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The risk of fracture in age-related macular degeneration according to the presence of visual disability: a nationwide cohort study



To evaluate the association between age-related macular degeneration (AMD) with or without visual disability (VD) and the risk of fracture using the National Health Insurance data in South Korea.


In total, 3,894,702 individuals who had taken part in health-screening programs between January 1, 2009, and December 31, 2009, were included in the cohort and followed until December 31, 2019. The participants with VD, which could be related to the severity of AMD, were defined as those with a loss of vision or visual field defect as certified by the Korean government’s Ministry of Health and Welfare. The hazard ratio was calculated for groups (control and AMD with/without VD) using the multivariable-adjusted cox regression analysis.


In total, 466,890 participants (11.99%) were diagnosed with fractures during the study period. An increased risk of fracture was observed in individuals with AMD compared with the control (adjusted hazard ratio (aHR), 1.09, 95% confidence interval (CI), 1.06–1.11). Furthermore, among the AMD individuals, an increased risk of fracture was prominent in individuals with VD (aHR 1.17, 95% CI 1.08–1.27) than those without VD (aHR 1.08, 95% CI 1.06–1.11) compared with the reference group (control).


AMD was associated with an increased risk of fracture even without VD. Prevention for fracture should be considered in AMD patients, especially when accompanied by VD.

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Fig. 1: Flow diagram for identifying the study population for incident fractures.
Fig. 2: Kaplan–Meier curves displaying the estimated incidence probability of fracture according to the presence of age-related macular degeneration with/without visual disability.

Data availability

The data supporting the findings of this study are available from the corresponding authors upon reasonable request.


  1. Smith W, Assink J, Klein R, Mitchell P, Klaver CC, Klein BE, et al. Risk factors for age-related macular degeneration: Pooled findings from three continents. Ophthalmology. 2001;108:697–704.

    Article  CAS  PubMed  Google Scholar 

  2. Klein R, Lee KE, Gangnon RE, Klein BE. Incidence of visual impairment over a 20-year period: the Beaver Dam Eye Study. Ophthalmology. 2013;120:1210–9.

    Article  PubMed  Google Scholar 

  3. Hong T, Mitchell P, Rochtchina E, Fong CS, Chia EM, Wang JJ. Long-term changes in visual acuity in an older population over a 15-year period: the Blue Mountains Eye Study. Ophthalmology. 2013;120:2091–9.

    Article  PubMed  Google Scholar 

  4. Wong WL, Su X, Li X, Cheung CM, Klein R, Cheng CY, et al. Global prevalence of age-related macular degeneration and disease burden projection for 2020 and 2040: a systematic review and meta-analysis. Lancet Glob Health. 2014;2:e106–16.

    Article  PubMed  Google Scholar 

  5. Groff H, Kheir MM, George J, Azboy I, Higuera CA, Parvizi J. Causes of in-hospital mortality after hip fractures in the elderly. Hip Int. 2020;30:204–9.

    Article  PubMed  Google Scholar 

  6. Meunier A, Maczynski A, Asgassou S, Baulot E, Manckoundia P, Martz P. [Mortality and functional independence one year after hip fracture surgery: extracapsular fracture versus intracapsular fracture]. Geriatr Psychol Neuropsychiatr Vieil. 2019;17:153–62.

    PubMed  Google Scholar 

  7. Cummings SR, Melton LJ. Epidemiology and outcomes of osteoporotic fractures. Lancet. 2002;359:1761–7.

    Article  PubMed  Google Scholar 

  8. Brody BL, Gamst AC, Williams RA, Smith AR, Lau PW, Dolnak D, et al. Depression, visual acuity, comorbidity, and disability associated with age-related macular degeneration. Ophthalmology. 2001;108:1893–900. discussion 900-1

    Article  CAS  PubMed  Google Scholar 

  9. Soubrane G, Cruess A, Lotery A, Pauleikhoff D, Mones J, Xu X, et al. Burden and health care resource utilization in neovascular age-related macular degeneration: findings of a multicountry study. Arch Ophthalmol. 2007;125:1249–54.

    Article  PubMed  Google Scholar 

  10. Klein R, Klein BE, Linton KL, De Mets DL. The Beaver Dam Eye Study: visual acuity. Ophthalmology. 1991;98:1310–5.

    Article  CAS  PubMed  Google Scholar 

  11. Attebo K, Mitchell P, Smith W. Visual acuity and the causes of visual loss in Australia. The Blue Mountains Eye Study. Ophthalmology. 1996;103:357–64.

    Article  CAS  PubMed  Google Scholar 

  12. Ivers RQ, Cumming RG, Mitchell P, Simpson JM, Peduto AJ. Visual risk factors for hip fracture in older people. J Am Geriatr Soc. 2003;51:356–63.

    Article  PubMed  Google Scholar 

  13. Anastasopoulos E, Yu F, Coleman AL. Age-related macular degeneration is associated with an increased risk of hip fractures in the Medicare database. Am J Ophthalmol. 2006;142:1081–3.

    Article  PubMed  Google Scholar 

  14. Wysong A, Lee PP, Sloan FA. Longitudinal incidence of adverse outcomes of age-related macular degeneration. Arch Ophthalmol. 2009;127:320–7.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Chong EW, Wang Y, Robman LD, Aung KZ, Makeyeva GA, Giles GG, et al. Age related macular degeneration and total hip replacement due to osteoarthritis or fracture: Melbourne Collaborative Cohort Study. PLoS One. 2015;10:e0137322.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Sun CC, Huang TS, Fu TS, Lee CY, Chen BY, Chen FP. Association of age-related macular degeneration on fracture risks among osteoporosis population: a nationwide population-based cohort study. BMJ Open. 2020;10:e037028.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Hong T, Mitchell P, Burlutsky G, Samarawickrama C, Wang JJ. Visual impairment and the incidence of falls and fractures among older people: longitudinal findings from the Blue Mountains Eye Study. Investig Ophthalmol Vis Sci. 2014;55:7589–93.

    Article  Google Scholar 

  18. Shin DW, Cho B, Guallar E. Korean national health insurance database. JAMA Intern Med. 2016;176:138.

    Article  PubMed  Google Scholar 

  19. Cheol Seong S, Kim YY, Khang YH, Heon Park J, Kang HJ, Lee H, et al. Data resource profile: the national health information database of the National Health Insurance Service in South Korea. Int J Epidemiol. 2017;46:799–800.

    PubMed  Google Scholar 

  20. Shin DW, Cho J, Park JH, Cho B. National General Health Screening Program in Korea: history, current status, and future direction. Precis Future Med. 2022;6:9–31.

    Article  Google Scholar 

  21. Belong Cho CML. Current situation of national health screening systems in Korea. J Korean Med Assoc. 2011;54:666–9.

    Article  Google Scholar 

  22. Choi S, Jahng WJ, Park SM, Jee D. Association of age-related macular degeneration on Alzheimer or Parkinson disease: a retrospective cohort study. Am J Ophthalmol. 2020;210:41–7.

    Article  PubMed  Google Scholar 

  23. Hwang S, Kang SW, Kim SJ, Han K, Kim BS, Jung W, et al. Impact of age-related macular degeneration and related visual disability on the risk of depression: a nationwide cohort study. Ophthalmology. 2023;130:615–23.

  24. Shin DW, Lee JW, Jung JH, Han K, Kim SY, Choi KS, et al. Disparities in cervical cancer screening among women with disabilities: a National Database Study in South Korea. J Clin Oncol. 2018;36:2778–86.

    Article  PubMed  Google Scholar 

  25. Yoo JE, Shin DW, Han K, Kim D, Yoon JW, Lee DY. Association of female reproductive factors with incidence of fracture among postmenopausal women in Korea. JAMA Netw Open. 2021;4:e2030405.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Shin HB, Park HS, Yoo JE, Han K, Park SH, Shin DW, et al. Risk of fracture incidence in prostate cancer survivors: a nationwide cohort study in South Korea. Arch Osteoporos. 2020;15:110.

    Article  PubMed  Google Scholar 

  27. Shin DW, Suh B, Lim H, Suh YS, Choi YJ, Jeong SM, et al. Increased risk of osteoporotic fracture in postgastrectomy gastric cancer survivors compared with matched controls: a Nationwide Cohort Study in Korea. Am J Gastroenterol. 2019;114:1735–43.

    Article  PubMed  Google Scholar 

  28. Farahmand BY, Persson PG, Michaëlsson K, Baron JA, Parker MG, Ljunghall S. Socioeconomic status, marital status and hip fracture risk: a population-based case-control study. Osteoporos Int. 2000;11:803–8.

    Article  CAS  PubMed  Google Scholar 

  29. Unnanuntana A, Gladnick BP, Donnelly E, Lane JM. The assessment of fracture risk. J Bone Jt Surgt Amt. 2010;92:743–53.

    Article  Google Scholar 

  30. Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, et al. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2011;173:676–82.

    Article  PubMed  Google Scholar 

  31. Kim H, Koo H, Han E. Socioeconomic and physical health status changes after visual impairment in Korea using difference-in-difference estimations. Sci Rep. 2021;11:820.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Sozen T, Ozisik L, Basaran NC. An overview and management of osteoporosis. Eur J Rheumatol. 2017;4:46–56.

    Article  PubMed  Google Scholar 

  33. Wood JM, Lacherez P, Black AA, Cole MH, Boon MY, Kerr GK. Risk of falls, injurious falls, and other injuries resulting from visual impairment among older adults with age-related macular degeneration. Invest Ophthalmol Vis Sci. 2011;52:5088–92.

    Article  PubMed  Google Scholar 

  34. Seitzman RL, Mangione CM, Cauley JA, Ensrud KE, Stone KL, Cummings SR, et al. Bone mineral density and age-related maculopathy in older women. J Am Geriatr Soc. 2007;55:740–6.

    Article  PubMed  Google Scholar 

  35. Yoo TK, Kim SH, Kwak J, Kim HK, Rim TH. Association between osteoporosis and age-related macular degeneration: the Korea National Health and Nutrition Examination Survey. Investig Ophthalmol Vis Sci. 2018;59:AMD132–AMD42.

    Article  Google Scholar 

  36. Thompson RB, Reffatto V, Bundy JG, Kortvely E, Flinn JM, Lanzirotti A, et al. Identification of hydroxyapatite spherules provides new insight into subretinal pigment epithelial deposit formation in the aging eye. Proc Natl Acad Sci USA. 2015;112:1565–70.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Layana AG, Minnella AM, Garhofer G, Aslam T, Holz FG, Leys A, et al. Vitamin D and age-related macular degeneration. Nutrients. 2017;9:1120.

    Article  PubMed  Google Scholar 

  38. Morrison MA, Silveira AC, Huynh N, Jun G, Smith SE, Zacharaki F, et al. Systems biology-based analysis implicates a novel role for vitamin D metabolism in the pathogenesis of age-related macular degeneration. Hum Genomics. 2011;5:538–68.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Lee H, Cho J, Shin DW, Lee SP, Hwang SS, Oh J, et al. Association of cardiovascular health screening with mortality, clinical outcomes, and health care cost: a nationwide cohort study. Prev Med. 2015;70:19–25.

    Article  PubMed  Google Scholar 

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This work was supported by a National Research Foundation of Korea grant provided by the Korean government Ministry of Education (NRF-2021R1C1C1007795; Seoul, Korea), which was received by DHL. This research was partially supported by a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI20C1073). The funding organizations had no role in the design or conduct of the study.

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Authors and Affiliations



JMY and DHL designed the research and wrote the main manuscript. BSK and KH performed the data collection and analysis. YL, HYK, SYJ, DWS and DIH reviewed the design and the results, and edited the final version of the manuscript.

Corresponding authors

Correspondence to Dong Wook Shin or Don-Il Ham.

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The authors declare no competing interests.

Ethical approval

All records in our database were anonymized. This study adhered to the Declaration of Helsinki and the study protocol was reviewed and approved by the institutional review board of Samsung Medical Center (SMC IRB no. 2022-03-060). Furthermore, the Deliberative Committee of the NHIS approved the conditional use of the database for this study.

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Yoon, J.M., Lim, D.H., Lee, YB. et al. The risk of fracture in age-related macular degeneration according to the presence of visual disability: a nationwide cohort study. Eye (2023).

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