Hundreds of vision disease experts came to Washington, D.C. this week for the 2014 Focus on Eye Health National Summit. BrightFocus and other vision advocacy groups help sponsor this annual event, which is organized by Prevent Blindness. Here are excerpts and insights from many of the featured speakers.
Visualizing Vision Loss Ahead
An astounding one in four Americans was born during the postwar Baby Boom of 1946-64, a total of 78 million people. As they reach 65, their average life expectancy is 80-plus years, and once they reach age 75 and above, their longevity increases.
“There’s more of them, and they’re living longer,” said John Wittenborn, an economist and research scientist at the University of Chicago’s National Opinion Research Center. Already, the 85-year plus age group is the fastest growing population group in the United States.
While there are obvious benefits to longevity, a secondary impact will be “a spike in the cost and prevalence of vision problems,” predicted Wittenborn, who’s conducted studies on the topic.
That includes more age-related macular degeneration (AMD), cataracts, and glaucoma, as well as vision problems from chronic diseases such as diabetes and stroke.
Awareness about vision diseases and earlier diagnoses—will help everyone cope. “If you are able to catch a [vision] disease in an 80-year-old and push it [vision loss] back five years,” that’s progress, Wittenborn said.
Navigating the Changing Landscape of Vision Problems
What will U.S. society look like when nearly one in four persons is a septa- or octogenarian?
Currently, about 15 percent of adults over 65 years have vision problems; however, this number will take on new dimensions as the same people face multiple chronic conditions associated with aging, such as hypertension, arthritis, heart disease, and cancer.
On one hand, impaired vision will make it more difficult for elderly people to manage their health problems and do things like drive themselves to doctor’s appointments and read labels on prescription bottles. In addition, chronic health problems will have a direct impact on vision, according to John Crews, DPA, of the U.S. Centers for Disease Control.
Stroke is one example. About one in 11 people is likely to have a stroke (8.6 percent of the population), typically in their later years. When that happens, one in four stroke victims (25 percent) develops a vision complication that makes recovery more difficult.
Using data from the National Health Interview Survey, Crews and colleagues developed an “Activity Performance Measure” describing the impact of multiple conditions on simple activities of daily life, like walking 2-3 blocks and shopping for groceries. Activities like this “are what we do,” Crews reminded the audience. “It’s how we define our lives.”
People > 65 years Reporting Moderate-Severe Difficulty
||No stroke or VI
||Stroke + VI
|Walking ¼ mile
As the chart shows, the impact of a stroke coupled with a visual impairment (VI) is considerably greater than either condition alone. “All this gets played out in the lives of real people—people who want social interaction, who want to be active,” Crews said.
“It’s not an intractable problem, we just need to sort it out,” he said. “In this huge landscape, where does vision reside, and what do we do about it?”
It’s Not the Numbers, But How You Use Them That Counts
Another speaker, Wayne Morse, JD, PhD, of the Lighthouse Guild, added that poor vision has a greater impact on walking than many other chronic diseases. Impaired mobility of this sort is the primary pathway leading to increased disability,” he said; thus poor vision becomes part of a “negative feedback loop” that can lead to social isolation, depression, and faster physical decline.
In his remarks, he made a distinction between “visual function,” which relates solely to the ocular system, and “functional vision,” which takes into account the whole person.
Some of our ways of assessing and describing vision problems may need to be revamped, Morse said. He described how measurements of visual acuity require up to 10 minutes for each eye—longer than most visits to a primary care doctor—yet often are unaccompanied by tests to assess contrast sensitivity and loss of visual field, which may have a greater impact on functional vision.
Treatment approaches are often similarly “clinical,” and don’t take into account rehabilitative approaches that help people restructure their activities to accommodate vision loss.
“Adding visual function without functional vision will not help,” Morse cautioned.
Or, as one patient described it:
You don’t realize how important some of the mundane tasks you do every day become until you can’t do them. Thinks like going to the grocery store to pick up a loaf of bread…may sound like a pain in the butt when your wife asks you to do it and you are in the middle of a football game, but you would give your left arm to do it under different circumstances.
Morse said that while sometimes vision loss can lead to depression, it’s mainly due to self-limitations stemming from loss of functional vision, rather than visual acuity.
“Support for a person suffering vision loss is not talk therapy, it’s rehabilitation,” he emphasized.
Fear of Falling
Risk of Falling
• Contrast sensitivity
• Depth perception
• Visual field
Items stored inaccessibly
“Here’s an old person behaving badly,” said Bernard Steinman, PhD, narrating his slide of an elderly woman climbing up on a stool to reach items stored on the top of her refrigerator.
Only half joking, he went on to explain that falls—the cause of so much injury and reduced mobility in old age—are rarely caused by one factor. Extrinsic and intrinsic risk factors, as well as behavior—such as whether or not one is “careful” by nature—all are to blame.
From a public health standpoint, falls have major impact. One in three persons aged 65 years and older falls annually, with resulting injury in 20-30 percent of cases. Falls are tied to 2.4 million emergency room visits and $30 billion in direct health care costs—a figure projected to rise to $58 billion by 2020. Falls are also the leading cause of injury-related deaths among persons 65 and older, 22,000 each year. Injuries and fear of falling are among the chief factors likely to impinge on an aging person’s mobility and ability to live independently.
Steinman, a research fellow at the Center for Social and Demographic Research on Aging at the University of Massachusetts, Boston, just completed his doctoral dissertation on falls. As a result, he’s thought long and hard about how to prevent them.
He recommends a multifactorial approach that includes education, medical risk assessment (including vision), exercise and physical training, and home hazard reduction. In addition to analyzing this matrix of risk factors, prevention strategies should be dynamic, he said, with assessments done on an ongoing basis, not just one point in time. If a person has a visual impairment, interventions should be selectively tailored. If a person with a visual impairment falls, there should be a post-fall evaluation to analyze the cause.
Tackling Preventable Causes of Vision Loss
Several additional speakers spoke passionately about preventable causes of vision loss that currently are on the rise.
Rear Admiral Boris D. Lushniak, MD, MPH, who is the acting U.S. surgeon general, keynoted the Eye Summit. He led off with the information that the newly released 2014 Surgeon General’s Report, for the first time, categorizes smoking as a “causal” (as opposed to merely associated) factor in AMD and other vision diseases, attributable for up to 20 percent of blindness in the United States.
The good news is that only 18 percent of the U.S. population now smokes, down from 40 percent two decades ago. Even so, smoking still causes more than a half-million premature deaths each year, and an estimated $289 billion in associated costs.
Smoking’s impact on vision makes it all the more shocking that many vision providers don’t intervene with a “teaching moment,” commented David Lee, PhD, of the University of Miami. He cited a survey of vision providers showing that three in 10 ophthalmologists and six in 10 optometrists do not routinely ask their patients whether they smoke, and even fewer—seven in 10 ophthalmologists and 8 in ten optometrists—advise patients to quit.
To rectify this situation, U Miami and other institutions in the CDC-funded INSIGHT initiative (Innovative Network for Sight Research Group) have developed web-based training for vision providers who want to do more. “It consists of three A’s and an R,” Lee said, “ask, advise to quit, assess readiness to quit, and refer for assistance in quitting.”. Referral are made to tobacco quit hotlines in each state.
Training and evaluation will take place among a study population of 500 eye care providers. However, Lee said anyone can go online to get the training module.
Along with smoking, diabetes is another leading preventable cause of vision problems leading to blindness, and this topic was tackled by Neil Bressler, MD, chief of the Retinal Division, Wilmer Eye Institute, Johns Hopkins.
Currently, one-third of Americans are overweight or obese, there’s led to an explosion of Type 2 diabetes. When poorly controlled, high blood glucose levels can lead to macular edema, or an inflamed and swollen macula.
In some ways the disease resembles AMD. The macula, responsible for detailed vision, “is like a computer screen with thousands of pixels (or dots forming the image), whereas the surrounding retina produces images with hundreds of pixels,” according to Bressler.
As with AMD, leaking capillaries cause blurred vision. The condition sometimes can be reversed, and at the very least brought under control indefinitely following a year’s worth of therapy with anti-vascular endothelial growth factor agents.
“Unlike treating AMD, very few injections are required after the first year,” Bressler said.
Unfortunately, as with smoking’s tie to vision loss, the most susceptible are often unaware of the problem. Lee cited statistics showing that up to 50 percent of diabetic patients with macular edema are never informed that they have it or of the potential consequence. Fewer than 40 percent are referred for an annual eye exam; and only about half are referred to diabetes educators.
This is in stark contrast to findings of a study done by Eli Lilly, he said, which showed that “going blind” or “having other eye problems” was among the top fears of people diagnosed with diabetes.
Federal Funding Too Low
On June 19, for the second day of the Eye Summit, attendees were encouraged to visit their legislators on Capitol Hill to request more federal funding for research and treatment of vision disorders.
Prepping them for this role was Emily Holubowich of the Coalition for Health Funding, who analyzed vision’s slice of the federal budgetary “pie.”
The outlook for health overall is not good, she said; increases in a couple of health initiatives (brain mapping and diabetes) have been won at the expense of level funding in other program areas. The result is no real increase in several years. Meanwhile, costs related to eye disease, including government, insurance & patient costs, are projected to increase 376% by 2050, according to Prevent Blindness.
Apologetic about being a “downer,” Holubowich nonetheless called the federal response inadequate to meet the growth in vision problems. “Unless we do something about it, we’re looking at a lost decade,” she concluded.
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