Beruflich Dokumente
Kultur Dokumente
Population
The Beaver Dam Eye Study
Ronald Klein, MD, Barbara E. K. Klein, MD, Kristine E. Lee, MS
Purpose: To describe the change in visual acuity over a 5-year period in persons
participating in a large population-based study.
Methods: Best-corrected visual acuity was measured, after refraction, with 10gMAR
charts using a modification of the Early Treatment Diabetic Retinopathy Study protocol
in 3684 persons living in Beaver Dam, Wisconsin, who ranged in age from 43 to 86
years at the time of a baseline examination from 1988 to 1990, and at a follow-up
examination from 1993 to 1995.
Results: The change in the number of letters read correctly over the 5-year period
varied from 0.4 4.9 (mean standard deviation) in people between 43 and 54 years
of age to -5.2 15.4 in people 75 years of age or older at baseline. Over the 5-year
period, vision became impaired (20/40 or worse in the better eye) in 2.9% of the population and severely impaired (20/200 or worse in the better eye) in 0.3%. The visual
angle doubled in 1.7% of the population, and 2.4% had improved vision. People 75
years of age or older at baseline were 12.5 times (95% confidence interval [CI], 8.618.2; P < 0.001) more likely to have impaired vision, 9.7 times (95% CI, 5.9-16.0; P <
0.001) more likely to have doubling of the visual angle, and 78 times more likely (95%
CI, 9.9-614.1; P < 0.001) to have severe visual impairment than people younger
than 75 years of age at baseline. People 75 years of age or older who were living in
nursing homes or group homes were 3.8 times more likely to have impaired vision,
3.3 times more likely to have severely impaired viSion, and 5.7 times more likely to
have a doubling of the visual angle than those not residing in a nursing home or a
group home.
Conclusion: These data provide precise population-based estimates of incidence
of visual loss over a wide spectrum of ages and show that decreased visual acuity in
people 75 years of age is a common finding, especially in those who are in nursing
homes or group homes. Ophthalmology 1996; 103: 1169-1178
1169
Ophthalmology
Methods
Population
Methods used to identify the population and descriptions
of the population have appeared in previous reports. 38.9
In brief, a private census of the population of Beaver Dam,
Wisconsin, was performed from September 15, 1987, to
May 4, 1988. Eligibility requirements for entry into the
study included living in the city or township of Beaver
Dam and being 43 to 84 years of age at the time of the
census. A total of 5924 individuals, both institutionalized
and noninstitutionalized, were eligible for inclusion in
the study. Of these individuals, 4926 participated in the
examination phase between March 1, 1988, and September 14, 1990. Ninety-nine percent of the population was
white. Of those who did not participate, 227 (3.8%) had
died before the examination, 99 (1.7%) had moved out
of the area, 18 (0.3%) could not be located, 276 (4.7%)
permitted an interview only, and 378 (6.4%) refused to
participate. Comparisons between participants and nonparticipants at the time of the baseline examination have
appeared elsewhere. 3
The members of the cohort who were eligible to participate at baseline had been divided randomly into ten
groups to be examined sequentially over the course of the
study. Surviving members of the cohort were invited to
participate in a 5-year follow-up examination in the same
order as at baseline examination. Of the 4926 people who
participated at the baseline examination, 385 (7.8%) died
before March 1, 1993, the beginning of the 5-year followup examination. Of the 4541 surviving persons who had,
participated in the baseline examination, 3684 (81.1 %)
participated in the follow-up examination from March 1,
1993, through June 14, 1995. One hundred seventy-one
(3.8%) died after the start of the follow-up but before examination. Four could not be located. Two hundred fiftynine (5.7%) permitted an interview only (48 of whom
moved out of the area) and 423 (9.3%) refused to participate (44 of whom moved out of the area). Both the mean
and median times between the baseline and 5-year followup examinations were 4.8 years (standard deviation, 0.4
years).
Of the 3684 people examined at baseline and at followup, 92 were living in a nursing home or a group home at
follow-up. Of these people, 24 were in a nursing home or
a group home at baseline. One person was in a nursing
home at baseline but moved home by follow-up.
Comparisons between participants and nonparticipants
at follow-up are presented in Table 1. The 686 nonparticipants who were alive at follow-up were more likely to
be older than the participants (Table 1). After controlling
for age at baseline, these nonparticipants were.more likely
at baseline to have retired and had fewer years of education
completed, a history of never drinking alcohol, lower in-
1170
Procedures
Similar procedures were used at both the baseline and
follow-up examinations. Letters from primary care physicians or from the principal investigators, if no primary
care physician was identified, were sent to those who were
eligible. The letters described the study and invited eligible
people to participate. This was followed by a call from
the study coordinator, who provided further information
about the study and made an appointment for the examination. People who were not interested in participating
in the examination were asked to respond by telephone
to the questionnaire that was administered at the time of
examination.
Human experimentation committee approval was
granted and informed consent was obtained from each
participant at the beginning of the examination. The parts
of the examination pertinent to this report consisted of a
standardized refraction and measurement of the visual
acuity using the Humphrey 530 refractor (Allergan Humphrey, San Leandro, CA). At follow-up only, before refraction, the participants first were asked to read the Early
Treatment Diabetic Retinopathy Study chart R with their
current prescription without covering either eye. The
number ofletters correctly read was recorded. At baseline
and follow-up, the refraction obtained using the refractor
was placed in a trial lens frame and the best-corrected
visual acuity was remeasured following the Early Treatment Diabetic Retinopathy Study protocol using chart R
and modified for a 2-m distance. 3. IO If the best-corrected
visual acuity was 20/40 or worse, an Early Treatment
Diabetic Retinopathy Study refraction was performed and
the visual acuity was measured. The interobserver variation among the examiners for obtaining the refractive
error or the best-corrected visual acuity was low and not
clinically significant (data not shown).
. At both examinations, visual acuity was obtainable and
considered reliable in both eyes in 3480 persons, in the
right eye only in 41 persons, and in the left eye only in
47 persons. Visual acuity was obtainable and considered
reliable in at least one eye at both visits for 17 of those in
a nursing home or a group home at both visits (11 were
older than 75 years of age) and 55 of those in a nursing
home or a group home at follow-up only (39 were older
than 75 years of age).
Definitions
For each eye, visual acuity was recorded as the number
of letters correctly identified (range, 0 [<20/200] to 70
[20/10)). For eyes with visual acuity poorer than 20/200,
one of nine levels of vision could be recorded: 20/250,
Participants
Characteristic
Age at baseline (yrs)
43-54
55-64
65-74
75+
Sex
F
M
Education
<high school
High school
College
> college
Employment
Full-time
Part-time
Retired
Other
Income ($)
-0:9000
10,000-19,000
20,000-29,000
30,000-44,000
::0:45,000
Visual acuity in worse eye
Better than 20/40
20/40-20/160
20/200 and worse
Central cataract
No
Yes
Age-related maculopathy
None
Early
Late
Hypertension
No
Yes
Cardiovascular disease
No
Yes
Cancer
No
Yes
Diabetes
No
Yes
Alcohol consumption
Never
Ever
Pack-years smoked
Cholesterol level (mg/dl)
Systolic level (mmHg)
Diastolic blood pressure
(mmHg)
Crude
%
(no.)
Crude
%
34.7
28.8
25.9
10.6
(1277)
(1063)
(953)
(391)
30.5
24.9
23.5
21.1
56.8
43.2
(2092)
(1592)
59.3
40.7
(407)
(279)
24.4
45.4
22.9
7.3
(897)
(1671)
(845)
(269)
40.4
40.4
16.0
3.2
41.1
10.3
36.0
12.6
(1513)
(378)
(1328)
(465)
13.3
26.1
21.2
22.3
17.2
Dead
Age-adjusted
P'
Crude
%
(no.)
Age-adjusted
Pt
<O.OO1t
9.4
12.3
26.3
52.0
(16)
(21)
(45)
(89)
<O.OOlt
0.65
52.6
47.4
(90)
(81)
0.01
(277)
(277)
(109)
(22)
<0.001
48.5
33.1
14.2
4.2
(82)
(56)
(24)
(7)
0.02
36.1
6.6
39.8
17.5
(248)
(45)
(273)
(120)
0.06
9.9
4.7
66.7
18.7
(17)
(8)
(114)
(32)
<0.01
(471)
(927)
(751)
(790)
(609)
21.9
27.0
19.9
19.2
12.0
(139)
(171)
(126)
(76)
3.4
(47)
(59)
(21)
(13)
(5)
0.001
(122)
32.4
40.7
14.5
9.0
88.3
9.3
2.4
(3241)
(339)
(89)
79.2
17.6
3.2
(540)
(120)
(22)
0.001
61.2
30.3
8.5
(101)
(50)
(14)
<0.001
84.2
15.8
(3016)
(566)
78.2
21.8
(510)
(142)
0.36
54.1
45.9
(79)
(67)
0.02
82.3
16.4
1.3
(2981)
(594)
(47)
81.7
16.3
2.0
(528)
(105)
(13)
0.36
74.5
23.5
2.0
(111)
(35)
(3)
0.20
65.6
34.4
(2415)
(1269)
60.5
39.5
(415)
(271)
0.13
49.4
50.6
(84)
(86)
0.09
88.2
11.8
(3211)
(430)
83.5
16.5
(563)
(111)
0.03
68.5
31.5
(113)
89.9
10.1
(3309)
(370)
88.1
11.9
(602)
(81)
0.56
81.3
18.7
(139)
(32)
0.18
92.3
7.7
(3356)
(281)
91.9
8.1
(625)
(55)
0.93
82.9
17.1
(141)
(29)
0.001
13.3
86.7
(489)
(3195)
19.9
80.1
(136)
(549)
<0.001
29.2
70.8
(50)
(121)
<0.001
(no.)
(209)
(171)
(161)
(145)
<0.001
(52)
<0.001
No.
Mean SD
No.
Mean SD
No.
Mean SD
3672
3675
3683
16.5 25.3
233.0 43.5
130.7 19.4
678
683
686
18.1 26.7
239.1 44.6
136.1 21.9
0.03
<0.01
<0.001
167
165
170
21.5 31.7
231.0 46.6
136.4 23.4
<0.001
0.23
0.58
3683
77.8 10.5
686
78.3 12.1
0.01
170
72.4 11.9
<0.01
1171
Ophthalmology
Statistical Methods
Comparisons of participants and nonparticipants were
done using analysis of variance and the Cochran-MantelHaenszel test of independence to adjust for age groups
with continuous (i.e., blood pressure) and categorical (i.e.,
visual acuity) characteristics, respectively. Student's t test
and analysis of variance were used to compare the change
in the number ofletters read between eyes and age groups,
respectively. Linear regression analyses were used to
compute estimates of age-adjusted (continuous and quadratic) and sex-adjusted change. Chi-square and CochranMantel-Haenszel tests were used to compute unadjusted
and age-group-adjusted comparisons of incidence, respectively. Unless noted, all results were unadjusted for
any confounders. SAS was used for all analyses. I 1.12
III
"0
.c
E
0
-1
-2
"
.5
III
Cl
Results
The mean age of the participants at baseline was 60.4
years, and 56.8% were women (Table 1). The mean number of years of school completed was 12, and the median
income was $25,000. Other characteristics of the participants at baseline are presented in Table 1.
1172
III
.J::
-4
-5
-6
43-54
55-64
65-74
75+
Age (years)
.....
.....
1215
998
882
342
3437
565
461
361
113
1500
650
537
521
229
1937
No. of Participants
at Risk
(0.9)
(2.5)
(6.7)
(13.5)
(4.1)
(2.2)
(7.8)
(11.5)
(3.8)
(1.1)
(0.8)
(2.8)
(6.0)
(14.4)
(4.3)
(%)
<0.001
0.86
<0.001
<0.001
Pt
1171
947
747
204
3069
545
440
321
78
1384
626
507
426
126
1685
No. of Participants
at Risk
(1.0)
(2.6)
(10.8)
(26.0)
(5.6)
(0.7)
(2 .3)
(10.0)
(24.4)
(4.7)
(3.0)
(11.5)
(27.0)
(6.3)
(1.3)
(%)
Visual Impairment
<0.001
0.23
<0.001
<0.001
Pt
1208
989
873
339
3409
560
456
358
115
1489
648
533
515
224
1920
No. of Participants
at Risk
(6.2)
(1.0)
(1.3)
(0.0)
(0.3)
(4.4)
(0.6)
(1.1)
(0.0)
(0.0)
(0.0)
(0.6)
(1.4)
(7.1)
(1.4)
(%)
Severe Impairment
<0.001
0.15
<0.001
<0.001
Pt
213
273
415
268
1169
60
76
121
80
337
153
197
294
188
832
No. of Participants
at Risk
(4.2)
(3.3)
(6.8)
(4.9)
(5.1)
(3.3)
(0.0)
(5.0)
(5.0)
(3.6)
(4.6)
(4.6)
(7.5)
(4.8)
(5.7)
(%)
Improvement
0.31
0.13
0.24
0.58
Pt
Incidence of monocular doubling of the visual angle defined as a loss of 15 letters or more in visual acuity in either eye at follow-up. Incidence of monocular impairment defined as development of visual
acuity of 20/40 or worse in either eye at follow-up in an individual who had better than 20/40 visual acuity in both eyes at baseline. Incidence of severe monocular visual impairment defined as development
of visual acuity of 20/200 or worse in either eye at follow-up in an individual who had better than 20/200 visual acuity in both eyes at baseline. Incidence of monocular improvement in visual acuity
defined as an improvement of 15 letters or more in visual acuity in either eye at follow-up.
Total
43-54
55-64
65-74
75+
Age-adjusted
Male versus female
Total
43-54
55-64
65-74
75+
Male
Total
43-54
55-64
65-74
75+
Female
Age (yrs)
Table 2. Five-year Incidence of Monocular Changes in Vision by Age and Sex in the Beaver Dam Eye Study
Ophthalmology
with age (Table 2). After controlling for age, men and
women were equally at risk for monocular impairment
(odds ratio [OR], 0.8; 95% el, 0.6- 1. 1; P = 0.23) or doubling of the visual angle in one eye only (OR, 1.0; 95%
el, 0.7-1.4; P = 0.86).
Over the 5-year period, impaired vision developed in
2.9% of the population at risk, severe impairment developed in 0.3%, doubling of the visual angle occurred in
1.7%, and 2.4% had improved vision. The 5-year incidence
of any visual impairment, severe visual impairment, doubling of the visual angie, and improvement by age and
sex are shown in Table 3. People 75 years of age or older
at baseline were 12.5 times (95 % el, 8.6-18.2; P < 0.001)
more likely to have impaired vision, 9.7 times (95% el,
5.9-16.0; P < 0.001) more likely to have a doubling of
the visual angle, and 78 times more likely (95% CI, 9.9614.1 ; P < 0.001) to have severe visual impairment than
people younger than 75 years of age at baseline. Similarly,
people 75 years of age or older were 2.1times (95% el,
1.2-3 .8; P = 0.01) more likely to have an improvement
in vision than those who were younger at baseline. After
controlling for age, the incidence of visual impairment or
doubling of the visual angle or improvement was not statistically different between men and women.
The relation of improvement of visual acuity to cataract
surgery was examined. In people 55 years of age or older,
the incidence of improvement in vision over the 5-year
period was consistently higher in eyes that had undergone
cataract surgery (26.7% in right eyes with cataract surgery
versus 0.8% in right eyes without cataract surgery; 18.3%
in left eyes with cataract surgery versus 0.7% in left eyes
without cataract surgery) between baseline and follow-up
compared with eyes which had not.
Among those persons without impaired vision at baseline, the 5-year incidence of the development of moderately impaired visual acuity (20/40-20/160) was 2.8%;
for development of severe visual impairment, it was 0.1 %;
and for doubling of the visual angle, it was 1.4% (Table
4). Of those who had moderately impaired vision at baseline, 39.4% were no longer visually impaired, whereas severe impairment had developed in 6.4% at follow-up. Of
eyes that were no longer visually impaired and had improved by 15 or more letters, 81.8% (27/33) of right eyes
and 71.4% (15/21) of left eyes had undergone cataract
surgery.
Of the 72 participants with reliable visual acuity who
were living in a nursing home or a group home at followup, vision became impaired in 48.2% and severely impaired in 4.4% (Table 5). In addition, 30.6% had doubling
of the visual angle. Of those individuals 75 years of age
or older in whom visual acuity could be measured (n =
375), those living in a nursing home or a group home at
follow-up (n = 50) were 3.8 times (95% el, 2.5-5.8; P <
0.001) more likely to have impaired vision, 3.3 times (95%
el, 0.9-12.9; P = 0.07) more likely to have severely impaired vision, and 5.7 times (95% el, 3.1-10.7; P < 0.001)
more likely to have a doubling of the visual angle than
those not residing in a nursing home or a gro,llp home (n
= 325) at follow-up. In addition, those individuals 75
years of age or older and institutionalized were 1.6 times
1174
(95% el, 0.6-5.4; P = 0.46) more likely to have an improvement in visual acuity over the 5-year period of the
study than those who were not institutionalized. Those
individuals living in a nursing home or a group home
with impaired vision at baseline were less likely to have
undergone cataract surgery over the 5-year period than
those not living in a nursing home or a group home (right
eye, 11.8% versus 35.6%, respectively, P = 0.06; left eye,
14.3% versus 33.3%, respectively, P = 0.16).
Over the 5-year period, 68 persons who had been examined and who were not institutionalized at baseline
entered a nursing home or a group home and were examined at the time of the 5-year follow-up. Of these persons, 55 (80.9%) had obtainable and reliable measurements of visual acuity at both examinations. In those persons 75 years of age or older who entered a nursing home
or a group home (n = 39), the mean number of letters
read correctly was slightly lower at baseline than in persons
similar in age who did not enter a nursing home or a
group home (n = 325) (right eye, 37.2 versus 45.5, respectively, P = 0.08; left eye, 41.4 versus 45.4, respectively,
P = 0.17). Those entering a nursing home or a group
home were 3.0 times (95 % el, 1.7-5.0) more likely to
have impaired vision, 2.9 times (95% el, 0.6-13.8) more
likely to have severely impaired vision, and 5.9 times (95%
el, 3.0-11.4) more likely to have doubling of the visual
angle than those who did not enter a nursing home or a
group home. The loss of vision was significantly greater
(change in number ofletters read: right eyes, -13.2 versus
-4.0, P = 0.02; left eyes, -14.7 versus -5.2, P = 0.01)
among those entering a nursing home or a group home
than those who did not.
The rate of improvement in the number ofletters read
correctly in the better eye by refraction compared with
the current prescription of glasses or contact lenses at follow-up was not significantly different in persons 75 years
of age or older living in a nursing home or a group home
than those who were not institutionalized (Fig 2). In both
the institutionalized (40.4%) and noninstitutionalized
(27.1 %) groups older than 75 years of age, a significant
number of persons had an improvement of five or more
letters of visual acuity after refraction.
Discussion
Most information about change in vision has been derived
from blindness registries. 4- 7. 13 To our knowledge, there
are no population-based estimates of objectively measured
incidence of loss or improvement of vision. The Beaver
Dam Eye Study provides data on changes in visual acuity
in a geographically defined population. This study is
unique in that a large cohort with a broad distribution of
ages was re-examined after a 5-year interval. The refusal
rate was low (9.3%), suggesting that bias would unlikely
distort our results. During both visits, the same standardized protocols for measuring visual acuity were used.
These data show that the overall change in visual acuity
over the 5-year period is, on average, approximately one
letter. This change is not clinically significant. However,
.....
.....
(0.1)
1239
1027
926
375
3567
(1.7)
(8.5)
<0.001
0.71
<0.001
<0.001
Pi'
1230
1022
894
318
3464
574
471
373
110
1528
656
551
521
208
1936
No. of Participants
at Risk
(3.2)
(17.9)
(2.9)
(1.3)
(0.2)
(2.7)
(14.6)
(2.2)
(1.3)
(0.4)
(3.7)
(19.7)
(3.5)
(1.3)
(0.2)
(%)
Visual Impairment"
<0.001
0.26
<0.001
< 0.001
Pi'
Incidence of doubling of the visual angle, visual impairment, and severe impairment defined by the better eye.
t Incidence of improvement defined by the worse eye.
t Mantel-Haenszel test of trend .
Total
43-54
55-64
65-74
75+
Total
Age-adjusted
Male versus
female
Male and
female
(1.1)
(1.7)
(0.0)
(0.6)
(2.1)
(8.3)
(1.4)
576
474
381
120
1551
43-54
55-64
65-74
75+
Total
Male
(0.2)
(1.5)
(1.5)
(8.6)
(1.9)
(%)
663
553
545
255
2016
No. of Participants
at Risk
43-54
55-64
65-74
75+
Female
Age (yrs)
1238
1027
926
368
3558
576
474
381
119
1550
662
553
544
249
2008
No. of Participants
at Risk
(0.0)
(0.1)
(0.0)
(2.5)
(0.3)
(0.0)
(0.0)
(0.0)
(0.8)
(0.1)
(0.0)
(0.2)
(0.0)
(3.2)
(0.5)
(%)
Severe Impairment"
<0.001
0.11
0.04
<0.001
Pi'
531
614
718
353
2216
202
217
263
108
790
329
397
455
245
1426
(3.3)
(4.3)
(2.4)
(1.3)
(1.1)
(1.0)
(0.0)
(1.9)
(4.6)
(1.5)
(1.5)
(1.8)
(4.2)
(4.1)
(2.9)
(%)
Improvementt
No. of Participants
at Risk
Table 3. Five-year Incidence of Changes in Vision by Age and Sex in the Beaver Dam Eye Study
<0.001
0.06
0.01
0.01
Pi'
.....
.....
(moderate)
standard error .
(0.0)
(0.0)
(54.3)
(100.0)
(6.4)
(0.1)
(%)
(%)
(2.8)
Severe
Moderate
94
3464
No. of Participants
at Risk
(77.8)
(6.4)
(1.4)
(%)
(1.1)
3495
72
(30.6)
(5.2)
(30.0)
(0.7)
(31.8)
(%)
325
50
3170
22
No. of
Participants
at Risk
0.2
5.4
1.2
6.5
0.1
9.9
SE
P
<0.001
<0.001
<0.001
3408
56
281
37
3127
19
No. of
Participants
at Risk
2.0
8.2
0.3
6.7
(2.2)
(48.2)
0.2
11.3
SE
(13.5)
(51.4)
(1.2)
(42.1)
(%)
Visual Impairment
<0.001
<0.001
<0.001
Incidence of doubling of the visual angle, visual impairment, and severe impairment defined by the better eye.
SE
Not institutionalized
Institutionalized
All ages
Not institutionalized
Institutionalized
75+
10
(39.4)
(97.1)
None
(%)
Impairment
Better Eye
<0.001
70
304
1842
No. of Participants
at Risk
3489
69
320
48
3169
21
No. of
Participants
at Risk
(0.2)
(4.4)
(1.9)
(6.3)
(0.0)
(0.0)
(%)
0.1
2.5
0.8
3.5
SE
Severe Impairment
<0.001
0.07
2148
68
305
48
1843
20
No. of
Participants
at Risk
(2.3)
(4.4)
(3.9)
(6.3)
(2.1)
(0.0)
(%)
Improvementt
(14.3)
(13.5)
(0.1)
(%)
Im/J'rovement
Worse Eye
Table 5. Incidence of Visual Change by Age and Nursing Home Residence Status in the Beaver Dam Eye Study
Not institutionalized
Institutionalized
<75
Age (yrs)
(severe)
20/200 or worse
94
3464
20/40-20/160
No. of Participants
at Risk
Visual Acuity
in Better Eye
at Baseline
(level of
impairment)
0.3
2.5
1.1
3.5
0.3
SE
0.27
0.46
0.52
<0.001
Table 4. Five-year Incidence of Visual Impairment, Severe Impairment, Doubling of the Visual Angle, and Improvement by Baseline Visual
Acuity in the Beaver Dam Eye Study
.5
60
20
Non-Institutionalized
Institutionalized
Figure 2. The frequency of improved vision in the better eye by refraction compared with current prescription at follow-up in noninstitutionalized and institutionalized participants in the Beaver Dam Eye
Study.
References
I. Tielsch JM, Sommer A, Witt K, et al. Blindness and visual
impairment in an American urban population. The Baltimore Eye Survey. Arch Ophthalmol 1990; 108:286-90.
2. Dana MR, Tielsch JM, Enger C, et al. Visual impairment
in a rural Appalachian community: prevalence and causes.
JAMA 1990;264:2400-5.
3. Klein R, Klein BE, Linton KL, DeMets DL. The Beaver
Dam Eye Study: visual acuity. Ophthalmology 1991 ;98:
1310-5.
4. National Society to Prevent Blindness. Operational Research
Dept. Vision problems in the U.S.: A statistical analysis.
New York: The Society, 1980; 1-46.
5. Kahn HA, Moorhead HB. Statistics on Blindness in the
Model Reporting Area, 1969-1970. Bethesda, MD: US Dept
1177
Ophthalmology
1178
15.
16.
17.
18.
19.
20.
21.
22.
23 .