Recommendations of Major Authorities

• American Academy of Family Physicians --
• Vision screening with Snellen acuity testing is recommended for the elderly.

• American Academy of Ophthalmology --
• A comprehensive eye examination, including screening for visual acuity and glaucoma by an ophthalmologist, should be performed every 3 to 5 years in African Americans aged 20 to 39 years, and, regardless of race, every 2 to 4 years in individuals aged 40 to 64 years, and every 1 to 2 years beginning at age 65 years. Diabetic patients, at any age, should have exams at least yearly.

• American College of Obstetricians and Gynecologists --
• Women 65 years of age and older should be evaluated for visual acuity yearly or as appropriate.

• American Optometric Association --
• Comprehensive eye and vision examinations are recommended for normal-risk adults as follows: 19 to 40 years of age, every 2 to 3 years; 41 to 60 years of age, every 2 years; 61 years of age and older, yearly. Adults 19 to 60 years of age at increased risk for eye disease (eg, with diabetes, hypertension, family history of glaucoma, work in highly visually demanding or eye hazardous occupations, taking certain systemic medications with ocular side effects) should have examinations every 1 to 2 years or as recommended.

• Canadian Task Force on the Periodic Health Examination --
• There is fair evidence to include in the periodic health examination visual acuity testing with a Snellen sight chart for adults aged 65 years or older. In addition, funduscopy or retinal photography is recommended for elderly patients (> 65 years) with diabetes of at least 5 years' duration. The place of funduscopy in the detection of age-related macular degeneration and glaucomatous changes is controversial. For patients at high risk for glaucoma (eg, positive family history, African American race, severe myopia, diabetes), a prudent recommendation would be to include periodic assessment by an ophthalmologist.

• National Eye Institute --
• A comprehensive eye examination, including screening for visual acuity and glaucoma, should be performed by an eye care professional every 2 years beginning at age 40 years in African Americans and at age 60 years in all other individuals. Diabetic patients, at any age, should have yearly exams.

• US Preventive Services Task Force --
• Routine vision screening with Snellen acuity testing is recommended among the elderly. The frequency is left to clinical discretion. Selected questions about vision may be helpful in detecting vision problems in the elderly, but do not appear to be as sensitive or specific as direct assessment of acuity. There is insufficient evidence to recommend for or against routine screening for diminished visual acuity among non-elderly adults. There is also insufficient evidence to recommend for or against routine screening by primary care clinicians for elevated intraocular pressure or early glaucoma. Effective screening for glaucoma is best performed by eye specialists who have access to specialized equipment to evaluate the optic disc and measure visual fields. Recommendations may be made on other grounds to refer patients at high risk for glaucoma for evaluation by eye specialists including: the substantial prevalence of unrecognized glaucoma in these populations, the progressive nature of untreated disease, and expert consensus that reducing intraocular pressure may slow the rate of visual loss with early glaucoma or severe intraocular hypertension. Patients at high risk for glaucoma include: African Americans over 40 years of age; Caucasians over 65 years of age; patients with diabetes, severe myopia, or a family history of glaucoma. The optimal frequency for glaucoma screening has not been determined.

Basics of Vision Screening

1.

Refer older adults and individuals at high risk to eye-care professionals for periodic examinations. See Recommendations of Major Authorities.

2.

Perform visual acuity screening using a standard Snellen wall chart at a distance of 20 feet. A tumbling "E" chart may be used for patients who are not familiar with the Western alphabet. Give a passing score for each line for which the patient gives a majority of correct responses. Test each eye separately. The patients should wear any corrective lenses during screening. If a patient is found to have significant changes in visual acuity or visual acuity of 20/40 or less when using corrective lenses, refer him or her to an eye-care specialist for further examination.

3.

Risk factors for glaucoma include increasing age, family history of glaucoma, African American race, diabetes mellitus, and myopia. Evaluate each patient's risk factors for glaucoma and other ocular problems, and refer appropriate patients to eye-care professionals for screening.

4.

Loss of vision can begin slowly and may go unnoticed for some time, particularly in older adults. Encourage patients to seek evaluation at the first sign of vision problems. Use of a standardized, self-administered questionnaire (Table 45.1) can help identify individuals needing evaluation of their vision. More extensive questionnaires have been developed (Mangione et al, 1992).

Table

Table 45.1. Visual Impairment Questionnaire.

Patient Resources

• Your Vision, the Second Fifty Years; Do Adult Vision Problems Cause Reading Problems? and other publications. American Optometric Association, 243 N Lindbergh Blvd, St. Louis, MO 63141; (314)991-4100. Internet address: http://www.aoanet.org/

• Age-Related Macular Degeneration; Cataracts; Diabetic Retinopathy; Don't Lose Sight of Diabetic Eye Disease; Don't Lose Sight of Glaucoma; Glaucoma. National Eye Health Education Program, National Institutes of Health, 2020 Vision Pl, Bethesda, MD 20892; (301)496-5248. Internet address: http://www.nei.nih.gov

• Age Page — Aging and Your Eyes. National Institute on Aging, Bldg 31, Room 5C27, 31 Center Dr MSC 2922 Bethesda, MD 20892-2922; (301)496-1752. Internet address: http://www.nih.gov/nia

Provider Resources

• Glaucoma; Cataracts; Strabismus in Adults; Cataract Surgery; Diabetic Retinopathy. American Academy of Ophthalmology, PO Box 7424, San Francisco, CA 94120. Send a business-size, self-addressed, stamped envelope with your request. Internet address: http://www.eyenet.org

• Policy Statement: Frequency of Ocular Examinations; National Eyecare Project (for those who do not have an eye doctor); Glaucoma 2001 Project (for people at risk for glaucoma). American Academy of Ophthalmology, PO Box 7424, San Francisco, CA 94120. Send a business-size, self-addressed, stamped envelope with your request. Internet address: http://www.eyenet.org

• Comprehensive Adult Eye and Vision Examination and other clinical practice guidelines. American Optometric Association, 243 N Lindbergh Blvd, St. Louis, MO 63141; (314)991-4100. Internet address: http://www.aoanet.org/

• National Eye Institute Statement on Detection of Glaucoma; National Eye Institute Statement on Vision Screening in Adults. National Eye Health Education Program, National Institutes of Health, 2020 Vision Pl, Bethesda, MD 20892; (301)496-5248. Internet address: http://www.nei.nih.gov

Selected References

1. American Academy of Family Physicians, Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997.
2. American Academy of Ophthalmology, Quality of Care Committee. Comprehensive Adult Eye Examination . San Francisco, Ca: American Academy of Ophthalmology; 1992.
3. American Academy of Ophthalmology. Detection and Control of Diabetic Retinopathy . San Francisco, Ca: American Academy of Ophthalmology; 1992.
4. American Optometric Association. Comprehensive Adult Eye and Vision Examination . St. Louis, Mo: American Optometric Association; 1994.
5. Canadian Task Force on the Periodic Health Examination. Screening for visual impairment in the elderly. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 78.
6. Leske MC. The epidemiology of open-angle glaucoma: a review. Am J Epidemiol . 1983; 118:166–169. [PubMed: 6349332]
7. Mangione CM, Phillips RS, Seddon JM, et al. Development of the activities of daily vision scale: a measure of visual functional status. Med Care . 1992; 30:1111–1126. [PMC free article: PMC265234] [PubMed: 1453816]
8. Nelson KA. Visual impairment among elderly Americans: statistics in transition. J Vis Impair Blind. . 1987; 81:331–334.
9. Podgor MJ, Leske MC, Ederer F. Incidence estimates for lens changes, macular changes, open angle glaucoma and diabetic retinopathy. Am J Epidemiology . 1983; 118:–. [PubMed: 6881126]
10. Reuben DB. Visual impairment. In: Beck JC, ed. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine. New York, NY: American Geriatrics Society; 1991.
11. Rubenstein LZ, Lohr KN. Conceptualization and Measurement of Physiologic Health for Adults . vol 12: Visual Impairments. Santa Monica, Ca: Rand Corporation; 1982. Publication R-2262/12-HHS.
12. US Preventive Services Task Force. Screening for glaucoma.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 34.
13. US Preventive Services Task Force. Screening for visual impairment.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 33.
14. Winograd CH, Gerety MB. Geriatric assessment and concepts: visual and hearing assessment . New York, NY: American Geriatrics Society; 1989. Abstract.