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Arcus senilis - an indicator of age

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Volume 11 Number 1 January - June 2011

Medico-Legal Update
An International Journal

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1 A pilot study of dilated cardiomyopathy (DCM) In western Uttar Pradesh, India -A four year review
Ajoy Deshmukh, Avnish Deshmukh, Geeta Deshmukh, Prem K. Garg
4 Epidemiological study of non fatal road traffic accidents in Rohilkhand Region
Ajit Singh, Anchit Goel, Shekhar
8 Arcus senilis – An indicator of age
S.S.Oberoi, R.K.Gorea, Hardev Singh, Parminder Sing, A.D.Aggarwal
11 Implants - defining absolute anchorage
Namrataa Rastogi, Dheeraj Kumar, Praveen Mehrotra, Amol Bansal
16 A case report of Suicidal death of a female prisoner consuming formalin in rims Hospital, Kadapa –
How far Hospital administration is responsible?
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17 Study of bilateral asymmetry of tibia in Vidarbha region of Maharashtra
Charulata Annaji Satpute*, Meena Meshram
19 The use of digital C-arm fluoroscopy in the surgical removal of foreign bodies from maxillofacial
region
Iqbal Ali, Mohd. Faisal, Chetan Chandra , Vikas Kumar, Abu Amir
21 Myocardial infarction in a 22 year old male- A case report
Shankar M Bakkannavar, Francis N P Monteiro*, Prashantha Bhagavath, Kiran Yagain, Yajnesh Kidiyoor,
Pradeep Kumar G
24 Profile of poisoning cases at Belgaum, Karnataka: A cross sectional study
Gurudut K.S, Hareesh .S.Gouda, Sunil.C.Aramani, Manjula Bai K.H
28 An analysis of 188 cases of fall from height at Belgaum, Karnataka
Hareesh .S.Gouda, Ajaykumar T.S
31 Adenomatoid odontogenic tumour of maxilla – A case report
Kamala R., Sunita Srivastava
34 Cyber crime - A Review
Satish.N.T, Dayananda.R, Harish.s
38 Primary squamous cell carcinoma of the gingiva -A case report
Nidha Gaba, Pramod G. V., Ashok L , D.s Mehta
42 Xerostomia: A review
Poornima R., Rajeshwari G. Annigeri, Ashok L
49 Sialorrhea: A review
Poornima R., Rajeshwari G. Annigeri, Ashok L
55 Clinico- medicolegal study of aluminium phosphide poisoning
Puneet Khurana, J.S.Dalal, A. S. Multani , H.R. Tejpal
60 Myocardial infarction resulting in head injuries-A medico legal point of view
Putul Mahanta
62 Fatal cardiogenic shock after electroconvulsive therapy: A case report
Manish Shrigiriwar*, Rajesh Bardale
64 A case report of- autohysterectomy
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66 Embalming of cadavers by gravitational method
Rohit C. Zariwala, Dimple S. Patel
68 Profile of medicolegal cases in northan tribal region of Andhra Pradesh
Ajay Khade, Rajinsh Borkar, Mohammed Shakeel Mohammed Bashir
71 Efficacy of preoperative ultrasonography in the evaluation of tumor thickness of tongue
Vijayalaxmi, Ashok L, Sujatha. G.P.

Medico-Legal Update. Jan. - June 2011, Vol. 11, No. 1

Arcus senilis – An indicator of age
S.S.Oberoi*, R.K.Gorea**, Hardev Singh***, Parminder Singh****, A.D. Aggarwal*****
*Associate Professor, Forensic Medicine, Government Medical College, Patiala, **Professor & Head, Forensic Medicine, Gian Sagar Medical College,
Banur, Patiala, ***Associate Professor, Ophthalmology, Government Medical College, Patiala, ****Medical Officer, Punjab Civil Medical Services,
Jalandhar, *****Assistant Professor, Forensic Medicine, Post Graduate Institute of Medical Sciences, Rohtak

Abstract study was done to find out whether there is any definite correlation
between arcus senilis with age or not; focussing on finding a useful
The findings suggestive of advancing age in adults include fusion relationship between changes of arcus senilis with age in the age group
of skull sutures, sternum, pubic symphysis, arcus senilis, elasticity of of 40-70 years. This can be of great value for poor patients in remote
skin in sun protected areas, evidence of osteoarthritis, gingival shrinkage, areas and rural dispensaries where no facility of investigation is present.
greying and thinning of hair, cataracts, kyphosis, etc. In this study, the
frequency and size of arcus senilis were found to be positively associated Aims and objectives
with age, but provided no useful guide to the determination of age.
Age should be estimated through physical examination; life history, 1. To determine the incidence of arcus senilis in the age group of
matching local or national events with personal milestones; and existing 40-70 years
nonformal documents. Individual ageing features have a poor positive 2. To generate data for age estimation using the age related changes
predictive value for age, but in combination, are suggestive of of arcus senilis
advancing age.
Material and methods
Keywords The present study comprised of 500 cases in the age group of 40-
Arcus senilis, incidence, grading, density, age estimation. 70 years of either sex taken randomly. The complete data of the
persons was collected including proof of age and filled on a proforma.
Introduction The persons having diabetes melitus, history of trauma to eye and
history of ocular surgery; and with no documentary proof of age were
Many adults do not have documents of birth, either because they excluded from the study. Each subject was examined for the presence
have been lost or because there has been no routine recording of of arcus senilis using the unaided human eye in adequate light. An
birth. In Western countries and now-a-days in India, date of birth is arcus senilis was said to be present if the cornea showed an opaque arc
used as a basic identifier, and access to services and support tends to (which is greater than a quarter of the circumference of the cornea) or
be age regulated. Doctors are not infrequently asked to write formal ring in either or both eyes. Arcus senilis was graded according to the
reports estimating the true age of adults; however, there are no existing position it is present in clockwise pattern.
guidelines to assist in this task. Determination of age in the living • Grade 0 No evidence of arcus senilis
person is a baffling problem and is very important in medicolegal cases • Grade 1 Arcus senilis 11’o clock to 1’o clock
especially in old age. As the person grows older, study of sternum, • Garde 2 Arcus senilis 10’o clock to 2’o clock
public symphsis and the closure of sutures of skull helps us in estimating • Grade 3 Arcus senilis 9’o clock to 3’o clock
the age. • Grade 4 Arcus senilis 8’o clock to 4’o clock
Like other body parts, age related changes also occur in cornea • Grade 5 Arcus senilis 7’o clock to 5’o clock
inlcuding change of curvature, diameter, aspherity, thickness, etc. • Grade 6 Arcus senilis complete
Arcus senilis is a deposition of lipids at the corneal periphery and is
dependent on vascularity for formation and is not a degenerative Observations
change. Arcus senilis needs accurate measurement of its width with
digitizier and biomicroscopic examination of cornea.1,2 The decrease in
clarity seen in all corneal layers with increasing age corresponds with Discussion
both the decrease in epithelial luster and the increased stromal relucency The results of our study are also similar with study of Pe’er et al4
that is known to occur in the aging eye. It has been demonstrated that which found that the size and frequency of arcus senilis is positively
a linear decrease in both anterior and posterior keratocyte density is a correlated with age. The present study shows that arcus senilis is
function of age.2 absent in 33.33% cases in the age group of 40-45 years and 3.23% in
The prevalence of arcus increases with age, and it appears more in the age group of 56-60 years. Arcus senilis is present in 100% cases in
blacks and males.3 The frequency and size of arcus senilis are positively age group of 61-70 years. Arcus senilis is complete in 3 out of 144
associated with age; there is a positive corelation between the size of cases in the age group 40-45 years and in 22 out of 30 cases in the age
corneal arcus and the level of cholesterol and low density lipoporotein group of 66-70 years. Present study shows that the development of
in males; and that there is negative corelation between corneal arcus arcus senilis starts at 12 o’clock sector of the peripheral cornea. It
and diastolic blood pressure in both sexes.4 Arcus senilis appears to be expands sideways nasally and temporally symmetrically. These results
related to cardiovascular diseases but is no reliable predictor of the are similar to the study of Phillips et al6.
disease. It has been found that there is no definite corelation between A high density of the same was observed in the age group of 66-
incidence of arcus senilis width and age.3 70 years (24 out of 30 cases). These results show that the frequency
Arcus senilis appears to be related with alcoholism and also with and density of arcus senilis is positively corelated with age and is similar
the levels of potassium, sodium, calcium, glycosated heamoglobulin, with the study of Phillips et al6. Further, age is highly significant for
vascular disease, myocardial infarction, weight of the body, smoking, frequency and density of arcus senilis. But arcus senilis is of little value
education, geographic areas, family history, contraceptive drug usage, in estimation of age; however, it may be used in conjunction with
sex hormone levels, menopausal history, body mass index, race and other factors. A recent study has found that greying of the hair, skin
strain on the eyes.5 inelasticity, arcus senilis, and baldness were not predictors of mortality
The presence and pattern of arcus senilis are visible indicators of as a measure of biological age.7 A study amongst London Civil Servants
age. Greying of hair and arcus senilis occur with advancing age. This aged from 37 to 58 years of age found that arcus senilis may be a

8 S.S. Oberoi / Medico-Legal Update. Jan. - June, 2011, Vol. 11, No. 1
Table 1: Age distribution of grades of Arcus senilis
Age Total cases Grade of arcus senilis
0 1 2 3 4 5 6
40-45 144 48 33.33% 29 20.14% 42 29.17% 18 12.50% 2 1.39% 2 1.39% 3 2.08%
46-50 144 12 8.33% 38 26.39% 26 18.06% 40 27.78% 10 6.94% 2 1.39% 16 11.11%
51-55 88 4 4.55% 16 18.18% 22 25.00% 32 36.36% 2 2.27% 1 1.14% 11 12.50%
56-60 62 2 3.23% 4 6.45% 4 6.45% 10 16.13% 8 12.90% 6 9.68% 28 45.16%
61-65 32 0 0.00% 0 0.00% 8 25.00% 10 31.25% 2 6.25% 2 6.25% 10 31.25%
66-70 30 0 0.00% 0 0.00% 0 0.00% 2 6.67% 2 6.67% 4 13.33% 22 73.33%
Total 500 66 13.20% 87 17.40% 102 20.40% 112 22.40% 26 5.20% 17 3.40% 90 18.00%
P <0.001 highly significant

Table 2: Arcus senilis according to built

Built Total cases Grade of arcus senilis
0 1 2 3 4 5 6
Thin 48 8 16.67% 8 16.67% 8 16.67% 8 16.67% 2 4.17% 2 4.17% 12 25.00%
Average 350 48 13.71% 66 18.86% 66 18.86% 84 24.00% 24 6.86% 11 3.14% 51 14.57%
Obese 102 10 9.80% 13 12.75% 28 27.45% 20 19.61% 0 0.00% 4 3.92% 27 26.47%
P >0.05 not significant

Table 3: Arcus senilis according to nourishment

Nourish Total Grade of arcus senilis
ment cases 0 1 2 3 4 5 6
Poor 2 0 0.00% 0 0.00% 2 100.00% 0 0.00% 0 0.00% 0 0.00% 0 0.00%
Moderate 276 26 9.42% 56 20.29% 60 21.74% 57 20.65% 14 5.07% 13 4.71% 51 18.48%
Well 222 40 18.02% 31 13.96% 40 18.02% 55 24.77% 12 5.41% 4 1.80% 39 17.57%
P >0.05 not significant

Table 4: Arcus senilis according to sex

Sex Total Grade of arcus senilis
cases 0 1 2 3 4 5 6
Male 330 40 12.12% 55 16.67% 64 19.39% 84 25.45% 20 6.06% 8 2.42% 59 17.88%
Female 170 26 15.29% 32 18.82% 38 22.35% 28 16.47% 6 3.53% 9 5.29% 31 18.24%
P >0.05 not significant

Table 5: Arcus senilis according to area

Area Total Grade of arcus senilis
cases 0 1 2 3 4 5 6
Urban 328 42 12.80% 59 17.99% 66 20.12% 68 20.73% 20 6.10% 9 2.74% 62 18.90%
Rural 172 24 13.95% 28 16.28% 36 20.93% 44 25.58% 6 3.49% 8 4.65% 28 16.28%
P >0.05 not significant

Table 6: Arcus senilis in hypertensive persons

Disease Total Grade of arcus senilis
cases 0 1 2 3 4 5 6
Hypertension 21 1 4.76% 2 9.52% 3 14.29% 6 28.57% 1 4.76% 1 4.76% 7 33.33% P
<0.05 significant

Table 7: Density of arcus senilis

Age/Sex Total cases Density of arcus senilis
Absent Low High
40-45 144 48 33.33% 81 56.25% 15 10.42%
46-50 144 12 8.33% 100 69.44% 32 22.22%
51-55 88 4 4.55% 53 60.23% 31 35.23%
56-60 62 2 3.23% 20 32.26% 40 64.52%
61-65 32 0 0.00% 10 31.25% 22 68.75%
66-70 30 0 0.00% 6 20.00% 24 80.00%
Total 500 66 13.20% 270 54.00% 164 32.80%
Male 330 40 12.12% 175 53.03% 115 34.85%
Female 170 26 15.29% 95 55.88% 49 28.82%

S.S. Oberoi / Medico-Legal Update. Jan. - June, 2011, Vol. 11, No. 1 9
 marker of biological rather than chronological age.8 Accurate estimation of age for living adults is of central importance
In the age of 40-70 years, 87.88% males and 84.71% females in ensuring access to correct services and medical care. Adults from
show arcus senilis. The high density of arcus senilis is present in 34.85% countries with fragile civil infrastructure often have incorrect dates of
males and 28.82% females in the age group of 40-70 years. Thus the birth accorded by clerical error, which they may need to change.
frequency and density of arcus senilis is not significant for sex. This is in Doctors should not rely on physical examination alone to estimate age,
agreement with the study by Pe’er et al4 who found that corneal arcus as there is significant interpersonal and intercultural variability in the
is more frequent in males and with study of Patterson3 who found relationship between morphological characteristics of aging and age.
that the arcus senilis appears more in males. Our study also agrees with A combination of physical examination, careful life history, and
study of Karoly and Balazsy9, who found that occurrence of arcus corroborating documents is likely to produce a more accurate
senilis, is significantly higher in males, but it increases in strong estimation of age. Accuracy of age estimation should be subject to
correlation with age in both sexes. three tests: biological plausibility, historical plausibility, and corroboration
A general absence of corelative significance of cornea with built, from reputable sources.12 Estimates of age made by forensic scientists
nourishment, sex and area of living has been observed. The built is not tend to underestimate the ages of older people, and overestimate the
significant for presence of arcus senilis. Present study shows that the ages of younger people.13
percentage of high density arcus senilis is higher in obese than that of
average built persons and thin built persons, but it is not significant References
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Arcus senilis has been found to have an association with Ophthalmol 1979;21:1485-95.
hypertension (p < 0.05). Similar findings have been reported by larger 2. Kotulak JC, Brungardt T. Age-related changes in the cornea. J Am
studies including hypercholesterolemia, xanthelasmas, alcohol, cigarette Optom Assoc 1980;51:761–5.
smoking, diabetes, age, and coronary heart disease. Nevertheless, it is 3. Patterson L. Arcus senilis: an important forensic physical finding.
not clear whether or not corneal arcus is an independent risk factor Am J Forensic Med Pathol 1982;3(2):115-8.
for coronary heart disease.10 4. Pe’er J, Vidaurri J, Halfon ST, Eisenberg S, Zauberman H. Association
between corneal arcus and some of the risk factors for coronary
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in middle-aged persons and no statistically significant difference in Alcohol Clin Exp Res 1980;4(1):104-6.
incidence was found. In agreement with previously published 6. Phillips CI, Tsukahara S, Gore SM. Corneal arcus: some morphology
observations there was a progressive rise and strong association of and applied pathophysiology. Jpn J Ophthalmol 1990;34(4):442-
corneal arcus with increasing age.11 The present study shows that age 9.
is highly significant for arcus senilis however we cannot estimate age of 7. Bulpitt CJ, Antikainen RL, Markowe HL, Shipley MJ. Mortality
a person from arcus senilis alone; and the arcus senilis may complete at according to a prior assessment of biological age. Curr Aging Sci
the age of 40 years and may not even start at the age of 60 years. 2009;2(3):193-9.
Further nourishment is also found to be a significant factor for the 8. Bulpitt CJ, Shipley MJ, Broughton PM, Fletcher AE, Markowe HL,
presence and density of arcus senilis; being inversely corelated. The sex Marmot MG, Semmence A, Rose G. The assessment of biological
and built are not significant determinants for presence of arcus senilis age: a report from the Department of Environment Study. Aging
and density of arcus senilis. The main conclusion from this study must (Milano) 1994;6(3):181-91.
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persons gives no useful guide to the determination of age. 1999;140(49):2755-61.
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variable and nonspecific, at best providing support for minimum age artery disease risk factor. Atherosclerosis. 2007;193(2):235-40.
estimations. The phenomena we typically associate with aging (greying 11. Fernandez A, Keyes MJ, Pencina M, D’Agostino R, O’Donnell CJ,
of hair, arcus senilis and loss of skin elasticity) are complex phenomena Thompson PD. Relation of Corneal Arcus to Cardiovascular Disease
that also reflect genetic and environmental patterns and occurrence (From the Framingham Heart Study Data Set). Am J Cardiol
of illness. Although there is little data on cross cultural differences, 2009;103(1):64–66.
some of these phenomena may not occur at the same ages across 12. Proof of age required – estimating age in adults without birth
different settings.12 Arcus senilis, appears to occur at an earlier age in records. Aust Fam Physician 2010:39(7):518-521.
African Americans, than in Caucasian Americans, but this may be 13. Aykroyd RG, Lucy D, Pollard AM. Regression analysis in adult age
confounded by smoking or hypercholesterolaemia. There is no estimation. Am J Phys Anthropol 1997;104;259–65.
correlation between arcus width and increasing age.3

10 S.S. Oberoi / Medico-Legal Update. Jan. - June, 2011, Vol. 11, No. 1

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