Baseline visual acuity gaps in age-related macular degeneration: AREDS smokers and non-smokers

BACKGROUND: Age-related macular degeneration (AMD) is a leading cause of blindness in developed countries. Smoking is the only modifiable risk factor and is associated with faster AMD progression. While Age-Related Eye Disease Study (AREDS) supplements are recommended for intermediate AMD, their impact on visual acuity over time remains unclear. OBJECTIVE: To describe baseline disparities and visual acuity trajectories in patients with intermediate dry AMD stratified by AREDS use and smoking status. DESIGN: Retrospective observational study of patients with intermediate dry AMD conducted under IRB protocol 22-0267. Data collected from January 1, 2014 to January 1, 2024. SETTING: Single academic medical center. PARTICIPANTS: A total of 450 patients (759 eligible eyes) with intermediate dry AMD (ICD code H35.3192) were included. Patients were stratified by smoking status and AREDS use. Participants with fewer than three ophthalmology visits during the 10-year study period were excluded. EXPOSURE: AREDS supplementation (AREDS1 or AREDS2) and smoking status (current/former vs. never). MAIN OUTCOMES AND MEASURES: Visual acuity measured in Logarithm of the Minimum Angle of Resolution (LogMAR) at first and final clinic visits. ANOVA, Chi-square tests, and mixed effect regression models were used for analysis. Changes in LogMAR over time were calculated descriptively. RESULTS: Among 450 patients (mean age, 82.32 years), 255 were smokers (423 eyes) and 195 were non-smokers (336 eyes). Baseline vision was better in non-smokers (mean LogMAR 0.28; SD 0.28) and smokers (mean LogMAR 0.30; SD 0.33) taking AREDS compared to non-smokers (mean LogMAR 0.48; SD 0.44) and smokers (mean LogMAR 0.45; SD 0.47) not taking AREDS (P < 0.0001). All groups experienced visual acuity decline from baseline with no significant differences in final visual acuity among the groups in a mean follow up period of 3.62 years. In a sub-analysis of greater than 5 years follow up mean years of 6.93 ± 1.55 years), a statistically significant difference in final LogMAR values across groups was observed (p = 0.033). The Smokers & AREDS group demonstrated the best final visual acuity (mean 0.39, SD 0.40), followed by Smokers & No-AREDS (mean 0.44, SD 0.43), Non-smokers & AREDS (mean 0.46, SD 0.47), and Non-smokers & No-AREDS (mean 0.72, SD 0.60). CONCLUSIONS AND RELEVANCE: These results suggest that less than 5 years AREDS users had larger decline in vision from baseline, protective associations of AREDS supplementation may become more discernible over longer follow-up horizons. Real-world observational findings should be interpreted cautiously and do not contradict AREDS efficacy shown in randomized trials.