The purpose of IAPB Briefing Papers is to inform IAPB members and others about

important and emerging issues affecting VISION 2020: The Right to Sight.

Paper prepared for VISION 2020 Netherlands by:

Prof. Dr. J.E.E. Keunen, Ophthalmologist, President of VISION 2020 Netherlands, Ophthalmology Institute, UMC St Radboud Nijmegen

M. Snouck Hurgronje-van de Ruit, Team Leader Nursing Staff, Ophthalmological Policlinic, Board Member VISION 2020 Netherlands, Leids UMC, Leiden

Prof. Dr. M.G.M. Olde Rikkert, Geriatrist, Geriatric Department, UMC St Radboud Nijmegen

Prof. Dr. G.H.M.B. van Rens, Ophthalmologist, Ophthalmology Department, VU MC, Amsterdam

Dr. J.J. Limburg, Physician-Researcher, acting Secretary VISION 2020 Netherlands

“Unless disabled people are brought into the development mainstream, it will be impossible to cut poverty in half by 2015”

James Wolfensohn, Former President of the Wold Bank, 2002

Introduction

The expression ‘Old age has its infirmities’ is commonly used and visual disabilities are a

good example of such infirmities. In 2009, an estimated 316,000 Dutch people had a visual

disability: 78,000 blind people and 238,000 visually impaired. 79.4% of those people (a

total of 251,000) were 65 years or older and 72.2% of them (181,000) were women.

Age is the most important risk factor for visual impairment and blindness. The prevalence

increases exponentially after the age of 65 and is on average higher in women than in men

(Figure 1.). In 2009 according to the Dutch Central Bureau of Statistics (CBS), of the 2.472

million older people (age 65 plus) 155,000 (6.3%) live in a care facility and 2,317,000

(93.7%) live independently. At over 40%, the prevalence of visual disability among those

living in a care facility is highest: 32,000 (20.6%) blind and 34,000 (21.9%) visually

impaired. Prevalence among older people living independently is lower (1.2% are blind and

A Simple Eye Test for Visually Impaired Older People in Care

Facilities in the Netherlands

August 2011

6.8% are visually impaired), but at 27,000, the number of older live-at-home blind people is

almost equal and the number of visually impaired at 154,000 is almost five times higher.

Major contributors to visual impairments among older people are age-related macular

degeneration (AMD or ARMD), cataract, refractive ametropia, glaucoma, and diabetic

retinopathy. Over the next 10 years, due to the aging of the population, the number of

people aged 65 and over will increase from 2.47 million people (15.0% of the population) in

2009 to 3.36 million (19.7%) in 2020. In concurrence, the number of visually-impaired older

people will increase to an estimated 378,000 in 2020.

Figure 1: Prevalence of blindness

and visual impairment in the

Netherlands according to age and

gender

[Dark blue] Men, blind

[Light blue] Men, visually impaired

[Purple] Women, blind

[Lilac] Women, visually impaired]

In a developed country like the Netherlands, visual impairment with acuity of ≤0.3 in the

best eye, can be very limiting: these people are no longer permitted to drive a car and

reading or working with a computer is difficult without special adaptations. It diminishes the

quality of life and depression is more common. Additionally, the number of falls and

fractures increases. This eventually leads to a greater dependency on special care—older

people with a double visual impairment often need care in a nursing home or residential

care home. Adequate preventive eye care can help change this situation. The care

necessity and quality of life increase after a cataract operation. This in turn, could diminish

the number of falls and fractures.

Over 80% of all visual impairment and blindness in the world is treatable or can be

prevented with timely intervention (‘avoidable blindness’). For this reason, in 1999, the

WHO and the International Agency for the Prevention of Blindness (an umbrella

organization consisting of more than 20 international NGOs, working on the prevention and

avoidance of blindness), launched a world-wide initiative under the name of ‘VISION 2020:

The Right to Sight’. Its objective is to eliminate all avoidable visual impairment and

blindness in the world before the year 2020. In 2003, the WHO project group VISION 2020

Netherlands was founded by the former Dutch minister of Welfare, Health and Sport, dr. E.

Borst-Eilers in order to achieve this goal in the Netherlands also. The project group

identified that 40% of all blindness and over 60% of all visual impairment in the

Netherlands is ‘avoidable,’ specifically symptoms deriving from treatable disabilities like

cataract, secondary cataract, and refractive ametropia and visual disabilities caused by

glaucoma, or diabetic retinopathy which could have been prevented by early diagnosis and

treatment. It was estimated that 63% of all visual disabilities among older people in care

facilities is avoidable. Among live-at-home older people, this is estimated to be 56%.

For this reason, in recent years, commercial optometrists offer eye care on location in a

number of care facilities to residents in need of care. Additionally, the Oogbus (Eye Coach

or Eye Bus) from insurance company CZ and the Rotterdamse Oogzorgnetwerk

(Rotterdam Eye Care Network) are emerging phenomena playing into this trend. The eye

coach is equipped to have an optometrist do an extensive on-site eye examination. People

can make an appointment there and the examination is free of charge for the CZ insured.

However, some older people are still not making use of these facilities. This may be

because visual impairment develops gradually and is therefore not always detected—

especially when dealing with comorbidity. In addition, many older people don’t want to

complain or be a ‘nuisance,’ or they think deterioration of eye sight is just part of ageing

(wrongful attribution to age). Many older people are prone not to report their medical

issues. Recent research into the demand for care and the care necessity of older people

with a visual impairment showed there is too little synchronization between the different

health and welfare care facilities for visually-impaired older people. Patients complain

about a ‘maze of care facilities and financial regulations and benefits.’ It also turned out

that, on average, only one-third of the visually-impaired or blind older people had informed

their GP of their disability. Less than 50% of the visually impaired had been referred to a

rehabilitation centre by the attending ophthalmologist.

When thinking of the screening process, it may be advised to consider the criteria as

formulated by Wilson and Jungner (see Frame 1, below). These criteria are all very

applicable to the issues mentioned above.

Frame 1 Wilson’s criteria for screening

The disease

is an important issue

it causes loss of productivity, dependency, heightens the risk of falls and fractures, depression, and negatively effects the quality of life

has a demonstrable stage of latent or early symptoms

gradual decrease of acuity

has a clear and known natural development

this is the case for almost all causes for visual disabilities

Research

an adequate test or examination is available

visual acuity examination, Amsler test and visual field test are standardized

the test should be acceptable for the target audience to be examined

avoid tests that are too demanding or invasive

screening should be a continuous process

every new resident should be examined and subsequently tested every other year

Aftercare

facilities for examination and treatment should be available

ophthalmologist, optometrist/optician and rehabilitation are available everywhere

there should be an acceptable and effective treatment

with over 50% of the people with a visual disability, improvement is possible; in case of permanent visual disability, visual aids and rehabilitation will increase the ability to provide for oneself

there should be consensus on who needs to be treated

there is consensus about the treatment of eye afflictions and GPs should refer accordingly upon diagnosis

Economy

screening costs should remain reasonable in comparison to the possible total cost of medical care

refractive eye surgery, cataract and glaucoma surgery, as well as monitoring and treatment of diabetic retinopathy are proven cost-effective interventions

The purpose of this article is to present a simple and quick eye test, which will make it

easier to detect visual-impairment in older people in care facilities. A nurse or caretaker

should be able to perform this screening and determine, based on the outcome, if the

patient should see their GP or a geriatric specialist and if necessary needs a subsequent

referral to an optometrist, ophthalmologist or rehabilitation center. These are the

provisional outlined results of a first pilot research using this screening method.

Figure 2. Test card for near- and farsightedness (back and front)

Definitions

In the Netherlands, blindness is defined when someone has an acuity of less than 0.05 in

their best eye, with optimal correction and/or when the peripheral visual field is damaged in

such a way that only a central visual field remains with an angle of ≤10° around the central

axis. Visual impairment is defined as acuity between 0.05 and 0.3 with optimal correction,

and/or a visual field between 10-30° around the central axis. The term ‘visual disability’

covers both groups, meaning acuity of less than 0.3 in the best eye with optimal correction.

Visual disabilities, due to not wearing proper eyeglasses are not counted in these

definitions, although this is an important cause for visual impairment—even among older

people in the developed west. The WHO therefore recently recommended adjusting the

definition of blindness and visual impairment. Visual acuity ‘with optimal correction’ was

changed to visual acuity ‘with available correction.’ Due to this change, not wearing proper

eyeglasses is also counted. In this article, the aforementioned new definitions have been

applied.

Methods Used

All residents and the client board received a letter explaining the background, the purpose

and the execution of the screening, two weeks before starting the visual acuity screening.

The visual acuity screening was executed on groups of 5-10 people, by specially trained

caretakers or nurses of the care facility who are familiar with the residents. The screening

took place in a small hall or gym room, or a shielded area. Coffee or tea was served to

facilitate interaction and discussion: it is often only in this environment that residents realize

they are not the only ones suffering from poor eye sight, making it easier to discuss the

topic. Visual acuity screening takes about 10 minutes per resident.

VISION 2020 Netherlands has designed a simple eye test for the screening of visual

impairment and blindness in nursing homes and residential care homes. This test includes

2 cards of manageable size (A5 format), printed on both sides and laminated with non-

shiny material. The screening consists of a test for farsightedness, a reading test for

nearsightedness, a simple test for the function of the retina (the Amsler Grid) and a simple

visual field exam (Figures 2 and 3). The farsightedness test uses the standard E Chart,

calibrated for a 4-meter distance; the reading test uses a text in different font sizes, in

standardized M units. The Amsler Grid and the Confrontation Visual Field Exam by

Donders are standard examination methods.

With these, the most common forms of blindness and visual impairment among older

people can be determined. The Amsler Grid helps detect age-related macular degeneration

by the characteristic optic distortion (or metamorphopsia). The Confrontation Visual Field

Exam is important for diagnosing glaucoma.

[Figure 3. Test card for retina function and visual field (back and front)]

Farsightedness Test

If the client has eyeglasses for farsightedness, they should wear them during the

screening. The test card is shown from a 4-meter distance and each eye is tested

separately. Clients should pass 4 out of 5 tests. If 2 or more tests are wrong, it should be

concluded that the client cannot see the E. With an acuity of less than 0.3 in one or both

eyes, the client should be referred to the GP (of the nursing home). Teachers in India using

the same E Charts, determined a sensitivity of 64% , a specificity of 93% and a Kappa

corrected for prevalence and bias of 0.78 (good similarity) compared to the usage of the

standard Snellen letter chart.

Nearsightedness Test

If the client has eyeglasses for nearsightedness, they should wear them during the

screening. The reading card should be read from a distance of 40 centimeters under

proper lighting, using both eyes at the same time. The observer watches how many lines of

text the client can read. At an acuity of 0.4 or less, the client should be referred to the GP

(of the nursing home).

Retina Function Test

The Amsler Grid is used to examine the retina function. The older person looks at the black

dot in the center of the grid from a distance of 30 centimeters—first using both eyes at the

same time, then with each eye separately. Then the observer should ask the client if they

can see the entire grid and if all lines are straight.

If this is confirmed, (in conformity with example A in Figure 3), there is no reason for

referral. However, if the client describes a grid similar to example B in Figure 3, the client

should be referred to the GP (of the nursing home).

Visual Field Test

This is a preliminary test to examine if the visual field is restricted. The examiner sits

opposite the client who has one eye covered and has the other eye fixed on the opposite

eye of the examiner: the examiner keeps the other eye closed. The examiner then moves

the outstretched arm, wriggling the fingers, from the outside toward the fixation point. They

should first measure both horizontal directions, then both vertical directions. The client

indicates when the wriggling fingers come into sight. Both eyes are tested separately. A

manual for this test is indicated on the card. If there is any indication that the visual field in

one or more areas is restricted, the client should be referred to the GP (of the nursing

home).

Reporting

It is imperative to keep good documentation on the outcome of the test in the client’s

personal file. VISION 2020 Netherlands has designed a form for this purpose (see Figure

4) which can be used as a supplementary sheet in the client’s file. This form can equally be

used as a referral letter for the GP (of the nursing home). It also allows for a scientific

analysis of the data obtained.

There is also special software to store the screening data and the subsequent follow-up.

This makes it easy to keep track of the data and the status of the individual residents within

the system. The software automatically generates reports about the number of older

people in the facility with visual disabilities, the number of potentially avoidable cases, the

number of clients that were referred to an ophthalmologist, optometrist, optician, or

rehabilitation facility, and finally, if the acuity has improved after intervention. Initially, all

residents of the care facility should be screened and it is advisable to follow up with

subsequent screening every other year unless indicated earlier. All new residents should

be screened upon admission.

The response rate for the acuity screening in the first pilot in a care facility was high. We

will only present some preliminary outlined data to show the feasibility of the screening in a

care facility: 87 out of 93 residents (93%) were screened. Four residents were unable to

undergo the screening procedure and one refused, because she was already regularly

visiting an ophthalmologist. Out of the 87 tested, 36 (41%) had a visual disability: 28 (32%)

expressed visual impairment in their best eye and 8 (9%) extreme visual impairment. The

results were in line with the estimated 40% of older people in care facilities with a visual

disability.

Of the 93 residents, 32 were referred to an ophthalmologist: 12 of them were known cases,

but their last visit had been too long ago or new issues had arisen in the meantime. Ten

residents were referred to an optometrist/optician (1 known case) and 7 residents were

enrolled in Visio (3 known cases). A few residents have already undergone surgery for

cataract or glaucoma, but not all data on these residents is complete yet, because we are

still missing some correspondence from referred residents, and some are still awaiting

surgery.

Figure 4. Reporting Form

Discussion

Two in five older people in care facilities in the Netherlands have a visual disability and in

over half those cases (31,000 people) the symptoms are treatable or could have been

avoided. Given the extra care necessity caused by a visual disability, directly and indirectly

(depressions, falls, and fractures), it is advised to detect avoidable visual disabilities in care

facilities for older people in an early stage and with minimal cost and to treat those cases

whenever possible. With this method, older people can better reap the benefits of

treatment of (wet) macular degeneration. The VISION 2020 test presented in this article

makes it possible to do a low-cost screening.

In practice, it will turn out that not all older people in care facilities are eligible for

ophthalmological screening. Those with severe psycho-geriatric disorders may not fully

understand the screening and dispensing and using eyeglasses or undergoing surgery for

cataract or glaucoma can cause severe issues for this group. There are also older people

with a visual disability who, even after ample deliberation, decide not to be treated: they

think they are too old, think it’s too much trouble to do the screening, or say the can

manage fine without help.

Nevertheless, the writers of this article plead for a routine acuity screening of all older

people in care facilities and for case finding on policlinics (e.g., in case of falling analysis).

The first screening can be performed by a nurse or caretaker after a short practical training

by a geriatric specialist. When the first screening shows no anomalies, there is no need for

follow-up. In all other cases, the client will be referred to their GP or geriatric specialist.

Based on the findings of the acuity screening and the data in the client’s personal file, the

doctor of the care facility can determine who the client should be referred to, or if no further

action is required. All these steps can take place at the care facility, causing minimal extra

case load for the attending physician as well as the client. In many cases, it is even

possible to agree with the optometrist/optician and the rehabilitation center that they also

perform their research at the care facility. Solid mutual agreements are an essential

condition for creating an adequately functioning care chain and offering proper intervention.

Such screening should of course also be possible as a method of diagnosing visual

disabilities at a visit to the GP’s practice, or the policlinic, or day clinic by clinic geriatrist.

In 2009, during the national symposium ’75 years of blindness prevention in the

Netherlands,’ VISION 2020 Netherlands Patron, HRH Princess Margriet emphasized that

the prevention of blindness and visual impairment needs a national basis to be successful.

“If you open up the conversation, it will bring all liaisons to the surface, so that pillared

thinking and acting can be prevented. Joining forces with patient unions is essential in

making this a success. The purpose is a society in which avoidable blindness and visual

impairment are no longer a handicap. … You are all part of the solution,” she noted.

VISION 2020 Netherlands works in conjunction with the Unie Katholieke Bond van

Ouderen (Union Catholic Association for Older People) and the national umbrella

association for older people, on the deployment of a national awareness program, which

will be kicked off in 2011. In preparation for this event, the first screening tests with the test

cards as described earlier in this article have begun in care facilities in Amsterdam-Noord,

Maastricht and Den Bosch. The small pilot described here, gives an idea of the practical

use of the test card as a piece of equipment to quickly establish that almost half the tested

older people had indeed a visual disability, which confirmed earlier estimations.

For live-at-home older people routine screening may not be the best option: the prevalence

is low and the number of older people high. It is probably better to adequately inform this

group, for instance using the previously mentioned initiative of the national unions for older

people. Perhaps it is an option to do a focused acuity screening of older people with a

heightened risk on visual disability, like on all older people getting medical help through

home care. Further investigation on the efficiency and effectiveness of such a screening

has yet to be investigated.

In conclusion, it is safe to say that the test cards presented in this article provide an easy

solution to identify older people with a visual disability. This will lead to a substantial

decrease in the high prevalence of visual impairment among older people in care facilities

and an improvement of the quality of life for a large group of vulnerable older people.