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Original Investigation | Epidemiology

Visual Impairment, Uncorrected Refractive Error, and Objectively Measured Balance in the United States

Jeffrey R. Willis, MD, PhD1; Susan E. Vitale, PhD, MHS1,2; Yuri Agrawal, MD1; Pradeep Y. Ramulu, MD, PhD1
[+] Author Affiliations
1Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
2Division of Epidemiology and Clinical Applications, National Eye Institute, National Institutes of Health, Bethesda, Maryland
JAMA Ophthalmol. 2013;131(8):1049-1056. doi:10.1001/jamaophthalmol.2013.316.
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Published online

Importance  Further research is crucial to better understand the reason for falls in individuals with visual impairment (VI) and to develop appropriate fall prevention strategies.

Objective  To compare balance measures in individuals with normal vision, VI, and uncorrected refractive error (URE).

Design and Setting  Cross-sectional study based on a national survey sample.

Participants  A total of 4590 adults, 40 years or older, participating in the 2001 through 2004 National Health and Nutrition Examination Survey.

Main Outcome Measures  Participants completed tests of standing balance with eyes open or eyes closed on a firm or compliant (foam) surface. Eyes-closed testing on a foam surface primarily assessed vestibular balance by minimizing visual and proprioceptive inputs. The main outcome measure was time to balance failure on firm and foam surface testing. Participants also self-reported difficulty with falling during the last year.

Results  Failure during eyes-open balance testing conditions or eyes-closed balance testing on a firm surface was not more common among participants with VI-associated or URE-associated vision loss (P > .22). In eyes-closed foam surface balance testing, multivariable models demonstrated higher rates of balance loss with VI-associated vision loss (P = .02) and with URE-associated vision loss (P = .04) (hazard ratio, 1.7 per logarithm of the minimum angle of resolution [logMAR] unit change [10 lines] for both). Self-reported falling difficulty was associated with worse VI (odds ratio, 3.7 per logMAR unit change; P = .03) but not with worse URE (odds ratio, 3.4 per logMAR unit change; P = .14).

Conclusions and Relevance  The vestibular contribution to balance (measured with eyes closed on a foam surface) was worse for individuals with VI or URE. Reduced visual inputs may weaken the vestibulo-ocular reflex, an important system that maintains the effectiveness of vestibular balance. Alternately, common degenerative pathways or lower physical activity levels may affect balance, particularly among those with VI.

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Figure 1.
Kaplan-Meier Analysis of Time to Balance Failure on Eyes-Open Foam Surface Balance Test, With Each Test Stopped at 30 Seconds

A, Across broad visual acuity status. *Presenting visual acuity better than or equal to 20/40. †Presenting visual acuity worse than 20/40 but refracting to 20/40 or better. ‡Visual acuity worse than 20/40 after refraction. §P < .05 relative to normal vision. B, Across detailed visual acuity status. *Presenting visual acuity better than or equal to 20/40. †Presenting visual acuity worse than 20/40 but better than 20/200, refracting to 20/40 or better. ‡Presenting visual acuity 20/200 or worse, refracting to 20/40 or better. §Visual acuity worse than 20/40 but better than 20/200 after refraction. ∥Visual acuity 20/200 or worse after refraction. ¶P < .05 relative to normal vision.

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Figure 2.
Self-reported Difficulty With Falling During the Last Year by Vision Status Group

Error bars represent standard errors. *Presenting visual acuity better than or equal to 20/40. †Presenting visual acuity worse than 20/40 but refracting to 20/40 or better. ‡Visual acuity worse than 20/40 after refraction.

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