ORIGINAL ARTICLE

An Evaluation of the Arcus Corneae For Age Estimation

Boonsak Hanterdsith

ABSTRACT
Although the arcus corneae (AC) has long been used as an age indicator for forensic purposes, its diagnostic value has not been eval-
uated. To evaluate the AC as a predictor of chronological age, the author has studied the correlation of AC with respect to age of the
deceased. A cross-sectional study was conducted of 342 Thai corpses at the Maharat Nakhon Ratchasima Hospital, Thailand. AC was
graded into three levels: no AC, incomplete ring, and complete ring. One-way analysis of variance, chi-square test, binomial logistic re-
gression, sensitivity, specificity, predictive values, and likelihood ratios were used for analysis. The Cohen’s kappa was used to determine
the intraobserver and interobserver reliability. The prevalence of AC and the probability of complete AC were significant higher in corpses
aged 60 years and above than in those under 60 years. Consequently, this study confirmed that the prevalence of AC was significantly
correlated with the age of Thai individuals. If the complete AC is used as an indicator of age of 60 years and above, complete AC has high
sensitivity (92.56%) but low specificity (72.85%), low positive predictive value (65.12%), but high negative predictive value (94.71%). For
diagnostic value, the presence of AC can be used for age screening but not for absolute confirmation. The absence of AC indicates young
age, incomplete AC indicates middle age, and complete AC indicates old age. The high intraobserver and interobserver reliability provides
assurance of the value of AC as a means to estimate personal age. Acad Forensic Pathol. 2019 9(3-4): 155-162

AUTHOR
Boonsak Hanterdsith MD LLB, Maharat Nakhon Ratchasima Hospital - Forensic Medicine
Roles: Project conception and/or design, data acquisition, analysis and/or interpretation, manuscript creation and/or revision, approved final version for publication,
accountable for all aspects of the work, principal investigator of the current study, principal investigator of a related study listed in the citations, coordinated funding
acquisition, general supervision, general administrative support, writing assistance and/or technical editing.

CORRESPONDENCE
Boonsak Hanterdsith MD LLB, Changpeuk Rd. Tambon Naimuang Amphure Muang, Nakhon Ratchasima, Thailand 30000, [email protected]
ETHICAL APPROVAL
As per Journal Policies, ethical approval was not required for this manuscript
STATEMENT OF HUMAN AND ANIMAL RIGHTS
This article does not contain any studies conducted with animals or on living human subjects
STATEMENT OF INFORMED CONSENT
No identifiable personal data were presented in this manuscript
DISCLOSURES & DECLARATION OF CONFLICTS OF INTEREST
The author, reviewers, editors, and publication staff do not report any relevant conflicts of interest
FINANCIAL DISCLOSURE
This work was supported by the Research and Service Development Center, Maharat Nakhonratchasima Hospital. The author has indicated that he
does not have any other financial relationships to disclose that are relevant to this manuscript
KEYWORDS
Forensic pathology, Arcus corneae, Age estimation, Postmortem examination, Identification
INFORMATION
ACADEMIC FORENSIC PATHOLOGY: THE PUBLICATION OF THE NATIONAL ASSOCIATION OF MEDICAL EXAMINERS FOUNDATION
©2019 The Author(s) • (ISSN: 1925-3621) • 10.1177/1925362119891708
Submitted for consideration on 8 Jul 2019. Accepted for publication on 11 Nov 2019

Page 155
 ORIGINAL ARTICLE
INTRODUCTION The author conducted a cross-sectional study of ran-
domly selected Thai medicolegal corpses from Jan-
Age estimation of unknown deceased individuals re- uary 1, 2017, to June 30, 2018, at the Maharat Na-
mains a challenge for medicolegal postmortem exam- khon Ratchasima Hospital, Thailand. Three hundred
ination. Several physical appearances are helpful for forty-two corpses were eligible for the study. Most
estimation of age such as skin wrinkling, gray hair, of the cases were examined within one day of their
arcus corneae (AC), bone osteophytes, teeth eruption death. Some cases were kept refrigerated for postmor-
and teeth changes due to age, bone age in children, and tem examination. A postmortem interval longer than
skull sutures. The AC can be easily and quickly exam- 24 hours, putrefied corpses, cases with eye injury or
ined as a part of identification during postmortem ex- an eye condition, and unknown cases were excluded
amination of a nonskeletalized body and, along with from the study. The eyes were carefully examined by
other features, provides useful information for an un- visual inspection and documented with photos during
known deceased. Accordingly, previous studies have the routine postmortem examination under adequate
shown that AC increases with ages in both genders of autopsy room light. Arcus corneae was evaluated sep-
Caucasians (1-5), Middle East (6), and Indian ethnic arately for both eyes and graded into three levels: no
groups (7, 8). It is rarely seen in people under 60 years AC, incomplete ring (any degree of presentation of
(9) and never seen in people under 20 years (3). How- AC but not circumferential ring), and complete ring
ever, the prevalence of AC within some ethnic groups based on its circumferential extension (Image 1). To
varies even in the same region (10-12). There have analyze intraobserver reliability and interobserver re-
been few such studies in an Asian population (13). liability, the author evaluated AC of the eyes from the
None of the previous studies of the Thai population taken photos one month after the first examination and
have used AC for age estimation, and reference data the same photos were sent to another doctor, respec-
from European countries cannot be used due to racial tively. The corpses were grouped into CVD and non-
difference (2, 9, 14-16). To date, there has been no CVD. The general characteristics of the sample were
clear diagnostic study of AC as a means to estimate analyzed with one-way analysis of variance and chi-
the age of persons. To address this gap in understand- square test. With regard to AC, gender, and the cause
ing, the author has studied the correlation of AC with of death, the predicted probability for each age group
respect to the chronological age to evaluate the value (under 45 years, 45-59 years, 60 years and above) was
of AC for the prediction of chronological age. analyzed with the binomial logistic regression mod-
el. Sensitivity, specificity, predictive values, and like-
MATERIALS AND METHODS lihood ratios were used for diagnostic analysis. The
Cohen’s kappa was run to determine the intraobserv-
Definition and Terminology er and interobserver reliability. The Stata SE version
12.0 was used for statistical analysis. A p value of less
Arcus corneae is an irreversible lipid deposition. It than 0.05 was considered statistically significant.
is defined as a gray-white opaque ring, 1 to 1.5 mm
wide located near the periphery of the corneae, but RESULTS
separates from the limbus by a clear zone, 0.3 to 1
mm wide (3, 5, 12, 17). However, AC has to be distin- All cases included had clear corneae. The general
guished from a corneal limbus (a dense white ring on characteristics of corpses are shown in Table 1. Age
the rim of the corneae). ranged from 7 to 95 years (average: 50.67 years). The
prevalence of AC and the probability of complete AC
Cardiovascular disease (CVD)-related death is defined as were significantly higher in the corpses aged 60 years
any death from cardiovascular diseases including acute compared with those under 60 years (Table 2). AC
myocardial infarction, coronary heart disease (CHD), was not seen in corpses aged 33 years and under and
cerebrovascular disease, and ruptured aortic aneurysm. some corpses aged above 60 years.

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 ORIGINAL ARTICLE

A B

Image 1: The degrees of arcus corneae. A) No arcus corneae. B) Incomplete arcus corneae: the arcus corneae is presented only on the
upper pole of the cornea. C) Complete arcus corneae: the arcus corneae is obviously presented as a complete ring on the margin of the
cornea.

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There was no difference in AC between the right and Based on Table 2, if the complete AC is used as a
the left eye. For the incomplete AC group, the cres- diagnostic indicator of age 60 and higher, complete
cent-shaped AC was found only on the upper pole or AC has a sensitivity of 92.56%, specificity of 72.85%,
both upper and lower poles of the corneae. It was nev- a positive predictive value of 65.12%, a negative pre-
er found on the medial or lateral pole. dictive value of 94.71%, a likelihood ratio positive of
3.41, and a likelihood ratio negative of 0.10. A high

Table 1: General Characteristics of the Study Sample

Characteristic No AC (n=119) Incomplete AC (n=51) Complete AC (n=172) p-value

Mean age (SD) 29.05 (12.10) 50.69 (8.06) 65.62 (12.42) <0.001*

Male 98 (82.4%) 42 (82.4%) 121 (70.4%) 0.033†

CVD-related death 4 (3.4%) 9 (17.6%) 40 (23.3%) <0.001†

AC - Arcus corneae
SD - Standard deviation
* One-way Analysis of variance: There is a statistically significant difference in each pair of AC groups.
†
Chi square test

Table 2: The Prevalence and Probability of Arcus Corneae, Gender, and Cause of Death to Age In Decades
Age Arcus Corneae Gender Cause of death
Group
(Years) No AC Incomplete Complete AC Probability of Male Female CVD-related* Non-CVD-related†
(n=119) AC (n=51) (n=172) Complete AC (n=261) (n=81) (n=53) (n=289)

0-9 2 0 0 0.00 1 2 0 3

10-19 28 0 0 0.00 28 2 0 30

20-29 37 0 0 0.00 30 5 0 35

30-39 26 3 2 0.08 30 6 2 34

40-49 19 18 16 0.34 42 8 6 44

50-59 5 23 42 0.57 57 18 16 59

60-69 2 6 47 0.92 38 15 13 40

70-79 0 1 42 0.98 24 17 11 30

80-89 0 0 20 1.00 10 8 4 14

90-99 0 0 3 1.00 1 0 1 0

AC - Arcus corneae
CVD - Cardiovascular disease
* Acute myocardial infarction and coronary heart disease, 41 cases; cerebrovascular disease, 3 cases; other CVD-related death such
as ruptured aortic aneurysm, 9 cases.
†
Traffic injury, 106 cases; any cancer, 14 cases; sudden unexplained death syndrome, 11 cases; poisoning, 11 cases; other injuries
including hanging and drowning, 60 cases; other natural diseases, 80 cases; other, 7 cases.

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 ORIGINAL ARTICLE
negative predictive value and a low likelihood ratio DISCUSSION
negative indicate that the absence of complete AC
is strongly associated with age under 60 years. The This study confirms that, for Thai individuals, the
Cohen’s kappa demonstrated high intraobserver reli- prevalence of AC is significantly correlated with
ability (right eye: kappa = 0.9271; left eye: kappa = chronological age, but it does not confirm that AC is
0.9271) and interobserver reliability (right eye: kappa rarely seen in the age under 60 years (Tables 2 and 3
= 0.8440; left eye: kappa = 0.8828). and Figure 1), unlike the previous mention (9). If AC
is negative or incomplete, age being under 60 years
Figure 1 demonstrates that the higher probability of has a predictive value of 94.71%. Conversely, if AC
complete AC corresponds with higher age. Table 3 is complete, being 60 years or above has a positive
demonstrates that male and CVD-related death also predictive value of only 65.12%. The predictive value
correlates with a higher probability for the presenta- was only calculated to distinguish between the corps-
tion of AC other than age. For instance, the predicted es aged over and under 60 years because 60 years is
age for an individual who has no AC, was male, and the threshold for old age in Thailand and many coun-
died of non-CVD related death is below 45 years with tries in the world. Moreover, our findings strongly
the probability of 0.91. contradict the statement that “AC is rarely seen in the
age under 60 years.” Therefore, this study provides

100%
Probability of Complete Arcus Corneae

80%

60%

40%

20%

0
0 20 40 60 80 100
Age (Years)
Figure 1: The logistic regression model for the probability of complete arcus corneae by chronological age.

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 ORIGINAL ARTICLE
a screening tool able to distinguish between older ic blood pressure (negative correlation) (20), high sys-
and younger persons. This distinction has very useful tolic blood pressure (positive correlation) (6), smoking
practical applications. For example, a situation where (6, 21), alcohol intake (4), and obesity (negative asso-
a distinction has to be made in a double death between ciation) (4). Dyslipidemia was the most common fac-
two people of different ages (one has complete AC, tor to be examined. Although some studies showed that
one has no AC), then AC may be of considerable use. AC was associated with high LDL-cholesterol concen-
Another situation might be an old age person missing tration (5, 14, 21, 22), others showed that AC was not
from home. Examination of the AC in any unknown significantly associated with cholesterol level (4, 23,
body could readily rule in or rule out the body as rele- 24). In addition, the factors mentioned above such as
vant to the investigation. However, as AC was graded CHD and smoking might not be associated with AC
into three levels, the practical value of AC for age esti- (4, 5, 20). In this study, male gender and CVD-related
mation is that the absence of AC indicates young age, death were significantly related to AC (Tables 1 and
incomplete AC indicates middle age, and complete 3). Therefore, age estimation using AC should be in-
AC indicates old age (Table 3). The high intraobserv- terpreted along with data on gender and cause of death.
er and interobserver reliability promotes the high val-
ue of AC for personal age estimation. In previous studies, the eyes have previously been
examined by various methods including naked eyes
Previous studies have reported associations between (1, 5, 10, 11, 15, 16, 19, 21, 25, 26), photography (8,
AC and several factors other than age, such as high se- 20), and slit-lamp examination (3, 6, 7, 20, 24). In this
rum lipid levels (5, 11, 13, 16), diabetes mellitus (4, 5, study, the author used the naked eye method for easy
18), male gender (5, 6, 11), CHD (14, 19), high diastol- and prompt examination under adequate room light. A

Table 3: Binomial Logistic Regression of the Highest Predicted Probability For Each Age Group Stratified by
Arcus Corneae, Gender, and Cause of Death
Arcus Corneae Gender Cause of Death Age (Years) Predicted Proba- p-value
bility

CVD-related death 0.72 <0.001

Male
Non-CVD-related death 0.91 <0.001
No AC (n=119) <45
CVD-related death 0.54 0.007
Female
Non-CVD-related death 0.81 <0.001

CVD-related death 0.73 <0.001

Male
Non-CVD-related death 0.60 <0.001
Incomplete AC (n=51) 45-59
CVD-related death 0.70 <0.001
Female
Non-CVD-related death 0.65 <0.001

CVD-related death 0.67 <0.001

Male
Non-CVD-related death 0.60 <0.001
Complete AC (n=172) >59
CVD-related death 0.77 <0.001
Female
Non-CVD-related death 0.72 <0.001

AC - Arcus corneae
CVD - Cardiovascular disease

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