Macular Degeneration and Occupational Therapy Scholarly Peer Reviewed Articles

Abstract

Purpose

Macular degeneration is a multi-factorial disease, leading cause of incomprehension for people over 50 years old in adult countries. To appointment, the noesis on possible occupational factors involved in the evolution of the disease is scant.

Method

We performed a systematic scientific literature search on the association between macular degeneration and occupational risk factors searching the MedLine and Scopus databases.

Results

We examined 158 manufactures and, according to the inclusion criteria, 13 peer-reviewed studies evaluating occupational adventure factors for macular degeneration or reporting the frequency of the disease in specific groups of workers were included in the review. Ten on 13 articles evaluated the presence of macular degeneration in workers exposed to solar radiation. Only one report found that not-specific history of occupational chemical exposure was associated with the illness. Ii studies showed an association between macular degeneration and the general category of "blue-collar" workers, simply they did not identify the specific risk factors involved.

Conclusions

To date few studies have examined occupational run a risk factors for macular degeneration. Even so, available data indicate that long-term occupational solar radiation exposure, in particular for its bluish-lite component, is associated with macular degeneration in outdoor workers.

Introduction

Macular degeneration (Dr.) is a chronic middle illness affecting the macula: the progressive loss of vision typical of the Doc, mainly in the centrum of the visual field, has a quite slow evolution and it tin can take years after the first diagnosis to induce an appreciable visual impairment (Christoforidis et al. 2011; Evans 2001; Shah et al. 2007). MD is currently the leading crusade of incomprehension for people over 50 years old in adult countries (Taylor et al. 2001). Its prevalence in Europe is 3.three% (Augood et al. 2006), and it is like likewise in the Us, where about 10 meg of people are affected (Tomany et al. 2004a, b).

In that location are 2 major forms of Medico, with different prognosis and therapy: the atrophic or dry out-type MD, representing approximately the 85–90% of the total number of cases, and the neovascular or wet-blazon Doc. The initial amending of the fundus is often represented by the so-called drusen, or colloids bodies, that are degenerative formations of yellowish color and circular shape mostly found at the posterior pole (Hughes et al. 2007; Virgili et al. 2015). Considering the mechanisms inducing the chronic retinal harm, an alteration of the metabolic sustainment of the photoreceptors cells (rods and cones) and of the retinal pigment epithelium (RPE) is supposed, depending on inflammation processes and vascular modifications (Gehrs et al. 2006; Nowak 2006).

Medico is a multi-factorial affliction: among the several risk factors involved in its etiology the most important is age (Hyman et al. 2002; Klein et al. 2004). Other recognized are smoke (Clemons et al. 2005; Fujihara et al. 2008), diabetes (Kearney et al. 2014), alcohol abuse (Baird et al. 2014; Chong et al. 2018) and inheritance (Tuo et al. 2004; Yoshimura 2010), while a possible clan with female gender (Cho et al. 2014) and other factors such every bit high C reactive poly peptide levels, low antioxidant vitamins intake, dyslipidemia, fair iris colour, previous cataract surgery (Chakravarthy et al. 2010; Ehmann et al. 2017; Gopinath et al. 2015; Kikuchi et al. 2007; Shaw et al. 2016) are supposed. Also an exposure to some chemicals, equally lead and iron, was found to exist associated with MD (Biesemeier et al. 2015; Hwang et al. 2015; Ugarte et al. 2013). Some other Md hazard factor is long-term exposure to optical radiations, in particular of the bands in the range of 400–550 nm of wavelength (virtually ultraviolet—UV-A—and visible "blue-lite"), able to induce, in laboratories and animal models, a photochemical damage of the retina due to the formation of oxygen free radicals (OFR) (Sui et al. 2013; Wang et al. 2003). Eye exposure to optical radiation is mainly related to solar radiation and, consequently, outdoor workers (OWs) may be at gamble, particularly if they work on surfaces able to reverberate optical radiations, as water, white sand, snow or shiny metals, as the center is anatomically quite well protected from the solar rays coming from the sky (ICNIRP 2010; Modenese et al. 2018). As well artificial sources may induce relevant exposures of the eye to optical radiation, as in instance indicator lamps and traffic signals, lamps used for the stage lighting and for projections, insect traps, LASERS, welding lights, etc (ICNIRP 2010; Modenese et al. 2016a; Thürauf 1979), but according to the current noesis the main bug are related to acute eye exposures as a outcome of occupational eye injuries caused by optical radiations, that are quite rare events (Gobba et al. 2017; Kuckelkorn et al. 1995).

Considering these premises, amid the various MD risk factors at least optical radiation and chemical exposure may be related to work, but to appointment the cognition on specific occupational risk factors and on particular categories of workers at increased risk for MD is scant. Information technology has to be also noted that, currently, the aging of the workforce is a growing trouble worldwide (Poscia et al. 2016), and in the next years an increasing number of workers beingness diagnosed with MD is expected.

For these reasons our aim is to systematically review the contempo evolution of research on the possible work-related risk of MD, studying if detail groups of workers have been constitute at risk for developing this disease and identifying the specific occupational risk factors detected in the studies and the methods applied to evaluate the exposure.

Materials and methods

An electronic search in accord with Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) (Liberati et al. 2009) was performed in the Medline (through PubMed) and Scopus databases. Broad limiters were set up to include scientific literature covering a period of 50 years, from 1st March 1967 to 1st March 2017. The systematic review was limited to original enquiry articles with an available English abstruse published in peer-reviewed journals. Reviews, case reports, comments or letters were non considered. The post-obit search string, modified by previous publications (Mattioli et al. 2010; Modenese et al. 2017), was built: "macular degeneration" AND (worker* OR job* OR occupation*).

Eligible were studies in which an assessment of the job history of patients with a Physician diagnosis has been performed, and as well studies in which workers accept been investigated for the detection of the retinal disease. For the diagnosis of MD we considered clinical diagnosis fabricated past an ophthalmologist and also studies evaluating surgical cases. Nosotros did not considered studies in which the subjects self-reported symptoms related to MD without a proved medical diagnosis or in which the cases were not humans.

Because occupation, nosotros included studies in which the specific occupation of the subjects was evaluated, and as well studies considering a generic work categorization, such as "outdoor/indoor worker" or "white collar/blue collar worker".

Data extraction was performed by 1 reviewer and checked by some other. The extraction was performed by reading all of the available abstracts of the studies returned from the input string in the ii databases. Following this, full papers were retrieved for all of the works that met the inclusion criteria. The reference listings of the selected papers were besides checked to find other pregnant enquiry articles.

To assess the quality of the studies, each writer independently rated the papers co-ordinate to a modified version of the Newcastle–Ottawa Scale (Poole et al. 2017). This method results in a score between 0 and 10, that can be assigned to the papers according to the following three domains:

• Pick bias domain: maximum 5 points; Items: (1) Is the sample representative of the population? (2) Was more than one site studied? (three) Was a power calculation undertaken? (four) Did the authors use standardized measurement tools to assess exposures? (5) Did the authors use standardized measurement tools to assess outcomes?

• Comparability domain: maximum 3 points; Items: (1) Were confounding factors assessed? (several considered: 2 points, some considered: i bespeak, none: nil) (2) Did the study employ an appropriate control grouping?

• Upshot domain: maximum ii points; Items: (ane) Were statistical tests appropriate? (2) Were conclusions justified?

It was necessarily to arrange the method to our Systematic Review: every bit we did not have information on ability calculation for none of the papers collected, but nosotros could not exclude that this procedure was performed in some of the retrieved studies, we decided not to consider this aspect in the Pick Bias domain and accordingly the maximum total score in our analysis is nine.

In case of disagreement in the evaluation, the two authors reconciled the differences in judgements through word.

Results

Study selection

The literature search resulted in 124 items from Medline and 128 items from Scopus. After the elimination of duplicates 158 articles take been selected. The two authors independently examined the abstracts and agreed on the studies to exist included in the review co-ordinate to criteria described in the "Methods" section 149 papers retrieved were excluded for the following reasons: 67 because they did not investigate, nor estimate, an occupational exposure to a specific risk gene in relation to the outcome of interest (i.e., macular degeneration, MD), 37 and nineteen as they were review/letters/comments and because non written in English linguistic communication, respectively, xix considering did non specifically investigate the outcome of involvement (i.e., macular degeneration), six because were on animals and, finally i as was a case report. nine on 158 studies were finally selected, and four more than studies were identified from a paw search of the references; as a consequence, in this review a full of 13 studies is included (Fig. 1).

Fig. 1

Selection procedure of the reviewed studies

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Synthesis of the results

Table 1 summarizes the master characteristics and findings of the 13 studies reviewed, including the occupational gamble factors considered and their evaluation methods, and reporting the odds ratio, crude or adjusted for specific confounders. Furthermore, the dissimilar types of Doc studied, with grading and diagnosing methods practical, when reported by authors, are shown in Tabular array one, as well as other relevant results of the studies on associations between MD and other factors. Finally, in Table one nosotros report also the scoring (range 0–ix) attributed to the papers retrieved, based on the quality cess performed according to an adapted version of the Newcastle–Ottawa Scale (run into "Materials and methods" department); the details of the evaluation, including the domains considered, are presented in Table 2.

Tabular array 1 Principal characteristics and results of the studies included in the systematic review on macular degeneration and exposure to occupational risk factors

Full size table

Table 2 Results of the quality assessment of the studies included in the systematic review on macular degeneration and exposure to occupational take a chance factors

Full size table

Of the xiii articles included in our Systematic Review, 10 evaluated the presence of Doc in OW exposed to solar radiation (SR). 4 Croatian studies assessed the frequency of MD simply considering occupational SR exposure classifying workers equally OW or indoor workers (IW). Njiric et al. (2007) performed a retrospective written report including all the patients visiting the Heart Polyclinic of Rijeka in Croatia during the years 1995, 2000 and 2005, for a total of 6617 subjects. The incidence of MD resulted 0.75% in 1995, 0.93% in 2000 and one.07% in 2005. The patients were divided in two groups according to the outdoor or indoor occupation: the one.9% of the OW were diagnosed with Physician during the 3 years of observation, VS only the 0.eight% of the IWs (p < 0.001). Vojnikovic et al. (2007) institute a higher Doctor frequency in farmers and fishermen of the Rab isle (Adriatic Sea, 44°40′N), within a sample of 1371 subjects anile 45–65 years, followed for a biennium. MD was diagnosed in the 18% of the OW, while merely in the 2.5% of the IWs. Plestina-Borjan et al. (2007) conducted a written report in 632 subjects over 50 years, of which 420 were mainly fishermen, seamen and farmers from a Croation island, while the others were from Zagreb city. Medico prevalence was college in OW from the island than in subject from Zagreb, 34.three vs 16%, respectively, and information technology was significantly associated with mean daily SR exposure (X ⁱⁱ = 216.4; p = 0.000). Caljkusic-Mance et al. (2010) evaluated the occupation history in a sample of threescore patients, median historic period was 70.2 (range 52–86), diagnosed with dry or moisture Physician during years 2008 and 2009 in an ophthalmologic dispensary in Croatia. 42 cases were OW (lxx%) and 18 patients were IW (30%) (p < 0.0001).

Another hospital-based 9 months prospective study from Nepal (Thapa et al. 2011) considered the occupation of a sample of patients representing all the consecutive cases of MD diagnosed from September 2008 to May 2009 at the local institute of ophthalmology. A total of 141 patients were recruited (mean age 69.5 years) and, considering work activity, the 42.5% of the sample were agriculture workers (p = 0.077) with occupational SR exposure.

In the previous studies workers were simply classified as outdoor or indoor workers, while in the following studies a detailed assessment of SR exposure has been performed. In a recent multi-centric European report conducted past Shick et al. (2016), SR exposure and task history were investigated with a detailed questionnaire. The results showed a prevalence of MD in general population of 20.3% for early on MD and 31.9% for tardily Physician. Doctor was not found to be associated with electric current SR exposure, but both, early and belatedly Doctor, proved clan with a history of past sunlight exposure major than 8 h outdoor per twenty-four hour period, typical of outdoor work, with an OR for early MD of five.54 (95% CI 1.25–24.58), and of 2.77 (95% CI i.25–6.sixteen, p = 0.01) for late Md. Furthermore, OW was more likely to take late Doc with an OR of two.57 (1.89–3.48), after adjustment for age, gender, and smoking beliefs, while no association with early Md was establish. In another multi-axial European study (Fletcher et al. 2008), a more than detailed method for SR exposure evaluation was adopted. In 4753 participants, aged 65 years or older, fundus photography was nerveless and in 101 individuals neovascular Dr. was diagnosed, in 2182 early on Doc was plant and 2117 subjects were classified as controls. All subjects were interviewed for developed lifetime sunlight exposure, and gave claret for antioxidant analysis. SR exposure was estimated by combining meteorological and questionnaire information. The questionnaire evaluated the history of sunlight exposure in various occupational periods of life, investigating for each period the number of hours spent outdoor between nine am and 5 pm, and specifically between 11 am and 3 pm, and the adoption of protective equipment such as chapeau and sunglasses. For all residences of one year or longer, ambient UVB and UVA were estimated from ecology databases, and blueish low-cal was estimated using a radiation model that estimates spectral radiation as a role of fourth dimension of solar day, day of the year, and latitude; exposure was adjusted for coefficients for cloud cover, surfaces, and protections. The Authors did not report a direct association betwixt SR exposure in outdoor workers and MD, but observed a significant association in subjects with the lowest dietary intake of antioxidants and high bluish low-cal exposure in midday hours with an OR of 1.95 (1.06–3.58) for course 3 MD vs grade 0.

History of cumulative exposure to the blue light component of SR exposure was found to be associated with severe MS (grade 4) also in the "watermen study" performed in Maryland, US, by Taylor et al. (1990) in late lxxx due south. 838 maritime workers underwent an ophthalmologic examination and grade 4 Physician showed a prevalence of ane.ii%. Cumulative sunlight exposure was evaluated with a mixed model, including laboratory measurements of eye exposure, environmental data available through meteorological databases and a questionnaire assistants. This method estimated the exposure for the different optical radiation bands of SR, UVA, UVB and blue light and the information was reported as a fraction of a standard "Maryland Sun-Twelvemonth", representing the hateful SR exposure in 1 year typical of this US country: grade four MD was significantly more frequent in watermen with an increasing of 0.1 "Maryland Sunday Years" of blue calorie-free exposure for a period of 20 years, OR 1.35 (i.0–one.81), while no significant clan was establish for the UV components. This study represented the baseline evaluation for the longitudinal study of Bressler et al. (1995), aimed to evaluate the 5-year Doctor incidence in 483 Maritime workers who underwent a follow-upwards examination. The Medico incidence increased with OWs age: 7% in the age group l–59 years (ys), 14% in 60–69 ys and 26% in > seventy ys. Too in this report SR exposure was evaluated with the aforementioned semi-quantitative method used by Taylor et al., and cumulative SR exposure resulted 0.84 ± 0.63 "Maryland sun years" in the group of maritime workers followed.

Finally, a unlike type of study investigating a sample of 111 patients with exudative MD classified every bit outdoor or indoor workers co-ordinate to their job titles was performed in Iran past Saadat et al. (2012). The aim of the study was to investigate the presence of polymorphism of the Cistron XRCC7, located on homo chromosome 8q12, where contiguous markers perhaps associated with Physician have previously been identified. This gene encodes the catalytic subunit of a nuclear DNA-dependent serine/threonine protein kinase, contributing in the recognition and repair of DNA double-strand breaks, found to be associated with cancer by other Authors. Saadat et al. constitute that the presence of gene XRCC7 polymorphism was significantly highly expressed in OWs than in indoor workers with Doc, OR 3.1 (1.04–ix.39), p = 0.042.

Moving now to possible other occupational MD risk factors, two studies investigated the occupation activity in large samples of population, just without hypothesizing a specific factor involved. Klein et al. (2001) performed a longitudinal examination of the accomplice of the "Beaver Dam Eye Study", Wisconsin—US—, composed by 3681 adults (range 43–86 years of historic period at baseline). Status and type of employment were investigated with a questionnaire and fundus photography was collected to diagnose Dr.. Blue neckband workers compared with white collars were more luckily to have early Md (p < 0.05), and in particular a higher v-year Md incidence was observed in waiters (17%), cooks (thirteen%) and bartenders (21%), and in personnel involved in cleaning services (xiii%) versus other working categories, including farmers (OR 1.83, CI 95% 1.01–3.32). As well in the S-Korean written report of Park et al. (2014) the prevalence of Doc was establish to be higher in blue neckband workers than in white collars, with a significant OR of one.82 (95% CI 1.37–2.42, p < 0.001). This study was conducted from 2008 to 2011 in fourteen,352 participants over xl years of historic period examined with fundus photographs, diagnosing Dr. in the half-dozen.half-dozen% of the sample, of which half-dozen% early on Physician and 0.six% belatedly Md. Demographic and socioeconomic factors were investigated with a questionnaire; no association with sun exposure evaluated independently of the chore, as major than 5 h per day pent in the sunday, was constitute.

Finally the example-control study performed in Baltimore, U.S., by Hyman et al. (1983) considered 162 cases of Dr. and 175 controls matched by age and sex. Written report participants were examined with fundus photographs and interviewed for by medical, residential, occupational, smoking and family unit histories, as well every bit social and demographic factors. Diagnoses were validated by means of fundus photographs. A statistically pregnant association was shown between Dr. and non-specific occupational chemic exposure investigated with the question "Did you ever work around chemicals which acquired your eyes to fire, on a regular basis?", OR 4.2 (95% CI i.1–15.2).

Discussion

Main findings of the studies reviewed

In almost studies included in this systematic review (10/thirteen) the adventure related to occupational solar radiation exposure was evaluated; all the ten studies institute a positive association betwixt SR exposure and Dr.. These results are in agreement with scientific literature, showing an OR of 2.09 (95% CI 1.19–iii.65) for SR exposure and early MD (Cruickshanks et al. 2001), and a relative risk of 2.20 (95% CI one.02–four.73) (Tomany et al. 2005) in general population; these studies accept been also included in a recent systematic review and meta-assay (Sui et al. 2013) of 14 studies, 12 of which showed an increased risk of MD for high levels of SR exposure, and in 6 cases the associations were statistically significant. In six studies the occupational SR exposure was evaluated but classifying workers every bit outdoor or indoor, while in four studies the exposure was evaluated with a more detailed method, considering subjective and objective information: two of these studies estimated, among the SR components, the contribution of different optical bands and found a specific clan between Doctor and cumulative blue light exposure, not for the UV components. It has to exist considered that, among the ultraviolet component, merely a part of UV-A from 380 to 400 nanometers (nm) of wavelength can reach the retina with a possible chronic photochemical damage, particularly in younger ages, while UV bands beneath 380 nm are absorbed in the anterior heart (Sliney 2002). The other optical bands of SR able to interact with macular cells with photochemical mechanisms are the visible "blue-light" bands between 400 and 550 nm of wavelength. The remaining part of the visible spectrum, also as the infrared bands, achieve the retina, but the interactions mechanisms are based on the possible thermal effects, mainly relevant in inducing acute disorders (ICNIRP 2004; Sliney 2002; Sliney et al. 2005).

Quite surprisingly, we found no studies evaluating the presence of MD in groups of workers exposed to bogus optical radiations, such as welders (Maier et al. 2005; Tenkate 2017), health personnel (Price et al. 2016) and others. It has to be noted that, as in instance, in Europe, according to the Directive 2006/25/EC, for artificial optical radiation exposure specific occupational limits for blue light and UV have to be respected to protect the eye (ICNIRP 2004; Sliney 2002; Sliney et al. 2005), too every bit for the skin (ICNIRP 2004; Modenese et al. 2016b; Ulrich et al. 2016).

The other work-related gamble for MD constitute in this review is a not-specific history of chemical exposure at work, found to be associated with MD in a 1983 U.S. study (Hyman et al. 1983). This result may be supported by some more than recent studies suggesting that chemicals like pb and atomic number 26 tin can accumulate in the macula inducing a chronic harm, while the depletion of fundamental chemicals similar zinc may play a office in the failure of the protective antioxidant mechanisms (Biesemeier et al. 2015; Hwang et al. 2015; Ugarte et al. 2013).

Other ii studies reviewed did not evaluate specific occupational risk factors, finding an clan between MD and the full general category of "blue-collar" workers: SR exposure may be involved, but also chemical exposure and possibly other factors; in the longitudinal U.S. report past Klein et al. the specific "blue collar" categories at college adventure were that of waiters, cooks, bartenders and cleaning personnel, and it is not articulate what occupational risk factor can exist involved, even if, at to the lowest degree for cleaning personnel, chemic exposure may be considered.

Limitations of the review

The quality of the analysis performed in the studies reviewed is rather inhomogeneous, and some weak aspects tin be observed. On the other paw, particularly considering the scarce number of studies published, to analyze all the literature of interest, nosotros decided not to exclude any pertinent study on the topic of "occupational risk factors for macular degeneration". Another problem is that the written report designs applied past researchers are quite different and scarcely comparable, precluding any possibility of a meta-assay. Based on our quality cess, 6 on 13 studies showed a rather poor quality, presenting problems in particular in the exposure cess phase and in the pick of the sample. These six studies (Caljkusic-Mance et al. 2010; Njiric et al. 2007; Plestina-Borjan et al. 2007; Saadat et al. 2012; Thapa et al. 2011; Vojnikovic et al. 2007) considered Doc and SR exposure of outdoor workers. The chief issue in all these studies is the exposure evaluation that was merely based on job title; moreover, in some studies is non clear the criteria for enrollment and for assignation of the subjects to the OW or IW groups. As well the statistical assay performed in these half dozen studies is not adequate to fully support their conclusions. On the other mitt, four very well designed studies, including a large number of subjects and a solid methodology for the assessment of both outcome and exposure, support an association between Doc and occupational sunlight exposure, especially considering the cumulative ocular blue-light exposure (Bressler et al. 1995; Fletcher et al. 2008; Schick et al. 2016; Taylor et al. 1990). Other iii well designed studies, with representative samples, skillful effect definition and adequate statistics (Hyman et al. 1983; Klein et al. 2001; Park et al. 2014) consider other possible occupational risk factors, just the exposure assessment is based on a subjective evaluation, not allowing whatsoever affordable inference regarding a possible clan between the investigated occupational take a chance factors (e.1000., chemical exposure) and Physician. This topic certainly deserves further research with more acceptable methods.

Conclusions

To engagement few studies have examined occupational take chances factors associated with MD, every bit well equally few studies evaluated the frequency of this disease in specific working groups. Nevertheless, available data support the hypothesis of an association betwixt long-term occupational SR exposure, in particular for its blue-lite component, and Doc in outdoor workers. According to the high number of OWs worldwide (due east.g., most fifteen million merely in Europe) and to the loftier prevalence of the disease in people anile 50 years or more, these results propose the opportunity of specific organizational and individual protective measures to prevent this affliction, possibly including a medical examinations of the workers' optics. No studies on the relations between occupational exposures to bogus lite and MD were plant, while some studies suggest that occupational exposure to chemicals may represent a possible adventure cistron for MD. Overall, the deficient number of studies, and their inhomogeneous quality, supports the demand of farther research on the possible association between MD and occupational risk factors.

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1. Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via 1000. Campi 287, 41125, Modena, Italia

   Alberto Modenese & Fabriziomaria Gobba

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Correspondence to Alberto Modenese.

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Modenese, A., Gobba, F. Macular degeneration and occupational risk factors: a systematic review. Int Arch Occup Environ Wellness 92, 1–eleven (2019). https://doi.org/10.1007/s00420-018-1355-y

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• Received: 27 September 2017

• Accepted: 04 September 2018

• Published: 06 September 2018

• Issue Date: 03 January 2019

• DOI : https://doi.org/10.1007/s00420-018-1355-y

Keywords

• Macular degeneration
• Occupational exposure
• Solar radiation
• Blue light
• Ultraviolet radiations
• Chemical exposure

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