described the study and invited eligible
people to participate. This was followed by a call from
the study coordinator, who provided further information
about the study and made an appointment for the examination. People who were not interested in participating
in the examination were asked to respond by telephone
to the questionnaire that was administered at the time of
examination.
Human experimentation committee approval was
granted and informed consent was obtained from each
participant at the beginning of the examination. The parts
of the examination pertinent to this report consisted of a
standardized refraction and measurement of the visual
acuity using the Humphrey 530 refractor (Allergan Humphrey, San Leandro, CA). At follow-up only, before refraction, the participants first were asked to read the Early
Treatment Diabetic Retinopathy Study chart R with their
current prescription without covering either eye. The
number ofletters correctly read was recorded. At baseline
and follow-up, the refraction obtained using the refractor
was placed in a trial lens frame and the best-corrected
visual acuity was remeasured following the Early Treatment Diabetic Retinopathy Study protocol using chart R
and modified for a 2-m distance. 3. IO If the best-corrected
visual acuity was 20/40 or worse, an Early Treatment
Diabetic Retinopathy Study refraction was performed and
the visual acuity was measured. The interobserver variation among the examiners for obtaining the refractive
error or the best-corrected visual acuity was low and not
clinically significant (data not shown).
. At both examinations, visual acuity was obtainable and
considered reliable in both eyes in 3480 persons, in the
right eye only in 41 persons, and in the left eye only in
47 persons. Visual acuity was obtainable and considered
reliable in at least one eye at both visits for 17 of those in
a nursing home or a group home at both visits (11 were
older than 75 years of age) and 55 of those in a nursing
home or a group home at follow-up only (39 were older
than 75 years of age).

Definitions
For each eye, visual acuity was recorded as the number
of letters correctly identified (range, 0 [<20/200] to 70
[20/10)). For eyes with visual acuity poorer than 20/200,
one of nine levels of vision could be recorded: 20/250,

Klein et al . Changes in Visual Acuity

Table 1. Distribution of Baseline Characteristics among Participants and Nonparticipants in Beaver Dam II
Nonparticipants
Alive

Participants
Characteristic
Age at baseline (yrs)
43-54
55-64
65-74
75+
Sex
F
M
Education
<high school
High school
College
> college
Employment
Full-time
Part-time
Retired
Other
Income ($)
-0:9000
10,000-19,000
20,000-29,000
30,000-44,000
::0:45,000
Visual acuity in worse eye
Better than 20/40
20/40-20/160
20/200 and worse
Central cataract
No
Yes
Age-related maculopathy
None
Early
Late
Hypertension
No
Yes
Cardiovascular disease
No
Yes
Cancer
No
Yes
Diabetes
No
Yes
Alcohol consumption
Never
Ever

Pack-years smoked
Cholesterol level (mg/dl)
Systolic level (mmHg)
Diastolic blood pressure
(mmHg)

Crude
%

(no.)

Crude
%

34.7
28.8
25.9
10.6

(1277)
(1063)
(953)
(391)

30.5
24.9
23.5
21.1

56.8
43.2

(2092)
(1592)

59.3
40.7

(407)
(279)

24.4
45.4
22.9
7.3

(897)
(1671)
(845)
(269)

40.4
40.4
16.0
3.2

41.1
10.3
36.0
12.6

(1513)
(378)
(1328)
(465)

13.3
26.1
21.2
22.3
17.2

Dead
Age-adjusted
P'

Crude
%

(no.)

Age-adjusted
Pt

<O.OO1t

9.4
12.3
26.3
52.0

(16)
(21)
(45)
(89)

<O.OOlt

0.65

52.6
47.4

(90)
(81)

0.01

(277)
(277)
(109)
(22)

<0.001

48.5
33.1
14.2
4.2

(82)
(56)
(24)
(7)

0.02

36.1
6.6
39.8
17.5

(248)
(45)
(273)
(120)

0.06

9.9
4.7
66.7
18.7

(17)
(8)
(114)
(32)

<0.01

(471)
(927)
(751)
(790)
(609)

21.9
27.0
19.9
19.2
12.0

(139)
(171)
(126)
(76)

3.4

(47)
(59)
(21)
(13)
(5)

0.001

(122)

32.4
40.7
14.5
9.0

88.3
9.3
2.4

(3241)
(339)
(89)

79.2
17.6
3.2

(540)
(120)
(22)

0.001

61.2
30.3
8.5

(101)
(50)
(14)

<0.001

84.2
15.8

(3016)
(566)

78.2
21.8

(510)
(142)

0.36

54.1
45.9

(79)
(67)

0.02

82.3
16.4
1.3

(2981)
(594)
(47)

81.7
16.3
2.0

(528)
(105)
(13)

0.36

74.5
23.5
2.0

(111)
(35)
(3)

0.20

65.6
34.4

(2415)
(1269)

60.5
39.5

(415)
(271)

0.13

49.4
50.6

(84)
(86)

0.09

88.2
11.8

(3211)
(430)

83.5
16.5

(563)
(111)

0.03

68.5
31.5

(113)

89.9
10.1

(3309)
(370)

88.1
11.9

(602)
(81)

0.56

81.3
18.7

(139)
(32)

0.18

92.3
7.7

(3356)
(281)

91.9
8.1

(625)
(55)

0.93

82.9
17.1

(141)
(29)

0.001

13.3
86.7

(489)
(3195)

19.9
80.1

(136)
(549)

<0.001

29.2
70.8

(50)
(121)

<0.001

(no.)
(209)
(171)

(161)
(145)

<0.001

(52)

<0.001

No.

Mean SD

No.

Mean SD

No.

Mean SD

3672
3675
3683

16.5 25.3
233.0 43.5
130.7 19.4

678
683
686

18.1 26.7
239.1 44.6
136.1 21.9

0.03
<0.01
<0.001

167
165
170

21.5 31.7
231.0 46.6
136.4 23.4

<0.001
0.23
0.58

3683

77.8 10.5

686

78.3 12.1

0.01

170

72.4 11.9

<0.01

Comparison of participants to nonparticipants who were alive at follow-up.

t Comparison of participants to those who died after the start of the follow-up and who were not examined.
t Mantel-Haenszel test of trend.

1171

Ophthalmology

Volume 103, Number 8, August 1996

20/320, 20/400, 20/500, 20/640, 20/800, hand motions,

light perception, and no light perception. Levels of impairment in visual function were defined by the best-corrected visual acuity in the eye, or, for a participant, in the
better eye. The definitions were no impairment (better
than 20/40, 41-70 letters correct), any visual impairment
(20/40 or worse, 40 or fewer letters correct), and severe
impairment (20/200 or worse, 5 or fewer letters correct).
Persons were at risk for vision becoming impaired if
their visual acuity was better than 20/40 in one or both
eyes at baseline. Similarly, persons were at risk for severe
loss of vision if their visual acuity was better than 20/200
in one or both eyes at baseline. Loss of vision over the 5year period is defined as a doubling of the visual angle, a
loss of 15 letters (e.g., a change from baseline to followup from 60 to 45 letters read correctly, corresponding to
a change in visual acuity from 20/16 to 20/32). For each
person, loss of vision was defined according to these criteria in the better eye. Persons with visual acuity of no
light perception at baseline were, therefore, not at risk to
lose vision. The incidence of monocular impairment was
defined as visual acuity declining from better than 20/40
visual acuity in both eyes at baseline to 20/40 or worse
in one eye only at follow-up. The incidence of severe
monocular impairment was defined as visual acuity declining from better than 20/200 in both eyes at baseline
to 20/200 or worse in one eye only at follow-up. Improvement in vision was defined as vision improving by 15 or
more letters (halving of the visual angle). People had improvement in vision ifthere were 55 letters or more (visual
acuity, 20/20 or worse) in at least one eye. Improvement
was computed for visual acuity measured in the worse
eye. Age was defined as the age at the time of the baseline
examination.

Statistical Methods
Comparisons of participants and nonparticipants were
done using analysis of variance and the Cochran-MantelHaenszel test of independence to adjust for age groups
with continuous (i.e., blood pressure) and categorical (i.e.,
visual acuity) characteristics, respectively. Student's t test
and analysis of variance were used to compare the change
in the number ofletters read between eyes and age groups,
respectively. Linear regression analyses were used to
compute estimates of age-adjusted (continuous and quadratic) and sex-adjusted change. Chi-square and CochranMantel-Haenszel tests were used to compute unadjusted
and age-group-adjusted comparisons of incidence, respectively. Unless noted, all results were unadjusted for
any confounders. SAS was used for all analyses. I 1.12

The decrease in the number of letters read correctly

(mean standard deviation) over the 5-year period was
small--0.9 8.6 letters in the right eye and -1.3 8.9
letters in the left eye. There was a significant inverse relation between the change in the number of letters read
correctly between examinations and increasing age. In the
right eye, the change in the number ofletters read correctly
varied from 0.4 4.9 in people 43 to 54 years of age to
-5.2 15.4 in people 75 years of age or older at baseline
(Fig 1). Similar relations between age and change in the
number of letters read correctly between examinations
were found in the left eye. Age-adjusted changes in visual
acuity scores (mean standard error) over the 5-year period were slightly higher in right eyes of men (-0.7 0.3)
versus women (0.0 0.2). Regarding changes in visual
acuity in left eyes, there was no difference between men
(-0.8 0.3) and women (-0.8 0.2). After controlling
for sex, the amount of change in visual acuity score
(logMAR) increased quadratically with age. In people 55
years of age at baseline, there was no change in visual
acuity score over the 5-year period (letters gained in right
eyes, 0.3 0.2; letters lost in left eyes 0.1 0.2). In persons
65 years of age at baseline, the visual acuity score diminished by 1.0 0.2 letter in right eyes and 1.6 0.2 letters
in left eyes. In persons 75 years of age at baseline, the
visual acuity score diminished by 3.5 0.3 letters in right
eyes and 4.1 0.3 letters in left eyes.
The incidence of visual impairment (right eye versus
left eye, 4.9% versus 5.4%; P = 0.35) or doubling of the
visual angle (right eye versus left eye, 2.8% versus 3.0%;
P = 0.53) was similar for right and left eyes. The 5-year
incidence of the development of monocular visual impairment (either eye) was 5.6%; for severe monocular visual impairment it was 1.0%; and for doubling of the visual
angle it was 4.1 % (Table 2). The 5-year incidence of improvement in vision in one eye only (either eye) (defined
by an increase of 15 or more letters read correctly at follow-up compared with baseline) was 5.1%. The 5-year
incidence of monocular impairment, severe monocular
visual impairment, and doubling of the visual angle in
one eye only increased with increasing age, whereas improvement of visual acuity in one eye only did not change

III

"0

.c
E

0
-1

-2

"

.5

III
Cl

Results
The mean age of the participants at baseline was 60.4
years, and 56.8% were women (Table 1). The mean number of years of school completed was 12, and the median
income was $25,000. Other characteristics of the participants at baseline are presented in Table 1.

1172

III
.J::

-4
-5
-6
43-54

55-64

65-74

75+

Age (years)

Figure 1. Five-year change in the number of letters read correctly in

the right eye by age and sex in the Beaver Dam Eye Study.

.....
.....

1215
998
882
342
3437

565
461
361
113
1500

650
537
521
229
1937

No. of Participants
at Risk

(0.9)
(2.5)
(6.7)
(13.5)
(4.1)

(2.2)
(7.8)
(11.5)
(3.8)

(1.1)

(0.8)
(2.8)
(6.0)
(14.4)
(4.3)

(%)

<0.001

0.86

<0.001

<0.001

Pt

1171
947
747
204
3069

545
440
321
78
1384

626
507
426
126
1685

No. of Participants
at Risk

(1.0)
(2.6)
(10.8)
(26.0)
(5.6)

(0.7)
(2 .3)
(10.0)
(24.4)
(4.7)

(3.0)
(11.5)
(27.0)
(6.3)

(1.3)

(%)

Visual Impairment

<0.001

0.23

<0.001

<0.001

Pt

1208
989
873
339
3409

560
456
358
115
1489

648
533
515
224
1920

No. of Participants
at Risk

(6.2)
(1.0)

(1.3)

(0.0)
(0.3)

(4.4)
(0.6)

(1.1)

(0.0)
(0.0)

(0.0)
(0.6)
(1.4)
(7.1)
(1.4)

(%)

Severe Impairment

<0.001

0.15

<0.001

<0.001

Pt

213
273
415
268
1169

60
76
121
80
337

153
197
294
188
832

No. of Participants
at Risk

(4.2)
(3.3)
(6.8)
(4.9)
(5.1)

(3.3)
(0.0)
(5.0)
(5.0)
(3.6)

(4.6)
(4.6)
(7.5)
(4.8)
(5.7)

(%)

Improvement

0.31

0.13

0.24

0.58

Pt

Mantel-Haenszel test of trend .

Incidence of monocular doubling of the visual angle defined as a loss of 15 letters or more in visual acuity in either eye at follow-up. Incidence of monocular impairment defined as development of visual
acuity of 20/40 or worse in either eye at follow-up in an individual who had better than 20/40 visual acuity in both eyes at baseline. Incidence of severe monocular visual impairment defined as development
of visual acuity of 20/200 or worse in either eye at follow-up in an individual who had better than 20/200 visual acuity in both eyes at baseline. Incidence of monocular improvement in visual acuity
defined as an improvement of 15 letters or more in visual acuity in either eye at follow-up.

Total

43-54
55-64
65-74
75+

Male and female

Age-adjusted
Male versus female

Total

43-54
55-64
65-74
75+

Male

Total

43-54
55-64
65-74
75+

Female

Age (yrs)

Doubling of Visual Angle

Table 2. Five-year Incidence of Monocular Changes in Vision by Age and Sex in the Beaver Dam Eye Study

Ophthalmology

Volume 103, Number 8, August 1996

with age (Table 2). After controlling for age, men and
women were equally at risk for monocular impairment
(odds ratio [OR], 0.8; 95% el, 0.6- 1. 1; P = 0.23) or doubling of the visual angle in one eye only (OR, 1.0; 95%
el, 0.7-1.4; P = 0.86).
Over the 5-year period, impaired vision developed in
2.9% of the population at risk, severe impairment developed in 0.3%, doubling of the visual angle occurred in
1.7%, and 2.4% had improved vision. The 5-year incidence
of any visual impairment, severe visual impairment, doubling of the visual angie, and improvement by age and
sex are shown in Table 3. People 75 years of age or older
at baseline were 12.5 times (95 % el, 8.6-18.2; P < 0.001)
more likely to have impaired vision, 9.7 times (95% el,
5.9-16.0; P < 0.001) more likely to have a doubling of
the visual angle, and 78 times more likely (95% CI, 9.9614.1 ; P < 0.001) to have severe visual impairment than
people younger than 75 years of age at baseline. Similarly,
people 75 years of age or older were 2.1times (95% el,
1.2-3 .8; P = 0.01) more likely to have an improvement
in vision than those who were younger at baseline. After
controlling for age, the incidence of visual impairment or
doubling of the visual angle or improvement was not statistically different between men and women.
The relation of improvement of visual acuity to cataract
surgery was examined. In people 55 years of age or older,
the incidence of improvement in vision over the 5-year
period was consistently higher in eyes that had undergone
cataract surgery (26.7% in right eyes with cataract surgery
versus 0.8% in right eyes without cataract surgery; 18.3%
in left eyes with cataract surgery versus 0.7% in left eyes
without cataract surgery) between baseline and follow-up
compared with eyes which had not.
Among those persons without impaired vision at baseline, the 5-year incidence of the development of moderately impaired visual acuity (20/40-20/160) was 2.8%;
for development of severe visual impairment, it was 0.1 %;
and for doubling of the visual angle, it was 1.4% (Table
4). Of those who had moderately impaired vision at baseline, 39.4% were no longer visually impaired, whereas severe impairment had developed in 6.4% at follow-up. Of
eyes that were no longer visually impaired and had improved by 15 or more letters, 81.8% (27/33) of right eyes
and 71.4% (15/21) of left eyes had undergone cataract
surgery.
Of the 72 participants with reliable visual acuity who
were living in a nursing home or a group home at followup, vision became impaired in 48.2% and severely impaired in 4.4% (Table 5). In addition, 30.6% had doubling
of the visual angle. Of those individuals 75 years of age
or older in whom visual acuity could be measured (n =
375), those living in a nursing home or a group home at
follow-up (n = 50) were 3.8 times (95% el, 2.5-5.8; P <
0.001) more likely to have impaired vision, 3.3 times (95%
el, 0.9-12.9; P = 0.07) more likely to have severely impaired vision, and 5.7 times (95% el, 3.1-10.7; P < 0.001)
more likely to have a doubling of the visual angle than
those not residing in a nursing home or a gro,llp home (n
= 325) at follow-up. In addition, those individuals 75
years of age or older and institutionalized were 1.6 times

1174

(95% el, 0.6-5.4; P = 0.46) more likely to have an improvement in visual acuity over the 5-year period of the
study than those who were not institutionalized. Those
individuals living in a nursing home or a group home
with impaired vision at baseline were less likely to have
undergone cataract surgery over the 5-year period than
those not living in a nursing home or a group home (right
eye, 11.8% versus 35.6%, respectively, P = 0.06; left eye,
14.3% versus 33.3%, respectively, P = 0.16).
Over the 5-year period, 68 persons who had been examined and who were not institutionalized at baseline
entered a nursing home or a group home and were examined at the time of the 5-year follow-up. Of these persons, 55 (80.9%) had obtainable and reliable measurements of visual acuity at both examinations. In those persons 75 years of age or older who entered a nursing home
or a group home (n = 39), the mean number of letters
read correctly was slightly lower at baseline than in persons
similar in age who did not enter a nursing home or a
group home (n = 325) (right eye, 37.2 versus 45.5, respectively, P = 0.08; left eye, 41.4 versus 45.4, respectively,
P = 0.17). Those entering a nursing home or a group
home were 3.0 times (95 % el, 1.7-5.0) more likely to
have impaired vision, 2.9 times (95% el, 0.6-13.8) more
likely to have severely impaired vision, and 5.9 times (95%
el, 3.0-11.4) more likely to have doubling of the visual
angle than those who did not enter a nursing home or a
group home. The loss of vision was significantly greater
(change in number ofletters read: right eyes, -13.2 versus
-4.0, P = 0.02; left eyes, -14.7 versus -5.2, P = 0.01)
among those entering a nursing home or a group home
than those who did not.
The rate of improvement in the number ofletters read
correctly in the better eye by refraction compared with
the current prescription of glasses or contact lenses at follow-up was not significantly different in persons 75 years
of age or older living in a nursing home or a group home
than those who were not institutionalized (Fig 2). In both
the institutionalized (40.4%) and noninstitutionalized
(27.1 %) groups older than 75 years of age, a significant
number of persons had an improvement of five or more
letters of visual acuity after refraction.

Discussion
Most information about change in vision has been derived
from blindness registries. 4- 7. 13 To our knowledge, there
are no population-based estimates of objectively measured
incidence of loss or improvement of vision. The Beaver
Dam Eye Study provides data on changes in visual acuity
in a geographically defined population. This study is
unique in that a large cohort with a broad distribution of
ages was re-examined after a 5-year interval. The refusal
rate was low (9.3%), suggesting that bias would unlikely
distort our results. During both visits, the same standardized protocols for measuring visual acuity were used.
These data show that the overall change in visual acuity
over the 5-year period is, on average, approximately one
letter. This change is not clinically significant. However,

.....
.....

(0.1)

1239
1027
926
375
3567
(1.7)

(8.5)

<0.001

0.71

<0.001

<0.001

Pi'

1230
1022
894
318
3464

574
471
373
110
1528

656
551
521
208
1936

No. of Participants
at Risk

(3.2)
(17.9)
(2.9)

(1.3)

(0.2)

(2.7)
(14.6)
(2.2)

(1.3)

(0.4)

(3.7)
(19.7)
(3.5)

(1.3)

(0.2)

(%)

Visual Impairment"

<0.001

0.26

<0.001

< 0.001

Pi'

Incidence of doubling of the visual angle, visual impairment, and severe impairment defined by the better eye.
t Incidence of improvement defined by the worse eye.
t Mantel-Haenszel test of trend .

Total

43-54
55-64
65-74
75+

Total
Age-adjusted
Male versus
female
Male and
female
(1.1)
(1.7)

(0.0)
(0.6)
(2.1)
(8.3)
(1.4)

576
474
381
120
1551

43-54
55-64
65-74
75+

Total
Male

(0.2)
(1.5)
(1.5)
(8.6)
(1.9)

(%)

663
553
545
255
2016

No. of Participants
at Risk

43-54
55-64
65-74
75+

Female

Age (yrs)

Doubling of Visual Angle"

1238
1027
926
368
3558

576
474
381
119
1550

662
553
544
249
2008

No. of Participants
at Risk

(0.0)
(0.1)
(0.0)
(2.5)
(0.3)

(0.0)
(0.0)
(0.0)
(0.8)
(0.1)

(0.0)
(0.2)
(0.0)
(3.2)
(0.5)

(%)

Severe Impairment"

<0.001

0.11

0.04

<0.001

Pi'

531
614
718
353
2216

202
217
263
108
790

329
397
455
245
1426

(3.3)
(4.3)
(2.4)

(1.3)
(1.1)

(1.0)
(0.0)
(1.9)
(4.6)
(1.5)

(1.5)
(1.8)
(4.2)
(4.1)
(2.9)

(%)

Improvementt

No. of Participants
at Risk

Table 3. Five-year Incidence of Changes in Vision by Age and Sex in the Beaver Dam Eye Study

<0.001

0.06

0.01

0.01

Pi'

.....
.....

(moderate)

standard error .

(0.0)

(0.0)

(54.3)
(100.0)

(6.4)

(0.1)

(%)

(%)

(2.8)

Severe

Moderate

94

3464

No. of Participants
at Risk

(77.8)

(6.4)

(1.4)

(%)

Doubling of Visual Angle

(1.1)

3495
72
(30.6)

(5.2)
(30.0)

(0.7)
(31.8)

(%)

325
50

3170
22

No. of
Participants
at Risk

0.2
5.4

1.2

6.5

0.1
9.9

SE
P

<0.001

<0.001

<0.001

Doubling of Visual Angle

3408
56

281
37

3127
19

No. of
Participants
at Risk

2.0
8.2
0.3
6.7

(2.2)
(48.2)

0.2
11.3

SE

(13.5)
(51.4)

(1.2)

(42.1)

(%)

Visual Impairment

Incidence of improvement defined by the worse eye.

<0.001

<0.001

<0.001

Incidence of doubling of the visual angle, visual impairment, and severe impairment defined by the better eye.

SE

Not institutionalized
Institutionalized
All ages
Not institutionalized
Institutionalized

75+

10

(39.4)

(97.1)

None
(%)

Impairment

Better Eye

<0.001

70

304

1842

No. of Participants
at Risk

3489
69

320
48

3169
21

No. of
Participants
at Risk

(0.2)
(4.4)

(1.9)
(6.3)

(0.0)
(0.0)

(%)

0.1
2.5

0.8
3.5

SE

Severe Impairment

<0.001

0.07

2148
68

305
48

1843
20

No. of
Participants
at Risk

(2.3)
(4.4)

(3.9)
(6.3)

(2.1)
(0.0)

(%)

Improvementt

(14.3)

(13.5)

(0.1)

(%)

Im/J'rovement

Worse Eye

Table 5. Incidence of Visual Change by Age and Nursing Home Residence Status in the Beaver Dam Eye Study

Not institutionalized
Institutionalized

<75

Age (yrs)

(severe)

20/200 or worse

94

3464

Better than 20/40

(none)

20/40-20/160

No. of Participants
at Risk

Visual Acuity
in Better Eye
at Baseline
(level of
impairment)

Visual Acuity (5-yr)

0.3
2.5

1.1

3.5

0.3

SE

0.27

0.46

0.52

<0.001

Table 4. Five-year Incidence of Visual Impairment, Severe Impairment, Doubling of the Visual Angle, and Improvement by Baseline Visual
Acuity in the Beaver Dam Eye Study

Klein et al . Changes in Visual Acuity

80 r - - - - - - - - - - - - - - - - - - - - - - - ,

.5

Number of letters Improvement

IiTI < 5 letters
to 14 letters .15+ letters

60

20

Non-Institutionalized

Institutionalized

Figure 2. The frequency of improved vision in the better eye by refraction compared with current prescription at follow-up in noninstitutionalized and institutionalized participants in the Beaver Dam Eye
Study.

significant decreases in visual acuity were found in persons

older than 75 years of age. This group of persons was 9.7
times more likely to have a doubling of the visual angle
and 12.5 times more likely to have impaired vision than
younger persons. The high incidence of visual loss in persons older than 75 years of age is consistent with the higher
frequencies of cataract and age-related maculopathy in
this age group.14-19
The 5-year incidence (0.3%) of severely impaired vision
in the population was low. However, among persons older
than 75 years of age at baseline, severe impairment in
vision developed in 2.5% of the Beaver Dam population.
This incidence is higher than that of 0. 16% for persons
75 to 84 years of age, which was estimated in 1978, using
the Model Reporting Area blindness registry.5 Underreporting may be responsible for the lower incidence reported in the blindness registry data compared with that
from Beaver Dam. 4,5 In the United States population,
based on our data, severe impairment will develop in approximately 113,128 people 75 to 86 years of age over a
5-year period. There are no population-based national
data available to compare incidence of severe impairment
in vision. The incidence of severe impairment in people
75 years of age or older has public health importance
because of the increasing proportion of the United States
population in this age group.
There are few population-based data describing loss of
vision in people in nursing homes or group homes. 3.20-22
We previously showed severe visual impairment in 20%
of institutionalized subjects in Beaver Dam in whom visual acuity could be measured reliably.3 More recently,
Tielsch et al 22 reported a 17% prevalence of bilateral
blindness (visual acuity, s:20/200) and a 19% prevalence
of visual impairment 20/40 but >20/200) in 499 subjects living in 30 nursing homes in the Baltimore area. In
their study, the prevalence of severe visual impairment
was 16 times higher in persons living in a nursing home
than in those not institutionalized. We find a significantly
higher incidence ofloss of vision in those living in nursing
homes (30.0%) than in those not institutionalized (5.2%).

These data are consistent with findings from cross-sectional studies.

In addition, those who were 75 years of age or older
at baseline and entered a nursing home or a group home
over the 5-year period were 5.9 times more likely to have
doubling of the visual angle than those 75 years of age or
older who did not enter a nursing home or a group home.
Reasons for admission to nursing homes or group homes
(e.g., stroke, dementia, fractures, and decreased vision)
are not known. We speculate that decreased vision may
act synergistically with loss of cognitive, motor, and other
sensory abilities in precipitating institutional admission
and perhaps in prolonging the stay. Our data suggest that
vision may be improved in some persons with a new refraction.
Rates of change in vision were similar in men and
women. This was unexpected, because prevalence data
from Beaver Dam suggested that women, especially those
75 years of age or older, were more likely to have nuclear
sclerotic cataracts, exudative macular degeneration, and
poorer vision than men.3 The difference between incidence and prevalence may be explained, in part, by
the higher incidence of cataract surgery in women compared with men in that age group (unpublished data;
Klein B, 1996).
Approximately 2% of the Beaver Dam population had
an improvement in their visual acuity of 15 or more letters. This was not unexpected, because 82% of right eyes
and 71 % of left eyes with improvement had undergone
cataract surgery, and age-related cataract is an important
cause of decrease in visual acuity. 1,23
Our data may underestimate the true incidence of impaired vision if those who died before the follow-up had
lost vision after the first examination. Because these persons who died were more likely to have had cataract and
poor vision at baseline, this supposition is plausible.
In summary, the Beaver Dam Eye Study data provide
precise estimates of the incidence of visual loss over a
wide spectrum of ages. Decreased visual acuity in people
75 years of age and older is a common finding. With increasing age of the United States population, our findings
indicate a significant public health problem. Etiologic
studies may show preventable causes of decreased vision.

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