Ophthalmic Disorders in the Elderly

1. Ophthalmic Disorders in the Elderly Thomas Braide, MD, CMD May 8, 2019

2. Ophthalmic disorders in the elderly Objectives: • Identification of common, as well as less common, eye diseases in the elderly. • Early identification of warning signs of eye disease • Identification of systemic side effects of ocular medications • Basic knowledge of prevention and management of eye disease in the elderly Disclosure: There is no financial disclosure to make

3. Basic anatomy

4. Magnitude of the problem • About 2.9 million affected in the US • Associated with high prevalence of chronic health conditions; falls with injuries; depression • Negative effect on quality of life: Reading; driving; social isolation. • US $8.3 billion a year

5. Prevalence • Increased prevalence of visual impairment (visual acuity of less than 20/40) and blindness (visual acuity of 20/200 or worse) with increasing age • Approximately 2.5 times greater in individuals 75 years and older than in those 45-64 years of age. • Prevalence of good vision (20/20-20/25) decreases steadily with increasing age.

6. Warning Signs of eye disorders in the elderly… • Sudden eye pain, nausea and redness: acute narrow angle glaucoma • Sudden blurring of vision in one eye: exudative age-related macular degeneration • Spots and floaters in field of vision: age-related vitreous detachment; retinal detachment/tear • Pain, tearing and irritation: Dry eye syndrome • Double vision: Stroke • Gradual vision loss/ distorted vision: Dry macular degeneration

7. Warning signs of vision problems in the elderly….. 7. Cloudy vision, night light halos, faded color vision: Cataracts 8. Blurred vision in a diabetic: Diabetic retinopathy Types of eye disorder in the elderly • Common:- Usually chronic • Less common : - Acute; usually associated with the red eye - Vascular conditions such as anterior ischemic optic neuropathy and retinal vein occlusion

8. common types…. • Refractive errors: 1. Presbyopia: Farsightedness -Progressively worsening ability to focus clearly on close objects -Due to progressive hardening of lens, associated with impaired ciliary muscle action; corrected with reading glasses ( may be obtained over the counter), bifocals 2. Myopia: Nearsightedness/ Shortsightedness -Inability to focus clearly on distant objects; close objects appear normal -Due to eye ball being too long; less commonly associated with aging -When severe, may increase the risk for retinal detachment, cataracts and glaucoma -Corrected with eye glasses, contacts and refractive surgery; surgery less successful in the elderly 3. Astigmatism -Eye lens does not focus light evenly on retina, resulting in distorted or blurred vision at all distances -Corrected with glasses, contact lenses and surgery

9. diagnosis… • History: • eye strain • blurred vision • headache • Examination: - Visual acuity test with Snellen chart (wall mounted or hand held)

10. Snellen: wall mounted

11. Snellen: hand held

12. Cataracts Most common eye disorder in the elderly: 52% • Risk factors: • Advancing age • Hypertension • Diabetes • Nutritional deficits: protein, riboflavin, selenium • Positive family history • Radiation exposure: ionizing; ultraviolet; microwave • Cataractogenic drugs: Steroids; Phenothiazines • Alcohol • Smoking • Types: • Nuclear sclerosis: Most common; central part of lens • Cortical cataract: Periphery of lens • Posterior subcapsular

13. Cataracts…. Manifestations: • Reduced visual acuity: blurry vision • Reduced contrast sensitivity • Reduced color vision • Increased glare sensitivity: trouble with bright lights; halos around lights • Loss of perception of depth of vision (stereopsis) Assessment: • Snellen visual acuity test • Comprehensive eye examination, including pupil dilation • Slit lamp examination • Retinal examination • Functional tests: used to assess function post cataract extraction

14. Cataract… Management: • Non-surgical: when function is not severely affected • New eye glasses • Antiglare sunglasses • Magnifying lens • Surgical: when function is severely affected by poor vision - Performed under general anesthesia or MAC anesthesia (monitored anesthesia care with local anesthesia, sedation and analgesia)

15. Cataract • Cataract surgery associated with improvement of vision to 20/40 or better in over 90%. 15% or more may complain of a hazy vision several months after the procedure due to opacification of the posterior capsule: corrected by laser ablation (capsulotomy) Age-related macular degeneration: • About 30% of eye disorders in the elderly • Significant clinical and public health challenge. • Limited treatment possibilities, unlike cataract, hence contributes significantly to incidence of low vision and blindness in the elderly.

16. Macular degeneration.. Macula: • Oval pigmented area near the center of the retina • Responsible for central high resolution vision possible in good light • The macula is yellow in color because of it’s content of the carotenoids lutein and zeaxanthine which are derived from food • In macular degeneration there is an imbalance between rate of degradation and regeneration of macular cells, leading to accumulation of harmful products such as drusen and amyloid.

17. Age-related macular degeneration.. Risk Factors: • Advancing age • Genetic predisposition • Cigarette smoking • Essential hypertension • Fair skin • Family history of AMD • Sunlight • Nutritional factors: Vitamin E and C deficiency Types: Dry and wet (exudative) Dry: ( 85-90%): Usually asymptomatic • Much more common • Submacular yellow deposits (drusen) composed of byproducts of metabolism • Not associated with vision loss, but larger and more numerous drusen may precede the wet type, with risk of vision loss

18. Macular degeneration.. Features: • Distorted vision: wavy lines while looking at mini-blinds at home or watching telephone poles while driving. Amsler grid will detect this • Central scotomas: shady or missing areas around vision • Slow recovery of visual function after exposure to bright light: photostress test • Gradual loss of central vision in non-exudative type; rapid onset of blurred vision in exudative type • Reduced visual acuity: detected with Snellen chart • Loss of contrast sensitivity.

19. Amsler grid

20. Dry Macular degeneration….

21. Wet macular degeneration… • Choroidal neovascularization (angiogenesis) • May occur denovo or be preceded by high risk drusen; progression of high risk drusen to wet macular degeneration may be slowed with high dose vitamin combination of beta carotene, vitamin E and vitamin C • Central visual blindness as a result of subretinal fluid/ blood accumulation • Treatments include laser therapy, photodynamic therapy and serial intravitreal injections with vascular endothelial growth factor inhibitors, eg Avastin, Pegaptinib.

22. Wet macular degeneration….

23. Diabetic retinopathy…. Prevalence: - Related to duration of diabetes and level of control of blood glucose; also prevalent with advancing age Risk factors: - HTN - CKD - Hyperlipidemia • Vision loss in diabetic retinopathy due to macular edema or macular hypoperfusion • Types: Non-proliferative, pre-proliferative and proliferative; 40% of pre-proliferative progress to proliferative in 1-2 years • Proliferative diabetic retinopathy may lead to vision loss or blindness as a result of neovascularization leading to vitreous hemorrhage or traction retinal detachment; treated with laser photocoagulation.

24. Diabetic retinopathy….

25. Glaucoma… • Group of diseases that can damage the eye’s optic nerve and result in vision loss and blindness. • Not a common cause of blindness in elderly non-blacks; most common cause of blindness in blacks, in whom it tends to present earlier Etiology: • Advancing age • Essential hypertension • Diabetes • Male gender • Black race • Family history of glaucoma • Occupational exposure to chemicals • Prolonged use of steroid eye drops

26. glaucoma • Feature: Increased cup/disc ratio of optic nerve head, associated with increased intraocular pressure. Types: Primary open angle glaucoma. • IOP only mildly elevated, chronically • Slow drainage of aqueous humor from the anterior chamber • Patients are usually asymptomatic for a long time, and present late with bilateral patchy blind spots, or tunnel vision in advanced cases Acute angle closure glaucoma : • Sudden blockage of aqueous humor drainage: Sudden dilatation of the pupil with mydriatics such as phenylephrine and atropine, as well as dim light. • Painful red eye with acute vision loss, nausea, vomiting, severe headache and halos around lights. • Ocular emergency

27. Glaucoma…

28. Glaucoma..

29. Glaucoma: Treatment…. Acute angle closure: • High index of suspicion and immediate ophthalmology referral • IOP reduction: Acetazolamide; topical beta blockers, egTimolol • Suppression of inflammation: Topical steroids • Analgesics for pain • Antiemetics for nausea • Surgical reversal of angle closure: Iridotomy Primary open angle: Medications: • Aqueous Suppressants: alpha-2 agonists (Brimonidine); beta blockers (Timolol); carbonic anhydrase inhibitors (Dorzolamide)

30. Open angle glaucoma: Treatment… • Aqueous outflow facilitators: miotics (pilocarpine); Prostaglandins (latanoprost); epinephrine Surgical: - Indicated with visual field loss despite adequate use of medications - Argon laser trabeculoplasty - Laser trabeculectomy - Drainage devices - Aqueous shunts.

31. Glaucoma meds side effects.. • Beta adrenergic antagonists, egTimolol • Bradycardia • Hypotension • Depression • Syncope • Headache • GI disturbance • Heart failure • Impotence • Blunting of hypoglycemia symptoms • Prostaglandin receptor antagonists, egLatanoprost • Muscle, joint and chest pain • Iris discoloration • Eye irritation • Skin discoloration

32. Glaucoma med side effects.. • Carbonic anhydrase inhibitors, egDorzolamide • Poor taste • Anorexia • Depression • Reduced libido • Metabolic acidosis • Paresthesias • Renal calculi • Fatigue • Parasympathetic agents, egPilocarpine • Headache • Hypotension • Diaphoresis • Bronchospasm • Arrhythmias

33. Glaucoma med side effects.. • Alpha2-adrenergic agents, egBrimonidine • Headache • Sleep disorders • Elevated blood pressure • Fatigue • Dry mouth • Arrhythmias • Dry mouth • GI disturbances Vascular disorders: • Anterior ischemic optic neuropathy • Retinal vein occlusion

34. Anterior ischemic optic neuropathy…. • Microvascular occlusion of blood supply to the optic nerve: Arteritic(in the setting of GCA) -Common in the elderly -ESR elevated; temporal artery biopsy diagnostic -May be associated oral tongue or scalp ulcers Non-arteritic(atherosclerotic): associated with other vascular risk factors, such as HTN, DM • Unilateral vision loss which may be sudden or develop over a few days. Painless in 90% of patients with non-arteritic ischemic optic neuropathy; usually noticed upon awakening in the morning. In arteritic type vision, loss is associated with headache, scalp tenderness, jaw pain during mastication, temporal artery tenderness and malaise

35. Anterior ischemic optic neuropathy (Non-arteritic)….

36. Anterior ischemic optic neuropathy (arteritic)..

37. Anterior ischemic optic neuropathy… Treatment: • Steroids: High dose for arteritic form; less common use in non-arteritic form • Vascular risk factor management in non-arteritic form, eg aspirin, statins as well as therapeutic life style modification

38. Retinal vein occlusion.. Due to blockage of retinal veins, either central or branch. • Symptom: Sudden blurring/ loss of vision in all, or part of visual field • Risk factors • Artherosclerosis • Diabetes Mellitus • Essential hypertension • Advancing age • Macular edema • Vitreous hemorrhage • Diagnosis: • Fundoscopy • Visual acuity test • Visual field testing • Retinal photography

39. Retinal vein occlusion..

40. Retinal vein occlusion: treatment May be transient and resolve without treatment • Non-invasive: - Management of diabetes, hyperlipidemia and hypertension • Aspirin, Plavix or anticoagulants • Invasive: • Intravitreal steroid implant • Pan-retinal Laser photocoagulation • Intravitreal anti vascular endothelial growth factor (anti-VEGF) drugs, egPagatanib, Ranibizumab

41. other eye conditions in elderly.. • Usually manifest acutely as red eye Red Flags: • History: Recent ocular surgery; trauma; contact lens overuse • Symptoms: Severe eye pain; severe photophobia; nausea/vomiting • Signs: Severe periorbital edema; reduced orbital motility; erythema; proptosis; abnormal pupil shape, size and reactivity; severe tenderness of globe or eyelid; eye discharge

42. Types.. • Corneal ulceration: traumatic or infective (dendritic ulceration in herpes simplex) • Corneal abrasion: Traumatic • Uveitis (anterior or posterior): Relatively uncommon in the elderly. Associated with photophobia and vision loss. May be caused by infection, autoimmune disease or malignancy. Treated with corticosteroid eye drops. Prompt ophthalmology referral needed. • Blepharitis: Dandruff of eyelids. Treated with gentle scrub with shampoo and occasionally topical antibiotics. Common in the elderly • Dry eye syndrome (keratitis sicca): Foreign body sensation with reflex tearing, due to reduced tear formation. May be associated with autoimmune disease such as Sjogrens.

43. Acute eye conditions.. • Viral conjunctivitis: Mucous discharge with matting of eyelids • Allergic conjunctivitis: Red itchy eyes. Treated with antihistamines, decongestants and topical steroids • Subconjunctival hemorrhage: Usually painless and may occur spontaneously

44. Red eye • Orbital cellulitis: Inflammation of structures in the eye socket resulting in pain with eye movement, chemosis, loss of vision and proptosis ; may be traumatic or infective from spread from the sinuses. Ocular emergency requiring intravenous antibiotics • Periorbital cellulitis: Inflammation of eyelid and surrounding skin; no pain with eye movement. No associated visual loss. • Chalazion: Inflammation of eye lid cyst, either Meibomian or Zeis

45. corneal ulcer

46. blepharitis

47. uveitis

48. dry eye syndrome

49. Chalazion.

50. Subconjunctival hemorrhage