1040-5488/15/9204-0471/0 VOL. 92, NO. 4, PP.

471Y479
OPTOMETRY AND VISION SCIENCE
Copyright * 2015 American Academy of Optometry

ORIGINAL ARTICLE

Different Amounts of Alcohol Consumption and

Cataract: A Meta-analysis
Yu Gong*, Kehong Feng*, Ning Yan†, Yong Xu‡, and Chen-Wei Pan§

ABSTRACT
Purpose. To evaluate the association between different amounts of alcohol consumption and the risk of age-related cataract.
Methods. We searched PubMed and Embase from their inception until May 2014 for case-control or cohort studies with
data on alcohol consumption and age-related cataract. Heavy alcohol consumption was defined as more than two
standard drinks per day, which is equal to a daily intake of 20 g of alcohol or 140 g per week. Moderate consumption was
defined as less than 20 g of alcohol per day but more than never any. We performed separate meta-analyses for
the associations of moderate or heavy alcohol consumption with age-related cataract under a random-effects model,
respectively.
Results. Five case-control and five cohort studies were identified through comprehensive literature search. In the meta-
analysis of 10 studies, the associations between moderate alcohol consumption and age-related cataract were marginally
nonsignificant (pooled relative risk, 0.88; 95% confidence interval, 0.74 to 1.05; I2 = 82.1%), whereas heavy alcohol
consumption was associated with an increased risk of age-related cataract (pooled relative risk, 1.26; 95% confidence
interval, 1.06 to 1.50; I2 = 58.9%). The association between heavy alcohol consumption and cataract was stronger in case-
control than in cohort studies. Adjusting for smoking as a potential confounder attenuated the association between heavy
alcohol consumption and cataract.
Conclusions. Heavy alcohol consumption significantly increased the risk of age-related cataract, whereas moderate
consumption may be protective for this ocular condition. Clinically, information on a patient’s alcohol drinking history
might be valuable to general physicians and ophthalmologists when there is a diagnosis of age-related cataract and should
be collected on a routine basis in eye clinics.
(Optom Vis Sci 2015;92:471Y479)

Key Words: alcohol, cataract, meta-analysis, epidemiology

A
ge-related cataract is the leading cause of visual impair-
ment worldwide.1Y8 With longer life expectancies and an
aging population throughout the world, the burden and
impact of age-related cataract tend to increase, resulting in a global
public health concern. The key step for the prevention of age-
related cataract is to identify the risk factors for this eye condi-
tion, especially modifiable ones. Up until now, few risk factors
have been consistently associated with age-related cataract except
*MD
†
BSc
‡
MSc
§
MD, PhD
Department of Ophthalmology, Children’s Hospital of Soochow University,
Suzhou, China (YG, KF); and Jiangsu Key Laboratory of Preventive and Trans-
lational Medicine for Geriatric Diseases, School of Public Health, Medical College
of Soochow University, Suzhou, China (NY, YX, C-WP).
smoking9 and ultraviolet exposure.10 In a recently published meta-
analysis, we found that obesity increased the risks of age-related
cataract.11
Alcohol consumption is a common modifiable lifestyle factor
and appears to be associated with a wide range of chronic diseases
such as cancers,12 type 2 diabetes mellitus,13 and cardiovascular
diseases.14 However, there is uncertainty regarding its association
with age-related cataract in elderly adults. A relationship between
alcohol consumption and an increased risk of cataract has been
reported from cross-sectional studies,15,16 but several prospective
cohort studies have not found this association.17,18
It is especially important to understand whether the association
between alcohol consumption and age-related cataract is modified
by the amount of alcohol consumption because there is always a
U-shaped association observed in epidemiologic studies between
alcohol consumption and clinical disorders. For example, light
and moderate alcohol consumption appears to be protective for

Optometry and Vision Science, Vol. 92, No. 4, April 2015

Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.

472 Alcohol Consumption and CataractVGong et al.
cardiovascular diseases whereas heavy consumption appears to be a
risk factor.14 Therefore, a systematic approach to combine the
results of all available studies evaluating the association of alcohol
consumption with age-related cataract would be informative to
answer this research question. To address this gap, we conducted a
systematic review and meta-analysis of the published literatures to
examine if different amount of alcohol consumption is associated
with different risks of age-related cataract.
METHODS
Search Strategy and Inclusion Criteria
We conducted a systematic review and meta-analysis to examine
the association of alcohol consumption with age-related cataract
based on the Meta-analysis of Observational Studies in Epidemi-
ology guidelines.19 We searched the electronic databases of PubMed
and Embase for relevant articles reporting the association published
up to May 2014 with the following search terms (formatted for
PubMed search): (‘‘ethanol’’[MeSH Terms] OR ‘‘ethanol’’[All
Fields] OR ‘‘alcohol’’[All Fields] OR ‘‘alcohols’’[MeSH Terms] OR
‘‘alcohols’’[All Fields]) AND ((‘‘cataract’[MeSH Terms] OR
‘‘cataract’’[All Fields]) OR (‘‘cataract’’[MeSH Terms] OR
‘‘cataract’’[All Fields] OR (‘‘lens’’[All Fields] AND ‘‘opacity’’[All
Fields]) OR ‘‘lens opacity’’[All Fields])). Titles and abstracts of the
studies were independently scanned by two authors (YG and KF).
Duplicate articles from the two databases were deleted. The
extracted studies were compared, and inconsistencies were resolved
by consensus. In addition, the reference lists of all identified studies
were examined. This study was approved by the Medical College of
Soochow University Institutional Review Board.
We included studies if they were case-control or cohort studies
and if they reported alcohol consumption as an exposure variable
and any subtypes of age-related cataract including cataract surgery as
the outcome measure. Furthermore, we included studies only if the
summary estimates such as odds ratios (ORs), relative risks (RRs),
and hazard ratios with 95% confidence interval (CI) were reported
in the article or allowed for the calculation of the summary estimates
based on the data presented in the article. We only included studies
in which age-related cataract was assessed based on lens photographs
or diagnosed by ophthalmologists. We excluded studies if they were
not case-control or cohort studies (e.g., cross-sectional designs or
ecology studies) or if they measured cataract by questionnaires (self-
reported). For cohort studies, if one study reported two results at
different follow-up periods, the result with a longer follow-up period
was included in the analysis. Although we did not specifically ex-
clude non-English literature, the studies included in the final
analysis were all in English.
Data Extraction and Assessment of Study Quality
For each study in the analyses, we extracted the following in-
formation: first author, publication year, study name, study de-
sign, sample size, age range of the study participants, follow-up
periods (for cohort studies only), definitions of alcohol con-
sumption and age-related cataract, summary estimates and cor-
responding 95% CI, and confounding factors adjusted for.
Optometry and Vision Science, Vol. 92, No. 4, April 2015
Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
We assessed the study quality using the tool described by
Sanderson et al.20 The variables examined included the methods for
selecting study participants, methods for measuring exposure (al-
cohol consumption) and outcome variable (age-related cataract),
design-specific sources of bias (excluding confounding), methods
for controlling confounding, statistical methods (excluding control
of confounding), and conflict of interest.
Statistical Methods
We performed the meta-analysis using Stata version 12.0
(StataCorp, College Station, TX). We meta-analyzed the fully
adjusted, study-specific summary estimates using a random-effects
model to account for both within- and between-study variability.
Age-related cataract was treated as the outcome measure, whereas
alcohol consumption was analyzed as the independent variable.
Heavy alcohol consumption was defined as more than two stan-
dard drinks per day, which is equal to a daily intake of 20 g of
alcohol or 140 g per week. Moderate alcohol consumption was
defined as less than 20 g of alcohol per day but more than never.
We treated ‘‘nonYalcohol drinker’’ as the reference category and
converted summary estimates if necessary. Statistical heteroge-
neity among studies was evaluated using I2 statistic.21 Values of
0 to 24%, 25 to 49%, 50 to 74%, and more than 75% denote no,
low, moderate, and high heterogeneity, respectively.22 Sensitivity
analysis was performed to investigate the contribution of each
study to the heterogeneity by sequentially removing one study and
reanalyzing the pooled estimate for the remaining studies.
The RRs were used as the common measure of association
across studies. Hazard ratios were directly considered as RRs.
Where necessary, ORs were transformed into RRs with the fol-
lowing formula:
RR ¼ OR=½ð1jPo Þ þ ðPo
ORÞ;
in which Po is the rate of the outcome of interest in the
nonexposed group.14
The SE of the resulting converted RR was then determined with
the following formula:
SE logðRRÞ ¼ SE logðORÞ
logðRRÞ= logðORÞ:
In some studies, a single summary estimate was not available
for moderate/heavy drinkers versus nondrinkers because the data
were presented as only a dose-response. In these cases, we first
pooled across levels of alcohol intake within the study using a
random-effects model to derive a single summary estimate for
moderate/heavy drinkers versus nondrinkers. The resulting single,
study-specific summary estimate was then pooled with those of
other studies.
We evaluated publication bias using the Egger regression
asymmetry test and the Begg test. A two-sided p value of less than
0.05 was regarded as significant for all analyses.
RESULTS
We identified 1542 unique titles and abstracts in the electronic
databases of PubMed and Embase. After two rounds of reviews and
searching citations of retained articles, we identified 42 studies as
potentially relevant for analysis, from which we retrieved 29 full text
 Alcohol Consumption and CataractVGong et al. 473

FIGURE 1.
Flow chart describing the selection of studies.

articles for review. Finally, we included 5 cohort studies17,18,23Y25 summarized in Table 1. Among the identified 10 studies, 4 were
and 5 case-control studies26Y30 in this meta-analysis (Fig. 1). conducted in the United States18,24,25,29 whereas the other 6
Characteristics of the 10 studies included in the meta-analysis are were in Australia,23 Sweden,17 Nigeria,26 India,27 Scotland,30 and
TABLE 1.
Characteristics of the included studies on association between alcohol consumption and age-related cataract in the
meta-analysis

Follow-up Cataract
Author (year) Study name Region Ethnicity Sample size Age, y Sex period, y assessment
Cohort studies
Kanthan et al. Blue Mountain Australia Whites 2078 Q49 Both 10 Extraction
(2010)23 Eye Study
Lindblad et al. Swedish Sweden Whites 34,713 49Y83 Female 7 Extraction
(2007)17 Mammography
Cohort
Klein et al. Beaver Dam United States Whites 3334 43Y86 Both 10 NC, CC,
(2003)18 Eye Study PSC
Chasan-Taber Nurses’ Health United States Whites 50,461 Q45 Female 12 Extraction
et al. (2000)24 Study
Manson et al. Physicians’ Health United States Whites 17,824 40Y84 Male 5 Extraction
(1994)25 Study
Case-control studies
Echebiri et al. V Nigeria Blacks 530 Case patients/ 40Y89 Both V NC, PSC
(2010)26 530 control subjects
Ughade et al. V India Indians 262 Case patients/ 51Y70 Both V Any
(1998)27 262 control subjects cataract
Phillips et al. V Scotland Whites 990 Case patients/ NA Both V Any
(1996)30 900 control subjects cataract
Tavani et al. V Italy Whites 207 Case patients/ Median age, Both V Any
(1996)28 706 control subjects 63/62 cataract
Munoz et al. V United States Whites 119 Case patients/ NA Both V PSC
(1993)29 120 control subjects
NA indicates not available; NC, nuclear cataract; CC, cortical cataract; PSC, posterior subcapsular cataract.

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474 Alcohol Consumption and CataractVGong et al.
TABLE 2.
Assessment of methodological quality of included studies on association between alcohol consumption and age-related
cataract

Methods for Methods for

measuring exposure measuring
Study Methods for selecting study participants (alcohol consumption) outcome (cataract)
23
Kanthan et al. (2010) At baseline examinations (1992Y1994), 3654 were Questionnaire Wisconsin Grading
interviewed and examined. All surviving participants System
were invited for reexamination after 5 y (1997Y1999)
and 10 y (2002Y2004), with 2335 (75.1% of survivors)
and 1952 (75.6% of survivors) returning for reexaminations
at these times, respectively.
Lindblad et al. (2007)17 Between March 1987 and December 1990, all women born Questionnaire National Cataract
between 1914 and 1948 living in the county of Uppsala Registry
and all women born between 1917 and 1948 living in the
county of Västmanland received by mail a self-administered
questionnaire regarding information about diet, family history
of breast cancer, and some lifestylefactors together with an
invitation to participate in a mammography screening program.
In September 1997, an extended follow-up questionnaire was
mailed to 56,030 women remaining in the cohort after
exclusion of those who had died or permanently moved out
of the study areas.
Klein et al. (2003)18 4926 persons participated in a baseline examination from March Questionnaire Wisconsin Grading
1988 to September 1990. Of the 3334 surviving persons who System
participated in a 5-y follow-up examination, 2764 (82.9%)
participated in the 10-y follow-up examination.
Chasan-Taber et al. The Nurses’ Health Study began in 1976 when 121,701, female Questionnaire Diagnosed by
(2000)24 registered nurses aged 30Y55 y and residing in 11 states ophthalmologist
returned a mailed questionnaire on medical history, use of oral
contraceptives, and risk factors for cancer and cardiovascular
disease. The follow-up rate for the cohort was 90.2% in 1992
as a percentage of total possible follow-up time.
Manson et al. (1994)25 Participants in the Physicians’ Health Study, a randomized trial Questionnaire Review of medical
of aspirin and beta-carotene among 22,071 male physicians record
aged 40Y84 y at entry in 1982, were included in these analyses
if they did not report cataract at baseline and if they provided
information about alcohol consumption and other cataract risk
factors. A total of 17,824 physicians satisfied these criteria.
Echebiri et al. (2010)26 530 subjects with visually impairing cataracts and 530 age- and Questionnaire Diagnosed by
sex-matched control subjects were recruited from patients ophthalmologist
aged 40 to 89 y attending the ophthalmology clinics at the
same hospital.
Ughade et al. (1998)27 The study included 262 cases of age-related cataract and an Questionnaire Diagnosed by
equal number of control subjects from the same hospital. ophthalmologist
Phillips et al. (1996)30 Stringently matched cataract-control pairs were included from Questionnaire Medical record
the same hospital.
Tavani et al. (1996)28 A total of 207 patients who had cataract extraction and 706 Questionnaire Diagnosed by
control subjects in a hospital for acute, nonneoplastic, ophthalmologist
nonoculistic, nondigestive tract diseases were interviewed
during their hospital stay.
Munoz et al. (1993)29 Clinical-based study including 238 case patients and Questionnaire Medical record
control subjects.
Kanthan et al. (2010)23 Lost-to-follow-up bias; survival bias; Multivariate analysis None reported
chance finding; residual confounding adjusted for age,
sex,smoking,
diabetes, myopia,
socioeconomic
status, and
steroid use

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 Alcohol Consumption and CataractVGong et al. 475
TABLE 2.
(Continued)

Methods for controlling

Study
17
Lindblad et al. (2007)
Klein et al. (2003)18
Chasan-Taber et al.
(2000)24
Manson et al. (1994)25
Echebiri et al. (2010)26
Ughade et al. (1998)27
Phillips et al. (1996)30
Tavani et al. (1996)28
Munoz et al. (1993)29
Design-specific sources of bias
Lost-to-follow-up bias; survival bias;
misclassification bias; chance finding;
residual confounding
Lost-to-follow-up bias; survival bias;
chance finding; residual confounding
Lost-to-follow-up bias; survival bias;
misclassification bias; chance finding;
residual confounding
Lost-to-follow-up bias; survival bias;
misclassification bias; chance finding;
residual confounding
Selection bias; misclassification bias;
chance finding; residual confounding
Selection bias; misclassification bias;
chance finding; residual confounding;
small sample size
Selection bias; misclassification bias;
chance finding; residual confounding
Selection bias; misclassification bias;
chance finding; residual confounding;
small sample size
Selection bias; misclassification bias;
chance finding; residual confounding;
small sample size
confounding and statistical methods Conflict of interest
Multivariate analysis adjusted for None reported
age, smoking,diabetes, hypertension,
steroid medication use, vitamin
supplement use, body mass index,
and educational level
Only age and sex were adjusted in None reported
the analysis
Multivariate analysis adjusted for age, None reported
period, smoking, body mass index,
area of residence, number of physician
visits, aspirin use, calories, regular
physical activity, hypertension,
or diabetes
Multivariate analysis adjusted for age, None reported
aspirin, and beta-carotene treatment,
smoking, history ofdiabetes, physical
activity, hypertension, and obesity
Only age and sex were adjusted in None reported
the analysis
Multivariate analysis adjusted for age, sex, None reported
socioeconomic status, illiteracy, history
ofdiabetes, diarrhea, glaucoma, myopia,
hypertension, and cheap cooking fuel
Only age and sex were adjusted in None reported
the analysis
Multivariate analysis adjusted for age, sex, None reported
education, smoking, diabetes, body mass
index, and energy intake
Multivariate analysis adjusted for age, None reported
sex, diabetes, education, smoking,
and hypertension

Italy.28 Of the 10 studies, 2 reported on all-female cohorts,17,24
1 reported on men only,25 and the other 7 included both men and
women. Two studies26,27 did not report the findings of moderate
alcohol consumption, whereas all identified studies reported the
associations between heavy alcohol consumption and cataract.
For the assessment of study quality, we examined the variables
included, methods for selecting study participants, methods for
measuring exposure (alcohol consumption) and outcome variable
(age-related cataract), design-specific sources of bias (excluding
confounding), methods for controlling confounding, statistical
methods (excluding control of confounding), and conflict of interest.
In general, all studies described sampling methods in the texts, albeit
in varying degrees. Six studies outlined specific exclusion criteria and
provided information on nonresponders. Among the five cohort
studies, three were population based and two were on specific working
groups. All the five case-control studies were clinically based. Data on
alcohol consumption were all self-reported and collected from
questionnaires whereas only two studies diagnosed cataract based on
lens photographs. In most of the included studies, cataract data were
retrieved by medical records or clinically diagnosed by ophthalmol-
ogists. Age and sex were adjusted in all included studies, whereas
smoking was adjusted in six studies. No studies reported conflict of
interest. The detailed assessment of study quality is shown in Table 2.
In the meta-analysis of 10 studies, the associations between
moderate alcohol consumption and age-related cataract were mar-
ginally nonsignificant (pooled RR, 0.88; 95% CI, 0.74 to 1.05; I2 =
82.1%) (Fig. 2), whereas heavy alcohol consumption was associated
with an increased risk of age-related cataract (pooled RR, 1.26; 95%
CI, 1.06 to 1.50; I2 = 58.9%) (Fig. 3).
Subgroup analyses were performed on study designs (cohort
studies vs. case-control studies) and confounders adjusted for (studies
adjusted for smoking vs. studies that did not adjust for smoking). The
association between heavy alcohol consumption and cataract was
stronger in case-control studies than in cohort studies. Adjusting for
smoking as a potential confounder attenuated the association between
heavy alcohol consumption and cataract. (Table 3).
Omission of individual studies revealed that no single study had
a particular influence on the pooled estimate. There was no evi-
dence of publication bias as indicated by a nonsignificant Egger
test (all p 9 0.05) and Begg test (all p 9 0.05) in all analyses.
DISCUSSION
In this systematic review and meta-analysis, we found that
heavy alcohol consumption significantly increased the risk of age-
related cataract, whereas moderate alcohol consumption may be

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476 Alcohol Consumption and CataractVGong et al.

FIGURE 2.
Random-effects meta-analysis evaluating the association between moderate alcohol consumption and cataract. ID, identification.

FIGURE 3.
Random-effects meta-analysis evaluating the association between heavy alcohol consumption and cataract. ID, identification.

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 Alcohol Consumption and CataractVGong et al. 477
TABLE 3.
Associations of alcohol consumption and age-related cataract stratified by study design and confounders adjusted for

Moderate alcohol consumption Heavy alcohol consumption

2
No. studies RR 95% CI I ,% No. studies RR 95% CI I2 , %
Study design
Cohort studies 5 0.87 0.70Y1.07 87.5 5 1.09 0.93Y1.28 46.7
Case-control studies 3 0.92 0.62Y1.37 68.4 5 1.64 1.28Y2.11 15.1
Confounders adjusted for
Adjusted for smoking 6 0.93 0.75Y1.16 84 6 1.17 0.97Y1.41 52.8
Did not adjust for smoking 2 0.76 0.65Y0.90 0 4 1.49 1.01Y2.21 69.2

protective for this ocular condition, although the finding was
marginally nonsignificant. Clinically, the findings indicated that in-
formation on a patient’s alcohol drinking history might be valuable to
general physicians and ophthalmologists when there is a diagnosis of
age-related cataract and should be collected on a routine basis in eye
clinics. Ophthalmologists should be aware that risk of age-related
cataract appears to vary by the amount of alcohol consumption.
Our study indicated that there may be a U-shaped association
between alcohol consumption and age-related cataract, which is
commonly observed in studies assessing the association between
alcohol consumption and cardiovascular diseases. These findings
may not be surprising as there are some shared risk factors between
age-related cataract and clinical cardiovascular diseases. A large
retrospective case-control study31 of adults older than 50 years
who underwent cataract surgery in Israel found that all risk factors
for cardiovascular diseases were significantly more prevalent in
cataract patients in univariate analysis. Meanwhile, multivariate
analysis also revealed a significant association of the exposures
related to cataractogenesis including diabetes, carotid artery dis-
ease, systemic arterial hypertension, peripheral vascular disease,
smoking, ischemic heart disease, chronic renal failure, hyperlip-
idemia, and Ashkenazi origin. In addition, the Blue Mountain Eye
Study found that baseline cardiovascular disease or vascular risk
factors such as obesity, hypertension, or angina were associated
with incident age-related cataract.32 Therefore, the effects of al-
cohol consumption on cardiovascular system and lens may share
common pathways in pathophysiology.
The biological plausibility behind the observed association has
not been elucidated, and we offer several possible explanations.
Oxidative stress is well known to be involved in the pathogenesis
of cataract.33 Heavy alcohol consumption could induce micro-
somal enzyme cytochrome CYP2E1 in the liver.34 Metabolism of
ethanol by cytochrome CYP2E1 could produce free radicals, which
may also lead to aggregation of lens proteins, leading to cataract
formation in elderly adults. Alternatively, maintenance of calcium
homeostasis is essential for normal functioning of the lens. Several
lens enzymes are calcium dependent and higher calcium levels are
shown to induce cataract in vitro, in both animal and human
studies.35 Acute alcohol exposure increases calcium permeability of
lens fiber cell membrane and inhibits calcium pumps on lens fiber
cells, resulting in higher intracellular lens calcium levels.36 This
disruption in calcium homeostasis may lead to cataract formation.
Despite a marginally nonsignificant association, our analysis re-
vealed that moderate alcohol consumption may reduce the risk for
age-related cataract. A population-based cohort study has shown
that light to moderate alcohol consumption could reduce the risk
of atherosclerosis of blood vessels.37 The protection afforded by
light to moderate alcohol consumption may possibly be attributed
to antithrombotic effects and inhibition of the atherogenic ac-
tion of high levels of low-density lipoprotein cholesterol. The ath-
erosclerosis of local blood vessels may reduce the risk of cataract by
supplying the lens with more oxygen and nutrients.
We have noticed that smoking is a confirmed risk factor for age-
related cataract and the observed association between alcohol
consumption and age-related cataract may be confounded by
smoking status. The subgroup analysis in our study found that
pooling the studies that had adjusted for smoking as a potential
confounder attenuated the associations between alcohol con-
sumption and age-related cataract but did not alter the trend.
Considering that there are only six studies that had adjusted for
smoking in this review, we cannot confirm whether smoking is a
confounder for the association between alcohol consumption and
age-related cataract. More well-designed cohort studies in non-
smokers are warranted to confirm if alcohol consumption is in-
dependently related to cataract.
During the peer-review process of this article, another meta-
analysis on the association between alcohol intake and age-
related cataract was published by Wang and Zhang.38 However,
the hypotheses, methods for study selection, and statistical anal-
yses between our study and theirs were completely different. First,
our hypothesis was that the risk of cataract is modified by the
amount of alcohol consumption whereas theirs was that the risk
of cataract differs between alcohol drinkers and nondrinkers.
Therefore, the main analyses as shown in the forest plots of the two
articles were completely different. In addition, some studies39,40
included in the article by Wang and Zhang were not included in
our analysis because these studies did not report the amount-
stratified analysis on the association between alcohol consumption
and cataract. Second, we included both case-control and cohort
studies whereas the article by Wang and Zhang only included cohort
studies. Although we acknowledge that cohort design provides
stronger evidence than case-control design, we think that it is im-
portant to include case-control studies in this meta-analysis, espe-
cially when the number of studies identified is small. Finally, we
believe that a stratified analysis for the studies that did and did not
adjust for smoking status should be performed on this research topic
because smoking is a well-established risk factor for age-related
cataract and is always associated with alcohol intake. Therefore,
smoking may be an important confounder for the association be-
tween alcohol intake and age-related cataract.
There are several strengths of the meta-analysis. From epidemio-
logic perspectives, only case-control or cohort studies were included,

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478 Alcohol Consumption and CataractVGong et al.
which results in the analysis having a higher evidence level than those
including cross-sectional studies or ecologic studies. In addition, the
sample sizes of the included studies are large and the follow-up periods
of the cohort studies are relatively longer (at least 5 years). Limitations
of this meta-analysis should also be acknowledged. First, the potential
biases in the original studies, methodological issues, and different
strategies for adjusting for confounders could affect the results from
this meta-analysis. The observed association may have been con-
founded by other unadjusted factors or selection bias. Second, the
number of the contributing studies was small such that the results of
subgroups analysis may not be robust. Third, different studies
reported different outcomes of age-related cataract, which make it
impossible for us to perform subgroup analysis on different cataract
subtypes including nuclear, cortical, and posterior subcapsular cata-
ract. Finally, publication bias could be of concern because studies that
report statistically significant results are more likely to get published
than studies that report nonsignificant results, and this could have
distorted the findings of our meta-analyses. Although the Egger test
and the Begg test indicated little evidence of publication bias in this
meta-analysis, the estimation may not be accurate enough as the
number of the studies is small.
In conclusion, this systematic review and meta-analysis of 10
epidemiologic studies demonstrated that effect of alcohol con-
sumption on age-related cataract is not linear and varies by the
amount of alcohol consumption. Moderate consumption appears to
be protective for age-related cataract with marginally nonsignificant
association, whereas heavy alcohol consumption is a risk factor for
this eye condition. The results of the meta-analysis suggest that
lifestyle changes in alcohol intake would help alter the incidence and
associated costs of age-related cataract, subsequently changing visual
functioning and health-related quality of life.
ACKNOWLEDGMENTS
Authors Yu Gong and Kehong Feng contributed equally to the work presented
and therefore should be considered equivalent first authors.
Received July 31, 2014; accepted February 6, 2015.
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Chen-Wei Pan
School of Public Health
Medical College of Soochow University
199 Ren Ai Rd
Suzhou 215123
China
e-mail: pcwonly@gmail.com