Care of Older Adults: Role of Primary Care Physicians in the Treatment of Cataracts and Macular Degeneration

Kyle V. Marra, BS; Sushant Wagley, AB; Mark C. Kuperwaser, MD; Rafael Campo, MD, DLitt; Jorge G. Arroyo, MD, MPH

Disclosures

J Am Geriatr Soc. 2016;64(2):369-377. 

In This Article

Abstract and Introduction

Abstract

This article aims to facilitate optimal management of cataracts and age-related macular degeneration (AMD) by providing information on indications, risk factors, referral guidelines, and treatments and to describe techniques to maximize quality of life (QOL) for people with irreversible vision loss. A review of PubMed and other online databases was performed for peer-reviewed English-language articles from 1980 through August 2012 on visual impairment in elderly adults. Search terms included vision loss, visual impairment, blind, low vision, QOL combined with age-related, elderly, and aging. Articles were selected that discussed vision loss in elderly adults, effects of vision impairment on QOL, and care strategies to manage vision loss in older adults. The ability of primary care physicians (PCPs) to identify early signs of cataracts and AMD in individuals at risk of vision loss is critical to early diagnosis and management of these common age-related eye diseases. PCPs can help preserve vision by issuing aptly timed referrals and encouraging behavioral modifications that reduce risk factors. With knowledge of referral guidelines for soliciting low-vision rehabilitation services, visual aids, and community support resources, PCPs can considerably increase the QOL of individuals with uncorrectable vision loss. By offering appropriately timed referrals, promoting behavioral modifications, and allocating low-vision care resources, PCPs may play a critical role in preserving visual health and enhancing the QOL for the elderly population.

Introduction

Mr. F, an 88-year-old retired fisherman, was evaluated for painless progressive loss of vision in both eyes over the course of 1 year. His medical history included hypertension, atrial fibrillation, benign prostatic hypertrophy, and hyperlipidemia. He was taking losartan, atenolol, lovastatin, alendronate, warfarin, and tamsulosin.

An optometrist determined that his best-corrected visual acuity was 20/70 in each eye because of cataracts and referred him to Dr. K, an ophthalmologist. Dr. K noted extensive drusen, which are a sign of moderate age-related macular degeneration (AMD), and began daily Age-Related Eye Disease Study (AREDS)-recommended vitamin and antioxidant supplements. Mr. F underwent cataract surgery in both eyes, after which his best-corrected vision improved to 20/20 in the right eye and 20/25 in the left eye.

Three years later, Mr. F's vision decreased in both eyes, and he underwent neodymium-doped yttrium aluminum garnet (Nd-YAG) laser treatment in the right eye to correct posterior capsular opacities, but his best-corrected vision had dropped to 20/80 in both eyes, and he was instructed to stop driving. High-resolution optical coherence tomography of the right eye revealed findings consistent with wet AMD, for which he received monthly intravitreal injections of an anti–vascular endothelial growth factor antibody. The visual acuity in his right eye subsequently improved enough for him to resume driving. His injections may continue at the discretion of his retina specialist.

Mr. F's case presents the two most-common age-related causes of vision loss: cataracts and AMD.[1,2] Affecting an estimated 20.5 million Americans aged 40 and older, cataracts are the most prevalent cause of vision loss in the United States and are the most prevalent leading cause of blindness in the world.[2] With modern surgical technology and appropriately coordinated care, cataracts can be safely treated and vision restored, although AMD is the leading cause of irreversible vision loss in the developed world and affects 1.75 million citizens, with an additional 7 million individuals at risk of developing the disease.[1] With limited treatment options available for AMD, early detection is the most-effective method of reducing vision loss, and knowledge of predisposing factors (including disease prevalence within age groups and risk profiling guidelines) can assist primary care physicians (PCPs) in determining which individuals may have an higher risk of cataracts and AMD. The Eye Disease Prevalence Group's report on the prevalence of cataracts and AMD in the U.S. population aged 65 and older has been summarized in Table 1.[1,2]

PCPs are often the first healthcare professionals to recognize the need for an eye examination for new-onset visual decline.[7] By detecting visual changes and issuing appropriately timed referrals, PCPs play a crucial role in preventing vision loss in the growing elderly population, especially in cases of AMD, for which early detection is critical to the preservation of vision. Although numerous other ocular diseases such as diabetic retinopathy and glaucoma are increasingly prevalent in the United States (with an estimated 4.1 million and 2.2 million affected, respectively), this article focuses solely on cataracts and AMD, alongside Mr. F's experience with these diseases, and aims to highlight the role of PCPs in the care of these individuals.[8,9]

First, the age-specific prevalence and epidemiology of cataracts and AMD are discussed to assist PCPs in effectively screening individuals at risk for vision loss. Cataracts account for 60% of all vision-related Medicare costs, of which 68.3% of people are in Mr. F's age group (≥80). Cataracts are a common progressive disease that occur with maturity, when the lens naturally thickens and becomes opaque, causing decreased visual acuity, color vision, and overall function.[2,10] Although age is the major contributor to the development of cataracts, epidemiological studies provide strong and consistent evidence of an association between the development of cataracts and other factors, including diabetes mellitus,[11] long-term corticosteroid use,[12,13] ultraviolet light exposure,[14] and ocular trauma.[15] Other observational studies have found a statistical association between cataract progression and smoking,[16] ionizing radiation,[17] prior intraocular surgery,[18] family history,[16] and hypertension.[7,19,20] Knowledge of age and risk factors for cataracts can provide information needed to direct an effective primary care screening.

AMD is a degenerative disease that can affect a large area of the macula but is most symptomatic to individuals when involving the central macula.[21] There are two distinct forms of AMD: dry and wet. Dry AMD is categorized by yellow fatty deposits (drusen) and pigmentary changes to the retinal epithelium.[22] As was the case for Mr. F, in wet AMD, new vessel formation (neovascularization) originating from the deeper choroidal layers extends into the retina. Although AMD presents in dry and wet forms, there is a separate classification system based on the disease's effect on vision that eye care specialists commonly use: early AMD (little to no effect on vision), intermediate AMD, and advanced AMD (significant effect on vision). Early AMD is by definition dry AMD, defined by the presence of small or intermediate-sized drusen, and is characterized by minimal effect on vision, if any. Intermediate AMD is dry AMD with extensive small or intermediate-sized drusen or any large drusen. Advanced AMD can be dry or wet. Advanced cases of dry AMD result in vision loss due to geographic atrophy, which is the degeneration of the underlying choroidal layers that support and supply nutrients to the light-sensitive photoreceptor cells of the retina. All cases of wet AMD are considered advanced AMD.

Knowledge of significant predisposing factors for AMD can help to identify at-risk individuals. Similar to cataracts, the prevalence of AMD increases substantially with age (Table 1).[22] Although various risk factors (family history,[23] higher body mass index,[24] hypertension,[25] underlying atherosclerotic disease,[25] low antioxidant levels,[26] systemic inflammation,[27] sunlight exposure[28]) are associated with AMD, cigarette smoking,[29,30] age, and white ethnicity are the only risk factors that are consistently associated with macular degeneration.[22]

The subsequent overview of common complaints and presentations provides guidelines for recognizing visual and functional manifestations of these diseases and for making appropriately timed referrals to optometrists or comprehensive ophthalmologists. Once an individual is under an ophthalmologist's care, PCPs may further contribute to care by ensuring that rehabilitation services aimed toward improving the individual's quality of life (QOL) are accessible. When necessary, this may require the PCP to refer the individuals to a low-vision specialist for instruction on the use of visual aids, to encourage the use of community services, and to provide referrals to mental health specialists for individuals with mental health problems that may stem from vision loss.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....