Visual Impairment
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  • Suggestions for Lecturer -1-hour lecture -Use GRS slides alone or to supplement own teaching materials -Refer to GRS5 , p. 176 for further content -Refer to Geriatrics at Your Fingertips for updated information -Supplement lecture with handouts of assessment instruments, eg, Screening in Primary Care (GRS5 , p. 418). -See GRS5 question #s 146, 166, 172, 199, 203 for additional case vignettes on visual impairment.
  • Suggestions for Lecturer -1-hour lecture -Use GRS slides alone or to supplement own teaching materials -Refer to GRS5 , p. 176 for further content -Refer to Geriatrics at Your Fingertips for updated information -Supplement lecture with handouts of assessment instruments, eg, Screening in Primary Care (GRS5 , p. 418). -See GRS5 question #s 146, 166, 172, 199, 203 for additional case vignettes on visual impairment.
  • Suggestions for Lecturer -1-hour lecture -Use GRS slides alone or to supplement own teaching materials -Refer to GRS5 , p. 176 for further content -Refer to Geriatrics at Your Fingertips for updated information -Supplement lecture with handouts of assessment instruments, eg, Screening in Primary Care (GRS5 , p. 418). -See GRS5 question #s 146, 166, 172, 199, 203 for additional case vignettes on visual impairment.
  • Suggestions for Lecturer -1-hour lecture -Use GRS slides alone or to supplement own teaching materials -Refer to GRS5 , p. 176 for further content -Refer to Geriatrics at Your Fingertips for updated information -Supplement lecture with handouts of assessment instruments, eg, Screening in Primary Care (GRS5 , p. 418). -See GRS5 question #s 146, 166, 172, 199, 203 for additional case vignettes on visual impairment.
  • Source: Figure 26.1, p. 177, in GRS5.
  • Source: Figure 26.3, p. 178, in GRS5.
  • Source: Figure 26.3, p. 178, in GRS5.
  • Source: Figure 26.4, p. 179, in GRS5.

Visual Impairment Visual Impairment Presentation Transcript

  • Whatever you may look like, marry a man your own age - as your beauty fades, so will his eyesight.
  • You know you're getting old when the candles cost more than the cake!
  • The spiritual eyesight improves as the physical eyesight declines. - Plato
  • Visual Impairment in the elderly… .. . Geriatrics Grand Rounds 24 th March 2006 Dr.Seraphine Soosaimanickam Geriatrics Fellow Hackensack Medical Centre UMDNJ
  • OBJECTIVES
    • Know and understand:
    • The leading causes and pathophysiology of visual loss
    • Techniques for preventing and treating visual loss
    • The signs of and treatments for common eye disorders in older persons
    • Techniques for low-vision rehabilitation
  • TOPICS
    • Causes of visual loss
      • Cataract
      • Age-related macular degeneration
      • Diabetic retinopathy
      • Glaucoma
      • Refractive error
      • Ischemic optic neuropathy
    • Keratitis sicca
    • Lid abnormalities
    • Herpes zoster ophthalmicus
  • VISUAL IMPAIRMENT
    • Visual impairment ( acuity < 20/40 )
      • Prevalence increases with age.
      • 20% to 30% of those aged 75+ years
    • Blindness ( acuity < 20/200 )
      • Prevalence: 2% of those aged 75+ years
      • 50% of blind population is aged 65 and older.
    • Visual impairment is associated with falls, car crashes, inability to perform ADLs,  quality of life.
  •  
  •  
  •  
  • CATARACT
    • Cataract is a clouding of the natural lens, the part of the eye responsible for focusing light and producing clear, sharp images.
    • The lens is contained in a capsule. As old cells die they become trapped within the capsule.
    • Over time, the cells accumulate causing the lens to cloud, making images look blurred. For most people, cataracts are a natural result of aging.
  • CATARACT
    • Prevalence: 20% of age group > 65 years; 50% of age group >75 years
    • Symptoms include increased glare, decreased contrast sensitivity,  visual acuity
    • Risk factors: decreased vitamin intake, light (ultraviolet B) exposure, smoking, alcohol use, long-term corticosteroid use, diabetes mellitus
  • Normal Vision
  • Vision with Cataract
  •  
  • CATARACT
    • Treatment: surgical extraction
      • 90% of patients achieve vision 20/40 or better.
      • 1.5 million surgeries are performed annually in US.
      • Local or topical anesthesia, sonographic breakdown and aspiration of the lens, placement of an artificial lens
  • SURGERY
    • Under an operating microscope, a small incision (3 mm) is made in the eye.
    • Tiny surgical instruments are used to break apart and remove the cloudy lens from the eye.
    • The back membrane of the lens (called the posterior capsule) is left in place.
  • Cataract surgery
  • CAPSULORHEXIS
  • Capsulorhexis
    • The surgeon creates an opening in the capsule, which is a micro-thin membrane surrounding the cataract. This procedure is called capsulorhexis.
    • It requires extraordinary precision since the capsule is only about four-thousandths of a millimeter thick! (thinner than a RBC)
  • Phacoemulsification
    • Phacoemulsification is the procedure in which ultrasonic vibrations are used to break the cataract into smaller fragments.
    • These fragments are then aspirated from the eye.
  • Phacoemulsification
  • Phacoemulsification
  • Irrigation/aspiration
    • First the denser central nucleus of the cataract is removed.
    • Then the softer peripheral cortex of the cataract is removed using an irrigation/aspiration handpiece.
    • The posterior capsule is left intact to help support the intraocular lens (IOL) implant
  • Irrigation/aspiration
  • IOL IMPLANTATION
    • The intraocular lens is folded and passed through the tiny incision inside the “capsular bag”.
    • In the following illustration, the lens is being inserted via an “injector”. This instrument keeps the incision small while allowing implantation of a 6 mm lens through a 3 mm (or even smaller) incision
  • IOL IMPLANTATION
  • Intra Ocular Lens
  • Intra Ocular Lens
  • Intraocular implant
  • Age-related macular degeneration
    • It is a degenerative condition of the macula (the central retina).
    • It is the most common cause of vision loss in the United States in those 50 or older
    • Prevalence increases with age
  • Pathophysiology
    • ARMD is caused by hardening of the arteries that nourish the retina.
    • This deprives the retinal tissue of oxygen and nutrients that it needs to function and thrive.
    • As a result, the central vision deteriorates.
  • AGE-RELATED MACULAR DEGENERATION
    • Risk factors: age, genetics, smoking, hypertension, fair skin
    • Diagnosis: presence (early) of drusen and (late) of choroidal neovascularization
    • Treatment is controversial
      • Vitamins, antioxidants, zinc
      • Prophylactic laser therapy
      • Photodynamic therapy
  • Vision with macular degeneration
  • Symptoms of Macular degeneration
    • The classic symptoms are
    • Decreased central visual acuity,
    • Metamorphopsia or image distortion,
    • and a central scotoma
  • Dry macular degeneration
    • The dry type is much more common
    • Typically results in a less severe, more gradual loss of vision.
    • Characterized by drusen and loss of pigment in the retina.
    • Drusen are small, yellowish deposits that form within the layers of the retina.  
  • Non-Exudative macular degeneration
  • Drusen
  • Drusen
    • The drusen allow an angiogenic stimulant (such as vascular endothelial growth factor) to promote the growth of underlying choroidal blood vessels into the subretinal space and retina.
    • These tufts of neovascularization are fragile and have a propensity to leak and bleed, eventually forming a fibrovascular scar and resulting in irreversible vision loss
  • Exudative macular degeneration
    • Patient with wet macular degeneration develop new blood vessels under the retina. 
    • This causes hemorrhage, swelling, and scar tissue but it can be treated with laser in some cases
  • Exudative macular degeneration
  • ARMD with subretinal hemorrhage Choroidal neovascularization and subretinal hemorrhage in a patient with late maculopathy.
  • Angiographic diagnosis
    • Hallmark of diagnosis of choroidal neovascularization has been the fluorescein angiogram .
    • It pinpoints the location and extent of neovascular membranes and can guide laser photocoagulation.
    • Unfortunately, only about 13% of angiograms show a treatable localized lesion, or &quot;classic&quot; choroidal neovascularization. The other 87% show diffuse,, hyperfluorescent lesions that are not amenable to laser photocoagulation
  • Iodocyanine green dye technique
  • Treatment
    • Currently there are no treatments or preventive measures, other than vision aids, for patients with dry macular degeneration.
    • The only clinically proven treatment for wet macular degeneration is laser photocoagulation
  • Laser treatment
    • Laser treatment guidelines vary, depending on the proximity of choroidal neovascularization to the fovea.
    • The common types of lesions are extrafoveal (200 to 2,500 micrometers from the fovea), juxtafoveal (1 to 199 micrometers from the fovea), and subfoveal (directly below the fovea).
  • Laser Photocoagulation
    • Laser photocoagulation is a destructive treatment in which tissue is ablated by heat.
    • This treatment quandary was investigated by the multicenter group
    • Their studies indicate that although patients treated with laser showed an immediate decrease in vision,
    • -20% of treated eyes had severe vision loss after 3 years,
    • -compared with 37% of untreated eyes.
    • However, the final visual acuities were very poor for both groups (20/320 for treated and 20/400 for control subjects
  • Photodynamic therapy
    • It is still experimental.
    • Photodynamic therapy, uses a photosensitive dye, which, when activated in the retinal vasculature by a light source, produces a thrombus that closes neovascular vessels.
    • Since the immunologic and coagulating systems naturally break down thrombi, this therapy may be a fast-acting temporizing measure, rather than a long-term treatment
  • Recommendations for ARMD
    • Use a halogen light. These have less glare and disperse the light better
    • Shine the light directly on your reading material. This improves the contrast and makes the print easier to see.
    • Use a hand-held magnifier.
    • Try large-print or audio books. Most libraries and bookstores have special sections reserved for these books.
    • Consult a low vision specialist. -specially trained to help visually impaired patients improve their quality of life.
  • DIABETIC RETINOPATHY
    • Among persons who have had type 2 diabetes for at least 10 years:
      • 70% show retinopathy.
      • nearly 10% show proliferative disease.
    • Duration of disease and control of blood sugar are the most important variables.
    • Prevention: Tight glucose control and blood pressure control ( ≤ 130/80)
    • Treatment: Panretinal laser photocoagulation inhibits growth stimulus for neovascularization.
  • DIABETIC RETINOPATHY STAGES
    • Nonproliferative
    • Preproliferative
    • Proliferative
  • DIABETIC RETINOPATHY: NONPROLIFERATIVE STAGE
    • Microaneurysms
    • Intraretinal hemorrhages
    • Exudates
    • Macular edema
  • DIABETIC RETINOPATHY: NONPROLIFERATIVE STAGE Intraretinal edema and exudate in the superior macular region with type 2 diabetes.
  • DIABETIC RETINOPATHY: PREPROLIFERATIVE STAGE
    • Progressive ischemia
    • Hemorrhages
    • Venous caliber changes
    • Intraretinal microvascular abnormalities
    • Capillary nonperfusion
  • DIABETIC RETINOPATHY: PROLIFERATIVE STAGE
    • Neovascularization of the retina
    • Neovascularization of the disc
    • Neovascularization of both
  • DIABETIC RETINOPATHY: PROLIFERATIVE STAGE Neovascularization of the disc in a patient with proliferative retinopathy.
  • GLAUCOMA
    • Affects > 2.25 million Americans aged >40 years
    • Second most common cause of blindness worldwide. Most common cause of blindness among black Americans
    • $1 billion for glaucoma-related Medicare and Medicaid payments and disability
    • Defined as characteristic optic nerve head damage and visual field loss
  • Progressive optic nerve damage
  • Glaucoma
    • Progressive optic nerve damage (indicated by the cup to disc ratio) caused by glaucoma. 
    • Notice the pale appearance of the nerve with the 0.9 cup as compared to the nerve with the 0.3 cup.
    • Grading is done by cup to disc ratio.  (the depressed area in the center of the nerve) to the entire diameter of the optic nerve. 
  • Vision with glaucoma
  • Vision with Glaucoma
    • The object you focus will appear clear -with an area to the side of your focus which will be blurry.
    • If you gaze at the blurry area it becomes crisp and now a different area on side will become blurry.
    • It is difficult to perceive early peripheral visual field defects .
    • Hence glaucoma is called the ‘ sneak thief of vision ’.
  • GLAUCOMA
    • Primary open-angle glaucoma is the most common type.
    • Slow aqueous drainage leads to chronically elevated intraocular pressures.
    • Patients are asymptomatic and may suffer substantial visual field loss before consulting a physician.
    • Causes are multifactorial and polygenic.
  • Glaucoma
    • Primary angle closure glaucoma (acute glaucoma) occurs much more rapidly when the flow of fluid inside the eye cannot pass through the pupil,
    • causing a rapid rise in pressure inside the eye.
    • Characterised by pain, redness and reduced vision.
    • The pupil of the eye is dilated.
    • The cornea is usually swollen, causing the haloes round lights and blurring of vision
  • Glaucoma Management :
    • Intraocular pressure-lowering medications (local and systemic, eg, latanoprost and brimonidine)
    • Argon laser trabeculoplasty
    • Intraocular surgery +/- antimetabolites
    • (5-fluorouracil, mitomycin-C)
    • Drainage devices
    • Ciliary body destructive procedures
  • REFRACTIVE ERROR
    • Leading cause of visual impairment
    • Treatment: eyeglasses, contact lenses, laser refractive surgery
    • Ametropia
      • Myopia (nearsightedness)
      • Hyperopia (farsightedness)
      • Astigmatism (visual distortion)
    • Presbyopia (  ability to focus at near objects)
      • Begins after age 40
      • Caused by gradual hardening of the lens and decreased muscular effectiveness of the ciliary body
  • Snellen chart
  • REFRACTIVE ERROR
    • Each line of the eye chart is assigned a notation in the form of a fraction that represents your visual acuity. 
    • The numerator is the distance in feet the patient is from the eye chart. 
    • The denominator represents the distance an eye with “normal” vision can read the same line. 
    • Interpreting the numbers is simple.  If you can read the 20/40 line, you’re able to see at 20 feet what a normal eye could see at 40. 
  • ANTERIOR ISCHEMIC OPTIC NEUROPATHY
    • Microvascular occlusion of the blood supply to the optic nerve
    • Due to atherosclerotic vascular disease or inflammation (temporal arteritis)
    • Results in acute vision or field loss
  • ANTERIOR ISCHEMIC OPTIC NEUROPATHY Pallid swelling of the optic nerve head in a patient with anterior ischemic optic neuropathy.
  • KERATITIS SICCA
    • Tear production decreases with age
    • Characteristics: redness, foreign body sensation, and reflex tearing
    • Management: replacement of tears (artificial tears during daytime and ointment at bedtime)
    • Temporary or permanent punctal plugs may retard tear egress in severe cases.
  • LID ABNORMALITIES
    • Common among older adults
    • Gradual loss of elasticity and tensile strength that develops with age
    • Blepharochalasis (drooping of the brow) and blepharoptosis (drooping of the eyelid) may cause cosmetic deformity and, if severe, may impair vision.
    • Lid ectropion (eversion) or entropion (inversion) may cause discomfort.
    • Treatment: surgery
  • HERPES ZOSTER OPHTHALMICUS
    • Painful reactivation of varicella zoster virus
    • Affecting the ophthalmic division of the trigeminal nerve
    • Hutchinson’s sign: lesions on the tip of the nose
    • Oral acyclovir may shorten the course.
    • Post-herpetic neuralgia may be debilitating; treat with local ointments (capsaicin, lidocaine) or systemic medications (corticosteroids, tricyclic antidepressants).
  • Herpes zoster Ophthalmicus
  • LOW-VISION REHABILITATION
    • Available to patients with acuity < 20/60
    • Improved lighting and selection of reading material with bold, enlarged fonts and accentuated black-on-white contrast
    • Magnification: high-plus spectacles, magnifiers, closed-circuit television, telescopic devices
    • Eccentric viewing for macular degeneration patients with central macular pathology : training to use off-center fixation
    • Talking devices or Braille for those who have lost vision altogether
  • SCREENING TO PREVENT VISUAL LOSS
    • Comprehensive eye examinations are recommended every 1 to 2 years for persons aged 65 years and olde r.
      • (By the American Academy of Ophthalmology
      • and USPSTF)
  • SUMMARY
    • Visual loss occurs commonly among older adults
    • Leads to reduced quality of life, high medical care costs, and loss of independence
    • Primary care providers should routinely screen older adults for visual loss
    • Treatment options are available for many types of visual loss
  • THANK YOU!