Visual impairment and eye diseases in elderly institutionalized Australians

Ophthalmic Care in Nursing Homes for the Blind: A Growing Challenge

BACKGROUND

The demographic change in Germany will lead to an increase in irreversible age-related eye diseases. This will increase the need for specialised care facilities for visually impaired people. Due to reduced mobility, residents in such facilities often do not receive adequate ophthalmological care. New concepts must therefore be considered for this group of patients. One approach is to set up an ophthalmological examination unit within the facility combined with regular visits by an ophthalmologist. We now present the experience with such a model in a home for the blind.

PATIENTS AND METHODS

The project was initiated in 2009. Since then there have been visits by medical staff of the Eye Center at Medical Center, University of Freiburg, every two weeks. All patient records (2010 - 2017) were reviewed systematically. The following data were extracted in a structured and anonymous way: Age at first presentation, gender, ophthalmological diagnoses and if a therapy was initiated. This data set was finally analysed descriptively.

RESULTS

Out of 130 residents aged between 48 and 100 years, half were between 78 and 90 years old. The youngest resident was 48, the oldest 100 years old. The median visual acuity was 0.2. Sixty percent of the residents had at least mild visual impairment according to the WHO (visual acuity < 0.5; category 1 - 6). In one of 6 - 7 residents, visual acuity could not be determined using Snellen charts. The most frequent ophthalmological diagnoses included cataract (44%), age-related macular degeneration (36%) and glaucoma (29%). In 67 residents (52%), the ophthalmological examination lead to treatment, such as application of local therapy or planning an operation.

CONCLUSION

In every second resident, the ophthalmologist's visit lead to treatment during the observation period. This underlines the difficulty of providing ophthalmological care even in specialised institutions for the blind and visually impaired, which is possibly due to the residents' mobility problems. The concept presented here has established a low-threshold, sustainable and high-quality ophthalmological service on site. These positive experiences indicate that corresponding measures may also be useful for other locations. However, in order to implement such a project on a larger scale, suitable financing and accounting modalities for the construction measures, the nursing staff and the ophthalmological procedure still need to be developed.

Hyderabad Ocular Morbidity in Elderly Study (HOMES) - Rationale, Study Design and Methodology

Purpose: To describe the study design, interobserver variability of the questionnaires and clinical procedures of Hyderabad Ocular Morbidity in Elderly Study (HOMES) designed to, (a) to investigate the prevalence, causes and risk factors for visual impairment, and (b) to assess the impact of dispensing spectacles and cataract surgery on visual functions, fear of falls (FOF) and depression among the elderly in India.Methods: Individuals aged ≥60 years are considered elderly. The non-clinical protocol was administered by two trained investigators and included collection of personal, sociodemographic information, ocular and systemic history, Indian Visual Function Questionnaire (IND-VFQ33), Patient Health Questionnaire (PHQ9), Mini-Mental State Examination (MMSE) questionnaire, Hearing Handicap Inventory for the Elderly Screening (HHIE), Short Falls Efficacy Scale (SFES) questionnaire. The eye examination was conducted by a trained optometrist and vision technicians in clinics set-up in the homes and included visual acuity (VA) assessment for distance and near, anterior segment examination and fundus examination, and imaging. The reliability assessments were carried out among 138 participants.Result: The intraclass correlation (ICC) coefficients for MMSE, PHQ9, HHIE, SFES was 0.73 (95% CI: 0.62-0.81), 0.67 (95% CI: 0.54-0.77), 0.63 (95% CI: 0.48-0.74) and 0.70 (95% CI: 0.58-0.79) respectively. The ICC for INDVFQ domains ranged from 0.66 (95% CI: 0.55-0.74) for Psychosocial Impact to 0.88 (95% CI: 0.84-0.91) for activity limitation. The ICC for VA was 0.94 (95% CI: 0.92-0.96).Conclusion: All questionnaires demonstrated acceptable reliability and can be applied in the main study. HOMES is expected to provide data that will help plan strategies to contribute towards 'healthy aging' in India.

The History and Future of Low Vision Services in the United States

This article discusses the history of low vision services in the United States. The field began to gain momentum as the term low vision was conceptualized and coined, and this momentum is rapidly increasing with changes in the demographics of visual impairment.

Visual impairment and some of ocular problem in nursing home residents

We decided to conduct a study to determine the prevalence of visual impairment, blindness, refractive errors, and other visual functions in nursing homes of Iran. In this cross-sectional study, 133 elderly persons were selected from seven nursing homes using proportional-to-size random sampling. A Snellen chart was used to measure visual acuity (VA). Refraction was measured in all participants using autorefractometry and retinoscopy. A cover test was applied to assess ocular deviation. Stereopsis, color vision, and contrast sensitivity were evaluated with distance glasses. The prevalence (95% confidence interval [CI]) of visual impairment (VI) (<20/60), low vision (<20/60 to <20/400), and blindness (⩽20/400) was 41.88% (32.81–50.95), 32.48% (23.87–41.09), and 9.40% (4.03–14.77), respectively, based on best-corrected visual acuity (BCVA). The prevalence of myopia (spherical equivalent (SE) < −0.5 D), hyperopia (SE < 0.5 D), and astigmatism (cylindrical power < 0.5 D) was 53.50% (44.19–62.58), 36.84% (28.38–46.19), and 86.84% (79.17–91.97), respectively. VI and refractive errors had no association with age and sex ( p-value > .05 for all). The prevalence of other ocular diseases was as follows: cataract 66.06% (57.02–75.09), glaucoma 1.52% (1.85–5.40), one eyed caused by injury 6.10% (2.67–11.67), and corneal opacity 3.81% (1.25–8.68). The prevalence of VI was 4–20 times and the prevalence of cataract was 3–4 times higher in NHRs compared with community-dwelling older people, indicating the grave situation of vision in these people. It is necessary to conduct further studies to find the reasons behind this disparity and perform interventions, including periodic and screening examinations upon entry to nursing homes to decrease the burden of ocular diseases in NHRs.

Challenges for the cataract surgeon treating people with dementia: a qualitative study exploring anesthetic choices

BACKGROUND

In light of the growing number of people with dementia and age-related cataract, as well as changing anesthetic practices for cataract surgery, this study aimed to explore the experiences of cataract surgeons in managing patients with dementia and making anesthetic decisions.

METHODS

This was a qualitative study using semistructured interviews with senior cataract surgeons from two centers in England. Fourteen surgeons were interviewed, and a thematic approach informed by grounded theory was used for the analysis.

RESULTS

Choice of anesthesia for people with dementia was a central theme arising from the data. Surgeons varied in their thresholds for using general anesthesia. Decisions about suitability for local anesthesia were limited by time constraints and generally made rapidly and based on instinct; dementia was not always apparent at the point of preassessment. Surgeons used a variety of topical, sub-Tenon's, and sharp needle blocks for people with dementia. Surgeons discussed techniques to help patients tolerate local anesthesia, such as clear communication, a primary nurse, hand-holding, and support from an anesthetist. However, within our sample, some surgeons had had negative experiences of operating on people with dementia, where an incorrect judgment had been made that they could tolerate local anesthetic cataract surgery.

CONCLUSION

This study highlights the differing practices of cataract surgeons when making anesthetic choices for people with dementia and the challenges they face. In order to avoid the situation of a patient with dementia becoming distressed during awake surgery, increased time at preassessment and anesthetic support may be beneficial.

Psycho-social impact of visual impairment on health-related quality of life among nursing home residents

BACKGROUND

Visual impairment (VI) affects physical, psychological, and emotional well-being, and social life as well. The purpose of this exploratory study was to assess the psycho-social impact of VI on health-related quality of life (HRQoL) among nursing home residents.

METHODS

This cross-sectional study involved 272 residents of 60 years or older residing in seven nursing homes of the Kathmandu Valley, Nepal. Comprehensive ocular examinations, including near and distance vision assessment and refractions were carried out. VI was defined as visual acuity (VA) less than 6/18 in the better eye. Residents were divided into two groups: one group did not have VI (in whom VA was greater than or equal to 6/18 in the better eye), and the other had VI (in whom VA was worse than 6/18 in the better eye).Face-to-face interviews were conducted filling out a 36-item The Medical Outcomes Study Short-Form (SF-36) questionnaire. The SF-36 questionnaire was scored according to the scoring algorithm SF-36 subscales.

RESULTS

The mean age of residents was 74.68 ± 8.19 years (range, 60-99 years) and the majority were female (78.68%). The mean composite score of SF-36 was 46.98 ± 13.08. VI detrimentally affected scores of both the physical and the mental components, but the impact of VI was slightly greater for the physical component than that for the mental component. There was a trend towards a lower composite score as well as each subscale score of the SF-36 in participants with VI than in those without VI.

CONCLUSION

VI has a negative effect on HRQoL. HRQoL is reduced among nursing home residents and the reduction in the HRQoL bears a positive association with VI.

Impact of visual impairment on vision-specific quality of life among older adults living in nursing home

BACKGROUND

Visual impairment (VI) has a significant negative impact on quality of life (QoL) amongst older people living in nursing homes. The purpose of this study was to determine the prevalence of VI and blindness and to explore the association between severity of VI and vision-specific QoL among older people living in nursing homes of Kathmandu, Nepal.

METHODS

This cross-sectional study involved 158 residents aged 60 years or older residing in seven nursing homes of Kathmandu Valley, Nepal. Near acuity, presenting and the best corrected distance visual acuity (VA) were assessed in each eye and considered in the better eye after adequate refraction. A complete anterior and posterior segment examination was carried out. Face-to-face interviews were conducted using a 57-item Nursing Home Vision-Targeted Health-Related Quality of Life (NHVQoL) questionnaire.

RESULTS

The mean age of residents was 75.60 ± 7.12 years and the majority were female (66.46%). The prevalence of VI and blindness was 45.57% and its leading cause was cataract, which was followed by age-related macular degeneration, corneal opacity, glaucoma and macular scar. The mean composite score of NHVQoL questionnaire was 52.22 ± 12.49. There was a consistent overall deterioration in the mean composite score as well as each subscale score of NHVQoL questionnaire with a worsening of VA.

CONCLUSION

VI and blindness are highly prevalent among older people living in nursing homes. VI has a significant negative impact on vision-specific QoL. Vision-specific QoL is reduced, and the reduction in the QoL bears a positive association with severity of VI among older people living in nursing homes.

Spectacle coverage and spectacles use among elderly population in residential care in the south Indian state of Andhra Pradesh

Background. There is limited research conducted on uncorrected refractive errors, presbyopia, and spectacles use among the elderly population in residential care in developing countries such as India. We conducted a cross-sectional study among elderly in residential care to assess the spectacle coverage and spectacles usage in the south Indian state of Andhra Pradesh. Methods. All 524 residents in the 26 “homes for aged” institutions in the district were enumerated. Eye examination was performed that included visual acuity (VA) assessment for distant and near vision. A questionnaire was used to collect information on spectacles use. Results. 494/524 individuals were examined, 78% were women, and 72% had no education. The mean age of participants was 70 years. The spectacle coverage for refractive errors was 35.1% and 23.9% for presbyopia. The prevalence of current use and past use of spectacles was 38.5% (95% CI: 34.2–42.8; n = 190) and 17.2% (95% CI: 13.9–42.8), respectively. Conclusions. There is low spectacle coverage for both refractive errors and presbyopia among elderly individuals in residential care in the south Indian state of Andhra Pradesh. Appropriate service delivery systems should be developed to reach out this vulnerable group of seniors on a priority basis.

A cross-sectional study of visual impairment in elderly population in residential care in the South Indian state of Andhra Pradesh: a cross-sectional study

OBJECTIVE

To assess the prevalence and major causes of visual impairment (VI) in elderly residents of 'home for the aged' institutions in the Prakasam district in India.

DESIGN

Cross-sectional study.

SETTING

'Home for the aged' institutions in the Prakasam district in the South Indian state of Andhra Pradesh.

PARTICIPANTS

All 524 residents in the 26 'homes for aged' institutions in the district were enumerated.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence and causes of VI; visual acuity (VA) was assessed using a Snellen chart at a distance of 6 m. Pinhole VA was assessed if presenting VA was <6/18. Torchlight examination and direct ophthalmoscopy were performed. VI was defined as presenting VA <6/18 in the better eye.

RESULTS

Of the 494 participants examined (response rate 94.3%), 78.1% were women, 72.1% had no formal schooling. The mean age of participants was 70 years (SD ±8.6 years). VI was present in 280/494 individuals (56.9%; 95% CI 52.3 to 61.3). Over 80% of the VI was due to avoidable causes including cataract (57.1%) and uncorrected refractive errors (26.4%). Among 134 individuals who had undergone bilateral cataract surgery, only 78 (58.2%) individuals had presenting VA ≥6/18 and 13/134 (9.7%) participants were blind.

CONCLUSIONS

There is high prevalence of VI in the institutionalised elderly population in the Prakasam district in India. A significant proportion of this elderly population with VI can benefit from spectacles and cataract surgery. Strategies are required to provide high-quality services to this population.

Cataract and cognitive impairment: a review of the literature

Acquired cataract and cognitive impairment are both common age-related problems, and ophthalmologists are increasingly likely to encounter patients who have both. Patients with dementia types who display early visuoperceptual impairment may present first to ophthalmology services. When these patients have coexisting cataract, it may be difficult to distinguish visual complaints due to cataract from those due to dementia. The interaction between visual impairment due to cataract and neurodegenerative disorders affecting the central visual pathways, is not fully understood. Visual impairment due to cataract may stress impaired attentional mechanisms and cataract extraction may improve cognitive performance in some patients with early cognitive impairment; however, the benefits of cataract surgery in established dementia are less clear. In this study, the literature on this subject was reviewed and the implications for practice were considered.

Prevalence and causes of bilateral blindness and visual impairment among institutionalized elderly people in Pamplona, Spain

PURPOSE

To estimate the prevalence and causes of bilateral blindness and visual impairment in an urban institutionalized population aged 65 years and older.

METHODS

A total of 392 nursing home residents completed a standardized eye examination, including measurement of visual acuity (VA), intraocular pressure, lens opacity grading, indirect ophthalmoscopy, and photography of the macular area. The major causes of vision loss identified for all participants were blindness and visual impairment.

RESULTS

The average subject age was 82 years (65-97); women outnumbered men 263 to 129. The prevalence of bilateral blindness (VA > or =1.0 logarithm of the minimum angle of resolution [logMAR]) was 14.9% (43/288); the prevalence of visual impairment (VA > or =0.5 and 1.0 logMAR) was 31.9% (92/288). Blindness and visual impairment increased significantly with age (p<0.05), odds ratio (OR) 1.047 and 1.088, respectively. Cataract was the most common cause of bilateral blindness and visual impairment (27.9% and 44.6%, respectively) followed by pathologic myopia (23.3%) and age-related macular degeneration (AMD) (20.9%) for blindness, and by AMD (27.2%) and pathologic myopia (12%) for visual impairment. Fifty percent of subjects with visual loss had the potential for improved vision with medical or surgical intervention.

CONCLUSIONS

Although the prevalences were high, these data are important since it is difficult for epidemiologic studies to include aged, institutionalized individuals, although their numbers are increasing. Recognition of the predominant causes of visual loss dependent on age is fundamental for early diagnosis and treatment of ocular diseases. Many cases of low vision can be treated with appropriate ophthalmologic care.

[Elderly people with visual impairment in The Netherlands]

AIM

To estimate the number of elderly people with visual impairment in The Netherlands, now and in the future. Possibilities for intervention are discussed.

METHODS AND MATERIALS

Estimates are based on a recent report on behalf of Foundation InZicht, ZonMw, in which prevalence data from population-based studies on blindness and low vision and its causes in The Netherlands, western Europe, The United States and Australia are related to the latest demographic data for The Netherlands.

RESULTS

Of the 16.4 million Dutch in 2008 2.4 million (14.7%) are 65 years of age and older. Of this last group 155,000 persons are living in nursing homes or residential homes, the others are living in their own homes. In 2008 an estimated 77,000 persons are blind and 234,000 have low vision. Of them 79% is 65 years of age or older. Of the older people in care institutions 20% is blind (32,000) and 22% has low vision (34,000). In 62% of them the visual impairment is treatable or could have been prevented ('avoidable'). Of the older people living independently 1.2% is blind (27,000) and 6.8% has low vision (154,000). In 57% of them the affliction is avoidable.

CONCLUSION

In 2008 247,000 elderly suffer from a visual impairment that could have been treated or prevented in 143,000 (58%) of them. Screening and treatment of elderly in care institutions seems indicated, as is health education to and goal-oriented screening of elderly who live independently.

[Quality of life by limited vision in old age: the example of age-related macula degeneration]

Age-related macula degeneration (AMD) is accompanied by considerable consequences regarding the psychosocial quality of life. A considerable body of research literature now indicates, for instance, an increased rate of depression and substantial loss of everyday capabilities in AMD patients. However, inter-individual differences are large and part of the explanation lies in differences in the ability to cope with and detach oneself from aims in life. The negative impact of AMD on the qualify of life is associated with a need for psychosocial support, but this need is barely met at present. A series of studies nevertheless supports the view that successful intervention is possible even with very old patients. In this respect the problems at present have less to do with recognition than with application and implementation.

Impact of cataract surgery on health-related quality of life in nursing home residents

AIM

To assess the impact of cataract surgery in nursing home residents on health-related quality of life, as compared to those who have cataracts but who do not undergo surgery.

METHODS

A prospective cohort study enrolled 30 nursing home residents (>or=60 years old) who had cataracts and underwent cataract surgery, and evaluated vision-targeted and generic health-related quality of life and depressive symptoms before and approximately 4 months after surgery. This cataract surgery group was compared to 15 nursing home residents who had cataracts but who did not have surgery, over the same timeframe.

RESULTS

Visual acuity for near and distance and contrast sensitivity improved following cataract surgery (p<0.001). Adjusting for age differences in the two groups, the cataract surgery group exhibited significant score improvement in the general vision (p = 0.005), reading (p = 0.001), psychological distress (p = 0.015), and social interaction (p = 0.033) subscales of the Nursing Home Vision-targeted Health-Related Quality of Life Questionnaire and the VF-14 (p = 0.004). There were no group differences in the SF-36, Geriatric Depression Scale or the Cataract Symptom Score.

CONCLUSION

Nursing home residents who underwent cataract surgery because of functional problems experienced significant improvements in their vision-targeted health-related quality of life, in addition to dramatically improved vision.

Changes in visual acuity in a population over a 15-year period: the Beaver Dam Eye Study

PURPOSE

To describe the change in visual acuity in a 15-year period.

DESIGN

Population-based study.

METHODS

setting: Beaver Dam, Wisconsin. participants: 4068 persons 43 to 86 years of age at the time of a baseline examination in 1988 to 1990, and with follow-up examinations every five years thereafter. observation procedures: Best-corrected visual acuity after refraction, assessed by a modification of the ETDRS protocol. main outcome measure: Doubling of the visual angle; incidence of visual impairment.

RESULTS

Eight percent of the population developed impaired vision (20/40 or worse), 0.8% developed severe visual impairment (20/200 or worse), 7% had doubling of the visual angle, and 2% had improved vision. People 75 years of age or older at baseline were more likely to develop impaired vision (odds ratio [OR] 12.8, 95% confidence interval [CI] 9.6 to 17.1, P < .001), doubling of the visual angle (OR 7.8, 95% CI 5.6 to 10.7, P < .001), and severe visual impairment (OR 20.6, 95% CI 9.5 to 44.8, P<0.001) compared with people younger than 75 years of age.

CONCLUSIONS

These data provide population-based estimates of the cumulative 15-year incidence of loss of vision over a wide spectrum of ages. In people 75 years of age or older the cumulative incidence of visual impairment accounting for the competing risk of death is 25%, of which 4% is severe, indicating a public health problem of considerable proportions as the US population in this age is expected to increase by 55% from 18 million in the year 2005 to 28 million by the year 2025.

Macrophages inhibit neovascularization in a murine model of age-related macular degeneration

BACKGROUND

Age-related macular degeneration (AMD) is the leading cause of blindness in people over 50 y of age in at least three continents. Choroidal neovascularization (CNV) is the process by which abnormal blood vessels develop underneath the retina. CNV develops in 10% of patients with AMD but accounts for up to 90% of the blindness from AMD. Although the precise etiology of CNV in AMD remains unknown, the macrophage component of the inflammatory response, which has been shown to promote tumor growth and support atherosclerotic plaque formation, is thought to stimulate aberrant angiogenesis in blinding eye diseases. The current theory is that macrophage infiltration promotes the development of neovascularization in CNV.

METHODS AND FINDINGS

We examined the role of macrophages in a mouse model of CNV. IL-10(-/-) mice, which have increased inflammation in response to diverse stimuli, have significantly reduced CNV with increased macrophage infiltrates compared to wild type. Prevention of macrophage entry into the eye promoted neovascularization while direct injection of macrophages significantly inhibited CNV. Inhibition by macrophages was mediated by the TNF family death molecule Fas ligand (CD95-ligand).

CONCLUSIONS

Immune vascular interactions can be highly complex. Normal macrophage function is critical in controlling pathologic neovascularization in the eye. IL-10 regulates macrophage activity in the eye and is an attractive therapeutic target in order to suppress or inhibit CNV in AMD that can otherwise lead to blindness.

The impact of Vision 2020 on global blindness

INTRODUCTION

Recent data suggest that there are 37 million blind people and 124 million with low vision, excluding those with uncorrected refractive errors. The main causes of global blindness are cataract, glaucoma, corneal scarring (from a variety of causes), age-related macular degeneration, and diabetic retinopathy.

CONCLUSION

It would appear that the global Vision 2020 initiative is having an impact to reduce avoidable blindness particularly from ocular infections, but more needs to be done to address cataract, glaucoma, and diabetic retinopathy.

Prevalence and burden of self-reported blindness and low vision for individuals living in institutions: a nationwide survey

BACKGROUND

The prevalence of self-reported low vision (LV) and blindness, and their associated disabilities, handicaps and socio-economic consequences for individuals living in institutions are poorly documented.

METHODS

2,075 institutions were selected at random and eight individuals were picked at random from the list of residents. Three groups of individuals were defined: blind, LV, and a control group (CG). These were compared after adjustment for age and co-morbidities. Of the 15,403 individuals, 14,603 interviews (94.9%) were completed.

RESULTS

The prevalence of blindness was 1.6% and the LV 13.4%. Blind individuals needed assistance more often (OR: 2.65 to 11.35) than CG members while the assistance required by LV individuals was similar to that for the CG. Blind individuals required institution adaptation (building and furniture changes) more often than the CG. Blind (57.9%) and LV individuals (35.4%) were more often registered for social allowances. Monthly social allowances were EUR 86 higher for blind than LV individuals. Monthly family incomes were found to be similar between the three groups (from EUR 782 to 797). Social and demographic data, institution description, income, handicaps, disabilities, social allowances and details of daily activities were collected interviews.

CONCLUSION

The results demonstrate the impact of self-reported blindness and LV on daily life for patients living in institutions.

Causes of visual impairment in people aged 75 years and older in Britain: an add-on study to the MRC Trial of Assessment and Management of Older People in the Community

BACKGROUND

Visual impairment and blindness are common in older people in Britain. It is important to know the causes of visual impairment to develop health service and research priorities. The authors aimed to identify the causes of visual impairment in people aged 75 years and older in Britain.

METHODS

In the MRC Trial of the Assessment and Management of Older People in the Community, trial nurses tested visual acuity in everyone aged 75 years and older in 53 general practices. For all visually impaired patients in 49 of the 53 medical practices, data regarding the cause of vision loss were extracted from the general practice medical notes. Additional follow up questionnaires were also sent to the hospital ophthalmologist to confirm the cause of vision loss. Visual impairment was defined as a binocular acuity of less than 6/18.

RESULTS

There were 1742 (12.5%) people visually impaired in the 49 participating practices. Of these, 450 (26%) achieved a pinhole visual acuity in either eye of 6/18 or better. In these people, the principal reason for visual loss was considered to be refractive error. The cause of visual loss was available for 976 (76%) of the remaining 1292 visually impaired people identified. The main cause of visual loss was age related macular degeneration (AMD); 52.9% (95% confidence interval 49.2 to 56.5) of people had AMD as a main or contributory cause. This was followed by cataract (35.9%), glaucoma (11.6%), myopic degeneration (4.2%), and diabetic eye disease (3.4%).

CONCLUSIONS

A substantial proportion of visual impairment in our sample of older people in Britain can be attributed to remediable causes-refractive error and cataract. There is considerable potential for visual rehabilitation in this age group. For the large proportion with macular degeneration, low vision services will be important.

Dissection of genomewide-scan data in extended families reveals a major locus and oligogenic susceptibility for age-related macular degeneration

To examine the genetic basis of age-related macular degeneration (ARMD), a degenerative disease of the retinal pigment epithelium and neurosensory retina, we conducted a genomewide scan in 34 extended families (297 individuals, 349 sib pairs) ascertained through index cases with neovascular disease or geographic atrophy. Family and medical history was obtained from index cases and family members. Fundus photographs were taken of all participating family members, and these were graded for severity by use of a quantitative scale. Model-free linkage analysis was performed, and tests of heterogeneity and epistasis were conducted. We have evidence of a major locus on chromosome 15q (GATA50C03 multipoint P=1.98x10-7; empirical P< or =1.0x10-5; single-point P=3.6x10-7). This locus was present as a weak linkage signal in our previous genome scan for ARMD, in the Beaver Dam Eye Study sample (D15S659, multipoint P=.047), but is otherwise novel. In this genome scan, we observed a total of 13 regions on 11 chromosomes (1q31, 2p21, 4p16, 5q34, 9p24, 9q31, 10q26, 12q13, 12q23, 15q21, 16p12, 18p11, and 20q13), with a nominal multipoint significance level of P< or =.01 or LOD > or =1.18. Family-by-family analysis of the data, performed using model-free linkage methods, suggests that there is evidence of heterogeneity in these families. For example, a single family (family 460) individually shows linkage evidence at 8 loci, at the level of P<.0001. We conducted tests for heterogeneity, which suggest that ARMD susceptibility loci on chromosomes 9p24, 10q26, and 15q21 are not present in all families. We tested for mutations in linked families and examined SNPs in two candidate genes, hemicentin-1 and EFEMP1, in subsamples (145 and 189 sib pairs, respectively) of the data. Mutations were not observed in any of the 11 exons of EFEMP1 nor in exon 104 of hemicentin-1. The SNP analysis for hemicentin-1 on 1q31 suggests that variants within or in very close proximity to this gene cause ARMD pathogenesis. In summary, we have evidence for a major ARMD locus on 15q21, which, coupled with numerous other loci segregating in these families, suggests complex oligogenic patterns of inheritance for ARMD.

Visual impairment and nursing home placement in older Australians: the Blue Mountains Eye Study

PURPOSE

To assess whether visual impairment at baseline is an independent contributor to subsequent nursing home placement during a 6-year follow-up.

METHODS

3654 non-institutionalised people aged 49+ years (82.4% of those eligible) who participated in baseline examinations of the Blue Mountains Eye Study (1992-94) were followed during 1997-99. Presenting visual acuity was measured with current glasses and a standardised refraction performed. We defined visual impairment as visual acuity reduced to <or=20/40. Permanent nursing home admissions during follow-up were confirmed by the regional Aged Care Assessment Team and government subsidy payment records.

RESULTS

At baseline, 511 participants had presenting visual impairment. After refraction, vision improved to 20/30 or better in 346 persons (68%, "correctable"), while 165 (32%) remained visually impaired. During follow-up, 162 study participants (5.0%) were admitted permanently to a nursing home. The age-adjusted 6-year incidence was 3.6% for participants with normal vision, 16.2% for those with visual impairment after best correction and 8.1% for those with "correctable" visual impairment. After adjusting for non-cognitive factors that predicted nursing home placement, the relative risk (RR) for nursing home admission among persons with visual impairment after best correction was 1.8 (95% CI 1.1-2.9). A similar magnitude of association was found among persons with "correctable" visual impairment (RR 2.1, 95% CI 1.4-3.1). For each line of reduction in presenting visual acuity at baseline, there was a 7% increased risk of subsequent nursing home placement.

CONCLUSIONS

This study suggests that decreased vision may be a marker or contributing factor to subsequent nursing home placement in general older populations.

A longitudinal study of visual acuity and visual rehabilitation needs in an urban Swedish population followed from the ages of 70 to 97 years of age

PURPOSE

To investigate the longitudinal change in visual acuity (VA) in the oldest members of the elderly population, to estimate future numbers of people with visual impairments, and to estimate needs for and the effects of visual rehabilitation.

METHODS

In the Gerontological and Geriatric Population Studies in Gothenburg, Sweden (H 70), subjects underwent repeated eye examinations at the ages of 70, 82, 88, 95 and 97 years. Logistic regression analysis was used to estimate the probability of independent living as a function of distance VA at different ages.

RESULTS

Rates of normal VA (>or= 0.8) declined from 86% of the study group at age 70 to 7% of the study group at age 95 (0% at age 97). The incidence of VA <or= 0.1 increased from 1.4% at age 70 to 27% (all women) at age 97. The deterioration was faster at higher ages. No statistically significant difference in best-corrected distance VA between genders was found. A substantial improvement was achieved by correcting refractive errors. There was a statistically significant correlation between distance VA and the probability of independent living at all ages except age 97. At ages 95 and 97, about 50% of the study group were able to read newspaper print with best-corrected glasses.

CONCLUSIONS

The number of old people with impaired vision will increase. People aged 80 years and older should have regular eye-screening in order to preserve vision and present conditions of living. Cataract surgery and low vision rehabilitation should be offered when the subject can still benefit from it, preferably during their 80s at the latest.