Download Module 2 - 729 KB

Diseases and Disorders of
the Special Senses
Module 2
Brenda K. Keller, MD
Geriatrics and Gerontology
University of Nebraska Medical Center
PROCESS
Series of 3 modules and questions on
1. Sensory Changes of Aging
2. Diseases and Disorders of the special senses
3. Treatments for vision and hearing impairment
Step #1 Power point module with voice
overlay
Step #2 Case-based question and answer
Step #3 Proceed to additional modules or take a break
Objectives for Module 2
Recognize the functional impact of disease of the special senses
Vision
Refractive Error
Cataracts
Age related macular
degeneration
Diabetic Retinopathy
Glaucoma
Dry Eyes
Lid abnormalities
Herpes Zoster
Hearing
Sensorineural
Conductive
Refractive Error
Leading cause of visual impairment
Treatment: eyeglasses, contact lenses, laser refractive
surgery
92% of people over age 70 wear glasses
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
Cataracts
Symptoms include
50%
 glare
 contrast sensitivity
 visual acuity
20%
Risk factors:
- vitamin intake,
-light (ultraviolet B)
exposure,
-smoking,
>65 years
>75 years
-alcohol use,
Percentage of population with cataracts
-long-term corticosteroid
use,
-diabetes mellitus
Age-Related Macular Degeneration
Most common cause of blindness among older
adults in developed world
Classic symptom is loss of central vision
Risk factors: age, genetics, smoking,
hypertension, fair skin
Diagnosis: presence (dry) of drusen and (wet) of
choroidal neovascularization
Monitor with dilated eye exams, Amsler grid
Glaucoma
Defined as characteristic optic nerve head damage and
visual field loss- generally loss of peripheral vision.
Elevated intraocular pressure is a major risk factor
Affects >2.25 million Americans aged >40 years
Second most common cause of blindness worldwide;
most common cause among African Americans
$1 billion for glaucoma-related Medicare and
Medicaid payments and disability
Glaucoma
Primary open-angle glaucoma is most common
Slow aqueous drainage leads to chronically elevated
intraocular pressure
Patients are asymptomatic and may suffer substantial
visual field loss before consulting a physician
Causes are multifactorial and polygenic
Requires monitoring of visual fields and intraocular
pressure
Diabetic Retinopathy
Epidemiology: Among persons who have had type 2
diabetes at least 10 years:
 70% show retinopathy
 Nearly 10% show proliferative disease.
Most important risk factors: Duration of disease
and control of blood sugar
Prevention: Tight glucose control (A1C < 7 %) and
BP control (≤140/80)
Visual loss spotty, occurring in areas of edema and
hemorrhage
Keratitis Sicca (Dry Eyes)
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
Eye 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, impair vision
Lid ectropion (eversion) or entropion (inversion) may
cause discomfort
Treatment: surgery
Herpes Zoster Ophthalmicus
Painful reactivation of varicella zoster virus
Dermatomal distribution of weeping vesicles
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)
Common Hearing Impairments
Conductive Hearing Loss
Sensory Hearing Loss
Sensorineural Hearing Loss
Due to cochlear or retrocochlear pathology
Pure tone audiograms show decreased
thresholds for both air and bone conduction
Presbycusis the most common type in elders
Other etiologies: ototoxic meds; infection,
trauma ,vascular events or tumors of 8th
nerve; Meniere’s disease
Sensorineural Hearing Loss
Conductive Hearing Loss
2nd most common cause of hearing loss
Sound transmission to inner ear is impaired
On audiogram bone conduction much better
than air conduction
Conductive Hearing Loss Causes:
External ear pathology
 Ceruminosis- a factor in 80% of cases
 Foreign body
 Skin diseases
Middle-ear pathology





Otosclerosis
Paget’s disease
Cholesteatoma
Tympanic membrane perforation
Middle ear effusion
Conductive Loss Audiogram
Summary
Acknowledgments
Slides adapted with permission from the
American Geriatrics Society, Geriatric
Review Syllabus teaching slide set.
Permission granted 1-10-07
Post-test question 1
A 70-year-old black American man notes gradually
decreasing vision in the right eye. He has a 10-year history
of non-insulin-dependent diabetes mellitus and a 3-year
history of hypertension. Current medications are two oral
hypoglycemic agents, a diuretic, and an angiotensinconverting enzyme inhibitor. He checks his blood glucose
weekly and does not follow a strict diet. Cardiopulmonary,
abdominal, and musculoskeletal findings are normal
except for obesity. Neurologic examination shows
decreased touch sensation in the fingertips. Urinalysis
shows mild proteinuria. Fingerstick blood glucose level is
greater than 200 mg/dL. Hgb A1c is 10.2%. Which of the
following is the least likely cause of the vision loss?
A.Cataract
B.Vitreous hemorrhage
C.Macular edema
D.Macular ischemia
E.Age-related macular degeneration
Correct Answer:
E. Age-related macular degeneration
Age-related macular degeneration is the most common cause
of vision loss in the elderly white population but is rare in
black persons, who may be protected by their
pigmentation. The most likely cause is longstanding,
poorly controlled diabetes. Cataract is more prevalent
among diabetic persons, in whom typical senile lenticular
changes may develop earlier than in the nondiabetic
persons. Caution must be exercised with cataract extraction
in diabetic patients, who are more prone to develop
visually debilitating macular edema. Vitreous hemorrhage
may cause severe visual loss in diabetic patients with
proliferative retinopathy.
Used with permission from: Murphy JB, et. Al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
Panretinal photocoagulation or laser destruction of
the peripheral retina will inhibit the stimulus for
growth of new blood vessels (neovascularization).
Vitrectomy may be indicated for a dense,
nonclearing hemorrhage that has been present
longer than 3 months. Macular edema is a
common cause of moderate visual loss in diabetic
patients. Argon laser therapy is beneficial in
stabilizing or improving visual acuity. Macular
ischemia may result from capillary nonperfusion
and is not directly amenable to therapeutic
intervention. Argon laser therapy also is indicated
for ischemia associated with macular edema,
although the prognosis for visual improvement is
poor.
Post-test question 2
69-year-old woman presents for a pre-employment physical
examination for work in a child-care center. Her general
health is good; an occasional "water pill" for dependent
edema is her only medication. She mentions worsening
hearing when around her preschool grandchildren,
although conversational hearing with her husband at home
appears less affected. There is no family history of hearing
loss. Physical examination of the external ear canals
reveals no wax accumulation. On handheld audiometric
screening she misses the 2000 and 4000 Hz frequencies at
40 dB of amplification bilaterally. Subsequent audiology
testing shows bilateral upper-frequency hearing loss along
with significant speech discrimination difficulties. Which
of the following conditions most likely underlies this
woman's hearing loss?
A. Meniere's disease
B. Eighth cranial nerve damage
C. Presbycusis
D. Ototoxic medication effect
Correct Answer: C. Presbycusis
Bilateral higher-frequency hearing loss with poor speech
discrimination is characteristic of presbycusis. The higher
pitch of children's voices and the greater degree of
background noise often make child-care settings
particularly difficult for persons with presbycusis.
Meniere's disease is a cause of lower-frequency hearing
loss and is often unilateral. It is often accompanied by
disabling vertigo and tinnitus. Though the latter symptoms
often improve with time and treatment, the hearing losses
may not improve and are a major source of chronic
disability. Damage to the eighth cranial nerve from either
ototoxic medication or from trauma causes a clinical
picture of sensory neural hearing loss. This hearing loss is
often of abrupt onset and affects a broad range of
frequencies. Loop diuretic agents are among the most
common offending medications causing sensorineural
hearing loss when used routinely. End
Vision Acknowledgments
Co-Editors:
Karen Blackstone, MD
Elizabeth L. Cobbs, MD
GRS6 Chapter Authors:
David Sarraf, MD
Anne L. Coleman, MD, PhD
GRS6 Question Writer:
Gwen K. Sterns, MD
Medical Writer:
Barbara B. Reitt, PhD, ELS (D)
Managing Editor:
Andrea N. Sherman, MS
© American Geriatrics Society
Hearing Acknowledgments
Co-Editors:
Karen Blackstone, MD
Elizabeth L. Cobbs, MD
GRS6 Chapter Author:
GRS6 Question Writer:
Priscilla Faith Bade, MD, MS
Barbara E. Weinstein, PhD
Medical Writer:
Barbara B. Reitt, PhD, ELS (D)
Managing Editor:
Andrea N. Sherman, MS
© American Geriatrics Society