Common Visual Problems: Symptoms and Treatment, Part II
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Part I of this article appeared in the August issue of the Journal.
THE CHALLENGE
In the year 2000, almost one million Americans over age 40 years were deemed “blind” and 2.4 million had “low vision.” The incidence of both blindness and low vision in Americans is projected to increase dramatically by the year 2020. Persons over age 80 years accounted for more than two-thirds of the observed blindness, and, as we know, this more elderly group is the fastest-growing segment of the U.S. population.1
In a 2-year study of individuals age 65-84 years, 25% suffered “significant vision loss” over that interval (visual acuity diminished in 25%; contrast sensitivity and visual field loss occurred in 10%). In a cohort of individuals over age 85 years, one-half had better than 20/40 acuity, but with low contrast and “veiling glare,” 75% had their acuity diminished to less than 20/200; 50% of these individuals had no stereopsis. “Glare recovery” took longer than 2 minutes versus 15 seconds for those under age 65 years, and visual fields tested with “divided attention” (ie, a central distracting task) is about one-half the expanse of that for individuals younger than age 65 years.2 In addition, this loss of visual function is often compounded by other age-related disabilities. Of special note is the fact that high-contrast visual acuity, the most commonly used measure of visual function, is the slowest and probably the least sensitive measure of visual function to decline with age.3-5
Poor visual function has deleterious effects on vocation and avocations, driving ability (especially at night), and routine activities of daily living. Positive correlations have been documented between vision loss and auto accidents, loss of employment, increasing dependence on others, social isolation, depression, personal accidents, hip fractures, and ultimately, mortality.6-12
AGE-RELATED MACULAR DEGENERATION
Dramatically increased awareness of macular degeneration among our elderly population has resulted in a great deal of physician time, both ophthalmologist and primary care provider, counseling justifiably concerned individuals about this condition, its treatment, and potential avoidance. Macular degeneration is the leading cause of irreversible vision loss in the developed countries, with a steep increase in incidence with aging. The frequency of macular degeneration in the 50- to 64-year-old age group has been estimated at anywhere from 1-8%. About 30% of those over age 70 years have some sign of macular degeneration, while in those over age 85 years, the incidence climbs to 53%. There are over 6 million individuals in the United States afflicted with this disorder.13,14
Some of the confusion and significant variation in incidence numbers results from a lack of standardization and definition. Many individuals in the older age group exhibit macular degeneration in the form of asymptomatic drusen or retinal changes that are characteristic of the disorder, but with no noticeable impact on visual function. Others may have minimal reduction of vision, but are not categorized as macular degeneration by some investigators until the reduction in vision has exceeded a certain threshold.
As a brief reminder of the anatomy and physiology of the retina and macula, it is worth recalling that the macular area, which is responsible for keen vision and acuity, represents only the central 2-millimeter diameter of the retina (about the diameter of the optic nerve head), located at fixation where objects of regard fall in direct focus (Figure 1). Anywhere outside this tiny central focal point of the retina, the resolving capacity of the photoreceptors is 20/200 or less, which decreases the more peripheral in the retina the light rays strike.
References
1. Munoz B, West SK, Rubin GS, et al. Causes of blindness and visual impairment in a population of older Americans: The Salisbury Eye Evaluation Study. Arch Ophthalmol 2000;118(6):819-825.
2. West SK, Munoz B, Rubin GS, et al. Function and visual impairment in a population-based study of older adults. The SEE (Salisbury Eye Evaluation) Project. Invest Ophthalmol Vis Sci 1997;38(1):72-82.
3. Robilotto R, Zaidi Q. Limits of lightness identification for real objects under natural viewing conditions. J Vis 2004;15;4(9):779-797.
4. Puell MC, Palomo C, Sanchez-Ramos C, Villena C. Normal values for photopic and mesopic letter contrast sensitivity. J Refract Surg 2004;20(5):484-488.
5. Pesudovs K, Marsack JD, Donnelly WJ III, et al. Measuring visual acuity: Mesopic or photopic conditions, and high or low contrast letters? J Refract Surg 2004;20(5):S508-S514.
6. Stevenson MR, Hart PM, Montgomery AM, et al. Reduced vision in older adults with age related macular degeneration interferes with ability to care for self and impairs role as carer. Br J Ophthalmol 2004;88(9):1125-1130.
7. de Boer MR, Pluijm SM, Lips P, et al. Different aspects of visual impairment as risk factors for falls and fractures in older men and women. J Bone Miner Res 2004;19(9):1539-1547. Epub 2004 May 10.
8. Turano KA, Broman AT, Bandeen-Roche K, et al; SEE Project Team. Association of visual field loss and mobility performance in older adults: Salisbury Eye Evaluation Study. Optom Vis Sci 2004;81(5):298-307.
9. Klein BE, Klein R, Knudtson MD, Lee KE. Relationship of measures of frailty to visual function: The Beaver Dam Eye Study. Trans Am Ophthalmol Soc 2003;101:191-199.
10. West CG, Gildengorin G, Haegerstrom-Portnoy G, et al. Vision and driving self-restriction in older adults. J Am Geriatr Soc 2003;51(10):1348-1355.
11. de Winter LJ, Hoyng CB, Froeling PG, et al. Prevalence of remediable disability due to low vision among institutionalised elderly people. Gerontology 2004;50 (2):96-101.
12. Cox A, Blaikie A, MacEwen CJ, et al. Visual impairment in elderly patients with hip fracture: Causes and associations. Eye 2004 Aug 27; [Epub ahead of print].
13. Klein R, Peto T, Bird A, Vannewkirk MR. The epidemiology of age-related macular degeneration. Am J Ophthalmol 2004;137(3):486-495.
14. Arnold J, Sarks S. Age related macular degeneration. Clin Evid 2004;(11):819-834.
15. Seddon JM, Chen CA. The epidemiology of age-related macular degeneration. Int Ophthalmol Clin 2004;44(4):17-39.
16. Verteporforin Roundtable Participants. Guidelines for using verteporfin (Visudyne) in photodynamic therapy for choroidal neovascularization due to age-related macular degeneration and other causes: An update. Retina 2005;25(2):119-134.
17. Michels S, Schmidt-Erfurth U. Photodynamic therapy with verteporfin: A new treatment in ophthalmology. Semin Ophthalmol 2001;16(4):201-206.
18. Eyetech Study Group. Anti-vascular endothelial growth factor therapy for subfoveal choroidal neovascularization secondary to age-related macular degeneration: Phase II study results. Ophthalmology 2003;110(5):979-986.
19. Bressler NM, Bressler SB, Congdon NG, et al; Age-Related Eye Disease Study Research Group. Potential public health impact of Age-Related Eye Disease Study results: AREDS Report No. 11. Arch Ophthalmol 2003;121(11):1621-1624.
20. Jampol LM. AREDS: Two years later. Arch Ophthalmol 2003;121(11):1634-1636.
21. Blodi BA. Nutritional supplements in the prevention of age-related macular degeneration. Insight 2004;29(1):15-18.
22. Arora S, Musadiq M, Mukherji S, Yang YC. Eye nutrient products for age-related macular degeneration: What do they contain? Eye 2004;18(5):470-473.
23. Ribaya-Mercado JD, Blumberg JB. Lutein and zeaxanthin and their potential roles in disease prevention. J Am Coll Nutr 2004;23(6 Suppl):567S-587S.
24. McBee WL, Lindblad AS, Ferris FL III. Who should receive oral supplement treatment for age-related macular degeneration? Curr Opin Ophthalmol 2003;14(3): 159-162.
25. Chang CW, Chu G, Hinz BJ, Greve MD. Current use of dietary supplementation in patients with age-related macular degeneration. Can J Ophthalmol 2003;38(1):27-32.
26. Comer GM, Ciulla TA, Criswell MH, Tolentino M. Current and future treatment options for nonexudative and exudative age-related macular degeneration. Drugs Aging 2004;21(15):967-992.
27. Centers for Disease Control and Prevention (CDC). Prevalence of visual impairment and selected eye diseases among persons aged > 50 years with and without diabetes: United States, 2002. MMWR Morb Mortal Wkly Rep 2004;53(45):1069-1071.
28. Harding S, Garvican L, Talbot J. The impact of national diabetic retinopathy screening on ophthalmology: The need for urgent planning. Eye 2004; [Epub ahead of print].
29. Harding S. Diabetic retinopathy. Clin Evid 2003;(9):718-728.
30. Walker R. Diabetic retinopathy: Protecting the vision of people with diabetes. Br J Community Nurs 2004;9(12):545-547.
31. Harding S. Diabetic retinopathy. Clin Evid 2004;(11):848-859.
32. Chew EY, Ferris FL III, Csaky KG, et al. The long-term effects of laser photocoagulation treatment in patients with diabetic retinopathy: The early treatment diabetic retinopathy follow-up study. Ophthalmology 2003;110(9):1683-1689.
33. Tranos PG, Topouzis F, Stangos NT, et al. Effect of laser photocoagulation treatment for diabetic macular oedema on patient’s vision-related quality of life. Curr Eye Res 2004;29(1):41-49.
34. Shah KB, Han DP. Proliferative diabetic retinopathy. Int Ophthalmol Clin 2004; 44(4):69-84.
35. Michels RG. Proliferative diabetic retinopathy: Pathophysiology of extraretinal complications and principles of vitreous surgery. Retina 1981;1(1):1-17.
36. Klein R, Zinman B, Gardiner R, et al. The relationship of diabetic retinopathy to preclinical diabetic glomerulopathy lesions in type 1 diabetic patients: The Renin-Angiotensin System Study. Diabetes 2005;54(2):527-533.
37. Dalzell MD. Dry eye: Prevalence, utilization, and economic implications. Manag Care 2003;12(12 Suppl):9-13.
38. Moss SE, Klein R, Klein BE. Incidence of dry eye in an older population. Arch Ophthalmol 2004;122(3):369-373.
39. Schein OD, Hochberg MC, Munoz B, et al. Dry eye and dry mouth in the elderly: A population-based assessment. Arch Intern Med 1999;159(12):1359-1363.
40. Eichenbaum JW, Burton WB, Eichenbaum GM, Mulvihill M. The prevalence of eye disease in nursing home and non-nursing home geriatric populations. Arch Gerontol Geriatr 1999;28(3):191-204.
41. Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among US women. Am J Ophthalmol 2003;136(2):318-326.
42. Bandeen-Roche K, Munoz B, Tielsch JM, et al. Self-reported assessment of dry eye in a population-based setting. Invest Ophthalmol Vis Sci 1997;38(12):2469-2475.
43. Pflugfelder SC. Hormonal deficiencies and dry eye. Arch Ophthalmol 2004;122(2):273-274.
44. Wilson SE. Inflammation: A unifying theory for the origin of dry eye syndrome. Manag Care 2003;12(12 Suppl):14-19.
45. Sheppard JD. Dry eye moves beyond palliative therapy. Manag Care 2003;12(12 Suppl):6-8.
46. Perry HD, Donnenfeld ED. Topical 0.05% cyclosporin in the treatment of dry eye. Expert Opin Pharmacother 2004;5(10):2099-2107.
47. Brown MM, Brown GC. Utility assessment and dry eye disease. Ophthalmology 2004;111(4):852-853.
48. Whitcher JP. The treatment of dry eyes. Br J Ophthalmol 2004;88(5):603-604.
49. Sheppard JD. Guidelines for the treatment of chronic dry eye disease. Manag Care 2003;12(12 Suppl):20-25.
50. Dana MR, Sullivan DA, Parke AL. Toward optimal health: The experts discuss dry eye syndrome. Interview by Jodi Godfrey Meisler. J Womens Health Gend Based Med 2001;10(8):725-729.
51. Perry HD, Donnenfeld ED. Dry eye diagnosis and management in 2004. Curr Opin Ophthalmol 2004;15(4):299-304.
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