Identifying and Treating Older Patients with Vision Loss in Primary Care

A recent article published in the journal American Family Physician discusses the important role family physicians play in helping to identify vision loss in older patients. The four conditions that are most responsible for vision loss in older patients are age-related macular degeneration, glaucoma, ocular complications of diabetes mellitus, and age-related cataracts.

In March 2016, the U.S. Preventive Services Task Force (USPSTF) concluded that there was insufficient evidence to assess the balance of benefits and harms of screening for impaired visual acuity in adults aged >65 years. The USPSTF identified no well-designed studies “demonstrating conclusive benefits of universal eye screening in older adults.”  However, Task Force member Michael Pignone, M.D., M.P.H, points out “in the absence of clear evidence, primary care doctors should use their clinical judgement when deciding whether to screen for vision problems in patients without vision symptoms.”

Vitamin supplements can aid in slowing the progression of age-related macular degeneration. Smokers should be counseled to avoid the original AREDS formula containing beta-carotene. Intravitreal injection of a vascular endothelial growth factor inhibitor can preserve vision in the neovascular form of macular degeneration, though the safety and efficacy of this intervention has not been evaluated past 24 months. Currently, pegaptanib, ranibizumab, and aflibercept are approved for the treatment of neovascular age-related macular degeneration bevacizumab is not approved to treat this condition.

Medicated eye drops decrease intraocular pressure and slow the progression of vision loss in patients with glaucoma but treatment adherence is poor with rates typically <50% at the 1-year mark. Strategies such as simplifying eye drop regimens, educating patients, coaching on proper eye drop technique, and offering continued support may improve adherence. Though laser trabeculoplasty also reduces intraocular pressure and preserves vision in patients with primary open-angle glaucoma, long-term studies are needed to see who is most likely to benefit from surgery.