Long-term ambient ozone exposure and prevalence of age-related macular degeneration in Korean adults: a nationwide cross-sectional study with stratified analyses

Age-related macular degeneration (AMD) is a leading cause of irreversible visual impairment among older adults. Despite the accumulation of evidence linking air pollution to AMD, epidemiological evidence regarding long-term ozone (O 3 ) exposure and AMD remains limited and inconsistent. We investigated the association between long-term ambient O 3 exposure and AMD prevalence in Korean adults. Data from 13,985 participants aged ≥ 40 years from the Korea National Health and Nutrition Examination Survey (2017–2021) were analyzed. AMD was assessed via fundus photography. Long-term O 3 exposure was estimated using 1-, 3-, and 5-year moving averages. Multivariable logistic regression estimated odds ratios (ORs) per interquartile range (IQR) increase in O 3 concentration. Among the participants, 1,999 (14.3%) had AMD. After full adjustment, O 3 exposure was significantly associated with higher odds of AMD across all exposure windows (1-year: OR 1.11 [95% CI 1.02–1.20]; 3-year: OR 1.12 [95% CI 1.04–1.22]; 5-year: OR 1.10 [95% CI 1.02–1.19]). In subgroup analyses, the association was generally consistent across subgroups, with significant effect modification only for residential region ( P -interaction < 0.0001). The association was stronger among urban residents (3-year OR 1.32; 95% CI 1.18–1.48) than rural residents (OR 0.97; 95% CI 0.86–1.09). Long-term ambient O 3 exposure was associated with a higher prevalence of AMD among Korean adults. Although the observed association may reflect other environmental characteristics, the stronger association observed among urban residents warrants further investigation. Prospective studies are needed to clarify temporal relationships and identify susceptible populations.