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visual impairment

- a decrease in visual function that is subjectively &/or objectively demonstrable. - any person may be considered visually impaired if - corrected distant visual acuity in the better eye is 20/80 or less, or - if visual fields are significantly restricted * see visual function. Etiology: 1) Acute visual loss lasting > 1 hour - keratitis* (+) - endophthalmitis (+) - retinal hemorrhage or vitreous hemorrhage - retinal detachment - retinal artery occlusion - retinal vein occlusion - optic neuritis (+) - ischemic optic neuropathy - occipital cortex infarction (stroke) * associated with red eye (+) accompanied by ocular pain 2) Major causes of impairment (USA) - diabetic retinopathy - glaucoma - age-related macular degeneration - cataracts - presbyopia (refractive error)* * Most common reversible cause of visual impairment Epidemiology: - 50% of persons > 75 years of age (excluding presbyopia) Pathology: - lens cloudiness, lens opacity [13] Clinical manifestations: (patterns) 1) slow central vision loss a) nuclear cataracts b) macular degeneration 2) peripheral loss: advanced open-angle glaucoma 3) hemianopsia 4) scotoma suggests lesions in the retinas or visual pathways 5) blurry vision (reduced visual acuity) 6) micropsia Complications: - depression - potentially modifiable risk factor for dementia [14,15] - functional limitations due to cognitive decline are more common among adults with vision impairment (RR=3) [10] - patterns of cognitive decline differ by type of visual impairment - impaired contrast sensitivity is associated with decline across more cognitive domains than other measures of visual function [11] - psychoactive substance use common in visually impaired adults of all ages [12] Management: - screening: - comprehensive eye exam every 1-2 years adults >= 65 years (American Academy of Ophthalmology) - inconclusive evidence for visual screening elderly (USPTF) - screening elderly (>= 65 years) does not improve function or quality of life [9] (CMAJ) - visual impairment in the elderly - refer to optometrist or ophthalmologist [3] - see specific etiology - sudden visual loss: refer to ophthalmologist - progressive or permanent visual impairment - address treatable causes with ophthalmologist - refer to vision rehabilitation specialist as needed

Interactions

disease interactions

Related

age-associated changes in the eye eye vision visual function

Useful

vision rehabilitation

Specific

blindness blurry vision (decreased visual acuity, DVA) color vision impairment (includes chromatopsia) hyperopia (hypermetropia, farsightedness) loss of central vision loss of peripheral vision micropsia photopsia transient monocular blindness (TMB); amaurosis fugax transient visual loss visual field loss

General

eye disease (ophthalmopathy) sensory impairment

References

  1. nlmpubs.nlm.nih.gov/hstat/ahcpr/
  2. Guide to Physical Examination & History Taking, 6th edition, Bates B, JB Lippincott, Philadelphia, 1995, pg 35
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 17. American College of Physicians, Philadelphia 1998, 2015
  4. Mangione CM, In:UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  5. Helenius J et al. Concurrent acute brain infarcts in patients with monocular visual loss. Ann Neurol 2012 Aug; 72:286. PMID: 22926859
  6. US Preventive Services Task Force (USPSTF) Screening for Impaired Visual Acuity in Older Adults. US Preventive Services Task Force Recommendation Statement. JAMA. 2016;315(9):908-914 PMID: 26934260 http://jama.jamanetwork.com/article.aspx?articleid=2497913
  7. Daien V, Peres K, Villain M et al Visual impairment, optical correction, and their impact on activity limitations in elderly persons: the POLA study. Arch Intern Med. 2011 Jul 11;171(13):1206-7. PMID: 21482828 Free PMC Article
  8. Dagnelie G. Age-related psychophysical changes and low vision. Invest Ophthalmol Vis Sci. 2013 Dec 13;54(14):ORSF88-93. Review. PMID: 24335074 Free PMC Article
  9. Wilson BJ, Courage S, Bacchus M et al Screening for impaired vision in community-dwelling adults aged 65 years and older in primary care settings. CMAJ Vol. 190, Issue 19, 14 May 2018 PMID: 29759965 http://www.cmaj.ca/content/190/19/E588
  10. Saydah S, Gerzoff RB, Taylor CA, Ehrlich JR, Saaddine J. Vision Impairment and Subjective Cognitive Decline-Related Functional Limitations - United States, 2015-2017. MMWR Morb Mortal Wkly Rep 2019;68:453-457 https://www.cdc.gov/mmwr/volumes/68/wr/mm6820a2.htm
  11. Varadaraj V, Munoz B, Deal JA et al Association of Vision Impairment With Cognitive Decline Across Multiple Domains in Older Adults. JAMA Netw Open. 2021;4(7):e211741. July 16. PMID: 34269806 Free article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2781965 - Gupta P, Vu TA, Lamoureux EL Beyond Visual Acuity - A Comprehensive Assessment of Vision and Cognition in Older Adults With Visual Impairment. JAMA Netw Open. 2021;4(7):e2119033. July 16. PMID: 34269812 Free article. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2781971
  12. Han BH, Leddy JF, Lopez FA et al. Prevalence of psychoactive substance use among middle-aged and older adults with visual impairment in the US. JAMA Ophthalmol 2021 Nov 11; [e-pub] PMID: 34762104 PMCID: PMC8587212 (available on 2022-11-11) https://jamanetwork.com/journals/jamaophthalmology/article-abstract/2785903
  13. Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  14. Ehrlich JR, Goldstein J, Swenor BK et al Addition of Vision Impairment to a Life-Course Model of Potentially Modifiable Dementia Risk Factors in the US. JAMA Neurol. Published online April 25, 2022 PMID: 35467745 https://jamanetwork.com/journals/jamaneurology/fullarticle/2791268 - Deal J, Rohas JC Visual Impairment as a Modifiable Risk Factor in Dementia Prevention and Management. JAMA Neurol. Published online April 25, 2022 PMID: 35467705 https://jamanetwork.com/journals/jamaneurology/fullarticle/2791267
  15. Killeen OJ, Zhou Y, Ehrlich JR. Objectively Measured Visual Impairment and Dementia Prevalence in Older Adults in the US. JAMA Ophthalmol. Published online July 13, 2023. PMID: 37440238 https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2807125
  16. Pelletier AL, Rojas-Roldan L, Coffin J. Vision Loss in Older Adults. Am Fam Physician. 2016 Aug 1;94(3):219-26. PMID: 27479624 Free article. Review.
  17. Thompson J, Lakhani N Cataracts. Prim Care. 2015 Sep;42(3):409-23. PMID: 26319346 Review.
  18. Cicinelli MV, Buchan JC, Nicholson M, Varadaraj V, Khanna RC. Cataracts. Lancet. 2023 Feb 4;401(10374):377-389. PMID: 36565712 Review.