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Research Tittle
Prevalence of enhanced retina light reflex (ERLR) sign and its association with social demographic factors in Clinic Optometry UKMKL.Introduction
Enhanced retina light reflex (ERLR) is a central ‘light streak’ that reflect from retina blood vessel wall which streaming with erythrocytes ADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“author”:{“dropping-particle”:””,”family”:”Brinchmann-hansenl”,”given”:”Olaf”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”id”:”ITEM-1″,”issued”:{“date-parts”:”1986″},”page”:”547-552″,”title”:”The intensity of the light reflex on retinal arteries and veins”,”type”:”article-journal”,”volume”:”64″},”uris”:”http://www.mendeley.com/documents/?uuid=ef3a8673-19d4-4dc5-8e94-ccbcd626f6ba”},”mendeley”:{“formattedCitation”:”(Brinchmann-hansenl, 1986a)”,”plainTextFormattedCitation”:”(Brinchmann-hansenl, 1986a)”,”previouslyFormattedCitation”:”(Brinchmann-hansenl, 1986a)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”}(Brinchmann-hansenl, 1986a). ERLR also described in other term including central arteriolar light reflex, arteriolar light reflex, blood vessel wall reflection, copper wiring and silver wiring ADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“DOI”:”10.1016/j.ophtha.2006.06.046″,”ISBN”:”1549-4713 (Electronic)”,”ISSN”:”01616420″,”PMID”:”17070582″,”abstract”:”Purpose: To assess the prevalence, associated risk factors and prognosis (mortality) of the enhanced retinal arteriolar light reflex sign in an older Australian population. Design: Population-based cross-sectional study. Participants: Three thousand six hundred fifty-four participants (82.4% response) ages ?49 years from Australia’s Blue Mountains region. Methods: Retinal photographs of participants were graded for presence and severity of the enhanced arteriolar light reflex sign by comparison with standard photographs. Associations with systemic factors (subject-specific) and ocular variables (eye-specific) were assessed by logistic regression. Mortality data were obtained using the Australian National Death Index. Hazard ratios were calculated using Cox regression. Main Outcome Measures: Prevalence of enhanced arteriolar light reflex and associations with demographic variables (age, gender), blood pressure, blood parameters, health risk behaviors, cataract, retinal vessel wall signs, retinopathy, and 10-year incident mortality. Results: The enhanced arteriolar light reflex sign was found in 1053 participants (31.7%, including 28.8% graded as mild and 2.9% as marked). Prevalence decreased with age (36.0%, 37.7%, 28.0%, and 18.8% for age groups ; 60, 60-69, 70-79 and ? 80 years, respectively, Ptrend;0.0001); odds ratio (OR) 0.78; and 95% confidence interval (CI) 0.72 to 0.85 per decade. Persons with cataract were less likely to have mildly enhanced light reflex (OR, 0.74; CI 0.64-0.87). After multivariate adjustment, mildly enhanced light reflex was significantly associated with serum glucose (OR 1.11 per SD increase), total cholesterol (OR 1.11), low-density lipoprotein (OR 1.55), triglycerides (OR 1.11), platelets (OR 0.89), and body mass index (OR 1.12). Markedly enhanced light reflex was significantly associated with mean arterial blood pressure (OR 1.24), heavy alcohol consumption (OR 2.66, ? 40 grams alcohol per day), and serum glucose (OR 1.16). Strong associations were demonstrated between presence of mildly enhanced light reflex and either arteriovenous nicking (OR 3.12) or retinopathy (OR 1.96). There was no association between mildly or markedly enhanced light reflex and either all-cause or vascular mortality. Conclusions: In this older population, the enhanced retinal arteriolar light reflex sign was a relatively common finding. Although some associations of this sign with vascular risk factors were found, only a marked level of enhanced li…”,”author”:{“dropping-particle”:””,”family”:”Kaushik”,”given”:”Shweta”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Tan”,”given”:”Ava Grace”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Mitchell”,”given”:”Paul”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Wang”,”given”:”Jie Jin”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”container-title”:”Ophthalmology”,”id”:”ITEM-1″,”issue”:”1″,”issued”:{“date-parts”:”2007″},”page”:”113-120″,”title”:”Prevalence and Associations of Enhanced Retinal Arteriolar Light Reflex. A New Look at an Old Sign”,”type”:”article-journal”,”volume”:”114″},”uris”:”http://www.mendeley.com/documents/?uuid=25841b4b-9b21-4561-a3c8-d9ea6294da33″},”mendeley”:{“formattedCitation”:”(Kaushik, Tan, Mitchell, ; Wang, 2007)”,”plainTextFormattedCitation”:”(Kaushik, Tan, Mitchell, ; Wang, 2007)”,”previouslyFormattedCitation”:”(Kaushik, Tan, Mitchell, ; Wang, 2007)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”}(Kaushik, Tan, Mitchell, & Wang, 2007). To access ERLR sign, fundus photo camera will be a valuable tool. It is possible to measure the width and intensity of blood column and central light reflex (Brinchmann-Hansen & Engvold 1986a).

The intensity and width of the ERLR depend on the reflectivity of the blood vessel. ERLR can be used to evaluate the morphological changes of the blood vessel especially related to systemic disease for example hypertension and arteriosclerosis (Wagner et al. 1947). Veins have lower intensity of ERLR compare to arteries. Previous researcher had explained theoretically about the changing of erythrocytes and plasma index affect the intensity of ERLR. Increasing of the plasma index and decreasing of the erythrocytes index will lower the intensity of veins compare to arteries ADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“author”:{“dropping-particle”:””,”family”:”Brinchmann-hansenl”,”given”:”Olaf”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”id”:”ITEM-1″,”issued”:{“date-parts”:”1986″},”title”:”The light streak on retinal vessels”,”type”:”article-journal”},”uris”:”http://www.mendeley.com/documents/?uuid=012c3eab-9929-4d71-b106-0354afe4a271″},”mendeley”:{“formattedCitation”:”(Brinchmann-hansenl, 1986b)”,”plainTextFormattedCitation”:”(Brinchmann-hansenl, 1986b)”,”previouslyFormattedCitation”:”(Brinchmann-hansenl, 1986b)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”}(Brinchmann-hansenl, 1986b).

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ERLR may affected by aging process. Enhanced retina arteriole light reflex sign was common with an overall prevalence of 32% among persons aged ? 50 years in Austrian population. Previous research showed that the presence mild enhanced retina arteriole reflex decrease as the age increasing. For marked enhanced retina arteriole, it does not have association with age ADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“DOI”:”10.1016/j.ophtha.2006.06.046″,”ISBN”:”1549-4713 (Electronic)”,”ISSN”:”01616420″,”PMID”:”17070582″,”abstract”:”Purpose: To assess the prevalence, associated risk factors and prognosis (mortality) of the enhanced retinal arteriolar light reflex sign in an older Australian population. Design: Population-based cross-sectional study. Participants: Three thousand six hundred fifty-four participants (82.4% response) ages ?49 years from Australia’s Blue Mountains region. Methods: Retinal photographs of participants were graded for presence and severity of the enhanced arteriolar light reflex sign by comparison with standard photographs. Associations with systemic factors (subject-specific) and ocular variables (eye-specific) were assessed by logistic regression. Mortality data were obtained using the Australian National Death Index. Hazard ratios were calculated using Cox regression. Main Outcome Measures: Prevalence of enhanced arteriolar light reflex and associations with demographic variables (age, gender), blood pressure, blood parameters, health risk behaviors, cataract, retinal vessel wall signs, retinopathy, and 10-year incident mortality. Results: The enhanced arteriolar light reflex sign was found in 1053 participants (31.7%, including 28.8% graded as mild and 2.9% as marked). Prevalence decreased with age (36.0%, 37.7%, 28.0%, and 18.8% for age groups < 60, 60-69, 70-79 and ? 80 years, respectively, Ptrend<0.0001); odds ratio (OR) 0.78; and 95% confidence interval (CI) 0.72 to 0.85 per decade. Persons with cataract were less likely to have mildly enhanced light reflex (OR, 0.74; CI 0.64-0.87). After multivariate adjustment, mildly enhanced light reflex was significantly associated with serum glucose (OR 1.11 per SD increase), total cholesterol (OR 1.11), low-density lipoprotein (OR 1.55), triglycerides (OR 1.11), platelets (OR 0.89), and body mass index (OR 1.12). Markedly enhanced light reflex was significantly associated with mean arterial blood pressure (OR 1.24), heavy alcohol consumption (OR 2.66, ? 40 grams alcohol per day), and serum glucose (OR 1.16). Strong associations were demonstrated between presence of mildly enhanced light reflex and either arteriovenous nicking (OR 3.12) or retinopathy (OR 1.96). There was no association between mildly or markedly enhanced light reflex and either all-cause or vascular mortality. Conclusions: In this older population, the enhanced retinal arteriolar light reflex sign was a relatively common finding. Although some associations of this sign with vascular risk factors were found, only a marked level of enhanced li…”,”author”:{“dropping-particle”:””,”family”:”Kaushik”,”given”:”Shweta”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Tan”,”given”:”Ava Grace”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Mitchell”,”given”:”Paul”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Wang”,”given”:”Jie Jin”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”container-title”:”Ophthalmology”,”id”:”ITEM-1″,”issue”:”1″,”issued”:{“date-parts”:”2007″},”page”:”113-120″,”title”:”Prevalence and Associations of Enhanced Retinal Arteriolar Light Reflex. A New Look at an Old Sign”,”type”:”article-journal”,”volume”:”114″},”uris”:”http://www.mendeley.com/documents/?uuid=25841b4b-9b21-4561-a3c8-d9ea6294da33″},”mendeley”:{“formattedCitation”:”(Kaushik et al., 2007)”,”plainTextFormattedCitation”:”(Kaushik et al., 2007)”,”previouslyFormattedCitation”:”(Kaushik et al., 2007)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”}(Kaushik et al., 2007). Another study done by ADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“author”:{“dropping-particle”:””,”family”:”Brinchmann-hansenl”,”given”:”Olaf”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Myhrez”,”given”:”Kjell”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”id”:”ITEM-1″,”issued”:{“date-parts”:”1987″},”page”:”206-212″,”title”:”The light reflex in retinal vessels and its relation to age and systemic blood pressure”,”type”:”article-journal”,”volume”:”65″},”uris”:”http://www.mendeley.com/documents/?uuid=415be689-0397-4009-bd89-a2a148cb4eef”},”mendeley”:{“formattedCitation”:”(Brinchmann-hansenl & Myhrez, 1987)”,”plainTextFormattedCitation”:”(Brinchmann-hansenl & Myhrez, 1987)”,”previouslyFormattedCitation”:”(Brinchmann-hansenl & Myhrez, 1987)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”}(Brinchmann-hansenl & Myhrez, 1987) show that as the age increasing, the intensity of ERLR increasing. This may due to morphological change of blood vessel wall. Young subject have high transparency of retinal vessel walls and light are reflected from erythrocytes in the blood column. While age increasing, optical and refractive index is changing occur. Light reflex increases when the variation of index between blood column and surrounding become greater. Thus, it is possible ERLR is highly affected by age.

Besides that, systemic disease such as diabetes retinopathy tends to affect the intensity of ERLR. Diabetes retinopathy is a complication of diabetes that damages the blood vessel of retina which can be observed through ERLR in fundus photography. Diabetes retinopathy will cause increasing ERLR especially arteriolar light reflex. The increasing of ERLR associated with the hyalinisation of the anterior wall. Lipid deposit at endothelium of the anterior wall. As the disease progress, the arteriole become rigid and contractile power diminished. These cause arteries have an extreme bright central light streak with a metallic appearance like bright burnished copper wire, copper wire artery. The light reflex on surface of the blood vessel lighter and wider than normal. If the condition become more severe, the ERLR appears as white cord, silver wire artery ADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“DOI”:”10.4172/2155-6156.S3-003″,”author”:{“dropping-particle”:””,”family”:”Kytö”,”given”:”Janne P”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Lindström-karjalainen”,”given”:”Maritta”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Summanen”,”given”:”Paula A”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”id”:”ITEM-1″,”issued”:{“date-parts”:”2012″},”title”:”Not Only Diabetic Retinopathy – Retinal Vascular Lesions and Signs in Diabetic Patients : Description and Associations”,”type”:”article-journal”},”uris”:”http://www.mendeley.com/documents/?uuid=c642596b-b9c3-4ae4-9cfa-e9b5f09bdcc2″},”mendeley”:{“formattedCitation”:”(Kytö, Lindström-karjalainen, & Summanen, 2012)”,”plainTextFormattedCitation”:”(Kytö, Lindström-karjalainen, & Summanen, 2012)”,”previouslyFormattedCitation”:”(Kytö, Lindström-karjalainen, & Summanen, 2012)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”}(Kytö, Lindström-karjalainen, & Summanen, 2012). Prevalence of the diabetic retinopathy higher among Indian 30.7%, follow by Chinese 26.2% and 25.5% in Malays for Singapore populationADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“DOI”:”10.1016/j.ophtha.2017.10.026″,”ISSN”:”15494713″,”abstract”:”Purpose: To evaluate the prevalence and risk factors for diabetic retinopathy (DR) in the Singapore Epidemiology of Eye Diseases (SEED) Study. Design: Population-based, cross-sectional study. Participants: Persons of Malay, Indian, and Chinese ethnicity aged 40+ years, living in Singapore. Methods: Diabetes was defined as nonfasting plasma glucose ?200 mg/dl (11.1 mmol/l), glycated hemoglobin A1c (HbA1c) >6.5%, self-reported physician-diagnosed diabetes, or the use of glucose-lowering medication. Retinal photographs, were graded for the presence and severity of DR using the modified Airlie House classification system. Main Outcome Measures: Diabetic retinopathy, diabetic macular edema (DME), vision-threatening diabetic retinopathy (VTDR), defined as the presence of severe nonproliferative or proliferative DR, or clinically significant macular edema (CSME). Results: Of the 10 033 subjects, 2877 (28.7%) had diabetes and gradable photographs for analysis. The overall age-standardized prevalence (95% confidence interval CI) was 28.2% (25.9-30.6) for any DR, 7.6% (6.5-9.0) for DME, and 7.7% (6.6-9.0) for VTDR. Indians had a higher prevalence of any DR (30.7% vs. 26.2% in Chinese and 25.5% in Malays, P = 0.012); a similar trend was noted for any DME (P = 0.001) and CSME (P = 0.032). Independent risk factors for any DR were Indian ethnicity (odds ratio OR, 1.41; 95% CI, 1.09-1.83, vs. Chinese), diabetes duration (OR, 1.10; 95% CI, 1.08-1.11, per year), HbA1c (OR, 1.25; 95% CI, 1.18-1.32, per %), serum glucose (OR, 1.03; 95% CI, 1.00-1.06, per mmol/l), and systolic blood pressure (OR, 1.14; 95% CI, 1.09-1.19, per 10 mmHg). Diastolic blood pressure (OR, 0.74; 95% CI, 0.65-0.84, per 10 mmHg increase), total cholesterol (OR, 0.87; 95% CI, 0.80-0.95, per mmol/l increase), and low-density lipoprotein (LDL) cholesterol (OR, 0.83; 95% CI, 0.74-0.92, per mmol/l increase) were associated with lower odds of any DR. Risk factors were largely similar across the 3 ethnic groups. Conclusions: Indian Singaporeans have a higher prevalence of DR and DME compared with Chinese and Malays. Major risk factors for DR in this study were similar across the 3 ethnic groups. Addressing these risk factors may reduce the impact of DR in Asia, regardless of ethnicity.”,”author”:{“dropping-particle”:””,”family”:”Tan”,”given”:”Gavin S.”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Gan”,”given”:”Alfred”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Sabanayagam”,”given”:”Charumathi”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Tham”,”given”:”Yih Chung”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Neelam”,”given”:”Kumari”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Mitchell”,”given”:”Paul”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Wang”,”given”:”Jie Jin”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Lamoureux”,”given”:”Ecosse L.”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Cheng”,”given”:”Ching Yu”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Wong”,”given”:”Tien Y.”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”container-title”:”Ophthalmology”,”id”:”ITEM-1″,”issued”:{“date-parts”:”2017″},”page”:”1-8″,”publisher”:”American Academy of Ophthalmology”,”title”:”Ethnic Differences in the Prevalence and Risk Factors of Diabetic Retinopathy. The Singapore Epidemiology of Eye Diseases Study”,”type”:”article-journal”},”uris”:”http://www.mendeley.com/documents/?uuid=0c2c8180-ab71-4161-89ae-0c4790fcd40c”},”mendeley”:{“formattedCitation”:”(Tan et al., 2017)”,”plainTextFormattedCitation”:”(Tan et al., 2017)”,”previouslyFormattedCitation”:”(Tan et al., 2017)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”}(Tan et al., 2017). Hence, ethnic may have association with ERLR sign according to the prevalence of diabetes retinopathy.

Next, the prevalence of diabetes retinopathy is higher in male (21.3%) compare to female (14.6%) with increasing age and duration of diabetes ADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“DOI”:”10.5455/2320-6012.ijrms201408069″,”ISSN”:”2320-6071″,”author”:{“dropping-particle”:””,”family”:”T”,”given”:”Naveen”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”T”,”given”:”Nagi”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”N”,”given”:”Radha”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”container-title”:”International Journal of Research in Medical Sciences”,”id”:”ITEM-1″,”issue”:”3″,”issued”:{“date-parts”:”2014″},”page”:”1045″,”title”:”Diabetic eye screening in multi ethnic population of Malaysia: epidemiological risk factors for development of diabetic retinopathy”,”type”:”article-journal”,”volume”:”2″},”uris”:”http://www.mendeley.com/documents/?uuid=d3a63788-1acf-4567-affc-28aa80268d02″},”mendeley”:{“formattedCitation”:”(T, T, & N, 2014)”,”plainTextFormattedCitation”:”(T, T, & N, 2014)”,”previouslyFormattedCitation”:”(T, T, & N, 2014)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”}(T, T, & N, 2014). According to ADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“DOI”:”10.4172/2155-6156.S3-003″,”author”:{“dropping-particle”:””,”family”:”Kytö”,”given”:”Janne P”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Lindström-karjalainen”,”given”:”Maritta”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Summanen”,”given”:”Paula A”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”id”:”ITEM-1″,”issued”:{“date-parts”:”2012″},”title”:”Not Only Diabetic Retinopathy – Retinal Vascular Lesions and Signs in Diabetic Patients : Description and Associations”,”type”:”article-journal”},”uris”:”http://www.mendeley.com/documents/?uuid=c642596b-b9c3-4ae4-9cfa-e9b5f09bdcc2″},”mendeley”:{“formattedCitation”:”(Kytö et al., 2012)”,”plainTextFormattedCitation”:”(Kytö et al., 2012)”,”previouslyFormattedCitation”:”(Kytö et al., 2012)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”}(Kytö et al., 2012), increasing of the ERLR is causing by diabetes retinopathy as it causing arteriole become rough and loss of contraction. With this, indirectly we saw that ERLR may affect by gender as well. But from ADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“author”:{“dropping-particle”:””,”family”:”Brinchmann-hansenl”,”given”:”Olaf”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Myhrez”,”given”:”Kjell”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”id”:”ITEM-1″,”issued”:{“date-parts”:”1987″},”page”:”206-212″,”title”:”The light reflex in retinal vessels and its relation to age and systemic blood pressure”,”type”:”article-journal”,”volume”:”65″},”uris”:”http://www.mendeley.com/documents/?uuid=415be689-0397-4009-bd89-a2a148cb4eef”},”mendeley”:{“formattedCitation”:”(Brinchmann-hansenl & Myhrez, 1987)”,”plainTextFormattedCitation”:”(Brinchmann-hansenl & Myhrez, 1987)”,”previouslyFormattedCitation”:”(Brinchmann-hansenl & Myhrez, 1987)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”}(Brinchmann-hansenl & Myhrez, 1987) research result, there are no association between sex and intensity of ERLR.

Justification
Prevalence of the ERLR sign and its association with age remains active investigation but not clearly approve that. From previous research ADDIN CSL_CITATION {“citationItems”:{“id”:”ITEM-1″,”itemData”:{“author”:{“dropping-particle”:””,”family”:”Brinchmann-hansenl”,”given”:”Olaf”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},{“dropping-particle”:””,”family”:”Myhrez”,”given”:”Kjell”,”non-dropping-particle”:””,”parse-names”:false,”suffix”:””},”id”:”ITEM-1″,”issued”:{“date-parts”:”1987″},”page”:”206-212″,”title”:”The light reflex in retinal vessels and its relation to age and systemic blood pressure”,”type”:”article-journal”,”volume”:”65″},”uris”:”http://www.mendeley.com/documents/?uuid=415be689-0397-4009-bd89-a2a148cb4eef”},”mendeley”:{“formattedCitation”:”(Brinchmann-hansenl & Myhrez, 1987)”,”plainTextFormattedCitation”:”(Brinchmann-hansenl & Myhrez, 1987)”,”previouslyFormattedCitation”:”(Brinchmann-hansenl & Myhrez, 1987)”},”properties”:{“noteIndex”:0},”schema”:”https://github.com/citation-style-language/schema/raw/master/csl-citation.json”}(Brinchmann-hansenl & Myhrez, 1987), it state that prevalence of ERLR increasing with age. But (Kaushik et al., 2007) found contra result that increasing of age will decreases the intensity of ERLR. In my research, I will continue investigate further about increasing intensity and width of ERLR start from age greater equal to 40 and above. Currently, the association between ERLR sign with race and gender still haven’t proved yet. No research has been done related to it. According to (Tan et al., 2017), Indian have highest prevalence to get diabetes retinopathy and (T, T, ; N, 2014) found that male have higher tendency to get diabetes retinopathy with increasing age. ERLR is an early sign to detect the progression of disease. Thus in my paper, I will do futher investigation about the Prevalence of enhanced retina light reflex (ERLR) sign and association of ERLR with social demographic factors especially age , gender and race in Clinic Optometry UKMKL age greater equal 40 and above.

Research Question
What is the prevalence of Enhanced Retinal Light Reflex (ERLR) sign age greater equal to 40 in Clinic Optometry UKMKL?
Is that any association between Enhanced Retinal Light Reflex (ERLR) sign with social demographic factors (age, gender and race)?
Research Objective
5.1 General Objective
To determine prevalence of enhanced retina light reflex (ERLR) sign and its association with social demographic factors in Clinic Optometry UKMKL.
5.2 Specific Objective
To determine the prevalence of Enhanced Retinal Light Reflex (ERLR) sign age greater equal to 40 in Clinic Optometry UKMKL
To identify association between Enhanced Retinal Light Reflex (ERLR) sign with social demographic factors (age, gender and race)
Research Hypothesis
Higher prevalence of Enhanced Retinal Light Reflex (ERLR) sign age greater equal to 40 in Clinic Optometry UKMKL
Positive association between Enhanced Retinal Light Reflex (ERLR) sign with social demographic factors (age, gender and race)
Research Design
Cross sectional study
Subject Sample
Sampling method
Random sampling method will be perform among people age ?40 who having eye examination at Clinic Optometry UKMKL.

Subject criteria
Inclusive Criteria
Age of ?40
Visual acuity 6/9 or better
Any type of optical refractive error
Medication control for diabetes patient
Good image quality of fundus photography
Exclusive Criteria
Media opacities disease ( cataract or corneal opacities)
Research Location
Clinic Optometry UKMKL
Sample size
Prevalence sample size calculation formula by (Daniel, 1999) is used.

n= Z2P(1-P)
d2
where n = sample size,
Z = Z statistic for a level of confidence,
P = expected prevalence or proportion
d = precision
n= 1.962(0.32)(1-0.32)
0.052
= 335 subjectExpected prevalence is 32% ( (Kaushik et al., 2007)
Prevalence between 10% to 90%, thus d =0.05 (Naing, Winn, ; Rusli, 2006)
Materials and method
Study Ethics Application
Ethical approval will be obtained from the Secretariat for Research and Ethnics, Faculty of Medicine, Univeristy Kebangsaan Malaysia and Medical Research and Ethnics Committee (MREC). All data collected will be confidential and only be used for this research only.
Subject Authority
The involvement of all participants in this study will be voluntary and the identity of the participants will be kept confidential by the researcher. All participants will be provided a written informed consent form and information sheet before data collection. Participants will be given the right to know the results of their tests. However, overall study findings will only be provided upon request.

Instrument
Fundus photography
Procedures
Demographic collection
Demographic data that will be collected is age, race and gender among people with age ?40
.

Grading ERLR from Fundus photography
Statistical Analysis
Statistical analyses for this study will be performed using the Statistical Package for the Social Sciences (SPSS) version 22.0 for Windows (SPSS inc, Chicago, IL). A p-value less than 0.05 is defined as statistically significant. Kolmogorov-Smirnov test will be used to test normality of the data distribution. Parametric test will be conducted if data is normally distributed (p;0.05). Otherwise, non-parametric test will be employed.

Logistic Regression Model Analysis
Logistic regression test can be use to analysis the relationship between prevalence of the ERLR with gender and race.

Pearson’s correlation/ Spearman correlation Analysis
Pearson’s correlation will be used to analysis the relationship between ERLR and age when the data are normally distributed. If data not normally distributed Spearman correlation analysis will be apply.

Thesis Flow Chart
55244965405Preparation Thesis Proposal
0Preparation Thesis Proposal

24384001206500
618490235585Proposal Presentation
0Proposal Presentation

24384001593850
7143753455035Thesis Writing
0Thesis Writing
2438400300926506184902423795Data Analysis
0Data Analysis
243840019615150243840071183506667501247140Find Subject age ?40 and taking fundus photography and taking demographic information
00Find Subject age ?40 and taking fundus photography and taking demographic information
61912518415Apply Ethics from Secretariat for Research and Ethics, National Univeristy of Malaysia
00Apply Ethics from Secretariat for Research and Ethics, National Univeristy of Malaysia

Gann Chart
Month
Activities 2018 2019
Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun July Aug
Literature Review Thesis Planning and start doing proposal Proposal Presentation Data Collection Data Analysis Thesis and manuscript writting Thesis submittionReferences
Brinchmann?Hansen,O.; Sandvik, L. (1986).The intensity of the light reflex on retinal arteries and veins. Acta ophthalmologica, 64(5), 547-552.Kaushik, S., Tan, A. G., Mitchell, P., ; Wang, J. J(2007). Prevalence and associations of enhanced retinal arteriolar light reflex: a new look at an old sign. Ophthalmology, 114(1), 113-120.

Wagener H P, Clay G E ; Gipner J F (1947): Classification of retinal lesions in the presence of vascular hypertension. Trans Am Ophthalmol SOC 45: 57-73.

Brinchmann?Hansen, O., Myhre, K., ; Sandvik, L. (1987). The light reflex in retinal vessels and its relation to age and systemic blood pressure. Acta ophthalmologica, 65(2), 206-212.Kytö, J. P., Lindström-Karjalainen, M., ; Summanen, P. A. (2012). Not Only Diabeti c Retinopathy-Retinal Vascular Lesions and Signs in Diabetic Patients: Description and Associations. J Diabetes Metab S, 3.

Tan, G. S., Gan, A., Sabanayagam, C., Tham, Y. C., Neelam, K., Mitchell, P. ; Wong, T. Y. (2018). Ethnic Differences in the Prevalence and Risk Factors of Diabetic Retinopathy: The Singapore Epidemiology of Eye Diseases Study. Ophthalmology, 125(4), 529-536.

Kumar, N. (2017). Diabetic eye screening in multi ethnic population of Malaysia: epidemiological risk factors for development of diabetic retinopathy. International Journal of Research in Medical Sciences, 2(3), 1045-1049.

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