Chapter 11: Vision
Objectives Vision-older adults Box 11-1
-Increase the proportion of adults who have had a comprehensive eye examination, including dilation, within the past 2 years. -Reduce visual impairment die to diabetic retinopathy. -Reduce visual impairment due to glamucoma. -Reduce visual impairment due to cataracts. -Reduce visual impairment due to age-related macular degeneration. -Increase the use of vision rehabilitation services by persons with visual impairment. -Increase the use of assistive and adaptive devices by persons with visual impairment.
Diabetic Retinopathy four stages:
-Mild nonproliferative retinopathy -Moderate nonproliferative retinopathi]y -Severe nonproliferative retinopathy -Proliferative retinopathy
Age-Related Macular Degeneration (ARMD)
-Most common cause of new visual impairment among persons greater than 50 years and increases with age -Progressive loss of central vision -Caused by systemic changes in circulation, accumulation of cellular waste, tissue atrophy, and growth of abnormal vessels in choroid layer beneath the retina -Fibrous scarring affects nourishment of photoreceptor cells
Diabetic Retinopathy
-Most diabetic patients will develop retinopathy within 20 years of diagnosis -Leading cause of new blindness between ages 20 and 74
Prevention of Visual Impairment
-Only about half of persons with diabetes know that their eyes could be affected -Have yearly dilated eye examination -Get routine eye examinations
Cataracts
-Opacity of the lens causing the lens to lose transparency and scatter light -Often caused by oxidative damage -Cardinal sign is appearance of halos around objects as light is diffused
Signs and Behaviors That May Indicate Vision Problems (Box 11-4)
-Pain in eyes -Difficulty seeing in the dark -Double vision/distorted vision -Migraine headaches with blurred vision -Flashes of light -Halos surrounding lights -Difficulty driving at night -Falls or injuries
Primary Open Angle
-Progressive, asymptomatic with visual field loss -May complain of headache, poor vision in dim lighting, tired eyes -Increased intraocular pressure damages optic nerve -Vision loss can be prevented if detected early
Treatment Cataracts
-Requires surgery under local anesthesia -95% return to excellent vision -Education regarding vision and adaptation to light changes -Post-surgery avoid heavy lifting, straining, bending at the waist -Fall prevention
Diabetic Macular Edema (DME)
-Thickening of the center of the retina -Most common cause of visual loss due to diabetes and leading cause of legal blindness -Treat with cortisone drugs and laser therapy -Retinal vessels become leaky and fluid accumulates within the macula -Annual dilated retinal examination
Promoting healthy aging- Intervention Considerations
-Warm incandescent lighting -Increase light intensity -Control glare -Use sunglasses -Select colors with good contrast -Reading material with large, dark, evenly spaced print -Red and orange colors can be seen the best
Dry (ARMD)
-90% of cases -Rarely causes severe impairment -Can lead to wet 3 stages -Common early sign: Drusen bodies seen on fundoscopic examination
Dry Eye (keratoconjunctivitis sicca)
-A common complaint rather than a disease -Tear production diminishes with age -More common in postmenopausal women -Can be related to medications, Sjogren's syndrome -Use artificial tears, consider Vitamin A deficiency
Screening and Treatment of Glaucoma
-Adults over the age of 65 or those at risk should have an annual eye examination with dilation -Treated with oral or topical eye drops to decrease intraorifice pressure (IOP) (beta-blockers first line of therapy), trabeculoplasty, and filtration surgery
Glacuoma
-Affects over 2.3 million persons over the age of 40 and almost half don't know they have it -African Americans at greater risk for developing glaucoma at an early age -Primary open angle glaucoma is most common and is the second leading cause of legal blindness in the United States -Other types include congenital, low and normal tension, secondary, and acute angle closure
Wet (ARMD)
-Also called neovascular -Abnormal blood vessels grow under the macula, causing its displacement -Affects central vision -Progression can be rapid with resultant blindness within 2 years
Low-Vision Optical Devices
-An array of low-vision assistive devices are available -Persons with severe visual impairment may qualify for disability, financial, and social service assistance through government and private programs
Consequences of Visual Impairment
-Associated with cognitive and functional decline, decreased quality of life, and depression -Associated with increased risk for injury and falls -"Snowball" effect, impacting families, caregivers, and society at large
Visual Impairment
-Blindness and visual impairment are major causes of disability in older adults -As the population ages, rates of blindness and visual impairment in disadvantaged and minority populations will increase in prevalence -In 2013, the World Health Organization approved the "Global Action Plan for Prevention of Avoidable Blindness and Visual Impairment"
Changes in Vision with Age
-Changes in eye structure begin early, are progressive, and affect both function and structure -Presbyopia (decreased near vision) is a common change of aging -Nearly 95% of those over 65 years of age wear glasses -Vision loss is not an inevitable part of aging, but age-related changes contribute to decreased vision (Table 11-1) -Even older persons with good visual acuity need accommodations to enhance vision and safety
Special Considerations in Long-Term Care (LTC)
-Cognitive impairment interferes with ability to communicate visual disturbances -If a person has glasses, he or she should wear them -Routine eye care is a gap in care and can lead to functional decline, decreased quality of life, and depression -One-third of vision problems in LTC setting are reversible
Ocular Changes
-Cornea becomes flatter, less smooth, thicker, and loses luster -Increased astigmatism -Chambers that control the movement of aqueous fluid decrease in size and volume capacity, leading to development of glaucoma -Iris is slower to respond to changes from light to dark -Glare is a major problem -Decreased ability of the lens to accommodate -Development of cataracts from ultraviolet exposure
Intraocular Changes
-Deterioration of vitreous humor may lead to development of "floaters" (lines, webs, spots, dots) -Retinal changes affect color, with red, orange, and yellow seen more easily -Color clarity diminishes by 59% in the eighth decade, secondary to yellowing of the lens -Drusen spots may appear on the macula
Screening and Treatment of Retinopathy
-Early detection is essential -Annual fundoscopic dilated eye examination -Fundoscopic evaluation includes flame shape hemorrhages, cotton wool spots, hard exudates dilated capillaries, and microaneurysms -Maintain strict control of blood sugar, cholesterol, and blood pressure
ARMD Screening and Treatment
-Early diagnosis is key -Amsler grid to determine clarity of vision helps identify central vision problems -Treatment: photodynamic therapy, laser photocoagulation, and anti-vascular endothelial growth factor (VEGF) therapy
Acute Angle Closure
-Emergency -Angle of iris obstructs flow of aqueous humor -May be related to infection or trauma -Intraocular pressure rises rapidly -Eye is red and painful, severe H/A, N/V -Avoid anticholinergics
Detached Retina
-Emergency medical treatment required to save vision -Actual areas of the retina are torn that lead to retinal detachment -May have gradual increase in floaters and/or light flashes in the eye -Repair requires surgery -Early intervention improves vision results
Extraocular Changes
-Eyelids lose elasticity contributing to drooping -Entropin: inward turning of the lower lid -Ectropion: outward turning of the lower lid (Figure 11-1) -Xerophthalmia: excessively dry eyes
Diseases and Disorders of the Eye
-Glacuoma -Primary Open Angle -Acute Angle Closure -Cataracts -Diabetic Retinopathy -Diabetic Macular Edema (DME) -Age-related Macular Degeneration -Detached Retina - Dry Eye (keratoconjunctivitis sicca)
One of the most common visual changes associated with aging is: A) macular degeneration. B) presbyopia. C) glaucoma. D) cataract.
B) presbyopia.
Which of the following is considered an eye emergency? A) Cataract B) Acute angle closure glaucoma C) Age-related macular degeneration (wet) D) DME
B) Acute angle closure glaucoma
