Normal age related changes Common pathological changes with age Optometric examination of geriatric population Complications in examination of older patient Vision Corrections in older patient

1. Optometric examination and
management of geriatric
problems
Presenter
Anisha Heka
B. Optometry 22nd batch
Moderators
Mr. Sanjeeb Mishra
Dr. Sanjeev Bhattarai

2. Presentation layout
Normal age related changes
Common pathological changes with age
Optometric examination of geriatric population
Complications in examination of older patient
Vision Corrections in older patient

3. Normal age related changes
Changes in cornea with age
Corneal sensitivity to touch decreases with age.
Increase in against the rule astigmatism.
Natural form of cornea was such that meridian of
greatest curvature was horizontal, but that cornea
was deformed in youth by pressure of lids so that
greatest curvature was vertical in youth.
As lid tension decreases, cornea goes back to its
natural form.

4. Changes in iris
Senile miosis (reduces retinal
illuminance).
Small pupil decreases the size of
blur circle and thereby increases the
depth of field.
Makes examination of fundus
difficult.

5. Changes in the lens with age
Axial thickness of lens increases linearly by approximately 28% by
age 70 years over that which existed at age 15 to 20 years.
Equatorial diameter increases at a slower rate than axial thickness.
As the lens thickens, it absorbs more light and there is pigment
deposition in the nucleus.

6. Yellow pigment of lens absorb short wavelengths more than longer
wavelengths. So, Older adults have decreased sensitivity at the violet
end of spectrum.
Cyrstalline lens in a 13 years old Cyrstalline lens in a 75 years old

7. Accumulation of discrete high molecular weight protein within lens
material causes scatter points for light under some conditions.
Power of accommodation of lens decreases with age and becomes 0
after the sixth decade of life
Duane's curve showing accommodative amplitude versus age

8. Changes in anterior chamber with age
Depth of anterior chamber decreases from an average of 3.6mm in
age range of 15 to 20 years to average of 3 mm by 70 years because
of growth of lens.

9. Changes in dark adaptation with age
Delay in rod mediated dark adaptation due to slowing of
rhodopsin regeneration.
Refractive error
ATR astigmatism with an increase in relative hyperopia (due to
decrease in axial length, changes in the gradient of refractive index
in the older lens and vitreous)

10. Contrast sensitivity
Declines rapidly past age of 65 years.
Contributed by senile miosis and nuclear sclerosis.
Changes in recovery from glare with age
Older adults are more sensitive to glare than are younger patients.
This reflects neural changes in the ability of the retina to recover.

11. What is the pratical implications of age
related reduction in contrast sensitivity?
For patients who have undergone cataract removal with subsequent
intraocular lens implantation, the rate of automobile accidents is half
that of patients who have not undergone the procedure (Owsley et al.,
2002). Greater contrast sensitivity following surgery probably
contributes to the improved driving safety, although there may be other
factors

12. Pathological changes with age
Visual system is also affected by age-related ocular pathological
condition, the most notable of which are:
Age related macular degeneration Cataract

13. Diabetic Retinopathy
Glaucoma

14. Dry eye
Reduction in tear quantity and quality in
aging eyes has been noted and
supported by histopathological
evidence. The force and completeness
of blinking are also reduced
Dry eye syndromes are frequently
complicated by lid-cornea incongruities
(ectropion, trichiasis, pterygium, lid
margin hypertrophy) or orbicularis
weakness.

15. Treatment
Using artificial tears, gels or inserts.
Use of punctal plugs.
Symptoms
Irritation
Foreign body sensation
Intolerance to dust and smoke
Excessive tearing.

16. Optometric examination of older adult
Case history
Goal :
To obtain an understanding of patients problems and needs
Shape the sequence of examination and assessment procedures
Design of treatment programs
Presentation of recommendations and advices.

17. Ocular Health Examination
A thorough inspection of the external and internal aspects of the eyes
with appropriate instrumentation is especially important in older
patients.
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
tissues

18. Tonometry should be performed routinely on
older patients because of the higher incidence of
raised intraocular pressure and glaucoma.
The inspection of the interior of the eye can be
more difficult than in younger patients because
of small pupils and lack of media clarity.
Easier observation is possible by using small-
diameter ophthalmoscope systems and perhaps
reducing the illumination level.

19. Pupil dilation
Pupil dilation is performed to increase the size of the pupil during an
eye exam so that full examination of the health of the optic nerve
and retina can be done.
Enables grading of cataract
The National Eye Institute generally recommends that starting at age
60 everyone should have an annual, comprehensive, dilated eye
examination .

20. Refraction
The older population experiences significant changes in refractive error.
What to expect?
Cataractous changes in the lens may precipitate rapid changes in
refraction.
Myopia (Index) Nuclear Sclerosis
Hypermetropia (Index) Cortical cataract during incipient and
immature stage

21. Often an individual’s refractive status is changed substantially as a
result of cataract surgery.
Patients with unstable blood glucose levels require a referral as
well as patient education on expected spectacle lens changes until
their glucose levels are stabilized.

22. Objective refraction
Retinoscopy can be more difficult in older patients because of small
pupils and media irregularities and opacities.
Moving to closer than usual observation distances or moving off
axis may provide an “easier” retinoscopic reflex known as radical
retinoscopy.

23. Keratometry or corneal topography to estimate total astigmatism
becomes more important when retinoscopy or objective optometer
measurement fails.

24. Subjective refraction
Sensitivity to blur may be reduced because of small pupils or
because of media or retinal changes that affect visual
discrimination.
Subjective refraction becomes more difficult because changes in
lens power do not change diameter of blur circles
as much as a similar change in eyes with larger pupils.
Slower presentation of alternatives and sometimes repeated
presentations can become necessary.
Astigmatism may be determined by using crossed-cylinder
techniques; the clock dial or related techniques also may be used.

25. Can duochrome be a reliable test for older patients?
Small pupils may make discriminating the relative clarity of the red and
green targets more difficult. The yellowing of the crystalline lens with age
may cause the brightness of the green background to be reduced more than
the red.
Importantly, clarity of the letters rather than the brightness of the red or
green background is the criterion.

26. Visual acuity measurement
Older patients are more affected by the
luminance of the test chart and the distribution
of light within the luminous environment.
Thus more care than usual should be taken to ensure that the chart
illumination is at a standard level (80 to 320 cd/m2 ) and that
potentially troublesome glare sources are eliminated from the field
of view.
Pinhole visual acuity testing can be used to estimate whether
imoaired VA is due to coorectable refractive error.

27. Assessment of near vision
The most appropriate near-vision addition can be determined in
various ways, but the desired viewing distance dominates the
decision for the typical older patient.
A variety of methods can be used to determine the power of the
addition; the range of clear vision, biochrome, or cross cylinder at
near techniques.
The quantity and quality of illumination should be optimized, and
older patients generally should be given advice on how to arrange
their lighting for prolonged near visual tasks

28. Visual field measurement
Visual field losses are more common in
older patients which may come from
glaucoma, chorioretinal disease, optic
atrophy, and visual pathway disorders.
Most visual field testing is done with automated perimetry.

29. Kinetic perimetry is done to map out detailed shape of scotomas and
Amsler grid to check central visual function and should be prescribed to
the geriatric population in presence of any recurrent retinal or neural
diseases.

30. Color vision testing
The purpose of testing color vision is twofold:
1. the identification of color vision anomalies can assist in the
diagnosis or detection of pathological changes in the visual
system
2. altered color vision can cause some difficulties with color
discrimination tasks, and the possibility of such functional
difficulties should be discussed with the patient.

31. Color discrimination usually changes slightly as the patient ages because
of yellowing of the crystalline lens and physiological and pathological
changes in the macular region.

32. Patients with normal aging changes affecting color vision typically make
only a few small magnitude errors of the tritanopic type.
When retinal disease is present, however, the number and magnitude of
errors in arranging the D-15 targets are greater.
Pelli Robson Chart
Farnsworth D-15 Color vision test

33. Ultrasonography
Mostly in cases of dense cataract, corneal opacities when the interior
is not visible.
Optical Coherence tomography
Diagnosis for proper treatment of retinal and macular diseases.

34. Factors that complicate eye examination in older adults
Communication
 Impaired hearing
 Impaired cognition
(dementia)
 Depression
 Complex ocular/medical
history
1. Communication can always be
improved by reducing
background noise, facing the
patient, and speaking with
deliberate clarity.
2. Close the door and eliminate as
much ambient noise as possible.
3. Leave the room lights on so the
patient can see the examiner’s
face and lips

35. Physical examination
• Limited mobility
• Diminished quality of vision

36. Visual corrections for older adults
Prescribing spectacles for the normally sighted
Most older patients require optical corrections for both distance and
near vision tasks.
Small in number are the emmetropes who do not need distance
glasses, myopes who never need near vision glasses, and people who
choose to use only single-vision glasses and switch spectacles when
they change from distance to near viewing.
Progressive addition lenses, bifocals, or trifocals are worn by older
patients.

37. Lens materials
Goal: A thinner, lighter lens with good optical performance
Polycarbonate
high index of refraction (n = 1.586)
low specific gravity (1.20 g/cm3 )
superior impact resistance compared with CR-39
offers good value to the patient with its inherent scratch-resistant
coating and ultraviolet (UV) blocking properties (blocks 97% of UV
radiation up to 400 nm).

38. Because of an Abbe value of 30, color fringes caused by lateral
chromatic aberration can sometimes be seen by patients, especially
when viewing off the lens optical center.
A reduction in contrast and peripheral acuity is a function of the
prismatic effect and the nu value of the lens material.
To minimize these unwanted effects, polycarbonate should be limited
to corrections less than 4 D.

39. Trivex : a viable alternative to polycarbonate
combines the best attributes of thermoplastics (polycarbonate)
and thermosets (CR39).
Trivex is a mid-index lens (n = 1.53) and has a specific gravity
of 1.11 g/cm3 . Its Abbe value of 43 to 46.
Trivex can also be surfaced down to 1.0-mm center or edge
thickness for dress lenses. These lenses are especially suited for
rimless because of reduced distortion.

40. Lens Designs
Bifocals :
Bifocals are lenses having two portions of different focal power;
one for distance vision and one region for near.
For patients with no accommodation, bifocal lenses might leave a
relatively deep range of intermediate distances over which vision
will be blurred.

41. Trifocals:
Lenses that have three regions which correct for distance, near and
intermediate distances.
Intermediate segment is half the power of the stronger reading
segment.

42. Progressives:
Not only have invisible segments but, as
the name implies, the power of the
addition gradually increases as the line of
vision sweeps downward through the lens.
Hence provides a continuous sequence of
focus for all possible intermediate distances.
Trifocals or PAL should be considered for any patient requiring
+2.00D addition or more, particularly if the individuals lifestyle
includes the frequent use of intermediate vision.

43. Although, a short period of adaptation to the intermediate segment is
necessary, most patients conclude that the adaptation period was
well worth the trouble.
Trifocals and bifocals provide wider fields of clear near vision than
do progressive additions.
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.

44. Lens performance, appearance and weight
When lens weight is a factor, both Trivex and polycarbonate are
available in aspheric designs.
Complaints of flat top segments being too visible can be helped by
prescribing round, blended, or curved top bifocal designs.

45. Image jump is the prismatic effect produced when the wearer is not
viewing through the optical center of the segment.
The jump is most bothersome at the top of the segment where the
distance from the segment optical center is greatest.

46. Executive bifocals in which the segment optical center is located on the
segment line have zero image jump. Round segments with lower optical
center locations have the greatest amount of image jump
Patients often perceive image jump as a shift or altered position of the
image as their line of site passes from the distance portion of the lens
to the reading segment, or vice versa.

47. Ocular changes from aging and various pathological conditions
can make the eyes hypersensitive to what normal eyes see as
moderate glare. This glare is often disabling glare, generally
within the eye because of light scatter. Patients may report hazy
vision and loss of contrast.
Glare and loss of contrast may arise from developing cataracts,
aphakia or pseudophakia, diabetic retinopathy, albinism, retinitis
pigmentosa, and aniridia.
Absorptive lenses

48. Prescribing an antireflective coating (ARC) can increase light
transmission up to 99% by reducing these spectacle lens surface
reflections
Older patients require more light to achieve the retinal illumination of
younger patients.

49. Tinted and photochromic lenses also attenuate glare, but polarized
lenses eliminate glare from reflected surfaces.
UV radiation may contribute to the development of certain retinal
diseases eg ARMD and cataracts so it is important to recommend
patients to wear lenses with ultraviolet filters when outdoors.

50. Frame considerations for older adults
As people age, the fatty tissue between the nose and the nose pads
thins, resulting in less cushioning for glasses. This can result in
pressure sores on the bridge of the nose.
Larger nose pads may be helpful because
the larger surface of the pads distributes the
weight over a larger surface area.
Silicone pads can also be used to minimize
frame slippage.

51. A round eyewire is the ideal frame shape to minimize weight.
Wide temples that block peripheral vision can be especially
hazardous for the elderly and should be avoided.

52. Precribing patients with low vision
The most common causes of low vision in elderly
are:
 Age related macular degeneration (ARMD)
 Cataract
 Glaucoma
 Diabetic retinopathy
 Central retinal vein occlusion

53. Low vision management of the elderly has to be seen within the
context of their overall health status.
Most older patients with low vision can benefit from different optical
and non-optical aids to enhance their visual performance

54. Elderly confused patients with Alzheimer’s disease cannot use
low vision aids, and their families need to be advised on practical,
high contrast, colour and size issues.
Those who have age-related ophthalmic pathology in the absence of
other health problems often do very well with conventional
illuminated stand magnifiers and portable hand magnifiers.
Hand magnifier Stand magnifier

55. Those with handling problems such as arthritis of the hands or spine ,
Parkinson’s disease need ergonomically suitable low vision aids like
spectacle mounted device and a reading stand.
Monocular spectacle mounted clip on magnifier Reading stand

56. Summary
Changes in visual function that occur with aging can be secondary
to ocular disease or can occur in the absence of disease.
These patients should be educated with regard to expected changes
in their visual capabilities and the manner in which these changes
can affect their daily activities
The diversity of vision needs and characteristics distinguishes older
adults from the rest of the patient population. Therefore, when
dealing with older patients, practitioners must use more imagination
and flexibility in structuring the examination and treatment to suit
these diverse individual needs.

57. References
• https://www.2020mag.com/article/vision-care-for-elder-eyes