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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.
  • Transcript

    • 1. Whatever you may look like, marry a man your own age - as your beauty fades, so will his eyesight.
    • 2. You know you're getting old when the candles cost more than the cake!
    • 3. The spiritual eyesight improves as the physical eyesight declines. - Plato
    • 4. Visual Impairment in the elderly… .. . Geriatrics Grand Rounds 24 th March 2006 Dr.Seraphine Soosaimanickam Geriatrics Fellow Hackensack Medical Centre UMDNJ
    • 5. 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
    • 6. 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
    • 7. 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.
    • 8.  
    • 9.  
    • 10.  
    • 11. 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.
    • 12. 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
    • 13. Normal Vision
    • 14. Vision with Cataract
    • 15.  
    • 16. 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
    • 17. 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.
    • 18. Cataract surgery
    • 19. CAPSULORHEXIS
    • 20. 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)
    • 21. 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.
    • 22. Phacoemulsification
    • 23. Phacoemulsification
    • 24. 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
    • 25. Irrigation/aspiration
    • 26. 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
    • 27. IOL IMPLANTATION
    • 28. Intra Ocular Lens
    • 29. Intra Ocular Lens
    • 30. Intraocular implant
    • 31. 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
    • 32. 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.
    • 33. 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
    • 34. Vision with macular degeneration
    • 35. Symptoms of Macular degeneration
      • The classic symptoms are
      • Decreased central visual acuity,
      • Metamorphopsia or image distortion,
      • and a central scotoma
    • 36. 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.  
    • 37. Non-Exudative macular degeneration
    • 38. Drusen
    • 39. 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
    • 40. 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
    • 41. Exudative macular degeneration
    • 42. ARMD with subretinal hemorrhage Choroidal neovascularization and subretinal hemorrhage in a patient with late maculopathy.
    • 43. 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
    • 44. Iodocyanine green dye technique
    • 45. 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
    • 46. 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).
    • 47. 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
    • 48. 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
    • 49. 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.
    • 50. 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.
    • 51. DIABETIC RETINOPATHY STAGES
      • Nonproliferative
      • Preproliferative
      • Proliferative
    • 52. DIABETIC RETINOPATHY: NONPROLIFERATIVE STAGE
      • Microaneurysms
      • Intraretinal hemorrhages
      • Exudates
      • Macular edema
    • 53. DIABETIC RETINOPATHY: NONPROLIFERATIVE STAGE Intraretinal edema and exudate in the superior macular region with type 2 diabetes.
    • 54. DIABETIC RETINOPATHY: PREPROLIFERATIVE STAGE
      • Progressive ischemia
      • Hemorrhages
      • Venous caliber changes
      • Intraretinal microvascular abnormalities
      • Capillary nonperfusion
    • 55. DIABETIC RETINOPATHY: PROLIFERATIVE STAGE
      • Neovascularization of the retina
      • Neovascularization of the disc
      • Neovascularization of both
    • 56. DIABETIC RETINOPATHY: PROLIFERATIVE STAGE Neovascularization of the disc in a patient with proliferative retinopathy.
    • 57. 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
    • 58. Progressive optic nerve damage
    • 59. 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. 
    • 60. Vision with glaucoma
    • 61. 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 ’.
    • 62. 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.
    • 63. 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
    • 64. 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
    • 65. 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
    • 66. Snellen chart
    • 67. 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. 
    • 68. 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
    • 69. ANTERIOR ISCHEMIC OPTIC NEUROPATHY Pallid swelling of the optic nerve head in a patient with anterior ischemic optic neuropathy.
    • 70. 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.
    • 71. 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
    • 72. 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).
    • 73. Herpes zoster Ophthalmicus
    • 74. 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
    • 75. 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)
    • 76. 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
    • 77. THANK YOU!