Ca ses of Geriatric
Causes
Ge iat ic Visual
Vis al
Impairment
pa
e t and
a d Their
e
Long Term Care
I
Implications
li ti
A Clinical Perspective
Long
g Term Care International Forum
Tampa, FL
Mayy 6,, 2010
5/19/2010
Douglas F. Buxton,
. M.D., F.A.C.S.
1
ADJUDICATION !
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
2
“We Have Met the Enemyy and He
Is PowerPoint”
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
3
“The
e Awareness
a e ess Test”
est
CONCENTRATE!
5/19/2010
Douglas F. Buxton,
. M.D., F.A.C.S.
4
Visual
sua Impairment
pa e in the
e
Elderly Objectives:
• Magnitude of the Challenge, the aging
population
• Four Major Causes off Vision Loss, the
h
Most Common Impairments
• Functional Impact & Risks of Vision Loss,
Adaptive Devices, Technology Assistance
5/19/2010
Douglas F. Buxton,
. M.D., F.A.C.S.
5
U.S. POPULATION
AGE 65 AND OVER
2009: 305,000,000
305 000 000 and counting!
70
60
50
Population 40
(millions) 30
20
10
0
1900
1990
Est. 2010
Est 2030
Year
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
6
VISUAL LOSS
ASSOCIATED WITH AGING
• 1 in 3 may face some visual loss by age 65
• Potential consequences
–
–
–
–
Daily activities curtailed
Social isolation,
isolation depression
Less mobility, falls and fractures
Loss of independent living
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
7
Visual Impairment
p
in the
Elderly (AAO)
Definitions:
• Total blindness: Inability to tell light from
dark, total inability to see.
• Visual impairment or low vision: Severe
reduction in vision not correctable with
glasses or contact lenses
lenses, severely
reducing person's ability to function at
certain or all tasks
tasks.
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
88
Visual Impairment
p
in the Elderlyy
Definitions (cont):
• Legal blindness (form of severe visual
impairment): Best
Best--corrected central vision
of 20/200 or worse in the better eye or a
visual acuity of better than 20/200 but
with a visual field no greater than 20°
20°
(e.g., side vision that is so reduced that it
appears as if the person is looking through
a tunnel).
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
9
VISUAL IMPAIRMENT OFTEN
UNTREATED
• Leading causes of blindness in the aging
eye (Baltimore Study):
–
–
–
–
AgeAge-related macular degeneration
Pi
Primary
openopen-angle
l glaucoma
l
Lack of surgical intervention for cataract
1/3 of new blindness is avoidable
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
10
Visual Impairment
p
in the
Elderly: Some Sobering Statistics
(SSS)
• 2008 NEI: 25.2 million answered “having
t bl seeing”
trouble
i ” or “totally
“t t ll bli
blind”
d” even with
ith
glasses or contact lenses
• At present level of technology and access
to appropriate ophthalmic care, visual
impairment in this group will grow from
3.4 to 5.5 million in 2010
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
11
Visual Impairment
p
in the
Elderly:
SSS (cont):
• NEI: Annual cost of this disability is $68
billion,
• This cost does not fully quantify direct
healthcare costs, lost productivity,
reduced independence,
independence diminished quality
of life, increased psychiatric stress and
even accelerated mortality
mortality. (NAEVR
(NAEVR, 2005)
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
12
CARE OF THE AGING EYE
• Decreased vision with age
• Common eye conditions affect people >
50
• Many conditions are preventable or
treatable
• Improve or maintain visual function
• Coordination between PCP and
Ophthalmologist ensures best care
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
13
PCP EVALUATION FREQUENCY:
Q
• Asymptomatic patients 65+: Every 1–
1–2 yrs
• Symptomatic patients: Evaluate and refer
on presentation
• Decreasedd visuall acuity: Routinely
l refer
f
• Treatment goal: Optimize visual function
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
14
The Four Major
j Causes of Vision
Loss in the Elderly Population:
1 Age
1.
Age--Related
l d Macular
l Degeneration
2.
3.
4.
5/19/2010
(ARMD)
Glaucoma
Cataracts
Diabetic Retinopathy (DR)
Douglas F. Buxton, M.D., F.A.C.S.
15
1. AgeAge-Related Macular
Degeneration
D
ti (ARMD)
• Leading cause of severe and irreversible
visual
i
l acuity
it (VA) loss
l
in
i older
ld adults
d lt in
i
the developed world
• Loss of central vision
• Risk factors: age,
g , genetic
g
load,, smoking,
g,
cardiovascular disease, UV exposure,
malnutrition
• Specific factors contributing to
pathogenesis and progression are not
completely understood
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
16
ARMD:
Pathogenesis and Progression
• Primarily involves the retinal pigment
epithelium
• Role of vitreo
vitreo--macular adhesion?
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
17
ARMD:
CENTRAL VISION LOSS IN
ADVANCED STAGES
• “Dry” ARMD
– Atrophy of photoreceptors and choriocapillaris
– Gradual vision loss
• “Wet” ARMD
– Neovascularization between retina and choroid
– Disc edema, disciform scar
– More sudden severe visual loss
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
18
ARMD:
SYMPTOMS
•Intermediate stage
– No symptoms or slight
difficulty with reading,
driving, etc, due to
atrophy
t h nott yett iinvolving
l i
center of macula
– Straight lines may appear
crooked
•Advanced stage
– Central blind spot
– Peripheral vision usually
remains intact
5/19/2010
Central blind spot
Douglas F. Buxton, M.D., F.A.C.S.
19
ARMD:
RISK OF PROGRESSION
• Early
l ARMD
•
•
•
– May not have any increased risk of advanced ARMD
compared to people without drusen
1 eye intermediate ARMD, 1 eye without ARMD
– 5% risk of progression to advanced ARMD within 5
y
years
Both eyes intermediate ARMD
– 25% risk of progression to advanced ARMD within 5
y
years
1 eye advanced ARMD
– 50% risk of advanced ARMD in second eye within 5
years
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
20
ARMD: Recent Diagnostic
g
Advances
• Ultrasound
• Time domain Ocular Coherence
Tomography (OCT)
• Scanning
S
i laser
l
ophthalmoscopy
hth l
(SLO)
• Spectral domain OCT
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
21
TREATMENT FOR ARMD
• Aim
Ai to
t reduce
d
risk
i k off progression
i in
i intermediate
i t
di t
to advanced stage
– Dietary supplements such as used in the Aged
Aged-Related Eye Disease Study (vitamin C 500 mg,
mg
vitamin E 400 IU, beta carotene 15 mg, and zinc
oxide 80 mg)
• Reducing risk of vision loss in selected cases of
neovascular ARMD
– Laser photocoagulation
– Photodynamic therapy with verteporfin
– Intraocular injection therapy with antianti-VEGF drugs
(some may increase chance of improving vision)
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
22
ARMD:
Impact on ADL’s and IADL’s
• Usually minimal impact on ADL’s in early,
moderate and even advanced stages
• Significant impact on IADL (managing money,
taking
g medications,, reading
g manuals,, telephone
p
use, etc.
• Patients with advanced ARMD frequently arrive
unaccompanied to my practice, with appropriate
appearance and self care
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
23
ARMD:
DEALING WITH VISION LOSS
• Low vision aids
• Treatment
T t
t off
depression and
anxiety when
indicated
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
24
ARMD
End Stage Disease:
“You will never g
go blind from this
condition”
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
25
2. GLAUCOMA
• Second most common cause of visual loss in
older people
• Affects
– 10% AfricanAfrican-Americans  70
– 2% Caucasians  70
• Early detection and treatment can prevent
blindness
• 3 million individuals with glaucoma
• 1 million unaware they have glaucoma
• 80,000 blind from glaucoma
• Leading cause of blindness among African
Americans
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
26
GLAUCOMA:
RISK FACTORS
• IOP (Intra(Intra-ocular pressure) may be high
• African racial heritage
• Advanced age
• Family history of glaucoma
• Hypertension, diabetes, myopia
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
27
TYPES OF GLAUCOMA
• Primary openopen-angle glaucoma (POAG)
– Most common type
yp in people
p p over age
g 50
• Angle
Angle--closure glaucoma
• Congenital
• Childhood
• Secondary
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
28
GLAUCOMA:
OPTIC NERVE HEAD CHANGES
• Increased size of the cup
• Thinning of disc rim
• Progressive loss of neural rim tissue
• Disc hemorrhages
g
• Loss of nerve fibers
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
29
Primary OpenOpen-Angle Glaucoma
Groove or wedge defect in nerve fiber layer
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
30
Types of Glaucoma
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
31
Types of Glaucoma
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
32
POAG: PROGRESSION
• Asymptomatic in early stages
• Often marked visual loss has occurred
when patient presents with vision
symptoms
sy
pto s
• Can result in blindness
• “Mrs
Mrs. Jones
Jones, you are really flirting with
disaster, if you don’t use your drops you
will go totally blind!
blind!”
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
33
“Flirting with Disaster
Disaster”
“Don’t
Don t Get Too
Cocky!
Cocky!”
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
34
THE “SILENT”
SILENT BLINDER
• Primary OpenOpen-Angle Glaucoma
• Visual field test results over time:
progressive scotoma
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
35
Primary OpenOpen-Angle Glaucoma
PROGRESSIVE NEURAL
TISSUE LOSS
Year 1
5/19/2010
Year 12
Douglas F. Buxton, M.D., F.A.C.S.
36
Primary OpenOpen-Angle Glaucoma
Extensive glaucomatous damage
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
37
The Four Major
j Causes of Vision
Loss in the Elderly Population:
1 Age
1.
Age--Related
l d Macular
l Degeneration
2.
3.
4.
5/19/2010
(ARMD)
Glaucoma
Cataracts
Diabetic Retinopathy (DR)
Douglas F. Buxton, M.D., F.A.C.S.
38
3. AGEAGE-RELATED CATARACT
Third most common cause of visual loss in older
people
• Leading cause of blindness worldwide
• Leading cause of vision loss in USA
• 20.5 million American over the age of 40 have
cataracts in one or both eyes
• 5.1% (6.1 million) have had cataract surgery
• Decreased vision (Framingham Eye Study)
65--74 years = 18%, 75
65
75--85
85-- years = 46%
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
39
MATURE CATARACT
Dense cataract causing pupil to appear gray
rather than black
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
40
CATARACT
SYMPTOMS & TREATMENT:
•
•
•
•
•
Disturbance of near or distance vision initially
Progresses to diminution of vision
Cataract severity and location determine impairment
Glare is bothersome
Surgery indicated if
– Significant visual impairment
– Daily activities curtailed (e
(e.g.,
g problems driving
driving,
reading, etc.)
• No current medical treatment
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
41
Implantation of an artificial intraocular lens
within the capsular bag
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
42
CATARACT
PROGNOSIS & SURGICAL
FOLLOW--UP:
FOLLOW
• 90% achieve 20/40 vision or better
• Infrequent complications
– Infection
– Glaucoma
– Retinal swelling or detachment
• Capsular bag opacifies, requiring Nd:YAG
laser capsulotomy in 15%
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
43
4. DIABETIC RETINOPATHY
(DR)
• Fourth most common cause of visual loss in
•
•
•
•
people
p
p over age
g 55
Type II diabetes more likely in people > age
55
Macular edema more common with Type I
Retinal complications of diabetes
Leading cause of blindness in workingworking-age
Americans
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
44
DR
• Diabetic Retinopathy (DR): 12,000 to
24,000 new cases of blindness
yearly=number
l
b one cause off new cases off
blindness in 2020-70 yo in USA
• 4.1 million Americans have DR, 25%
vision threatening
• Early detection and treatment proven
effective
• 50% of diabetics do not under go routine
eye exams or diagnosed too late
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
45
DR
MINIMIZING EFFECTS:
• PCP andd Ophthalmologist
O hth l l i t workk together
t
th
– Type I: Annual eye exam beginning 5 years
after
ft di
diagnosis
i
– Type II: Eye exam at time of diagnosis, and
then annually
• Good glycemic control
– Type I: Insulin
– Type II: Diet, exercise, weight loss
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
46
Pathogenesis
l
Normal
5/19/2010
Diabetic Retinopathy
Douglas F. Buxton, M.D., F.A.C.S.
47
Clinical Stages of Retinopathy
DIABETIC MACULAR EDEMA
• Diabetes ≤5 yrs = 5% prevalence
• Diabetes ≥15 yrs = 15% prevalence
Healthy macula
5/19/2010
Edematous macula
Douglas F. Buxton, M.D., F.A.C.S.
48
Clinical Stages of Retinopathy
Vitreous hemorrhage
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
49
Clinical Stages of Retinopathy
New vessel growth
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
50
Treatment
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
51
GOALS FOR SUCCESS:
• Timely screening reduces risk of blindness
from 50% to 5%
• 100% screening estimated to save $167
million annually
• Systemic
S t i control
t l
• Team approach: Primary Care Physician,
Ophthalmologist, Nutritionist,
Endocrinologist, Nephrologist,
Nephrologist, etc.
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
52
Teamwork
or “Lending a
Helping Hand
Hand”
5/19/2010
5/19/2010
DouglasF.F.Buxton,
Buxton, M.D.,
Douglas
M.D.,F.A.C.S.
F.A.C.S.
53
53
Differential Characteristics of
Visual Impairment
• ARMD: Education, ““peri
peri--genetic” and
psych counseling, access to competent
ophthalmic specialist and other supportive
care--Not truly a “preventable” condition
care
• Glaucoma: Education of at risk
populations
popu
a o s and
a d PCP’s,
C s, screening,
sc ee g, early
ea y
assessment and treatmenttreatment-highly
p
preventable
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
54
Differential Characteristics of
Visuall Impairment
• Cataracts: Usually mild to moderate and
highly
g y reversiblereversible-manage
g expectations
p
and
cost--effectiveness
cost
• Diabetic Retinopathy: Profound
Profound, complex
visual impairment, frequently linked to
other coco-morbidities,
morbidities including other eye
disorders, ischemic heart disease, renal
failure etc.
failure,
etc
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
55
Prevention of Visual Impairment
• ARMD: Avoidance of excess UV exposure,
smoking, nutritional supplementation
smoking
• Glaucoma: Appropriate monitoring of
ocular pressure and visual fields,
fields
especially in high risk populations
• Cataracts: Access to competent surgical
specialist
• Diabetic retinopathy: Education, life
life--long,
multi--disciplinary team approach with
multi
frequent visits and monitoring
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
56
Visual
sua Impairment
pa e in the
e
Elderly Objectives:
• Magnitude of the Challenge, the aging
population
• Four Major Causes off Vision Loss, the
h
Most Common Impairments
• Functional Impact & Risks of Vision Loss,
Adaptive Devices, Technology Assistance
5/19/2010
Douglas F. Buxton,
. M.D., F.A.C.S.
57
Functional Impact & Risks of
Vision Loss,
Loss Adaptive Devices,
Devices
Technology
gy Assistance:
Definitions
• Good visual acuity: greater than or equal
to 20/25
• Moderate visual acuity: 20/32 - 20/40
• Reduced visual acuity: 20/50 - 20/63
• Visual impairment:
p
less than or equal
q
to
20/80
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
58
Visual Impairment Has a
Substantial Impact on the
Q lit off Life
Quality
Lif
Compared
p
with other
Chronic Conditions
Dunlop,
p, et al.,, “Incidence of
functional limitation in older
adults”,, Arch Phys
y Med Rehabl.
2002; 83(7): 964964-971
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
59
Impact of Visual Impairment on
QOL Compared to Chronic
Conditions,, Greater Than:
• Diabetes II
• Coronary Syndrome
• Hearing
H i Impairment
I
i
5/19/2010
Ophthal.. Epidem.,
Ophthal
Epidem., 14: 119
119--126,
‘07
Douglas F. Buxton, M.D., F.A.C.S.
60
Impact of Visual Impairment on
QOL Compared to Chronic
Conditions,, Less than:
• Stroke
• Multiple Sclerosis
• Chronic Fatigue Syndrome
• Major Depressive Disorders
• Severe
S
M
Mental
t l Illness
Ill
5/19/2010
Dutch Study, Ophth. Epidem.,
14:119-126, 2007
61
Major
j Affects of Visual Loss in
Activities of Daily Living:
• Distance visual acuity
• Mental health
5/19/2010
AJO, 137, No 2, 2004
Douglas F. Buxton, M.D., F.A.C.S.
62
Reduced Visual Acuityy
(VA < 20/40)
• Two
Two--fold increase in likelihood of ADL and
IADL limitations
• Adjusted for some sociosocio-demographic
factors
acto s a
and
d cchronic
o cd
diseases
seases
• Controversial with several contradictory
studies due to differences in definitions,
definitions
classifications, etc.
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
63
Visual Impairment
p
(less than 20/80)
• At least one ADL disability 4x more likely
than those with better vision than 20/80
• IADL disabilities and performanceperformance-based
ob ty limitations
tat o s 5
5x more
o e likely
e y vs.
s
mobility
those with good VA (banking and
sshopping)
opp g)
• Reported mobility limitations 3x more
likely vs
vs. good VA
VA.
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
64
Conclusions
• Visual Acuity (VA) level exerts a strong,
independent influence on functional ability
• Visual impairment (<20/80) increased odds for
ADL, IADL, and mobility limitations three - to
fivefold
• VA has a strong, independent influence on
physical functioning in persons aged 55 and
above.
• Even slight decrease in VA is associated with
limitations ADL, ADL and mobility task
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
65
Visual Rehabilitation ((VR)) for
the Visually Impaired
• Traditionally VR directed to the blind or
severely impaired
• Increasing evidence that less severe vision
loss
oss assoc.
assoc with
t increased
c eased risks
s sa
and
d co
co-morbidities in an ever increasing elderly
population
popu
a o
• 2003 AAO SmartSight project outlined a
graduated Low Vision intervention model
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
.
66
High Tech Visual Aides
• Video magnifiers: enlarge and enhance contrast ($1,600
($1,600-•
•
•
•
•
$ ,
$5,000)
)
Hand--held magnifiers will capture and generate enlarged
Hand
digital photos ($800
($800--$1,700)
Word processing and Web surfing enhancing programs:
ZoomText and MAGic ($595) magnifies print
Screen and book readers: JAWS and WindowWindow-Eyes and
OpenBook ($895)
Talking Walk signs and Humanware’s GPSGPS-based Trekker
($1,695)
Ultracane (Sonar
(Sonar--based object detector) ($995)
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
67
Video Magnifier
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
68
“Seeing
Seeing Machine
Machine”
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
69
Reduce avoidable blindness and severe visual impairment.
HELP LINE / INFORMATION AND PATIENT
REFERRAL
800 391 EYES 800-391-3937
800-391-EYES
800 391 3937
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
70
“I’ve had a p
perfectlyy
wonderful morning!
BUT THIS WASN
WASN’T
T IT!
IT!”
-
GROUCHO MARX
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
71
SOME OF MY FAVORITE
THINGS!
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
72
NEVER FORGET THEIR
SACRIFICE
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
73
Game
6!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
74
AJ and Diana
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
75
Communication
Co
u cat o iss tthe
e Key!
ey
“SPEAK THE
SAME LANGUAGE”
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
76
Questions?
5/19/2010
Douglas F. Buxton, M.D., F.A.C.S.
77