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Vision status, ophthalmic assessment, and quality of life in the very old

Visão, avaliação oftalmológica e qualidade de vida em longevos

ABSTRACT

Purpose:

To determine the vision status, ophthalmic findings, and quality of life among the very elderly.

Methods:

This was a cross-sectional observational study of individuals aged 80 years and above. A comprehensive ophthalmic exam was performed with mea surement of both the presenting (PVA) and best-corrected visual acuity. The Quality of Life Short Form-36 (SF-36) and the Visual Function Questionnaire (VFQ-25) were also administered.

Results:

A total of 150 non-institutionalized participants were assigned to three age groups: 80-89 years (n=70), 90-99 years (n=50), and 100 years and older (n=30). PVA and best-corrected visual acuity were normal (≥20/30) in 20 (13.3%) and 37 participants (24.7%), respectively. Regarding PVA, mild visual impairment (<20/30 to ≥20/60) was found in in 53 (35.4%), moderate visual impairment (<20/60 to ≥20/200) in 50 (33.3%), severe visual impairment (<20/200 to ≥20/400) in 8 (5.3%), and blindness (<20/400) in 19 (12.7%) participants. Regarding best-corrected visual acuity, mild, moderate, and severe visual impairments were present in 55 (36.7%), 38 (25.3%), and 5 (3.3%) participants, respectively, and blindness was present in 15 (10%). The main causes of visual impairment/blindness were cataract (43.8%), refractive errors (21.5%), age-related macular degeneration (17.7%), and myopic degeneration (3.8%). SF-36 scores were worse in those with low visual acuity, while VFQ-25 domain scores were poorer in those with vision impairment/blindness.

Conclusion:

Vision impairment and blindness was present in three-quarters of this sample, but it was notable that adequate correction with spectacles improved visual acuity. This reinforces the need for regular ophthalmic care in elderly patients to improve their quality of life by optimizing vision.

Keywords:
Aging; Vision disorders/diagnosis; Geriatric assessment; Blindness; Vision, low; Quality of life; Surveys and questionnaires; Aged; Aged, 80 and over

RESUMO

Objetivos:

Determinar a visão, achados oftalmológicos e qualidade de vida em longevos.

Métodos:

Estudo observacional transversal em indivíduos com idade entre 80 anos ou mais. Realizado exame oftalmológico com medida da acuidade visual apresentada e da acuidade visual melhor corrigida. Foram administrados os questionários: Qualidade de Vida Forma Curta - 36 (SF-36) e Qualidade de Função Visual (VFQ-25).

Resultados:

Total de 150 indivíduos não-institucionalizados foram estudados, divididos em três faixas etárias: 80 a 89 anos (n=70); 90 a 99 anos (n=50) e 100 anos ou mais (n=30). Acuidade visual apresentada normal (≥20/30) foi encontrada em 20 (13,3%) participantes; deficiência visual leve (<20/30 a ≥20/60), em 53 (35,4%); deficiência visual moderada (< 20/60 a ≥20/200) em 50 (33,3%); deficiência visual grave (<20/200 para ≥20/400) em 8 (5,3%) e cegueira (<20/400) em 19 (12,7%). A acuidade visual com a melhor correção aumentou para 37 (24,7%) indivíduos normais; deficiência leve aumentou para 55 (36,7%); deficiência visual moderada diminuiu para 38 (25,3%); deficiência visual grave foi reduzida para 5 (3,3%) e cegueira foi reduzida para 15 (10%). As principais causas de deficiência visual/cegueira foram: catarata (43,8%) erro refrativo (21,5%), degeneração macular relacionada à idade (17,7%), e degeneração miópica (3,8%). A pontuação no Questionário de Qualidade de Vida foi pior naqueles com baixa visão para perto. No questionário VFQ -25 os domínios com menor pontuação ocorreram nos indivíduos com baixa visão/cegueira.

Conclusão:

Deficiência visual/cegueira mostrou-se presente em três quartos desta amostra de longevos. A prescrição de óculos adequados proporcionou melhora da acuidade visual, reforçando a necessidade de atendimento oftalmológico regular desses pacientes para assegurar a qualidade de vida e de visão.

Descritores:
Envelhecimento; Transtornos da visão/diagnóstico; Avaliação geriátrica; Cegueira; Baixa visão; Qualidade de vida; Inquéritos e questionários. Idoso; Idoso de 80 anos ou mais

INTRODUCTION

Aging is a universal and inexorable biological process that results in a progressive loss of functional reserve in each body organ throughout life(11 Cypel MC, Belfort Jr R. Oftalmogeriatria. São Paulo: Roca; 2008.). Population aging is both a cause and consequence of remarkable social changes that must be properly understood when planning public policies(22 Veras RP. Disease prevention in the elderly: misconceptions in current models. Cad Saúde Pública. 2012;28(10):1834-40.). The number of people worldwide older than 60 years is now approximately 600 million, and this number is expected to reach 2 billion by the year 2050, mostly due to people living in industrialized countries(33 World Health Organization. Ageing and life course [Internet]. Geneva, Switzerland; WHO; 2013. [cited 2014 Sep 24]. Available from: http://www.who.int/aging/en/
http://www.who.int/aging/en/...
). Brazil comprises 2.5% of all elderly people in the world(44 Brasil. Ministério da Saúde. Rede Interagencial de Informações para a Saúde - RIPSA Indicadores demográficos. A.15. Índice de envelhecimento [Internet]. Brasília: Ministério da Saúde; 2007. [citado 2016 Jul 1]. Disponível em: http://tabnet.datasus.gov.br/cgi/idb2007/a15.htm.
http://tabnet.datasus.gov.br/cgi/idb2007...
), and it is expected to have the sixth largest elderly population by the year 2025 (13.8% of its population(55 Instituto Brasileiro de Geografia e Estatística. Tábuas completas de população e sua projeção até 2060 [Internet]. Brasília: IBGE; 2013. [citado 2016 Jun 1]. Disponível em: http://downloads.ibge.gov.br/downloads_estatisticas.htm?caminho=Projecao_da_Populacao/Projecao_da_Populacao_2013/
http://downloads.ibge.gov.br/downloads_e...
)).

Even though the population older than 80 years is growing fast(22 Veras RP. Disease prevention in the elderly: misconceptions in current models. Cad Saúde Pública. 2012;28(10):1834-40.,33 World Health Organization. Ageing and life course [Internet]. Geneva, Switzerland; WHO; 2013. [cited 2014 Sep 24]. Available from: http://www.who.int/aging/en/
http://www.who.int/aging/en/...
), most publications have considered samples up to 80 years old(66 Leibowitz HM, Krueger DE, Maunder LR, Milton RC, Kini MM, Kahn HA, et al. The Framingham Eye Study monograph: An ophthalmological and epidemiological study of cataract, glaucoma, diabetic retinopathy, macular degeneration, and visual acuity in a general population of 2631 adults, 1973-1975. Surv Ophthalmol. 1980;24 (Suppl): 335-610.

7 Klaver CC, Wolfs RC, Vingerling JR, Hofman A, deJong PT. Age-specific prevalence and causes of blindness and visual impairment in an older population: the Rotterdam Study. Arch Ophthalmol. 1998;116(5):653-8.

8 Buch H, Vinding T, La Cour M, Appleyard M, Jensen GB, Nielsen NV. Prevalence and causes of visual impairment and blindness among 9980 Scandinavian adults: the Copenhagen City Eye Study. Ophthalmology. 2004;111(1):53-61.

9 Attebo K, Mitchell P, Smith W. Visual acuity and the causes of visual loss in Australia. The Blue Mountains Eye Study. Ophthalmology. 1996;103(3):357-64.

10 Hsu WM, Cheng CY, Liu JH, Tsai SY, Chou P. Prevalence and causes of visual impairment in an elderly Chinese population in Taiwan: the Shihpai Eye Study. Ophthalmology. 2004;111(1):62-9.
-1111 Hennis AJ, Wu SY, Nemesure B, Hyman L, Schachat AP, Leske MC; Barbados Eye Studies Group. Nine-year incidence of visual impairment in the Barbados Eye Studies. Ophthalmology. 2009;116(8):1461-8.). A previous study in a small group of centenarians emphasized de mographic characteristics such as female gender, good general health, arterial hypertension, reading difficulties, and visual impairment due to age-related macular degeneration (AMD)(1212 Cypel MC, Palacio G, Dantas PE, Lottenberg CL, Belfort Jr. R. Achados oculares em pacientes com mais de 99 anos. Arq Bras Oftalmol. 2006;69(5):665-9.). To date, however, the relationship between very elderly population, the im pact of low vision, and the psychological impact on health-and vision-related quality of life has not been extensively studied(22 Veras RP. Disease prevention in the elderly: misconceptions in current models. Cad Saúde Pública. 2012;28(10):1834-40.,33 World Health Organization. Ageing and life course [Internet]. Geneva, Switzerland; WHO; 2013. [cited 2014 Sep 24]. Available from: http://www.who.int/aging/en/
http://www.who.int/aging/en/...
,1313 Bledowski P, Mossakowska M, Chudek J, Grodzicki T, Milewicz A, Szybalska A, et al. Medical, psychological and socioeconomic aspects of aging in Poland: assumptions and objectives of the PolSenior project. Exp Gerontol. 2011;46(12):1003-9.,1414 Cypel MC, Kasahara N, Atique D, Umbelino CC, Alcântara MP, Seixas FS, et al. Quality of life in patients with glaucoma who live in a developing country. Int Ophthalmol. 2004;25(5-6):267-72.). Nevertheless, it is important to understand these relationships for planning and execution of adequate interventions and health policies.

The purpose of the study was to investigate the frequency of eye conditions along with the occurrence and main causes of visual impairment and blindness in the very elderly. We specifically considered how these abnormalities might affect quality of life and vision.

METHODS

This was a cross-sectional observational study performed between April 2007 and July 2008. The research ethics committee of Universidade Federal de São Paulo (UNIFESP) approved the study protocol, which adhered to the tenets of the Declaration of Helsinki and Resolution 196/96 of the Ministry of Health, Brazil. Informed consent was obtained from all participants after explaining the nature of the study and the potential consequences of examination.

Study population

Subjects aged 80 years and older were recruited from three distinct sources: the Department of Ophthalmology, UNIFESP; the Center for Studies in Aging (project EPIDOSO, UNIFESP); and the Albert Einstein Residential Senior Community. All patients were included pro vided they were in good general health to allow examination in the clinic, and provided they could fully understand the written informed consent form. The enrolled participants were grouped into three categories by age: 80-89 years, 90-99 years, and ≥100 years.

Procedures

Individual interviews were performed to obtain demographic, ge neral health, and medical history details. The ophthalmic exam in cluded measurement of the following: presenting visual acuity with glasses when used (the distance at a 6 m projected Snellen optotypes), refraction, measurement of best-corrected visual acuity for distance (measured after refraction testing with the best optical correction), and tear break-up time. We also performed anterior segment biomicroscopy, applanation tonometry with a Goldmann tonometer, and indirect ophthalmoscopy. All exams were executed by the same ophthalmologist (MC). When necessary, supplementary tests were performed to confirm diagnosis, including optical coherence tomography, fluorescein angiography, ultrasound biomicroscopy, and vi sual field testing.

Visual status was stratified as follows, considering visual acuity in the best-seeing eye: normal vision as ≥20/30; mild visual impairment as <20/30 to ≥20/60; moderate visual impairment as <20/60 to ≥20/200; severe visual impairment as <20/200 to ≥20/400; and blindness as <20/400(1515 Resnikoff S, Pascolini D, Mariotti SP, Pokharel GP. Global magnitude of visual impairment caused by uncorrected refractive errors in 2004. Bull World Health Organ. [Internet]. 2008 [cited 2016 Sep 24];86(1):63-70. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647357/
https://www.ncbi.nlm.nih.gov/pmc/article...

16 Salomão SR, Cinoto RW, Berezovsky A, Araujo-Filho A, Mitsuhiro MR, Meendieta L, et al. Prevalence and causes of vision impairment and blindness in older adults in Brazil: the São Paulo Eye Study. Ophthalmic Epidemiol. 2008;15(3):167-75.
-1717 Zhao J, Ellwein LB, Cui H, Ge J, Guan H, Lv J, et al. Prevalence of vision impairment in older adults in rural China: the China Nine-Province Survey. Ophthalmology. 2010; 117(3):409-16. Comment in: Ophthalmology. 2010;117(3):407-8.). Eyes with a presenting visual acuity of ≤20/40 were assigned a principal cause of visual impairment/blindness. Refractive error was assigned as the cause for those eyes where distance visual acuity improved to 20/30 or better with refractive correction. Cataract was diagnosed when lens opacity was commensurate with the altered visual acuity. Age-related macular degeneration was classi fied as determined in the Age-Related Eye Disease Study (AREDS)(1818 Ferris FL, Davis MD, Clemons TE, Lee LY, Chew EY, Lindblad AS, Milton RC, Bressler SB, Klein R; Age-Related Eye Disease Study (AREDS) Research Group. A simplified severity scale for age-related macular degeneration: AREDS Report No. 18. Arch Ophthalmol. 2005;123(11):1570-4. Comment in: Arch Ophthalmol;123(1):1484-98; Arch Ophthalmol;123(11):1598-9.). Glaucoma was diagnosed when at least two of the following events were present: family history of glaucoma, previous diagnosis of glaucoma (with or without anti-hypertensive ocular medication), elevated intraocular pressure (IOP), glaucomatous disc changes, and glaucomatous visual field abnormalities(1616 Salomão SR, Cinoto RW, Berezovsky A, Araujo-Filho A, Mitsuhiro MR, Meendieta L, et al. Prevalence and causes of vision impairment and blindness in older adults in Brazil: the São Paulo Eye Study. Ophthalmic Epidemiol. 2008;15(3):167-75.).

Two questionnaires were administered by interview: Quality of Life Short Form-36 (SF-36) and the Visual Function Questionnaire (VFQ-25). The SF-36 is a practical and reliable instrument that gives valid information on functional health and wellbeing from the patient's point of view, with an eleven-question instrument and eight dimensions of health/wellbeing that comprise physical functioning, physical role limitation, bodily pain, general health, vitality, social role functioning, emotional functioning, and mental health(1919 Chia M, Chia M, Rochtchina E, Wang JJ, Mitchell P. Utility and validity of the self-administered SF-36: Findings from an older population. Ann Acad Med Singapore. 2006; 35(7):461-7.

20 Dev MK, Paudel N, Joshi ND, Shah DN, Subba S. Psycho-social impact of visual impairment on health-related quality of life among nursing home residents. BMC Health Serv Res. 2014;14:345.
-2121 Lima MG, Barros MB, Goldbaum M, Ciconelli RM. Health related quality of life among the elderly: a population-based study using SF-36 survey. Cad Saude Pública. 2009; 25(10):2159-67.). The Portuguese-adapted version of the VFQ-25 (translated and validated in Portuguese) was used in this study, consisting of 12 domains: general health, general vision, near vision, distance vision activities, ocular pain, vision-related social function, vision-related role function, vision-related mental health, vision-related dependency, driving difficulties, color vision, and peripheral vision(2222 Mangione CM, Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD; National Eye Institute Visual Function Questionnaire Field Test Investigators. Development of the 25-item National Eye Institute Visual Function Questionnaire. Arch Ophthalmol. 2001; 119(7):1050-8.,2323 Simão LM, Lana-Peixoto MA, Araújo CR, Moreira MA, Teixeira AL. The Brazilian version of the 25-Item National Eye Institute Visual Function Questionnaire: translation, reliability and validity. Arq Bras Oftalmol. 2008;71(4):540-6.). Both questionnaires are standardized on a 0-100 scale, where 0 is the worst and 100 the best. The same interviewer (MC) administered both instruments in the same visit before clinical ophthalmic assessment.

Statistical analysis

Snellen visual acuity measurements were converted to the logarithm of the minimum angle of resolution (logMAR). The correlations between observations in right and left eyes were assessed for the following variables: break-up time, intraocular pressure, and cup-disk ratio(2424 Glynn RJ, Rosner B. Regression methods when the eye is the unit of analysis. Ophthalmic Epidemiol. 2012;19(3):159-65.). When results between eyes were very similar (no statistic variation) the right eye only was selected for analysis(2525 Ederer F. Shall we count numbers of eyes or numbers of subjects? Arch Ophthalmol. 1973;89(1):1-2.). Comparisons among groups were done with the Kruskal-Wallis one-way analysis of variance by ranks or the Mann-Whitney U test, as appropriate. Multiple comparison tests were used to identify significant pairwise differences between visual status categories per SF-36 and VFQ-25 domain. P-values <0.05 were considered statistically significant. All analyses were conducted using the SPSS for Windows, Version 11.0 (SPSS Inc., Chicago, IL, USA).

RESULTS

Participants

A total of 150 elderly participants were enrolled and assigned into the three age categories: 80-89 years (70 participants), 90-99 years (50 participants), and ≥100 years (30 participants). For the older group, we had previously reported the results for visual acuity and ocular findings for 20 individuals, but without the data about quality of life (SF-36 questionnaire) or quality of vision (VFQ-25)(1212 Cypel MC, Palacio G, Dantas PE, Lottenberg CL, Belfort Jr. R. Achados oculares em pacientes com mais de 99 anos. Arq Bras Oftalmol. 2006;69(5):665-9.). The demographic features of all participants are shown in table 1. Most were female (n=103; 68.6%) and white (n=121; 80.6%). The most frequent systemic disease was arterial hypertension (n=67; 44.7%), followed by osteoarticular disease (n=21; 14%), while diabetes was reported by 15 (10%; none in the centenarian group). Another 30 participants (20%) claimed to have no disease.

Table 1
Demographic characteristics of the participants

Visual acuity

Graphic 1 shows the presenting and best-corrected visual acuities. Presenting normal vision was found in 20 participants (13.3%), with mild visual impairment in 53 (35.4%), moderate visual impairment in 50 (33.3%), severe visual impairment in 8 (5.3%), and blindness in 19 (12.7%). With best-correction visual acuity, normal vision was present in 37 participants (24.7%), mild visual impairment in 55 (36.7%), moderate visual impairment in 38 (25.3%), severe visual impairment in 5 (3.3%), and blindness in 15 (10%). None of the participants had 20/20 PVA in the best-vision eye, irrespective of the age group.

Graphic 1
The distribution of presenting and best-corrected visual acuity by the following distance visual acuity categories in best-seeing eyes: normal vision (≥20/30), mild visual impairment (<20/30 to≥ 20/60), moderate visual impairment (<20/60 to ≥20/200), severe visual impairment (<20/200 to ≥20/400), and blindness (<20/400)(1515 Resnikoff S, Pascolini D, Mariotti SP, Pokharel GP. Global magnitude of visual impairment caused by uncorrected refractive errors in 2004. Bull World Health Organ. [Internet]. 2008 [cited 2016 Sep 24];86(1):63-70. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647357/
https://www.ncbi.nlm.nih.gov/pmc/article...
,1717 Zhao J, Ellwein LB, Cui H, Ge J, Guan H, Lv J, et al. Prevalence of vision impairment in older adults in rural China: the China Nine-Province Survey. Ophthalmology. 2010; 117(3):409-16. Comment in: Ophthalmology. 2010;117(3):407-8.).

Ocular findings

Ocular findings per eye for the three age groups are shown in table 2. On the anterior segment, the most frequent finding was arcus senilis (n=226; 75.3%), followed by eyelid disorders (n=218; 72.6%). Lens status per eye was classified as present with some degree of opacity in 199 eyes (66.3%), pseudophakic in 82 eyes (27.3%), aphakic in 6 eyes (2.0%), and replaced by an ocular prosthesis in 1 eye. In 10 eyes (3.3%), the lens was fully clear. Age-related macular degeneration was present in 240 eyes (80%), hypertensive retinopathy in 40 eyes (13.3%), and diabetic retinopathy in 2 eyes (0.6%).

Table 2
Ocular findings by age groupa a More than one ocular finding identified per person.

Refractive errors were found in 68 participants (45.3%), which included 41 (58.6%) aged 80-89 years, 13 (26%) aged 90-99 years, and 14 (46.6%) aged ≥100 years. Glasses for distance were used by 91 participants (60.7%), and 105 (70.0%) required additional lenses.

Break-up time less than 10 seconds was noted in 95 (63.3%) patients. Intraocular pressure (IOP) ranged from 6 to 28 mmHg in the group aged 80-89 years, with a mean of 13.7 mmHg (SD 3.64) and 3 individuals in this group having an IOP ≥20 mmHg. In the group aged 90-99 years, IOP ranged from 9 to 18 mmHg, with a mean of 12.4 ± 3.84 mmHg. In the centenarian group, IOP ranged from 7 to 28 mmHg, with a mean of 12.8 ± 4.77 mmHg, with 1 having an IOP ≥20 mmHg. Glaucoma was diagnosed in 18 participants (12.0%), and 6 (4.0%) had previously had glaucoma surgery.

Principal causes of visual impairment/blindness

The principal causes of visual impairment/blindness are summarized in table 3 and graphic 2 (for the visual status of 130 individuals with mild visual impairment or worse). Overall, cataract was the most frequent cause of visual impairment (n=57; 43.8%), followed by uncorrected refractive error (n=28; 21.5%), AMD (n=23; 17.7%), and myopic degeneration (n=5; 3.8%); glaucoma was described as the principal cause of visual impairment/blindness in 3 participants (2.3%).

Table 3
Principal causes of visual impairment/blindness by age group (years)

Graphic 2
Percentage distribution of the principal causes of visual impairment/blindness by age (years).

Quality of life and vision-related quality of life

Of the 150 participants, 137 were competed interviews for both the SF-36 and VFQ-25; the other 13 non-respondents included 2 from group aged 80-89 years, 1 from the group aged 90-99, and 10 from the centenarian group. Major reasons for non-response/partial interviews were obstacles to comprehension, including severe hearing loss and/or unreliable information.

SF-36 scores by visual status, and per domain, are shown in table 4. In general, participants with normal presenting visual acuity had significantly higher scores for the following domains: physical functioning, physical/role limitation, general health, vitality, social role functioning, emotional role functioning, and mental health. No statistical differences were found among the five visual status categories for the bodily pain domain.

Table 4
SF-36 scores by visual status

Table 5 shows the VFQ-25 scores by visual status category, per domain. Subjects with normal vision presented significantly higher scores for the domains general health and general vision. No statistical differences were found among the five visual status categories for the ocular pain domain. Distance activities, social functioning, mental health, role difficulties and dependency domains presented significantly higher scores in those with normal visual acuity and all other categories except mild visual impairment (normal versus either moderate visual impairment, severe visual impairment, or blindness; all p=0.001). No statistical differences were found among the five visual status categories for the driving domain.

Table 5
VFQ-25 scores by visual status

The color vision domain showed significantly higher scores when comparing normal vision to severe visual impairment (p=0.001) and to blindness (p=0.001). Significantly higher scores were found in the normal vision group when compared with the moderate visual impairment (p=0.009), severe visual impairment (p=0.001), and blindness (p=0.001) groups for the peripheral vision domain. In the near activities domain, significantly higher scores were found for the normal vision group when compared with the mild (p=0.001) and moderate (p=0.001) visual impairment categories.

DISCUSSION

This study comprised a large sample of very elderly participants, even though it was only a convenience sample. In general, the participants were in good health, which contrasts to that usually seen with patients living in nursing homes or who have cognitive dysfunction.

The care of the very old may be neglected by family members and, as a result, damaged or antiquated eyeglasses may not be replaced in a timely fashion. Besides a lack of attention from the family, very old individuals often assume that vision loss is a natural consequence of aging(2626 Owen CG, Rudnicka AR, Smeeth L, Evans JR, Wormald RP, Fletcher AE. Is the NEI-VFQ-25 a useful tool in identifying visual impairment in an elderly population? BMC Ophthalmol. 2006;6:24.). Clinically, regardless of the expected physiological changes in vision, full attention should be given to those with visual impairment/blindness(11 Cypel MC, Belfort Jr R. Oftalmogeriatria. São Paulo: Roca; 2008.). Our study showed, however, that a number of participants did achieve better vision after adequate refractive correction. Correcting refractive errors improves potential vision, and can stimulate wider contact, independence, and a social life, thereby helping age-related quality of life.

As confirmed in this study, it is known that visual acuity decreases as age increases(66 Leibowitz HM, Krueger DE, Maunder LR, Milton RC, Kini MM, Kahn HA, et al. The Framingham Eye Study monograph: An ophthalmological and epidemiological study of cataract, glaucoma, diabetic retinopathy, macular degeneration, and visual acuity in a general population of 2631 adults, 1973-1975. Surv Ophthalmol. 1980;24 (Suppl): 335-610.,88 Buch H, Vinding T, La Cour M, Appleyard M, Jensen GB, Nielsen NV. Prevalence and causes of visual impairment and blindness among 9980 Scandinavian adults: the Copenhagen City Eye Study. Ophthalmology. 2004;111(1):53-61.,99 Attebo K, Mitchell P, Smith W. Visual acuity and the causes of visual loss in Australia. The Blue Mountains Eye Study. Ophthalmology. 1996;103(3):357-64.,2727 McGwin G1, Khoury R, Cross J, Owsley C. Vision impairment and eye care utilization among Americans 50 and older. Curr Eye Res. 2010;35(6):451-8.). The age-related decline in visual performance may be explained in terms of reductions in the illuminance of the visual stimulus due to changes in the ocular media and losses of efficiency at a neural level(2626 Owen CG, Rudnicka AR, Smeeth L, Evans JR, Wormald RP, Fletcher AE. Is the NEI-VFQ-25 a useful tool in identifying visual impairment in an elderly population? BMC Ophthalmol. 2006;6:24.). Such physiological modifications may explain why none of the patients in this sample had a presenting visual acuity of 20/20.

Most causes of reversible low vision can be treated easily. This is particularly true for uncorrected refractive errors(2828 Araujo-Filho A, Salomão SR, Berezovsky A, Cinoto RW, Morales PH, Santos FR, et al. Prevalence of visual impairment, blindness, ocular disorders and cataract surgery outcomes in low-income elderly from a metropolitan region of Sao Paulo- Brazil. Arq Bras Oftalmol. 2008;71(2):246-53.). In this study, 20% of participants achieved better visual acuity for distance with appropriate correction. After refractive correction, the frequency of visual impairment decreased from 33.3% to 25.3%, while that for blindness decreased from 12.7% to 10%. In all three age groups, individuals achieved better vision with proper spectacles, even when they had AMD and early cataracts, except for those with glaucoma.

AMD affected over half of the patients aged 80-89 years, most of those aged 90-99 years, and all of those aged ≥100 years, a trend that is consistent with previous studies(77 Klaver CC, Wolfs RC, Vingerling JR, Hofman A, deJong PT. Age-specific prevalence and causes of blindness and visual impairment in an older population: the Rotterdam Study. Arch Ophthalmol. 1998;116(5):653-8.,88 Buch H, Vinding T, La Cour M, Appleyard M, Jensen GB, Nielsen NV. Prevalence and causes of visual impairment and blindness among 9980 Scandinavian adults: the Copenhagen City Eye Study. Ophthalmology. 2004;111(1):53-61.,2929 Geirsdottir A, Stefansson E, Jonasson F, Helgadottir G, Sigurdsson H. Age-related macular degeneration in very old individuals with family history. Am J Ophthalmol. 2009;143(5):889-90.). Although AMD was present in all centenarians, when stratified by severity and different forms, most had an initial atrophic form of the disease that was sometimes not even considered the primary cause of low vision. A study of very old adults in Iceland reported that AMD was present in 54% of those aged ≥75 years, 64% of those aged ≥85 years, 74% of those aged ≥95 years, and 100% of those aged ≥100 years(2929 Geirsdottir A, Stefansson E, Jonasson F, Helgadottir G, Sigurdsson H. Age-related macular degeneration in very old individuals with family history. Am J Ophthalmol. 2009;143(5):889-90.).

Glaucoma was detected in 12% of the sample: 14.3% aged 80-89 years, 12% aged 90-99 years, and 8% aged ≥100 years. In general, glaucoma prevalence varies by the population studied, ranging from 3% to 14% (average 7%-9%) in most studies, but rising with age(99 Attebo K, Mitchell P, Smith W. Visual acuity and the causes of visual loss in Australia. The Blue Mountains Eye Study. Ophthalmology. 1996;103(3):357-64.

10 Hsu WM, Cheng CY, Liu JH, Tsai SY, Chou P. Prevalence and causes of visual impairment in an elderly Chinese population in Taiwan: the Shihpai Eye Study. Ophthalmology. 2004;111(1):62-9.
-1111 Hennis AJ, Wu SY, Nemesure B, Hyman L, Schachat AP, Leske MC; Barbados Eye Studies Group. Nine-year incidence of visual impairment in the Barbados Eye Studies. Ophthalmology. 2009;116(8):1461-8.,1616 Salomão SR, Cinoto RW, Berezovsky A, Araujo-Filho A, Mitsuhiro MR, Meendieta L, et al. Prevalence and causes of vision impairment and blindness in older adults in Brazil: the São Paulo Eye Study. Ophthalmic Epidemiol. 2008;15(3):167-75.,2828 Araujo-Filho A, Salomão SR, Berezovsky A, Cinoto RW, Morales PH, Santos FR, et al. Prevalence of visual impairment, blindness, ocular disorders and cataract surgery outcomes in low-income elderly from a metropolitan region of Sao Paulo- Brazil. Arq Bras Oftalmol. 2008;71(2):246-53.). The large variance in prevalence may result from the use of different diagnostic criteria among the studies. Surprisingly, though, our results revealed that rates decrease as age increases, and we are uncertain as to why this occurred. We posit that it might be due to selection bias.

The main causes of low visual acuity in the study were cataract followed by uncorrected refractive error, AMD, myopic degenera tion, and glaucoma. These findings corroborate previous studies(66 Leibowitz HM, Krueger DE, Maunder LR, Milton RC, Kini MM, Kahn HA, et al. The Framingham Eye Study monograph: An ophthalmological and epidemiological study of cataract, glaucoma, diabetic retinopathy, macular degeneration, and visual acuity in a general population of 2631 adults, 1973-1975. Surv Ophthalmol. 1980;24 (Suppl): 335-610.,77 Klaver CC, Wolfs RC, Vingerling JR, Hofman A, deJong PT. Age-specific prevalence and causes of blindness and visual impairment in an older population: the Rotterdam Study. Arch Ophthalmol. 1998;116(5):653-8.,99 Attebo K, Mitchell P, Smith W. Visual acuity and the causes of visual loss in Australia. The Blue Mountains Eye Study. Ophthalmology. 1996;103(3):357-64.,1010 Hsu WM, Cheng CY, Liu JH, Tsai SY, Chou P. Prevalence and causes of visual impairment in an elderly Chinese population in Taiwan: the Shihpai Eye Study. Ophthalmology. 2004;111(1):62-9.,1616 Salomão SR, Cinoto RW, Berezovsky A, Araujo-Filho A, Mitsuhiro MR, Meendieta L, et al. Prevalence and causes of vision impairment and blindness in older adults in Brazil: the São Paulo Eye Study. Ophthalmic Epidemiol. 2008;15(3):167-75.,2727 McGwin G1, Khoury R, Cross J, Owsley C. Vision impairment and eye care utilization among Americans 50 and older. Curr Eye Res. 2010;35(6):451-8.,2828 Araujo-Filho A, Salomão SR, Berezovsky A, Cinoto RW, Morales PH, Santos FR, et al. Prevalence of visual impairment, blindness, ocular disorders and cataract surgery outcomes in low-income elderly from a metropolitan region of Sao Paulo- Brazil. Arq Bras Oftalmol. 2008;71(2):246-53.,3030 Bergman B, Nilsson-Ehle H, Sjöstrand J. Ocular changes, risk markers for eye disorders and effects of cataract surgery in elderly people: a study of an urban Swedish population followed from 70 to 97 years of age. Acta Ophthalmol Scand. 2004;82(2):166-74.). Cataract is described as an important cause of low visual acuity. Its prevalence as a cause of visual impairment/blindness increased consistently with age and severity of vision impairment(2828 Araujo-Filho A, Salomão SR, Berezovsky A, Cinoto RW, Morales PH, Santos FR, et al. Prevalence of visual impairment, blindness, ocular disorders and cataract surgery outcomes in low-income elderly from a metropolitan region of Sao Paulo- Brazil. Arq Bras Oftalmol. 2008;71(2):246-53.,3030 Bergman B, Nilsson-Ehle H, Sjöstrand J. Ocular changes, risk markers for eye disorders and effects of cataract surgery in elderly people: a study of an urban Swedish population followed from 70 to 97 years of age. Acta Ophthalmol Scand. 2004;82(2):166-74.). Uncorrected refractive errors were also an important cause of low vision, especially in the younger age groups and in those with mild to moderate visual impairment. In other studies, AMD was the third main cause of visual impairment, usually being the primary cause of low vision in studies from industrialized countries(1515 Resnikoff S, Pascolini D, Mariotti SP, Pokharel GP. Global magnitude of visual impairment caused by uncorrected refractive errors in 2004. Bull World Health Organ. [Internet]. 2008 [cited 2016 Sep 24];86(1):63-70. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647357/
https://www.ncbi.nlm.nih.gov/pmc/article...
,1717 Zhao J, Ellwein LB, Cui H, Ge J, Guan H, Lv J, et al. Prevalence of vision impairment in older adults in rural China: the China Nine-Province Survey. Ophthalmology. 2010; 117(3):409-16. Comment in: Ophthalmology. 2010;117(3):407-8.). This finding provides a basis for the requirement that public policies are needed to ensure early diagnosis and adequate treatment for the very old in Brazil.

Health promotion is an important goal in the elderly, and can positively affect health-related quality of life(2121 Lima MG, Barros MB, Goldbaum M, Ciconelli RM. Health related quality of life among the elderly: a population-based study using SF-36 survey. Cad Saude Pública. 2009; 25(10):2159-67.). Visual impairment detrimentally interferes with daily functions and social activities, significantly affecting health-related quality of life(1919 Chia M, Chia M, Rochtchina E, Wang JJ, Mitchell P. Utility and validity of the self-administered SF-36: Findings from an older population. Ann Acad Med Singapore. 2006; 35(7):461-7.,2121 Lima MG, Barros MB, Goldbaum M, Ciconelli RM. Health related quality of life among the elderly: a population-based study using SF-36 survey. Cad Saude Pública. 2009; 25(10):2159-67.). The SF-36 is an efficient and validated measure for use in the elderly community, and using the interviewer- administered version improves completion rates(1919 Chia M, Chia M, Rochtchina E, Wang JJ, Mitchell P. Utility and validity of the self-administered SF-36: Findings from an older population. Ann Acad Med Singapore. 2006; 35(7):461-7.). The perception of quality of life, as measured by the SF-36, was worse in elderly patients with low visual acuity, similar to the results described in other studies of elderly populations(1919 Chia M, Chia M, Rochtchina E, Wang JJ, Mitchell P. Utility and validity of the self-administered SF-36: Findings from an older population. Ann Acad Med Singapore. 2006; 35(7):461-7.,2020 Dev MK, Paudel N, Joshi ND, Shah DN, Subba S. Psycho-social impact of visual impairment on health-related quality of life among nursing home residents. BMC Health Serv Res. 2014;14:345.). This finding can be explained by the fact that visual impairment reduces physical activity, independent mobility, and social functioning, each of which are investigated in the SF-36 domains. The VFQ-25 scores for each domain were consistently lower in participants with lower visual acuity results, similar to those described in another study(2222 Mangione CM, Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD; National Eye Institute Visual Function Questionnaire Field Test Investigators. Development of the 25-item National Eye Institute Visual Function Questionnaire. Arch Ophthalmol. 2001; 119(7):1050-8.). The near VFQ-25 domain presented higher scores in the elderly who had the best visual acuity, irrespective of age, emphasizing the importance of near vision for elderly participants. When adversely affected, near vision interferes directly with perception of vision quality. The information obtained by questionnaires on quality of life can help determine the type of care needed to support the independence and improve the quality of daily life among the elderly population(2020 Dev MK, Paudel N, Joshi ND, Shah DN, Subba S. Psycho-social impact of visual impairment on health-related quality of life among nursing home residents. BMC Health Serv Res. 2014;14:345.,2222 Mangione CM, Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD; National Eye Institute Visual Function Questionnaire Field Test Investigators. Development of the 25-item National Eye Institute Visual Function Questionnaire. Arch Ophthalmol. 2001; 119(7):1050-8.).

It is important to note that the association between visual impairment and decreased function and wellbeing are integral to a person's health-related quality of life; moreover, it is not easy to isolate these factors from other medical conditions, as observed in this and other studies(2020 Dev MK, Paudel N, Joshi ND, Shah DN, Subba S. Psycho-social impact of visual impairment on health-related quality of life among nursing home residents. BMC Health Serv Res. 2014;14:345.). In agreement with other publications, the use of questionnaires that consider self-reported functioning and wellbeing can provide data of the effect of disease on daily activities from the patient perspective(2020 Dev MK, Paudel N, Joshi ND, Shah DN, Subba S. Psycho-social impact of visual impairment on health-related quality of life among nursing home residents. BMC Health Serv Res. 2014;14:345.,2222 Mangione CM, Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD; National Eye Institute Visual Function Questionnaire Field Test Investigators. Development of the 25-item National Eye Institute Visual Function Questionnaire. Arch Ophthalmol. 2001; 119(7):1050-8.). When considering visual status, it can give information about the direct influence of reduced visual acuity on health-related quality of life(11 Cypel MC, Belfort Jr R. Oftalmogeriatria. São Paulo: Roca; 2008.,2222 Mangione CM, Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD; National Eye Institute Visual Function Questionnaire Field Test Investigators. Development of the 25-item National Eye Institute Visual Function Questionnaire. Arch Ophthalmol. 2001; 119(7):1050-8.). Visual impairment is a particular risk factor for isolation, depression, and falls(11 Cypel MC, Belfort Jr R. Oftalmogeriatria. São Paulo: Roca; 2008.,2222 Mangione CM, Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD; National Eye Institute Visual Function Questionnaire Field Test Investigators. Development of the 25-item National Eye Institute Visual Function Questionnaire. Arch Ophthalmol. 2001; 119(7):1050-8.). These facts affect the elderly at both individual and societal levels, resulting in greater use of healthcare services despite remaining active and productive. Depending on others for activities of daily life may necessitate increased expenditure for the elderly themselves, their family, and wider society in general. Special care and attention should be given to the vision of the very old, aiming to prevent or diagnose ocular disorders early.

In the very old, we showed that AMD was very frequent, affecting 100% of all centenarians. Cataracts were also highly prevalent, with more than a third of the sample having previously undergone cataract surgery. Adequate spectacle correction is always desirable in this population, even when a small improvement in visual acuity is achieved, because small changes in image quality might significantly affect daily activities. The negative impact of visual impairment and blindness was confirmed by decreased scores in health- and vision-re lated quality of life instruments. We conclude that the shift in developing countries' populations toward older ages justifies high quality eye care to ensure best vision and quality of life.

  • Funding: This study was supported by CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) for doctoral fellowship (MCC) at Departamento de Oftalmologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil. SRS and RBJ are research scholars from Conselho Nacional de Desenvolvimento Cientifico e Tecnológico (CNPq, Brasília, Brasil).
  • Approved by the following research ethics committee: Universidade Federal de São Paulo-Escola Paulista de Medicina (#158/04); Instituto de Ensino e Pesquisa do Hospital Albert Einstein (#04/175).

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Publication Dates

  • Publication in this collection
    May-Jun 2017

History

  • Received
    26 Sept 2016
  • Accepted
    30 Nov 2016
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