 Alright, so I'm honored to have the privilege of talking to you a little bit about some of the work that we're just kind of getting off the ground at Indiana, looking at the concurrent age-related macular degeneration and open-angle glaucoma when they occur in the same patient, and we've started by looking at the co-prevalence and then plan to take it from there. So, just a brief overview of the talk today, an introduction to the diseases and sort of what they mean, and then the meat of the talk will be the prevalence of concurrent open-angle glaucoma and macular degeneration. And then finally just a little conclusion in some future directions where we plan to take the project in the next couple of years. Both macular degeneration and glaucoma are significant causes of low vision and blindness in the United States. In whites, particularly, macular degeneration plays a very large role. About a quarter of cases of low vision, and it accounts for more than half of cases of blindness. About 14% in both low vision cases and blindness in Hispanic populations. Glaucoma plays a little bit larger role, particularly in blindness in Hispanic persons, but also a fairly significant piece of the pie of low vision and blindness in whites. As you can imagine, low vision and blindness is a major cause of disability. I was a little surprised to see that it ranks in the top ten, however, for disability in U.S. adults. And really after you get past the first three arthritis back and spine problems and heart problems, the rest of the top ten is pretty comparable. Blindness and vision problems comes in number nine, but really there's not much difference between the number four and number ten spots. Also causes a lot of, there's a lot of vision related quality of life issues. This is a little bit busy, this slide here, but if we look at the composite score for a quality of life measure, bilateral, moderate to severe vision loss compared with no vision loss causes a very significant effect size. So typically the convention is to say an effect size of about .8 is considered to be a large effect. This is all the way up to more than one and a half, which is very, very significant. And even in bilateral mild vision loss or unilateral moderate to severe causes or has a moderate effect size of about .5. That same pattern can be seen basically across the board with the exceptions of general health and ocular pain, which is not really terribly surprising, but the point here is that these vision related issues, glaucoma, macular degeneration and others, really do impede people's lives. Driving you can see has an enormous effect size, which is again not terribly unexpected. This 2005 survey of public knowledge attitudes and practices related to eye health and disease was very interesting to me. It was a very large survey done, they probed a lot of different areas of vision related health. They asked this question to adults to think about certain conditions that would affect their day-to-day living, and 71% of them responded that the loss of eyesight would be at 10 on a scale of 1 to 10, with 10 indicating the greatest impact. So obviously people, I think fear is probably not an inappropriate word. Fear, loss of vision. Surprisingly though, the subsequent questioning revealed that in some cases they don't know an awful lot about it. So with glaucoma, most people were familiar with glaucoma. They responded correctly that glaucoma can cause vision loss. Fewer correct responses, more unsure responses that vision loss could be prevented. But I think this one is really striking that there are no early warning symptoms with glaucoma. Two-thirds of the respondents answered incorrectly there, showing that there's really a lot of education that could be done. Macular degeneration, there's no similar sort of big red bars indicating incorrect responses. But overall the correct responses related to macular degeneration were fewer, down to as low as 40% that it's hereditary. I think this just highlights the need to educate the public about these diseases and what to look for and how to prevent vision loss. So why study macular degeneration and open-angle glaucoma together? A classic sign of glaucoma is ganglion cell layer neuron loss. But some work from Medeiros and Cercio showed that a 47% loss of GCL neurons in exudative macular degeneration, they didn't find any such GCL neuron loss in non-exudative macular degeneration. Now I don't think this necessarily speaks to these diseases being closely linked or dependent on one another, but I do think that it raises the question at least of is there a similar process going on, especially in exudative AMD that may be related to some of the processes going on in glaucoma. Another study found optic disc changes that were associated particularly with larger extents of macular degeneration. But the literature is not completely clear on these issues. There have been a couple of studies particularly with optic disc appearance that found no relationship between macular degeneration, the extent of the macular degeneration, or the type and optic disc appearance. So we started our project using data from the Beaverdam eye study which included mostly whites and from the Los Angeles Latino eye study which included mostly Hispanics. These data for prevalence of glaucoma macular degeneration have been published previously in these individual studies. And these are just the definitions of glaucoma macular degeneration. Rather than go point by point through this, I think the take home is that these studies are very comparable. They use very similar definitions and their reading center was actually, they use the same reading center for all of their photographs, allowing I think for better comparison between these two studies and the prevalence estimates that they get, then maybe for other studies that don't have, that don't share those same similarities. From those studies, we see that the prevalence of open-angle glaucoma increases with age. About 20% of Hispanics over the age of 80 are affected with open-angle glaucoma and about 10% of whites over the age of 80. Macular degeneration is similarly in age-related disease. Almost 40% of whites over the age of 80 are affected with macular degeneration, with early macular degeneration, and again about a quarter of Hispanics. The numbers, the overall prevalence is much lower in late macular degeneration, but it's still between 5 and 10% and represents I think a significant number because of the vision loss that's associated with late macular degeneration. So we took those numbers from those studies to look at the prevalence of concurrent open-angle glaucoma and macular degeneration. As is expected, the overall numbers are much lower, but interestingly there seems to be not much difference between the prevalence of concurrent disease in whites and Hispanics. So early macular degeneration and open-angle glaucoma, about 6% of individuals over 80 and about 2% for open-angle glaucoma and late macular degeneration. With those numbers, we then wanted to ask sort of what does the future hold? The prevalence can be affected and there's actually some studies that have shown the prevalence of particularly macular degeneration may be decreasing, but assuming that those co-prevalence numbers hold steady, as the population ages, we would expect that the total number of cases would increase. So to get sort of an idea of how much we took the 2008 U.S. Census Bureau information with standard estimates of immigration, immigration rates, to estimate the total number of cases through 2050. If we start in 2015, about 1.3 million white people are expected to be affected with both open-angle glaucoma and macular degeneration. The numbers, about a tenth of that in the Hispanic population, 170,000 cases in 2015, but what's really striking is over the next 40 years in whites, the numbers expected to increase by about 50%, which is significant but not nearly to the extent that we see in Hispanics where the percent increase in the number of cases is expected to be about 350%, representing a much larger increase in the burden in the Hispanic population than in whites. So conclusions from our studies so far. Up to 8% of individuals over the age of 80 are affected with both open-angle glaucoma and macular degeneration. And the number of cases, the total number of cases is expected to increase over the next few decades as the population ages. I think it really highlights the importance of education but culturally appropriate education so that individuals are aware of the diseases that they exist. Their symptoms or lack thereof which I think is particularly important based on the survey data that we have as well as the potential for treatment and prevention of vision loss if proper treatment is sought. Just very briefly, our future, where we're going with in the future, we really want to explore this question of the independence of open-angle glaucoma and macular degeneration. The assumption so far has been that they are independent and the data are not overwhelmingly against that hypothesis, but we want to take a closer look using the Beaver Dam I study and the Los Angeles Latino I study data. We also hope to be able to identify risk factors for concurrent disease. We have, I think, a pretty good idea of risk factors for each of the diseases independently, but we want to take a closer look at individuals who have concurrent disease. And then we also plan to take a closer look at these glaucoma-like changes that occur in macular degeneration in our own sample of patients. And finally, we hope to contribute something to management in developing plans to take care of individuals who have both glaucoma and macular degeneration. This can be a particular problem as they're typically seen by two different people. Central vision loss can affect following glaucoma with visual fields, difficulties fixating centrally, things like that. So there's a lot of issues to be worked out that way. A list of references for the talk. And then I just want to acknowledge Lynn Rosette, who I've been working with most closely on this project in Indiana, as well as all of the individuals involved with the Beaver Dam I study, Los Angeles Latino I study, and then Dr. Weinreb at UCSD, who was Lynn's mentor and his provider. Yeah, so the definition of glaucoma specifically excluded ocular hypertensives without signs of disease. So the most, the important changes, optic disc appearance, nerve fiber layer loss, go back. I can't remember. I think there was one more that I'm not. Interocular pressure was considered, but it was not sufficient for diagnosis by itself. It had to occur in conjunction with one of the other things. But visual acuity loss is what I was thinking. So strict ocular hypertensives without any other manifestations of the disease were not included in the glaucoma. Thank you very much.