Marjan Farid, MD Director of Cornea, Cataract, and Refractive Surgery
Vice-Chair of Ophthalmic Faculty
Gavin Herbert Eye Institute
University of California, Irvine
Relevant Disclosures:
none
1 out of 3 have some visual loss by age 65
Consequences:
Daily activities curtailed
Social isolation, depression
Less mobility; falls and fractures
Loss of Independent living
Visual Loss in the Elderly
Visual Acuity declines
Visual Impairment Increases (contrast
sensitivity, Glare)
Legal Blindness Increases
Effects of Aging on Vision
Yellows:
Color discrimination becomes difficult
Opacifies: Cataract
Hardens
Loss of Accommodation: Presbyopia
Aging and the Lens
Hypertension: Glaucoma
Atherosclerosis/Cholseterol/Heart
Disease: Retinal Vascular Occlusion
Diabetes: Glaucoma, Diabetic
Retinopathy, Cataracts
Systemic Disease and the
Aging Eye
Macular Degeneration
Glaucoma
Cataract
Diabetic Retinopathy
1/3 of new blindness is avoidable
Leading Causes of Vision Loss in the
Elderly:
Most Common Cause of elderly Visual
Loss
Loss of Central Vision
Risk Factors:
Advanced Age
Fair Skin
Family history of macular degeneration
Smoking
Heart Disease
Age Related Macular Degeneration
DRY:
Gradual Visual Loss
Drusen
WET:
Sudden Visual Loss
Abnormal vessels grow underneath the retina
Bleeding and accumulation of fluid under the
retina
Types of Macular Degeneration
EARLY:
Difficulty Reading
Difficulty Driving
Straight Lines may appear crooked
ADVANCED:
Central Blind Spot
Peripheral Vision Remains Intact
Independent Living Skills
Macular Degeneration: Symptoms
Monitor Vision
Stop Smoking
Control Cardiovascular Disease Cholesterol
Blood Pressure
Diet High in Fruits and Vegetables lowers risk
Antioxidants may be helpful (Zinc, Vit C and E)
Lutein Over the Counter Vitamin Formulations available
Ocular Injections and/or Laser
Macular Degeneration Treatment:
Anterior Segment Device for
Macular Disease
IMT™ by Dr. Isaac Lipshitz
Implantable Telescope Technology
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Profoundly Reduced Function/Quality of Life
Functional Daily Living Social
End-Stage AMD
Patient Implications
24
Scarred Macula Central Visual Field Projection (Natural Lens/IOL)
CAT CAT
Telescope Implant Central Visual Field Projection
Mechanism of Action
25
20/326 Baseline
20/200 20/127
Source: * Stevenson, **Ebert,† Erber/Osborn
Ability to care for self & others*
More able to perform activities
of daily living**
Face-face communication†
Mean Improvement with 3X model
Statutory Blindness
Efficacy
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Multidisciplinary Evaluation & Care
CentraSight™ Program
Step Action Practitioner
1 Diagnosis Retina Specialist
2 Candidate Screening Retina Specialist Low Vision Optometrist Occupational Therapist
3 Implantation Cornea/Cataract Surgeon
4 Visual Rehabilitation/Training
Low Vision Optometrist Occupational Therapist
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Pre-Op Candidacy Assessment
•Diagnosis
•Refer
• Cornea health
•AC depth, other
1 Retina
OT
•Functional Goals
•Rehab Potential
Optom
•Low Vision Eval
•Eye Selection
2 Low
Vision
3 Anterior Segment
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Second most common cause of visual loss
in the elderly
Affects:
10% African Americans >70 years
2% Caucasians >70 years
Early detection and treatment can prevent
blindness
Glaucoma
High intraocular pressure
African American race
Advanced Age
Family History of glaucoma
Hypertension
Diabetes
Glaucoma Risk Factors
1.Halt Visual field loss
2.Prevent further optic nerve damage
3.Use medications to lower intraocular
pressure
4.Assess visual fields and optic nerve
damage 2-3 times per year
Goals of medical treatment:
1. Beta-Blockers:
Timolol (Timoptic), Betagan, Betaxolol
2. Adrenergic Agonists:
Alphagan
3. Cholinergic Agonists:
Pilocarpine
4. Prostaglandin Analog:
Xalatan, Lumigan, Travatan
5. Carbonic Anhydrase Inhibitors:
Trusopt, Azopt
6. Combination drops:
Cosopt, Combigan
Glaucoma medications:
Laser Surgery
Filtering Surgery (trabeculectomy)
Cyclodestructive Surgery
Placement of drainage device
Baerveldt or Ahmed Implant
Trabectome
Surgical treatment of Glaucoma:
Opacification or ‘clouding’ of the natural
crystalline lens
Causes poor focusing and scattering of light
In 90% of cases, this is a consequence of aging
Other risk factors include:
Exposure to UV light
Diabetes Mellitus
Trauma
Medications e.g. steroids
What is a Cataract?
1. Disturbance of Vision
Difficulty with glare at night
Needing more light to read
General haziness
2. Progresses to diminution
3. Cataract size and location determine
impairment
Cataract symptoms:
Cataract elevates crash risk in older drivers
• Cataract surgery reduces this risk by 50% – Owsley et al. Impact of
Cataract Surgery on Motor Vehicle Crash Involvement by Older Adults. JAMA 2002. 288: 841-849.
Surgery indicated if:
Significant visual impairment
Daily activities of living curtailed:
– Problems with driving (especially at night)
– Reading
– Knitting/sewing
– Golfing
No current medical treatment
Cataract Treatment:
95% performed under Topical anesthesia
Patient Awake
+/- IV sedation if necessary
General anesthesia only required in children or
adults with claustrophobia, mental deficiency, or
physically unable to lie still.
Operating time 6-12 minutes
Patients DO NOT need to come off their blood
thinner medications in most cases.
Cataract Surgery
Standard Monofocal IOL
Patient to decide to refractive goal
– Set for distance (will need reading glasses)
– Set for near (will need distance glasses)
– Set for monovision (dominant eye distance & the other for near)
Toric IOL – treats astigmatism
Presbyopic IOL
Independence from glasses for most of the day
1. Multifocal IOL (Tecnis MTF, ReStor)
2. Accommodating IOL (Crystalens)
Intraocular Lens Implant options:
Patient goes home with a clear shield or no shield
Eye Drops started immediately – (for 4-6 weeks)
Antibiotic
Steroid
Topical NSAID
No lifting over 10-15 lbs for 1 week
No bending from the waist for prolonged periods
No swimming for 1 month
Eye shield at night for the first week to prevent inadvertent rubbing of the eye when asleep
Post-operative Requirements and
Recovery:
>99.9% success rate
Complications infrequent and rare
Infection – 0.01-0.15%
– Drop in vision, pain, severe redness
Transitory intraocular pressure elevation
Retinal tear or detachment - 0.01-0.02%
Posterior capsular opacification – 15%
Treated with non-invasive Nd:Yag laser
capsulotomy in the clinic setting
Outcomes and Complications:
Many conditions are treatable
Early detection and treatment is important
Advancing technology allows excellent
visual and refractive outcomes with current
cataract surgery
Eye Care for the Elderly