Cataract and hearing loss in a population-based study: the Beaver Dam studies

Cataract and Hearing Loss in aPopulation-based Study:The Beaver Dam Studies

BARBARA E. K. KLEIN, MD, MPH, KAREN J. CRUICKSHANKS, PHD,DAVID M. NONDAHL, MS, RONALD KLEIN, MD, MPH, AND DAYNA S. DALTON, MS

● PURPOSE: Cataract and hearing loss are each commonat older ages and together may influence the ability tofunction independently and affect the sense of well-being. For these reasons, we sought to estimate the riskfactors for comorbidity of age-related cataract and hear-ing loss.● METHODS: A cross-sectional evaluation of a popula-tion-based cohort of older adults was conducted inBeaver Dam, Wisconsin, for presence of age-relatedcataract and hearing loss. The study evaluation includedtaking standardized medical histories, measuring bloodpressures, and obtaining blood specimens. Standardizedphotographs, which were graded according to well-de-fined protocols to assess the presence of nuclear, corticalor posterior subcapsular cataract, were taken. Audiomet-ric testing was performed according to well-defined studyprotocols.● RESULTS: Any type of cataract in combination withhearing loss in either ear was frequent, occurring in27.8% of the population overall and increasing consis-tently with age. Nuclear and posterior subcapsular cata-ract in combination with hearing loss occurred moreoften in men. Lifestyle factors that were associated withat least one cataract–hearing loss end point in at least onesex were history of heavy drinking and smoking.● CONCLUSIONS: In this community, older adults appearto be at high risk of cataract and hearing loss. Althoughrisk is strongly associated with age, some elective expo-sures appear to influence risk. It is possible that modifi-cation of certain lifestyle habits may alter these risks.

(Am J Ophthalmol 2001;132:537–543. © 2001 byElsevier Science Inc. All rights reserved.)

C ATARACTS AND HEARING LOSS OCCUR TOGETHER

in a variety of situations. They may present inconcert with other findings in genetic syndromes,

such as Waardenburg syndrome type II,1 Wolfram syn-drome,2 Stickler syndrome,3 proximal myoclonic dystro-phy,4 and others.5–10 There are other acquired disordersthat are related to cataract and hearing loss, such ascongenital rubella11 and the Vogt-Koyanagi-Harada syn-drome.12

It is possible that traumatic events, such as direct severehead injuries and possibly starvation, may also cause bothcataract and hearing loss.13 However, in light of the factthat both cataracts14 and hearing loss15 are highly preva-lent in older adult populations, it is likely that the mostcommon risk factor for them is age.

Cataracts severe enough to impair vision, occurring inthe presence of hearing loss, can be limiting in manyfunctions of daily living and are likely to diminish thequality of life. Therefore, if common risk factors for thesecombined disabilities could be identified, it would bereasonable to target them for preventive interventions. Forthese reasons, we investigated the relationship betweencataract and hearing loss and evaluated risk factors forthese combined end points in a population of adults.

METHODS

A CROSS-SECTIONAL EVALUATION OF A POPULATION-

based cohort of older adults was conducted in 1993 to 1995in Beaver Dam, Wisconsin, for the presence of age-relatedcataracts and hearing loss. Details of the methods ofidentification and description of the population haveappeared in previous reports.16–19 In summary, a privatecensus of the population of Beaver Dam, Wisconsin, wasperformed from September 15, 1987, to May 4, 1988, toidentify all residents in the city and township of Beaver

Accepted for publication Jun 12, 2001.From the Department of Ophthalmology and Visual Sciences

(B.E.K.K., K.J.C., D.M.N., R.K., D.S.D.), and the Department of Pre-ventive Medicine (K.J.C.), University of Wisconsin Medical School,Madison, Wisconsin.

This research is supported by National Institutes of Health GrantEY06594 (R.K., B.E.K.K) and by National Institutes of Health GrantAG11099 (K.J.C.).

Reprint requests to Barbara E.K. Klein, MD, MPH, Department ofOphthalmology and Visual Sciences, University of Wisconsin-Madison,610 North Walnut St, 460 WARF, Madison, WI 53705-2397; fax: (608)263-0279; e-mail: [email protected]

© 2001 BY ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED.0002-9394/01/$20.00 537PII S0002-9394(01)01126-6

Dam who were 43 to 84 years of age. Of the 5924 eligibleindividuals, 4926 participated in the baseline examinationof the Beaver Dam Eye Study between March 1, 1988, andSeptember 14, 1990. Ninety-nine percent of the popula-tion was non-Hispanic white. Nonparticipants consisted of226 persons (3.8%) who had died before the examination,18 (0.3%) who could not be located, 337 (5.7%) whopermitted an interview only (of these, 61 had moved), and417 (7.0%) who refused to participate (of these, 39 hadmoved). Comparisons between participants and nonpar-ticipants at the time of the baseline examination haveappeared elsewhere.19

Before the start of the 5-year follow-up eye examinationin the Beaver Dam Eye Study on March 1, 1993, 385(7.8%) of the participants had died. Of the 4541 survivingparticipants in the baseline examination, 3684 (81.1%)participated in the follow-up examination between March1, 1993, and June 14, 1995. Four participants could not belocated, 259 (5.7%) permitted an interview only (of these,48 had moved out of the area), 423 (9.3%) refused toparticipate (of these, 44 had moved out of the area), and171 died during the examination period. Both the meanand median times between the baseline and 5-year fol-low-up eye examinations were 4.8 years, and the standarddeviation was 0.4 years.

Comparisons between participants and nonparticipantsat that follow-up have been presented elsewhere.15 Personswho were alive and did not participate in the second eyeexamination (n � 686) were older at baseline than thosewho did (62.7 versus 60.4 years, P � .0001). Afteradjusting for age, those who were alive during the studyperiod and did not participate were more likely to havecompleted fewer years of education, lower income, poorervisual acuity, a history of cardiovascular disease, neverdrunk alcohol, smoked more, higher serum cholesterol,higher systolic and diastolic blood pressure, and reportedbeing retired at baseline than persons who participated.

The Epidemiology of Hearing Loss Study is a popula-tion-based study of hearing loss in those same Beaver Damresidents 48 to 92 years of age who participated in thebaseline examination of the Beaver Dam Eye Study andwere alive on March 1, 1993. There were 3571 participantswho underwent a hearing examination (1993 to 1995) and182 who completed only an interview. There were 3471participants with analyzable data for this report (examinedin both the 5-year follow-up eye examination in theBeaver Dam Eye Study and in the Epidemiology of HearingLoss Study and who had gradable lens photographs andmeasured hearing thresholds).

Informed consent was obtained from each participant atthe beginning of the examination. Similar procedures wereused at both the baseline and follow-up eye examinationsand have been described in detail elsewhere.18,19 A stan-dardized questionnaire was administered by the examiners.Photographs of the lenses were taken with two differentcameras: a slit-lamp camera and a retroillumination cam-

era.20 Grading procedures for the lens were based ondetailed codified decision rules.20 Graders were masked tosubject identity, personal characteristics, and for the pres-ence and/or severity of lens lesions at the first examination.Scores for nuclear sclerosis were based on comparisonswith standard slit-lamp photographs. The scale has fivesteps of severity based on opacity of the nucleus. Scores forcortical and posterior subcapsular cataract were based onweighted estimates of degree of opacity of lens area asdefined by a circular grid, divided into eight “pie-wedged”peripheral areas and a central circular area overlaid onretroillumination photographs.

Levels 4 and 5 on the five-level scale of nuclear sclerosiswere considered to be cases of nuclear cataract.14

Cases of cortical cataract were those with opacity of 5%or more of the lens “surface” based on gradings of theretroillumination photographs. Posterior subcapsular opac-ity was defined as 5% or more of a grid segment. Theclassification of prevalent cataract corresponded to lensopacity of sufficient severity to meet the criteria that aclinical ophthalmologist would be comfortable labeling asa cataract. In the “any cataract” classification, we includethose who had cataract surgery, because they may repre-sent persons who had more severe cataract of any kind.

The Epidemiology of Hearing Loss Study examinationincluded an interviewer-administered questionnaire aboutmedical and family history, history of noise exposure, andquality of life. The hearing examination included anotoscopic evaluation,21 screening tympanometry21,22 (GSI37 Autotymp; Lucas GSI, Inc, Littleton, Massachusetts),and pure-tone air-conduction and bone-conduction audi-ometry.15 Audiometric testing was conducted according tothe recommended guidelines of the American Speech-Language-Hearing Association23 in sound-treated booths(Industrial Acoustics Company, New York, New York)using computer-based clinical audiometers (Virtual 320,Virtual Corporation, Seattle, Washington) equipped withTDH-50 earphones. Insert earphones (ERA 3A, CabotSafety Corporation, Indianapolis, Indiana) and maskingwere used as necessary. Pure-tone air-conduction thresh-olds were obtained for each ear at 250, 500, 1000, 2000,3000, 4000, and 8000 Hz. Bone-conduction thresholdswere measured only at 500 and 4000 Hz because of timeconstraints. People unable to travel to the clinic site(nursing home residents, home-bound participants, andpeople living in remote areas; n � 132) were tested at theirplace of residence using a portable audiometer (Beltone112; Beltone Electronic Corporation, Chicago, Illinois).

All audiometers were initially calibrated in accordancewith American National Standards Institute standards24

and were periodically re-calibrated during the study period.Ambient noise levels were measured at each home ornursing home visit and were routinely monitored at theclinic site at the Beaver Dam Community Hospital toensure that testing conditions complied with AmericanNational Standards Institute standards.25

AMERICAN JOURNAL OF OPHTHALMOLOGY538 OCTOBER 2001

Hearing loss was defined as a pure-tone average ofthresholds at 500, 1000, 2000, and 4000 Hz greater than 25decibels hearing level in either ear. This definition encom-passes the spectrum of hearing loss from mild to severe.15

We consider a cataract end point in either eye andhearing loss in either ear as the end point in the results ofthis investigation.

Current age was defined as the age at the time of theEpidemiology of Hearing Loss Study examination. Aperson was defined as having a positive history of cardio-vascular disease if he/she responded affirmatively to thequestions regarding history of angina, heart attack, orstroke. Cigarette-smoking status at the time of the exam-ination was determined as follows. A subject was classifiedas having never smoked if he/she had smoked less than 100cigarettes in his/her lifetime, as being an exsmoker ifhe/she had smoked at least this number of cigarettes inhis/her lifetime but had stopped smoking before the exam-ination, or as a current smoker if he/she had not stopped.

Statistical analyses used version 6.09 of the SAS System(SAS Institute, Inc, Cary, North Carolina).26 Analyticaltechniques included contingency table analysis and logisticregression.27 Analyses were run for the worse eye and worseear. Specific tests included chi-square test for overallassociation to assess unadjusted association between cata-ract and hearing loss, overall and within age groups;Mantel-Haenszel test to assess overall trend in hearing lossprevalence for variables with more than two discretecategories28; t tests for testing differences in mean age byparticipation status; Cochran-Mantel-Haenszel test forassociation to assess age-adjusted gender differences inprevalences.

RESULTS

CHARACTERISTICS OF THE STUDY POPULATION, GIVEN IN

Table 1 (age, cigarette smoking status, and other variablesthat were used in the analyses) indicate some differencesbetween the sexes. For this reason, most of the analyses aresex specific. Table 2 shows the prevalence of specificcataract end points and the number with hearing loss.Each of the individual conditions is common, with theleast frequent being posterior subcapsular cataract (7.1%).Cataract and hearing loss comorbidity is common in thispopulation (Table 3). This is particularly true for nuclearcataract and hearing loss. These combined events increasewith age in both sexes with precipitous increases in theeldest age group. Those women and men with nuclearcataract and women with more severe cortical cataractwere more likely to have hearing loss than persons withoutthese cataract types when adjusting for age (data notgiven). Nuclear cataract and hearing loss, as well ascortical cataract and hearing loss, occur as comorbidconditions slightly more often than one would expectunder the assumption of independence (Table 4).

In our initial analyses, we evaluated many possible riskfactors. Then we proceeded to multivariable models todetermine the relative importance of risk factors whilesimultaneously considering others. In women (Table 5),age, total cholesterol, history of heavy drinking, currentsmoking, and inability to walk six blocks were positivelyassociated with the risk of nuclear cataract and hearingloss. In men, ratio of total to high-density–lipoproteincholesterol was associated with decreased risk, whereasboth past and current smoking were associated risk ofnuclear cataract and hearing loss.

In women (Table 5), age, presence of diabetes, use ofdiuretics in the past, heavy drinking, and proteinuria wereassociated with cortical cataract and hearing loss. Diabeteswas more strongly associated with cortical cataract thanwith hearing loss (data not shown). In men (Table 5), agewas associated with cortical cataract and hearing loss.Aspirin and blood glucose protective against this com-bined end point.

In women (Table 5), age, serum creatinine, diabetes,never using diuretics (versus current use), and inability towalk six blocks were associated with increased risk ofposterior subcapsular cataract and hearing loss. In men(Table 5), age and diabetes status were related to posteriorsubcapsular cataract and hearing loss.

DISCUSSION

IN BEAVER DAM, THE COMBINATIONS OF CATARACT OF

any type and hearing loss were common, occurring in 28%of the population. This is an age-dependent phenomenasuch that prevalence of the combinations increase witheach decade (Table 3). For the specific combinations ofnuclear cataract and hearing loss and cortical cataract andhearing loss, the combinations more commonly occurtogether than chance alone would dictate (Table 4). Thismay suggest an underlying vulnerability of sensory systems.This prompted our search for risk factors for the combinedend points. We chose to investigate specific cataract typesin conjunction with hearing loss, because the differentcataracts have been found to have different patterns ofassociations with protective and with risk factors. This isreflected in our current analyses in which different arrays offactors influence the combined end points; this is mostly afunction of the different risk factors related to the cataractcomponents, because risk factors for hearing loss alone aresimilar in subgroups defined by the cataract component.There appears to be a synergistic effect of some risk factorsfor the combined end point, as seen in the simplerage-adjusted models (not shown) and in the more complexmultivariable models. For example, for nuclear cataractand hearing loss in women, heavy drinking is morestrongly associated with the combined end point (oddsratio � 3.5 from Table 5) than with either nuclear cataract

CATARACT AND HEARING LOSSVOL. 132, NO. 4 539

(odds ratio � 1.3) or hearing loss (odds ratio � 1.9) alone(analyses not shown); a similar situation exists for currentsmoking. These findings could be related to a geneticsusceptibility to the noxious exposure affecting the lensand the auditory system.29–32 The models in general differin the odds of risk factors for men and women, and risk

factors in women tend to be more apparent in our datathan those for men.

Increased risks of cataract and hearing loss related tocurrent smoking and heavy drinking were found. Althoughsignificant, the relationships with heavy drinking werefound only in women. Because both of these are exposuresrelated to elective behaviors, these data suggest thatmodifying these behaviors may reap real benefits in dimin-ishing the likelihood of the sensory morbidities we studied.

Associations of these combined end points with char-acteristics related to renal function is of interest in thatexposures that are ototoxic have been noted in some casesto be nephrotoxic as well.33 Moreover, renal functionabnormalities were associated with cataract incidence indata from this cohort at the 5-year follow-up examina-tion.34 In the current analyses, gross proteinuria wasassociated with cortical cataract and hearing loss in wom-en; the odds were substantial for the individual outcomes

TABLE 1. Characteristics of the Study Population, Beaver Dam, 1993 to 1995

Characteristic

Women Men

% n % n

Age group

48–59 years 33.9 664 37.3 564

60–69 years 28.2 552 31.8 481

70–79 years 26.2 514 23.4 353

80–92 years 11.7 229 7.5 114

Smoking status

Never 58.8 1149 29.3 442

Past 27.3 534 55.2 833

Current 13.9 272 15.6 235

Education

�12 years 22.1 432 25.3 382

12 years 48.8 956 42.3 640

13–15 years 17.5 342 13.2 199

16 or more years 11.6 228 19.3 291

History of cardiovascular disease 10.7 209 19.5 293

Diabetes 9.7 186 10.4 156

Use of diuretics

Never 54.2 1049 72.3 1080

Past 19.9 386 10.2 152

Current 25.9 501 17.5 262

Able to walk 6 blocks without help 84.6 1629 92.0 1378

History of heavy drinking of ethanol 5.4 106 31.3 471

Gross proteinuria, �30 mg/dl 2.7 51 4.7 70

Aspirin taken at least twice a week for 3 months 24.1 472 33.6 508

Mean* n Mean* n

Total cholesterol 246 (46) 1959 229 (43) 1499

HDL cholesterol 57 (17) 1926 46 (14) 1496

Ethanol, grams per week 22 (51) 1947 73 (127) 1504

Creatinine, mg/dl 1.1 (0.2) 1930 1.3 (0.4) 1499

HDL � high-density lipoprotein.

*Numbers in parentheses are standard deviations.

TABLE 2. Prevalence of Cataract and Hearing Loss,Beaver Dam, 1993 to 1995

Condition % n

Nuclear cataract 26.1 821

Cortical cataract 20.0 627

Posterior subcapsular cataract 7.1 223

Any cataract 44.4 1476

Hearing loss 45.6 1584


as well (data not shown). Serum creatinine was associatedwith the combined outcome of posterior subcapsular cat-aract and hearing loss, and with the individual end pointsin women. A physiologic link between renal function andthese end points is unclear. A toxic exposure could injurethe kidneys, lenses, and hearing organs. It is possible thatblood levels of drugs (or other potentially toxic sub-stances), which are excreted by the kidney, would beelevated in the presence of renal malfunction. This couldpotentiate a toxic effect.

Diabetes mellitus affects the combined end points ofcortical cataract with hearing loss and of posterior subcap-sular cataract and hearing loss in women and with poste-rior subcapsular cataract and hearing loss in men. Thislargely reflects the associations of diabetes with the cata-

TABLE 3. Prevalence of Simultaneous Cataract and Hearing Loss, Beaver Dam, 1993 to 1995

Disorders, by Age Group

Women Men Both Genders

n % n % n %

Nuclear cataract and hearing loss

All ages 1744 16.2 1403 17.3 3147 16.7

48–59 years 637 1.4 542 1.5 1179 1.4

60–69 years 509 7.5 453 11.5 962 9.4

70–79 years 446 30.9 319 38.2 765 34.0

80–92 years 152 63.8 89 67.4 241 65.2

Cortical cataract and hearing loss

All ages 1735 12.6 1396 12.7 3131 12.6

48–59 years 641 0.9 544 1.1 1185 1.0

60–69 years 504 8.1 452 10.8 956 9.4

70–79 years 442 22.2 317 27.4 759 24.4

80–92 years 148 49.3 83 42.2 231 46.8

Posterior subcapsular cataract and hearing loss

All ages 1735 3.4 1393 5.4 3128 4.3

48–59 years 646 0.2 545 1.3 1191 0.7

60–69 years 512 1.6 455 4.0 967 2.7

70–79 years 438 5.9 316 10.1 754 7.7

80–92 years 139 17.3 77 23.4 216 19.4

Any cataract* and hearing loss

All ages 1868 25.8 1459 30.4 3327 27.8

48–59 years 644 2.5 544 3.9 1188 3.1

60–69 years 525 15.8 468 24.4 993 19.8

70–79 years 494 43.7 342 63.2 836 51.7

80–92 years 205 81.5 105 88.6 310 83.9

Women Men P Value†

Age-adjusted prevalences

Nuclear/hearing loss 16.8 20.2 .004

Cortical/hearing loss 13.2 14.7 .126

Posterior subcapsular cataract/hearing loss 3.7 6.5 �.001

Any cataract/hearing loss 24.6 33.2 �.001

*At least one type of cataract or cataract surgery.†Cochran-Mantel-Haenszel test for overall association.

TABLE 4. Joint Occurrence of Cataract and Hearing Loss,Beaver Dam, 1993 to 1995

Observed* Expected* P Value†

Nuclear cataract/hearing loss 18.2 17.2 .001

Cortical cataract/hearing loss 13.9 13.1 .004

Posterior subcapsular

cataract/hearing loss

4.9 4.6 .31

Any cataract/hearing loss 28.2 26.6 �.001

*These prevalences are adjusted for age group and gender

using the direct method. “Any cataract” includes history of

cataract surgery.†Cochran-Mantel-Haenszel test for overall association.


racts as has been previously observed.36 There was littleeffect of diabetes on hearing loss alone.37

Total cholesterol or total cholesterol to high-density–lipoprotein cholesterol ratio was related to nuclear cataractand hearing loss for both sexes. The relationship forwomen was driven by the relationship to nuclear cataract.However, there were opposing effects for the sexes withhigher cholesterol associated with increased risk in womenand low ratios associated with increased risk in men. It is

possible that these apparently contradictory associationsare chance findings or related to a survival effect. Also,collinearity in these complex models may be causingstatistical artifacts.

There are limitations of our investigation. We haveevaluated relationships cross-sectionally in a cohort thathad been defined 5 years before the examination data usedin this study. The loss to death, moving, and nonpartici-pation (approximately 18%), may have resulted in biasesthat affect the relationships we found. Also, the BeaverDam community is similar to many other midsize towns inthe Midwest in regard to ethnic, educational, and eco-nomic background, but the experience here may not beidentical to the experience in very large or very small UScommunities or of those with different ethnic composi-tions. Nevertheless, the coincidence of cataract and hear-ing loss in older adult populations is likely to be substantialacross a variety of communities.

We have found relationships of smoking and heavydrinking and other risk factors to cataract and hearing loss.It will be possible for studies in other communities toevaluate whether there is further evidence to substantiatethe risk factors we have identified as well as to re-evaluatethe importance of the others for which we found noincrease in risk. It will be of special importance to furtherexplore the nature of the relationships for which interven-tion could substantially alter risk.

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TABLE 5. Odds Ratios and 95% Confidence Intervalof Having Both Cataract and Hearing Loss

(From Logistic Regression Models), Beaver Dam,1993 to 1995

Disorders and Risk Factors OR and 95% CI*

Women


Age (unit � 5 years) 2.57 (2.27, 2.90)

Total cholesterol (unit � 25 mg/dl) 1.10 (1.01, 1.20)

History of heavy drinking of ethanol 3.52 (1.84, 6.76)

Past smoking (versus never) 1.01 (0.68, 1.49)

Current smoking (versus never) 3.13 (1.87, 5.25)

Able to walk 6 blocks without help 0.60 (0.41, 0.88)


Age (unit � 5 years) 2.18 (1.96, 2.44)

Diabetes 1.68 (1.03, 2.75)

Past diuretic (versus never) 1.70 (1.08, 2.67)

Current diuretic (versus never) 1.42 (0.97, 2.08)

History of heavy drinking of ethanol 3.11 (1.58, 6.12)

Gross proteinuria (�30 mg/dl) 4.44 (1.98, 9.98)

Posterior subcapsular cataract and

hearing loss

Age (unit � 5 years) 1.92 (1.59, 2.31)

Creatinine 2.87 (1.28, 6.42)

Diabetes 3.56 (1.77, 7.13)

Able to walk 6 blocks without help 0.47 (0.25, 0.92)

Past diuretic (versus never) 1.11 (0.52, 2.40)

Current diuretic (versus never) 0.38 (0.18, 0.80)

Men


Age (unit � 5 years) 2.53 (2.24, 2.85)

Total cholesterol � HDL cholesterol 0.90 (0.81, 1.00)

Past smoking (versus never) 1.70 (1.13, 2.56)

Current smoking (versus never) 4.12 (2.33, 7.29)


Age (unit � 5 years) 1.97 (1.77, 2.19)

Aspirin taken at least twice a week

for 3 months

0.64 (0.44, 0.93)

Glucose (unit � 25 mg/dl) 1.11 (1.00, 1.23)

Posterior subcapsular cataract and

hearing loss

Age (unit � 5 years) 1.74 (1.51, 2.00)

Diabetes 2.11 (1.12, 3.98)

*Each group of odds ratios (for example, for nuclear cataract

and hearing loss) is from one multiple logistic regression model.


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29. Cruickshanks KJ, Klein R, Klein BE, Wiley TL, NondahlDM, Tweed TS. Cigarette smoking and hearing loss: theepidemiology of hearing loss study. JAMA 1998;279:1715–1719.

30. Popelka MM, Cruickshanks KJ, Wiley TL, Tweed TS, KleinBEK, Klein R. Moderate alcohol consumption and hearingloss: a protective effect. J Am Geriatr Soc 2000;48:1273–1278.

31. Klein BEK, Klein R, Linton KLP, Franke T. Cigarettesmoking and lens opacities. The Beaver Dam Eye Study.Am J Prevent Med 1993;9:27–30.

32. Klein BEK, Klein R, Jensen SC, Linton KLP. Hypertensionand lens opacities from the Beaver Dam Eye Study. Am JOphthalmol 1995;119:640–646.

33. Hatala R, Dinh T, Cook DJ. Once-daily aminoglycosidedosing in immunocompetent adults: a meta-analysis. AnnIntern Med 1996;124:717–725.

34. Klein BEK, Klein R, Lee KE. Renal function abnormalitiesand incident cataract after a five-year interval: the BeaverDam Eye Study. Curr Eye Res 1998;17:720–725.

35. Klein BEK, Klein R, Lee KE. Diabetes, cardiovascular dis-ease, selected cardiovascular disease risk factors, and the5-year incidence of age-related cataract and progression oflens opacities: the Beaver Dam Eye Study. Am J Ophthalmol1998;126:782–790.

36. Klein BEK, Klein R, Wang Q, Moss SE. Older-onset diabetesand lens opacities. The Beaver Dam Eye Study. OphthalEpidemiol 1995;2:49–55.

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Cataract and hearing loss in a population-based study: the Beaver Dam studies