Here’s to a healthy, longer life!
View(s):The Sri Lanka Association of Geriatric Medicine last year released a comprehensive manual ‘Aid for Healthy Ageing’ with the aim of empowering the older generation with knowledge to faciliate a healthy and longer life.The writers/resource persons were drawn from the respective Medical Colleges.
Starting this March, MediScene will publish extracts from the book.
Early Detection and Prevention of Eye Disorders in older people by Dr Deepani Wewewala, Consultant Eye Surgeon at the National Eye Hospital
As people get older, they tend to take a reduction in vision as part of “normal ageing”. Even doctors, under whose care they are, sometimes consider reduced vision, changes in facial appearance and “pain” to be just age-related.
However, paying attention to eye health in the elderly helps to save vision and sometimes to save lives.
Even in the absence of any symptoms and signs, routine comprehensive eye examinations to exclude age-related eye disease is necessary to prevent future vision loss.
Clinical Presentations
The clinical presentation of the eye disor
ders in the elderly could take one or more of the following forms:
Visual defects
n Ocular pain
n Floaters
n Change in appearance
Visual defects
Sudden Loss of Vision
Dense loss of vision of acute onset usually alarms both the patient and the physician. The patient presenting with blurring and distortion of vision, a transient loss of vision and a loss of a definable field of vision should also need urgent attention as those with dense loss of vision.
The sudden loss of vision is usually due to a vascular event where the central retinal artery or the central retinal vein is involved. Usually, the loss of a field of vision is recognized by patients only when it is acute, which happens when an arterial or venous branch is occluded or when a haemorrhage occurs in the macular area.
Central Retinal Artery Occlusion (CRAO) which presents with a sudden dense loss of vision is an ocular emergency. If attended to urgently (within 6 hours of the onset of vision loss), at least a small field of vision in the affected eye may be saved.
If a direct ophthalmoscope is used, palid retinal edema with a cherry red macula is the typical appearance of CRAO. If this facility is not available, it is best to consider any sudden onset unilateral loss of vision as CRAO. Basic “first aid” for CRAO for the patient will help to minimize the damage/save a part of the vision. Keep the patient supine, with the head slightly low and massage the eye globe to improve ocular perfusion. ‘CO2 breathing’ is thought to cause ocular vascular dilatation to exert the same effect.
Patients with hypertension and abnormal lipids are at a higher risk of CRAO. Episodes of amaurosis fugax may herald CRAO and is an indication for carotid doppler studies in the elderly.
Progressive vision loss
The progressive loss of vision happens at different rates in different pathological events. Rapid progression within hours is typically seen in vitreous haemorrhage (where the loss of vision gradually becomes denser) or in retinal detachment (where the initial field loss progresses to involve the entire visual field).
The progression of the visual loss in uveitis and some optic neuropathies continues for days, whereas diabetic maculopathy progresses for months and cataract for months or years before the patient seeks medical advice.
The distortion of vision occurs in both Age-Related Macular Degeneration (ARMD) and in Diabetic Macular Edema (DME) before irreversible visual loss occurs.
Ocular pain
Chronic mild discomfort due to blepheritis and dry eye which usually occur together are very common. Warm massaging, lid scrubbing, artificial tears and antibiotic ointment help relieve this chronic nagging symptom.
When an elderly person presents with gradually worsening pain and severe pain which distract the sleep, consider uveitis and scleritis, which may or may not be associated with red eye or altered vision in the initial stages.
Episodic unilateral eye pain or unilateral headache is angle closure glaucoma until proven otherwise.
If pain or irritation follows trauma to the eye (however trivial) urgent referral to an eye unit is indicated, as corneal ulceration may have occurred and could progress readily in the elderly, more so in the presence of diabetes.
Floaters and
flashes
The acute onset appearance of ‘a ring’, ‘a string’, ‘a mosquito’ or ‘a spider’ moving in the centre of the visual field, associated with lightning flashes seen in the temporal visual field is usually an alarming symptom. This occurs due to age-related vitreous degeneration succeeding in detachment of the posterior surface of the vitreous from the retina.
During this event the adjacent retina may break at the point of the vitreous and retina. The degenerated vitreous can enter through the retinal break, causing retinal detachment.
Patients who present with floaters and flashes need urgent eye referral – within 24-48 hours. A thorough fundus examination to reveal any retinal breaks which can be treated with laser reduces the risk of retinal detachment.
Change in appearance
Most people stop paying attention to their facial appearance after a certain age. The knowledge of potentially dangerous lesions that change the facial appearance is important.
Colour changes of conjunctiva (especially unilateral) should be noted. Closer examination of a chronic red eye may reveal the slightly elevated ‘Salmon patch’ lesion characteristic of lymphoma.
Newly appearing black spots /enlarging birth marks are of concern as they could be melanomatous. Changes of colour or contour of lid margin could similarly be an indication of a pre-malignant or malignant condition.
Nerve / muscle palsies usually present with diplopia or ‘acute squints’ and the ability to note specific eye movement defects of the third, fourth, and sixth nerves is important. If a patient presents with acute divergent eye with partial ptosis, the examination of the pupil is mandatory. If the pupil is larger on the affected side, surgical third nerve palsy due to an aneurysm adjacent to the third nerve should be suspected and urgent neuro-imaging performed.Although a certain degree of ptosis could occur with age-related levator weakness, elderly patients with troublesome ptosis should be checked for fatigability, the clinical test for myasthenia gravis.
Routine screening
As the better eye compensates in terms of slowly progressive visual loss, a self-check at home covering one eye at a time, while reading a calendar or a small print newspaper should be encouraged at all times, especially in the elderly.
Comprehensive screening should begin as early as 35-40 years to minimise visual impairment due to progressive and irreversible ocular diseases such as glaucoma, diabetic retinopathy and ARMD.
For diabetics, an annual screening from the date of diagnosis of diabetes is recommended. More frequent examinations need to be done after retinopathy is detected.
For the non-diabetic elderly, screening should be done every three years.
Routine screening of
the vision includes;
Checking of distance and near vision and correction whenever necessary (older people especially the illiterate tend to go on without spectacle correction as they can just ‘manage’ with their day-to-day life but as a result tend to miss detection of early visual loss).
n Dilated fundus examination, ideally with slit lamp and fundus lens. Fundus photography or direct opthalmoscopy are also acceptable alternatives.
n Intra-ocular pressure, ideally with applanation tonometry ( slit lamp). Air puff and electric tonometers are also considered adequate for screening.
Recommendations for
referral to a specialist in ocular emergencies (non-trauma)
n Sudden loss of vision- within 6 hours
n H/O transient loss of vision – within 24-48 hours
n Floaters and flashers- within 24-48 hours
n Unilateral severe episodic or persistent ocular pain- within 24-48 hours
n Surgical third nerve palsy- as early as possible to the neurology or neurosurgical unit.