Download GRS8VisionImpairment

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VISUAL IMPAIRMENT
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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 people
• Techniques for low-vision rehabilitation
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TO P I C S C O V E R E D
• Common Eye Conditions
• Causes of Visual Loss
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Refractive Error
Cataract
Age-related Macular Degeneration (ARMD)
Diabetic Retinopathy
Glaucoma
Ischemic Optic Neuropathy
• Low-Vision Rehabilitation Strategies
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I M PA C T O F V I S U A L I M PA I R M E N T
• Visual impairment (acuity < 20/40)
 Prevalence increases with age
 Affects 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
• Most common causes of blindness in the older adult US
population are ARMD, refractive error, cataract, diabetic
retinopathy, glaucoma
S C R E E N I N G TO P R E V E N T
VISUAL LOSS
The American Academy of Ophthalmology
recommends comprehensive eye examinations
with dilation every 1 to 2 years for people ages
65 years and older
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COMMON EYE CONDITIONS
I N O L D E R A D U LT S
• Red eye, ocular swelling or discomfort, diplopia,
sudden loss of vision, and floaters are common eye
complaints
• Ask, “Has your vision changed?”
• Decreased vision can indicate a serious condition
 Check visual acuity
 Check for afferent pupillary defect
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S I G N S A N D S Y M P T O M S O F E Y E C O N D I T I O N S7
R E Q U I R I N G I M M E D I AT E R E F E R R A L T O
OPHTHALMOLOGIST (1 of 2)
Condition
Symptoms and signs
Retinal detachment Flashes, floaters, decreased vision
Acute angleclosure glaucoma
Ischemic optic
neuropathy
Central artery
occlusion or giant
cell arteritis
Eye pain or headache, ocular hyperemia,
dilated pupil, decreased vision, nausea,
vomiting
Sudden loss of vision (complete or partial)
in one eye
Sudden painless loss of vision in one eye;
if from giant cell arteritis, then review of
symptoms may reveal jaw claudication,
headache, transient diplopia, etc.
S I G N S A N D S Y M P T O M S O F E Y E C O N D I T I O N S8
R E Q U I R I N G I M M E D I AT E R E F E R R A L T O
OPHTHALMOLOGIST (2 of 2)
Condition
Bacterial keratitis
Scleritis
Symptoms and signs
Decreased vision, eye redness, pain,
discharge
Eye redness, pain, decreased vision
Posterior uveitis
Floaters, decreased vision
Corneal ulcers
Eye redness, pain, decreased vision,
corneal infiltrate
Photophobia, eye redness, decreased
vision
Eye redness, pain, burning, rash,
decreased vision, light sensitivity,
characteristic skin lesions
Uveitis
Herpes zoster
ophthalmicus
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T R E AT M E N T O F E Y E C O N D I T I O N S C O M M O N LY
SEEN B Y PR IMA RY C A R E PR OVID ER S ( 1 of 3 )
Condition
Red eye
Subconjunctival
hemorrhage
Dry eye
Blepharitis
Lid malposition or
lid exposure
Treatment and/or cause
Supportive treatment with artificial tears
Artificial tears, cyclosporin 0.2% eye drops
Lid scrubs, ophthalmic antibiotic ointment qhs
to eyelids, oral doxycycline
Ocular lubricant, refer for surgical repair
Allergic conjunctivitis Cold compresses, allergen avoidance,
topical/systemic antihistamines
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T R E AT M E N T O F E Y E C O N D I T I O N S C O M M O N LY
SEEN B Y PR IMA RY C A R E PR OVID ER S ( 2 of 3 )
Condition
Red eye (continued)
Viral conjunctivitis
Chalazion
Herpes simplex
keratitis
Herpes zoster
ophthalmicus
Angle-closure
glaucoma
Treatment and/or cause
Supportive treatment with artificial tears; refer
to ophthalmologist if vision significantly
affected
Warm compresses, may refer for excision
Trifluridine eye drops, refer to ophthalmologist
Tear drops, refer to ophthalmologist
immediately if there are lesions on tip of nose
(Hutchinson’s sign)
Refer to ophthalmologist immediately
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T R E AT M E N T O F E Y E C O N D I T I O N S C O M M O N LY
SEEN B Y PR IMA RY C A R E PR OVID ER S ( 3 of 3 )
Condition
Floaters, flashes
Sudden decrease in
vision
Diplopia
Monocular
Binocular
Treatment and/or cause
Refer to ophthalmologist immediately; may be
retinal detachment or vitreous hemorrhage
Refer to ophthalmologist immediately; may be
secondary to a number of vision-threatening
problems
Refractive error, cataract
Microvascular infarct to cranial nerve, giant cell
arteritis, compressive tumor
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K E R AT I T I S S I C C A ( D RY E Y E S )
• Tear production decreases with age
• Characteristics: redness, foreign body sensation, and
reflex tearing
• Management: artificial tears during daytime and
ointment at bedtime
• Topical cyclosporin A (0.2%) eye drops in severe cases
to treat underlying inflammatory causes
• Treat accompanying blepharitis
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LID ABNORMALITIES
• Common among older adults
• Elasticity and tensile strength are gradually lost 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 and ocular drying
• 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 or famciclovir may shorten the course
• Post-herpetic neuralgia may be debilitating
 Treat with local ointments (capsaicin, lidocaine) but not in eye,
OR
 Treat with systemic medications (off-label): narcotics, tricyclic
antidepressants, gabapentin, pregabalin
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REFRACTIVE ERROR
• Leading cause of visual impairment, along with cataracts
• Treatment: eyeglasses, contact lenses, laser refractive
surgery
• Ametropia
 Myopia (nearsightedness)
 Hyperopia (farsightedness)
 Astigmatism (visual distortion)
• Presbyopia ( ability to focus on near objects)
 Begins after age 40
 Caused by gradual hardening of the lens and decreased
muscular effectiveness of the ciliary body
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CATARACT (1 of 2)
• Symptoms include
 glare,  contrast
sensitivity,  visual acuity
• Risk factors:  age,
 vitamin intake, light
(ultraviolet B) exposure,
smoking, alcohol use,
long-term corticosteroid
use, diabetes mellitus
50%
20%
>65 years
>75 years
Percentage of population with cataracts
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C ATA R A C T ( 2 o f 2 )
Treatment: surgical extraction
• 90% of patients achieve vision ≥ 20/40
• 1.5 million surgeries are performed annually
in US
• Local or topical anesthesia, small-incision
sonographic breakdown and aspiration of the
lens, placement of an artificial lens
AGE-RELATED
MACULAR DEGENERATION (1 of 2)
• Most common cause of irreversible blindness among
older adults in developed world
• Risk factors: age, genetics, smoking, hypertension,
fair skin
• Diagnosis: presence of drusen (dry form) or of
choroidal neovascularization (wet form)
• Treatment
 Vitamin C, vitamin E, zinc, β-carotene
 Intravitreal injections of vascular endothelial growth factor
inhibitors and laser surgery
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AGE-RELATED
MACULAR DEGENERATION (2 of 2)
Choroidal neovascularization in a patient with
wet ARMD demonstrating a gray-green membrane
with surrounding subretinal hemorrhage
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DIABETIC RETINOPATHY
• Epidemiology: Among people 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, control
of blood sugar and BP
• Prevention: Tight glucose control (A1C < 7%) and BP
control (≤130/80)
• Treatment: Laser treatment and intravitreal injections;
tight control of blood glucose and BP
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DIABETIC RETINOPATHY STAGES
• Nonproliferative
• Preproliferative (severe nonproliferative)
• Proliferative
DIABETIC RETINOPATHY:
NONPROLIFERATIVE (1 of 2)
• Microaneurysms
• Intraretinal hemorrhages
• Exudates
• Macular edema
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DIABETIC RETINOPATHY:
NONPROLIFERATIVE (2 of 2)
Intraretinal edema and exudate in the superior
macular region consistent with diabetic macular
edema in a patient with type 2 diabetes
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DIABETIC RETINOPATHY:
PREPROLIFERATIVE
• Multiple intraretinal hemorrhages
• Venous caliber changes
• Intraretinal microvascular abnormalities
(capillary shunting)
• Capillary nonperfusion or ischemia
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DIABETIC RETINOPATHY:
PROLIFERATIVE (1 of 2)
• Neovascularization of the retina
• Neovascularization of the disc
• Visual loss due to vitreous hemorrhage or
traction retinal detachment
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DIABETIC RETINOPATHY:
PROLIFERATIVE (2 of 2)
Florid neovascularization of the disc in a patient
with high-risk proliferative diabetic retinopathy
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O V E RV I E W O F G L A U C O M A
• Defined as characteristic optic nerve head damage and
visual field loss
• Affects >2.25 million Americans >40 years old
• Second most common cause of irreversible blindness
worldwide; most common cause among black Americans
• $1 billion for glaucoma-related Medicare and Medicaid
payments and disability
• Elevated intraocular pressure is a major risk factor
P R I M A RY
OPEN-ANGLE GLAUCOMA
• Most common form of glaucoma
• 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
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ACUTE ANGLE-CLOSURE
GLAUCOMA
• Precipitous increase in intraocular pressure
• Redness and pain with acute vision loss and
often nausea and vomiting
• Emergent ophthalmologic referral required
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GLAUCOMA MANAGEMENT
• Intraocular pressure–lowering medications (local
and systemic)
 Aqueous suppressants
 Aqueous outflow facilitators
• Laser trabeculoplasty
• Filtering surgery  antimetabolite
• Drainage devices
• Ciliary body destructive procedures
ANTERIOR ISCHEMIC
OPTIC NEUROPATHY (1 of 2)
• Microvascular occlusion of the blood supply
to the optic nerve
• Due to atherosclerotic vascular disease or
inflammation (temporal arteritis)
• Results in acute visual or field loss
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ANTERIOR ISCHEMIC
OPTIC NEUROPATHY (2 of 2)
Pallid swelling of the optic nerve head in an older
adult patient with anterior ischemic optic neuropathy
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L O W- V I S I O N R E H A B I L I TAT I O N
• Available to patients with acuity < 20/60
• Improve lighting and provide reading material with bold,
enlarged fonts and accentuated black-on-white contrast
• Magnification: high-plus spectacles, magnifiers, closedcircuit TV, telescopic devices
• Eccentric viewing for patients with ARMD who have
central macular pathology: training to use off-center
fixation
• Talking devices or Braille for those who have lost vision
altogether
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S U M M A RY
• Visual loss occurs commonly among older
adults and may lead 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
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CASE 1 (1 of 4)
• An 80-year-old woman comes to the office because
her arthritis is making it difficult for her to apply
prescribed eye drops.
• History includes severe rheumatoid arthritis and openangle glaucoma.
• Medications include eye drops and systemic drugs
that lower intraocular pressure (IOP) that have been
prescribed for several years because of IOP.
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CASE 1 (2 of 4)
• At her most recent ophthalmologic examination 6
months ago, IOP was well controlled and visual field
was normal.
• She asks whether she can discontinue her glaucoma
medications, because she is getting older and has
never had symptoms from the increased IOP.
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CASE 1 (3 of 4)
Which of the following is the most appropriate response?
A. Recommend stopping eye medication, because the
benefit of treating increased IOP at her age is negligible.
B. Explain that without her current medication she risks an
immediate attack of painful glaucoma and loss of vision.
C. Suggest that she stop the eye medication on a trial basis
but see an ophthalmologist immediately if eye pain or
decreased vision develops.
D. Refer her to an ophthalmologist for consideration of laser
trabeculoplasty.
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CASE 1 (4 of 4)
Which of the following is the most appropriate response?
A. Recommend stopping eye medication, because the
benefit of treating increased IOP at her age is negligible.
B. Explain that without her current medication she risks an
immediate attack of painful glaucoma and loss of vision.
C. Suggest that she stop the eye medication on a trial basis
but see an ophthalmologist immediately if eye pain or
decreased vision develops.
D. Refer her to an ophthalmologist for consideration of laser
trabeculoplasty.
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CASE 2 (1 of 2)
An 85-year-old man comes to the office because he has
severe pain and blurring of his right eye that improves with
blinking or when he rubs the affected eye.
Which of the following is the most likely cause of the symptoms?
A. Acute angle-closure glaucoma
B. Anterior uveitis
C. Keratitis sicca
D. Chalazion
E. Allergic conjunctivitis
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CASE 2 (2 of 2)
An 85-year-old man comes to the office because he has
severe pain and blurring of his right eye that improves with
blinking or when he rubs the affected eye.
Which of the following is the most likely cause of the symptoms?
A. Acute angle-closure glaucoma
B. Anterior uveitis
C. Keratitis sicca
D. Chalazion
E. Allergic conjunctivitis
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CASE 3 (1 of 3)
• An 80-year-old man comes to the office because he
needs a refill prescription for ophthalmic corticosteroids.
The corticosteroids were prescribed for him 2 weeks
ago at an urgent care center he visited for symptoms of
red eye and mucous discharge.
• The patient believes that the eye drops have helped his
chronic itching.
• There is no prior history of use of topical corticosteroids.
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CASE 3 (2 of 3)
Which of the following is the most appropriate response
to the patient’s request?
A. Do not refill the prescription; arrange for the patient
to see an eye specialist within the next 24 hours.
B. Do not refill the prescription; ask the patient to see
an eye specialist within the next month.
C. Refill the prescription; ask the patient to see an eye
specialist within the next 2 weeks.
D. Refill the prescription for the patient to continue the
medication until symptoms resolve.
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CASE 3 (3 of 3)
Which of the following is the most appropriate response
to the patient’s request?
A. Do not refill the prescription; arrange for the patient
to see an eye specialist within the next 24 hours.
B. Do not refill the prescription; ask the patient to see
an eye specialist within the next month.
C. Refill the prescription; ask the patient to see an eye
specialist within the next 2 weeks.
D. Refill the prescription for the patient to continue the
medication until symptoms resolve.
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GRS8 Slides Editor:
Annette Medina-Walpole, MD, AGSF
GRS8 Chapter Authors:
JoAnn A. Giaconi, MD
David Sarraf, MD
Anne L. Coleman, MD, PhD
GRS8 Question Writer:
Gwen Sterns, MD
Medical Writers:
Beverly A. Caley
Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2013 American Geriatrics Society