This presentation contains headings - Visual performance in the ageing eye Routine optometric and ocular examination of an older adult: History Ocular health examination Visual acuity measurement Refraction Binocular vision Visual field measurement Colour vision Management of vision problems in older adults Frame requirement Lens requirements And special instructions etc.

1. MANAGEMENT OF VISUAL
PROBLEMS OF AGAING
 REPRESENTED BY – Mr. ASHITH TRIPATHI
 B. Optometry 3rd year student

2. OCULAR EXAMINATION IN OLDER ADULTS
 Introduction
 Visual performance in the ageing eye
 Routine optometric and ocular examination of an older adult:
 History
 Ocular health examination
 Visual acuity measurement
 Refraction
 Binocular vision
 Visual field measurement
 Colour vision

3. Introduction
 Aging brings inevitable changes to the visual system, such as
loss of accommodation, reduced transmittance of ocular
media and ocular media and pupillary miosis.
 The visual system is also affected by age related ocular
pathological conditions, the most notable of which are
maculopathy, cataracts, glaucoma, and retinopathy.
 When dealing with older patients, practitioners must use more
imagination and flexibility in structuring the examination and
treatment to suite these diversre individual needs.

4. Visual performance in the aging eye
 In the aging eye, the pupil becomes smaller reducing the
amount of light incident upon the retina, the crystalline lens
becomes progressively more yellow, and opacities develop,
and there is increasing light absorption with advancing years,
resulting in reduced retinal luminance.
 Finally, neuronal changes in the retina and higher visual
pathways are likely to affect visual function.
 Colour vision is also likely to be adversely affected in the
ageing eye by change in the visual neural mechanisms.

5. Routine optometric and ocular
examination of an older adult:
History:
As with any optometric examination, symptoms and history are
crucial in determining the course of examination.
 Distance vision
 Near vision
 Ocular and general health history
 Psychological changes and fear of blindness
 Social, vocational and recreational activities

6. Ocular health examination:
 Slit lamp examination of the eyelids conjunctiva, cornea,
anterior chamber, iris, and lens requires more attention in
older patients because of the relatively high prevalence of
aging changes affecting these tissue.
PHARMACOLOGIC DILATION
 Dilation of the pupil is generally required for through
stereoscopic evaluation of the ocular media; posterior
segment, including the macula and optic nerve; and the
peripheral retina.
 Commonly it can be achieved with 0.5% or 1% tropicamide.

7. Visual acuity measurement
 Visual acuity measurement requires a little more care in older
patient than in younger ones.
 Older patients are more affected by the luminance of the test
chard and the distribution of light within the luminance
environment.
 In assessing visual acuity, many optometric practices only
have access to a Snellen chart.
 However, this is not ideal when examining a patient with a
visual impairment.

8. Refraction
 The older population experiences significant changes in
refractive error.
 Commonly a shift toward more against-the-rule-astigmatism
occurs, and the spherical component of refraction shifts in the
direct of hyperopic.
 Retinoscopy can be more difficult in older patient because of
small pupil and media irregularities and opacities.
 Radical retinoscopy
 Subjective refraction often requires more time with older
patiets.

9. Binocular vision
 As patient grow older, they are more likely to have some ocular
motor difficulties because of changes affecting the neuromuscular
mechanism and the structural tissues around eyes.
 To check binocular co-ordination, examines the versions
movement of the eyes in six cardinal eye movement directions.
 Older patients lack accommodation and have no stimulus to
accommodative convergence; because of they show more
exophoria at near.
 In elderly population, there are special groups where issues in
refraction can become different. These are hearing impaired
patient, alzhemer disease, Parkinson disease and wheel chair
bound patients.

11. Visual field measurement
 Field affected may come form glaucoma, optic atrophy, and
visual pathway disorders.
 Visual sensitivity is reduced with age and, for a given visual
stimulus strength, the measured visual field becomes reduced
in size for older patients.
 The recommended test for visual field measurement is
automated perimetry.

12. Colour vision
 Colour discrimination usually changes slightly as the patient
ages because of yellowing of the crystalline lens and
physiological changes in the macular region.
 The test of choice for the routine assessment of colour vision
in older patients is the Franswroth Panel D – 15 coloured
chips are arranged so that they appear to be in order
according their chromatic similarity.
 Patients with normal ageing changes affecting colour vision
typically make only a few small magnitude errors of the
tritanopic type.

13. Management of vision problems in older
adult
 Most older patients require optical corrections for both distance and
near vision tasks.
 Progressive addition lenses, bifocals, or reading glasses are worn by
older patients.
 Monovision solutions for enabling good vision for both distance
and near tasks have become more common in recent years.
 Cataract surgery, contact lens corrections , and sometimes refractive
surgery deliberately correct one eye for distance vision and the
other for near.

14.  Aphakic spectacle corrections, through currently uncommon,
require special lens design considerations.
 Worldwide, 6% of presbyopes waring soft contact lenses and
only half group wearing bifocal or multifocal lenses.
 Most older patients with low vision can benefit from optical
aids to enhance their visual performance.
 Patients who need low vision aids usually need more then one
special optical aid.
 The field of view, portability, convenience, cost, working
distance, and maintence requirements are other factors that
enter the decision – making process.

15. Frame requirement
• Frame could be plastic or could be metal as well.
• Cellulose acetate ( plastic ) frames are generally perceived as
more comfortable to wear.
• A saddle bridge would provide adequate support to the frame
on a very sensitive nose.
• The temples can be usually skull or library depending on usage.
• Colour of the frame should be on the darker side so that it can
be spotted easily by the failing eyesight.

16.  Thicker frames are preferred as they are easy to handle and
hold.
 The delicate skin of the elderly person may need
Hypoallergenic frames and hence good quality not absorbent
frames need to be selected.
 Metal frames should be Nickel free to avoid weight and
allergy.
 In either case the frame has to be adjusted for maximum
comfort and special attention is needed for the bend and the
nose pad adjustments.

17. Lens requirement
 Lens should be CR 39 at least and never glass – This would
make the spectacles light and comfortable to wear.
 The lens should be scratch resistant and may also have anti-
reflection coating depending on the requirement.
 UV protection may also be prescribed especially in ocular
diseases where the condition progresses faster if exposure to
UV rays occurs.( eg. Retinitis pigmentosa ).
 Trivex lenses would make the spectacle more lighter or wear
and impact resistant in case of any trauma due to fall.

18.  Lens type needed would be a bifocal or a progressive most
often.
 Choose the designs with wider field of view for near as
reading at this age would be one of the most important
activities.
 Special requests should be read on the spectacle prescription
like Decentration, prism, tints, UV protection and lightness.

19. Special instructions:
 We should instruct the wearer to clean the lenses with a microfiber cloth
after blow drying and keeping it in the spectacle case provided.
 Also instruct about the correct position in which the spectacle needs to be
kept in the case. Most often plus lenses which are needed in this age
group are bulging in the center and are more prone to scratching.
 Nose pads may need sine adjustments if metal frame is prescribed. This
would ensure a comfortable fit. Frame needs to serviced once in six
months.
 With little effort we can please the elderly patient and win their
appreciation. They would remain loyal customers for the rest of their life.