August 2011
A Simple Eye Test for Visually
Impaired Older People in Care
Facilities in the Netherlands
The purpose of IAPB Briefing Papers is to inform IAPB members and others about
important and emerging issues affecting VISION 2020: The Right to Sight.
Paper prepared for VISION 2020 Netherlands by:
 Prof. Dr. J.E.E. Keunen, Ophthalmologist, President of VISION 2020
Netherlands, Ophthalmology Institute, UMC St Radboud Nijmegen
 M. Snouck Hurgronje-van de Ruit, Team Leader Nursing Staff,
Ophthalmological Policlinic, Board Member VISION 2020
Netherlands, Leids UMC, Leiden
 Prof. Dr. M.G.M. Olde Rikkert, Geriatrist, Geriatric Department, UMC
St Radboud Nijmegen
 Prof. Dr. G.H.M.B. van Rens, Ophthalmologist, Ophthalmology
Department, VU MC, Amsterdam
 Dr. J.J. Limburg, Physician-Researcher, acting Secretary VISION
2020 Netherlands
“Unless disabled people are brought into the development mainstream, it will be
impossible to cut poverty in half by 2015”
James Wolfensohn, Former President of the Wold Bank, 2002
Introduction
The expression ‘Old age has its infirmities’ is commonly used and visual disabilities are a
good example of such infirmities. In 2009, an estimated 316,000 Dutch people had a visual
disability: 78,000 blind people and 238,000 visually impaired. 79.4% of those people (a
total of 251,000) were 65 years or older and 72.2% of them (181,000) were women.
Age is the most important risk factor for visual impairment and blindness. The prevalence
increases exponentially after the age of 65 and is on average higher in women than in men
(Figure 1.). In 2009 according to the Dutch Central Bureau of Statistics (CBS), of the 2.472
million older people (age 65 plus) 155,000 (6.3%) live in a care facility and 2,317,000
(93.7%) live independently. At over 40%, the prevalence of visual disability among those
living in a care facility is highest: 32,000 (20.6%) blind and 34,000 (21.9%) visually
impaired. Prevalence among older people living independently is lower (1.2% are blind and
6.8% are visually impaired), but at 27,000, the number of older live-at-home blind people is
almost equal and the number of visually impaired at 154,000 is almost five times higher.
Major contributors to visual impairments among older people are age-related macular
degeneration (AMD or ARMD), cataract, refractive ametropia, glaucoma, and diabetic
retinopathy. Over the next 10 years, due to the aging of the population, the number of
people aged 65 and over will increase from 2.47 million people (15.0% of the population) in
2009 to 3.36 million (19.7%) in 2020. In concurrence, the number of visually-impaired older
people will increase to an estimated 378,000 in 2020.
Figure 1: Prevalence of blindness
and visual impairment in the
Netherlands according to age and
gender
[Dark blue] Men, blind
[Light blue] Men, visually impaired
[Purple] Women, blind
[Lilac] Women, visually impaired]
In a developed country like the Netherlands, visual impairment with acuity of ≤0.3 in the
best eye, can be very limiting: these people are no longer permitted to drive a car and
reading or working with a computer is difficult without special adaptations. It diminishes the
quality of life and depression is more common. Additionally, the number of falls and
fractures increases. This eventually leads to a greater dependency on special care—older
people with a double visual impairment often need care in a nursing home or residential
care home. Adequate preventive eye care can help change this situation. The care
necessity and quality of life increase after a cataract operation. This in turn, could diminish
the number of falls and fractures.
Over 80% of all visual impairment and blindness in the world is treatable or can be
prevented with timely intervention (‘avoidable blindness’). For this reason, in 1999, the
WHO and the International Agency for the Prevention of Blindness (an umbrella
organization consisting of more than 20 international NGOs, working on the prevention and
avoidance of blindness), launched a world-wide initiative under the name of ‘VISION 2020:
The Right to Sight’. Its objective is to eliminate all avoidable visual impairment and
blindness in the world before the year 2020. In 2003, the WHO project group VISION 2020
Netherlands was founded by the former Dutch minister of Welfare, Health and Sport, dr. E.
Borst-Eilers in order to achieve this goal in the Netherlands also. The project group
identified that 40% of all blindness and over 60% of all visual impairment in the
Netherlands is ‘avoidable,’ specifically symptoms deriving from treatable disabilities like
cataract, secondary cataract, and refractive ametropia and visual disabilities caused by
glaucoma, or diabetic retinopathy which could have been prevented by early diagnosis and
treatment. It was estimated that 63% of all visual disabilities among older people in care
facilities is avoidable. Among live-at-home older people, this is estimated to be 56%.
For this reason, in recent years, commercial optometrists offer eye care on location in a
number of care facilities to residents in need of care. Additionally, the Oogbus (Eye Coach
or Eye Bus) from insurance company CZ and the Rotterdamse Oogzorgnetwerk
(Rotterdam Eye Care Network) are emerging phenomena playing into this trend. The eye
coach is equipped to have an optometrist do an extensive on-site eye examination. People
can make an appointment there and the examination is free of charge for the CZ insured.
However, some older people are still not making use of these facilities. This may be
because visual impairment develops gradually and is therefore not always detected—
especially when dealing with comorbidity. In addition, many older people don’t want to
complain or be a ‘nuisance,’ or they think deterioration of eye sight is just part of ageing
(wrongful attribution to age). Many older people are prone not to report their medical
issues. Recent research into the demand for care and the care necessity of older people
with a visual impairment showed there is too little synchronization between the different
health and welfare care facilities for visually-impaired older people. Patients complain
about a ‘maze of care facilities and financial regulations and benefits.’ It also turned out
that, on average, only one-third of the visually-impaired or blind older people had informed
their GP of their disability. Less than 50% of the visually impaired had been referred to a
rehabilitation centre by the attending ophthalmologist.
When thinking of the screening process, it may be advised to consider the criteria as
formulated by Wilson and Jungner (see Frame 1, below). These criteria are all very
applicable to the issues mentioned above.
Frame 1 Wilson’s criteria for screening
The disease

is an important issue

it causes loss of productivity, dependency, heightens the risk of falls and
fractures, depression, and negatively effects the quality of life

has a demonstrable stage of latent or early symptoms

gradual decrease of acuity

has a clear and known natural development

this is the case for almost all causes for visual disabilities
Research

an adequate test or examination is available

visual acuity examination, Amsler test and visual field test are standardized

the test should be acceptable for the target audience to be examined

avoid tests that are too demanding or invasive

screening should be a continuous process

every new resident should be examined and subsequently tested every other year
Aftercare

facilities for examination and treatment should be available

ophthalmologist, optometrist/optician and rehabilitation are available everywhere

there should be an acceptable and effective treatment

with over 50% of the people with a visual disability, improvement is possible; in
case of permanent visual disability, visual aids and rehabilitation will increase the
ability to provide for oneself

there should be consensus on who needs to be treated

there is consensus about the treatment of eye afflictions and GPs should refer
accordingly upon diagnosis
Economy

screening costs should remain reasonable in comparison to the possible total cost
of medical care

refractive eye surgery, cataract and glaucoma surgery, as well as monitoring and
treatment of diabetic retinopathy are proven cost-effective interventions
The purpose of this article is to present a simple and quick eye test, which will make it
easier to detect visual-impairment in older people in care facilities. A nurse or caretaker
should be able to perform this screening and determine, based on the outcome, if the
patient should see their GP or a geriatric specialist and if necessary needs a subsequent
referral to an optometrist, ophthalmologist or rehabilitation center. These are the
provisional outlined results of a first pilot research using this screening method.
Figure 2. Test card for near- and farsightedness (back and front)
Definitions
In the Netherlands, blindness is defined when someone has an acuity of less than 0.05 in
their best eye, with optimal correction and/or when the peripheral visual field is damaged in
such a way that only a central visual field remains with an angle of ≤10° around the central
axis. Visual impairment is defined as acuity between 0.05 and 0.3 with optimal correction,
and/or a visual field between 10-30° around the central axis. The term ‘visual disability’
covers both groups, meaning acuity of less than 0.3 in the best eye with optimal correction.
Visual disabilities, due to not wearing proper eyeglasses are not counted in these
definitions, although this is an important cause for visual impairment—even among older
people in the developed west. The WHO therefore recently recommended adjusting the
definition of blindness and visual impairment. Visual acuity ‘with optimal correction’ was
changed to visual acuity ‘with available correction.’ Due to this change, not wearing proper
eyeglasses is also counted. In this article, the aforementioned new definitions have been
applied.
Methods Used
All residents and the client board received a letter explaining the background, the purpose
and the execution of the screening, two weeks before starting the visual acuity screening.
The visual acuity screening was executed on groups of 5-10 people, by specially trained
caretakers or nurses of the care facility who are familiar with the residents. The screening
took place in a small hall or gym room, or a shielded area. Coffee or tea was served to
facilitate interaction and discussion: it is often only in this environment that residents realize
they are not the only ones suffering from poor eye sight, making it easier to discuss the
topic. Visual acuity screening takes about 10 minutes per resident.
VISION 2020 Netherlands has designed a simple eye test for the screening of visual
impairment and blindness in nursing homes and residential care homes. This test includes
2 cards of manageable size (A5 format), printed on both sides and laminated with nonshiny material. The screening consists of a test for farsightedness, a reading test for
nearsightedness, a simple test for the function of the retina (the Amsler Grid) and a simple
visual field exam (Figures 2 and 3). The farsightedness test uses the standard E Chart,
calibrated for a 4-meter distance; the reading test uses a text in different font sizes, in
standardized M units. The Amsler Grid and the Confrontation Visual Field Exam by
Donders are standard examination methods.
With these, the most common forms of blindness and visual impairment among older
people can be determined. The Amsler Grid helps detect age-related macular degeneration
by the characteristic optic distortion (or metamorphopsia). The Confrontation Visual Field
Exam is important for diagnosing glaucoma.
[Figure 3. Test card for retina function and visual field (back and front)]
Farsightedness Test
If the client has eyeglasses for farsightedness, they should wear them during the
screening. The test card is shown from a 4-meter distance and each eye is tested
separately. Clients should pass 4 out of 5 tests. If 2 or more tests are wrong, it should be
concluded that the client cannot see the E. With an acuity of less than 0.3 in one or both
eyes, the client should be referred to the GP (of the nursing home). Teachers in India using
the same E Charts, determined a sensitivity of 64% , a specificity of 93% and a Kappa
corrected for prevalence and bias of 0.78 (good similarity) compared to the usage of the
standard Snellen letter chart.
Nearsightedness Test
If the client has eyeglasses for nearsightedness, they should wear them during the
screening. The reading card should be read from a distance of 40 centimeters under
proper lighting, using both eyes at the same time. The observer watches how many lines of
text the client can read. At an acuity of 0.4 or less, the client should be referred to the GP
(of the nursing home).
Retina Function Test
The Amsler Grid is used to examine the retina function. The older person looks at the black
dot in the center of the grid from a distance of 30 centimeters—first using both eyes at the
same time, then with each eye separately. Then the observer should ask the client if they
can see the entire grid and if all lines are straight.
If this is confirmed, (in conformity with example A in Figure 3), there is no reason for
referral. However, if the client describes a grid similar to example B in Figure 3, the client
should be referred to the GP (of the nursing home).
Visual Field Test
This is a preliminary test to examine if the visual field is restricted. The examiner sits
opposite the client who has one eye covered and has the other eye fixed on the opposite
eye of the examiner: the examiner keeps the other eye closed. The examiner then moves
the outstretched arm, wriggling the fingers, from the outside toward the fixation point. They
should first measure both horizontal directions, then both vertical directions. The client
indicates when the wriggling fingers come into sight. Both eyes are tested separately. A
manual for this test is indicated on the card. If there is any indication that the visual field in
one or more areas is restricted, the client should be referred to the GP (of the nursing
home).
Reporting
It is imperative to keep good documentation on the outcome of the test in the client’s
personal file. VISION 2020 Netherlands has designed a form for this purpose (see Figure
4) which can be used as a supplementary sheet in the client’s file. This form can equally be
used as a referral letter for the GP (of the nursing home). It also allows for a scientific
analysis of the data obtained.
There is also special software to store the screening data and the subsequent follow-up.
This makes it easy to keep track of the data and the status of the individual residents within
the system. The software automatically generates reports about the number of older
people in the facility with visual disabilities, the number of potentially avoidable cases, the
number of clients that were referred to an ophthalmologist, optometrist, optician, or
rehabilitation facility, and finally, if the acuity has improved after intervention. Initially, all
residents of the care facility should be screened and it is advisable to follow up with
subsequent screening every other year unless indicated earlier. All new residents should
be screened upon admission.
The response rate for the acuity screening in the first pilot in a care facility was high. We
will only present some preliminary outlined data to show the feasibility of the screening in a
care facility: 87 out of 93 residents (93%) were screened. Four residents were unable to
undergo the screening procedure and one refused, because she was already regularly
visiting an ophthalmologist. Out of the 87 tested, 36 (41%) had a visual disability: 28 (32%)
expressed visual impairment in their best eye and 8 (9%) extreme visual impairment. The
results were in line with the estimated 40% of older people in care facilities with a visual
disability.
Of the 93 residents, 32 were referred to an ophthalmologist: 12 of them were known cases,
but their last visit had been too long ago or new issues had arisen in the meantime. Ten
residents were referred to an optometrist/optician (1 known case) and 7 residents were
enrolled in Visio (3 known cases). A few residents have already undergone surgery for
cataract or glaucoma, but not all data on these residents is complete yet, because we are
still missing some correspondence from referred residents, and some are still awaiting
surgery.
Figure 4. Reporting Form
Discussion
Two in five older people in care facilities in the Netherlands have a visual disability and in
over half those cases (31,000 people) the symptoms are treatable or could have been
avoided. Given the extra care necessity caused by a visual disability, directly and indirectly
(depressions, falls, and fractures), it is advised to detect avoidable visual disabilities in care
facilities for older people in an early stage and with minimal cost and to treat those cases
whenever possible. With this method, older people can better reap the benefits of
treatment of (wet) macular degeneration. The VISION 2020 test presented in this article
makes it possible to do a low-cost screening.
In practice, it will turn out that not all older people in care facilities are eligible for
ophthalmological screening. Those with severe psycho-geriatric disorders may not fully
understand the screening and dispensing and using eyeglasses or undergoing surgery for
cataract or glaucoma can cause severe issues for this group. There are also older people
with a visual disability who, even after ample deliberation, decide not to be treated: they
think they are too old, think it’s too much trouble to do the screening, or say the can
manage fine without help.
Nevertheless, the writers of this article plead for a routine acuity screening of all older
people in care facilities and for case finding on policlinics (e.g., in case of falling analysis).
The first screening can be performed by a nurse or caretaker after a short practical training
by a geriatric specialist. When the first screening shows no anomalies, there is no need for
follow-up. In all other cases, the client will be referred to their GP or geriatric specialist.
Based on the findings of the acuity screening and the data in the client’s personal file, the
doctor of the care facility can determine who the client should be referred to, or if no further
action is required. All these steps can take place at the care facility, causing minimal extra
case load for the attending physician as well as the client. In many cases, it is even
possible to agree with the optometrist/optician and the rehabilitation center that they also
perform their research at the care facility. Solid mutual agreements are an essential
condition for creating an adequately functioning care chain and offering proper intervention.
Such screening should of course also be possible as a method of diagnosing visual
disabilities at a visit to the GP’s practice, or the policlinic, or day clinic by clinic geriatrist.
In 2009, during the national symposium ’75 years of blindness prevention in the
Netherlands,’ VISION 2020 Netherlands Patron, HRH Princess Margriet emphasized that
the prevention of blindness and visual impairment needs a national basis to be successful.
“If you open up the conversation, it will bring all liaisons to the surface, so that pillared
thinking and acting can be prevented. Joining forces with patient unions is essential in
making this a success. The purpose is a society in which avoidable blindness and visual
impairment are no longer a handicap. … You are all part of the solution,” she noted.
VISION 2020 Netherlands works in conjunction with the Unie Katholieke Bond van
Ouderen (Union Catholic Association for Older People) and the national umbrella
association for older people, on the deployment of a national awareness program, which
will be kicked off in 2011. In preparation for this event, the first screening tests with the test
cards as described earlier in this article have begun in care facilities in Amsterdam-Noord,
Maastricht and Den Bosch. The small pilot described here, gives an idea of the practical
use of the test card as a piece of equipment to quickly establish that almost half the tested
older people had indeed a visual disability, which confirmed earlier estimations.
For live-at-home older people routine screening may not be the best option: the prevalence
is low and the number of older people high. It is probably better to adequately inform this
group, for instance using the previously mentioned initiative of the national unions for older
people. Perhaps it is an option to do a focused acuity screening of older people with a
heightened risk on visual disability, like on all older people getting medical help through
home care. Further investigation on the efficiency and effectiveness of such a screening
has yet to be investigated.
In conclusion, it is safe to say that the test cards presented in this article provide an easy
solution to identify older people with a visual disability. This will lead to a substantial
decrease in the high prevalence of visual impairment among older people in care facilities
and an improvement of the quality of life for a large group of vulnerable older people.