vision lecture

7/30/2019 Vision Lecture

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Sensory Function: Vision and Aging"

Marlon Maus MD, DrPH, FACS

UC Berkeley School of Public Health

[email protected]

PH 217C,

Tuesday March 5th, 2013


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Introduction

Background

Common roots of Public Health and Built

Environment

Health problems in the 21st Century:

effects on older adults

Vision in older adults

Conclusion


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Common Roots of PH and Planning

Schilling, Am J of Prev Med, 2005, The public health roots of zoning: In search of active livings legal genealogy


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U.S. Population 1900


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Leading Causes Of Death United States: 1900


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Of the 30 years of increased life expectancy 1890 -1990

5 years can be attributed to medical care.

The rest has come from:

Infrastructure (including housing, clean water)

Public Health (esp. immunization)

Bunker cited in Prescription for a Healthy Nation Farley and Cohn 2004


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Leading causes of death United States:

2000

The real


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Obese People WorldwidePeople with Diabetes

Worldwide

Worldwide:

25% Obese

7% Diabetic


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Obesity: US Adults


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Diabetes: US Adults


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Childhood obesity Rates of overweight and obesity have quadrupled among 6-11

year olds in the last three decades Over 9 million American children over the age of 6 are

considered obese

Cuts life expectancy by 15 years, qualys by 22 years.

In CA only 25% of 5th graders met state fitness standards: onemile run, pushups and body mass index measurements

Babey SH, et al. (2009.) Bubbling Over: Soda Consumption and Its Link to Obesity in California.UCLA Center for Health Policy Research. ; http://www.cde.ca.gov/nr/ne/yr11/yr11rel95.asp#tab1


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Costs of Diabesity

Diabetes consumes $226 billion or 14% of US

healthcare expenditures (2% of GNP)

Obesity consumes $147 billion or 9.1%

Human cost: increased deaths, cancers,

strokes, heart disease, hypertension and

reduced quality of life

5 million blind, leading cause

82,000 amputations per year


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Diabesitythe causes


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Hardee's introduces new Mega-Calorie

Monster Thickburger

1410 calories! 107 grams of fat! 7.1 hours of walking!

---All for $5.49---


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One 20 Ounce Soda Per Day

17 teaspoons of SUGAR

250 calories

50 gallons per person per year

Children and teens 2 cans perday (25% 4 or more!)

No. 1 source of calories in our

diets Soda portion sizes have

increased dramatically.


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High Fructose Corn syrup (HFCS)

HFCS: 63 pounds

consumed per

capita

Most commonsweetener in

processed foods

$$$$$ Corn

subsidies make it

cheap!


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Fast food industry spent$4.2 billion inadvertisement

$294 million targetingchildren

Federal 5 A DayCampaign $9.55 million

Center for NutritionPolicy andPromotion.$6.5 million


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Exercise for the treatment of

depression and anxiety.

International Journal of Psychiatry and Medicine. 2011;41(1):15-28. Carek, PJ et al

Department of Family Medicine, Medical University of South Carolina, Charleston 29406, USA.

Depression and anxiety most

common psychiatric

conditions

10% of American adults

Leading cause of disability

Physical activity as effectiveas medication for depression


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Building Design

UC Berkeley School of Public Health. (1959, Welton and Beckett Building )


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Stairs Inspired by???


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Celebration, Florida

Walkable

Neighborhoods


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Walkable Neighborhoods

Residents weigh 7 poundsless than in suburbs

For every 10 minutes a

person spends in a daily

car commute, time incommunity activities falls

10%.

Benefits to the

environment, our health,our finances, and our

communities.

Paris, France

Key elements:

A center

People

Mixed income, mixed

use

Parks and public space

Pedestrian design

Schools andworkplaces


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Health problems in the 21st Century:

Diabesity and depression epidemics

Common roots of Public Health andBuilt Environment

Collaborations between PH and

Planners

What is the relation to vision????

First we shape our buildings;

thereafter, they shape us.Winston Churchill


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>80 million people have potentially blinding diseases

Blindness or low vision affects 3.3 million Americans 40 years and older

Economic impact:

>50 billion dollars in 2002 for health care for individuals with visual disorders (bothdirect and indirect costs)

Estimate: by 2030 the number of visually impaired and legally blind individuals inthe US may double

Ranks behind arthritis and CVD as the third most common chronic cause of impairedfunction in persons older than 70 years.

Three fourths of all blindness and vision impairment is either preventable ortreatable

Two-thirds of all blind individuals in the world are female Most are older than 50 years

90% of blind people live in poverty

British Columbia Centre for Epidemiologic & International Ophthalmology (BCEIO), 2000.Healthy People 2010 http://www.healthypeople.gov/document/html/volume2/28vision.htm

Statistics


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Behavioral Risk Factor Surveillance System (BRFSS)

Since 1984 survey of civilian, noninstitutionalized U.S. adults aged 18 years

or older

350,000 people surveyed

State-based telephone surveillance system. Vision data collected from 19 states that used the supplemental Vision

Impairment and Access to Eye Care Module (Vision Module)

Provides information about access to eye care, health status, comorbid

conditions among older adults.

Summarizes the prevalence of vision loss and eye diseases reported bypeople aged 65 or older

Statistics BRFSS


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Findings:

Prevalence of blindness and vision impairment increases

rapidly with age among all racial and ethnic groups, particularly

among people older than 75 years.

Cases of early age-related macular degeneration are expected

to double by 2050, from 9.1 million to 17.8 million for those

aged 50 years or older

Cases of diabetic retinopathy among people aged 65 or older

are expected to quadruple by 2050, from 2.5 million to 9.9

million

Statistics BRFSS

S i i BRFSS


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Statistics BRFSS


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Visual Loss is Associated With.

Decreased quality of life

Changes in independent living

Increased injury and falls

Increased depression

Increased isolation

Untreated poor vision is associated with cognitive decline and onset

of dementia

Death

Rogers, MA, Langa KM. Untreated poor vision: a contributing factor to late-life dementia. Am. J.

Epidemiol. 2010 171:728


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Visual Impairment and Falls

Falls in older adults Occur in 35-40% of individuals

Responsible for 90% of fractures in the elderly

Clinical risk factors include vision impairment, gait

abnormality and muscle weakness

Fractures associated with

Poor visual acuity in older women

Poor contrast sensitivity Decreased depth perception

Binocular visual field loss

Coleman AL, el al. J Am Geriatr Soc. 2009; 57:1825. Patino CM el

al. Ophthalmology. 2010; 117:199.


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23% ignorant that early eye disease

has no noticeable symptoms 27% believe must wait until

symptoms before eyes tested

51.4% believe mostly under 40 y/o

need eyes checked 30% of people surveyed listed

blindness as their greatest fear

second to cancer (43%)

(Vision 2020 Australia)

Misconceptions Among Elderly


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Normal Changes of Aging

Physical changes related to Normal aging ARE NOTdisease

Changes occur in most body systems to include:

Sensory SystemBrain and Central Nervous System

Muscles and Bones

Digestion

Heart/Circulatory System

Respiratory System


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Vision Not all older people have impaired vision!

Normal visual changes that occur with aging:

Presbyopia: loss of ability to see items that are close upbegins in the 40s

Decreased contrast sensitivity caused by retinal changes

Decreased dark/light adaptation Night vision not as acute

Delayed glare recovery.

Vitreous Humor Haziness Flashing Lights Moving Spots

Color

Lens of eye yellows making it more difficult to see redand green colors

Discrimination as cones

Visual Field Size 1 to 3 degrees per decade


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Common Eye Diseases in the United

States Associated with Vision Loss In the U.S., the most prevalent etiologies of

vision loss in persons 40 years and older are:

AMD (Age-Related Macular

Degeneration): 1.6 million age >60 Diabetic Retinopathy: 5.3 million

Cataracts: 20.5 million age >65, most

prevalent eye disease in older persons

and are the leading cause of blindness

worldwide Glaucoma: 2.2 million diagnosed, 2

million NOT diagnosed

Vision Problems in the USA NEI/PBA Report: Eye Diseases


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ARMD: leading cause of legal blindness inthe USA

9 million people have some form ofARMD

1.6 million have advanced disease

accounts for 54 % of all blindness

Age is the greatest risk factor

55-64: one percent are affected

65-74: four percent are affected

>75: thirty percent are affected

Age-Related Macular Degeneration

(AMD)


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AMD Other risk factors

Smoking. Family history.

Obesity.

Race. Caucasians are more

likely to lose vision fromAMD.

Women tend to live longer

than men, F:M lifetime risk2:1

6% for females

3% for males


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AMD Symptoms

Asymptomatic initially

No pain.

Blurred vision.

Loss of central vision (reduced visual acuity causingdifficulties with detail discrimination)

Metamorphopsia (i.e., distortion of objects)

Central scotomas

Increased glare sensitivity

Contrast sensitivity

Decreased color vision.

Key: Peripheral vision remains intact, and the patientdoes not progress to total blindness


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AGE-RELATED MACULAR DEGENERATION

Damage of the central retina,or macula

Two types

Nonexudative (DRY ) -

drusen (hyaline deposits)

and areas of alternatingbands of depigmentation/

hyperpigmentation in the

retinal pigmented

epithelium

Exudative (WET) -neovascularization


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Treatment options:

Age-related eye disease study (AREDS): high-dose regimen of vitamin

C, vitamin E, beta carotene, and zinc shown to decrease risk of

developing vision loss caused by advanced AMD in patients with

intermediate AMD or advanced AMD in one eye.

Patients without AMD and those with early AMD did not benefit fromsupplementation.

Laser surgery.

Photodynamic therapy and intravitreal injections of antivascular

endothelial growth factor and corticosteroids have shown promise in

treating subsets of patients with macular degeneration. Control of vascular disease risk factors

Exercise to increase circulation

Sunglasses for UV light protection

AMD


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AMD

What can you do? Eat a healthy diet

Dont smoke, or stop

smoking Maintain normal

blood pressure

Maintain a healthy

weight Exercise


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Increased ocular pressure that can

damage the optic nerve in the eye.

Symptoms:

Loss of peripheral vision that can lead

to decreased central acuity

Difficulty functioning in dim light

Decreased contrast sensitivity

Glare disability

Decreased dark/light adaptation

Glaucoma can develop in one or botheyes.

Primary open-angle glaucoma is the

most common

Glaucoma


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Glaucoma

Same scene as viewed by a

person with glaucomaNormal vision


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Glaucoma Risk factors: age > 40, hispanic, african

american, family history, diabetes, HTN, eye

injury, myopia, chronic steroids

Treatment: Topical prostaglandins, beta blockers,

adrenergics, carbonic anhydrase inhibitors

Oral medications

Laser therapy

Filtering surgery

About 50% of individuals with glaucoma are

not diagnosed


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Glaucoma

What can you do?

People at higher risk

should get a

comprehensive dilated

eye exam every one to

two years or as instructed

by your eye care

professional.

Cataract


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Cataract

Cataract prevalence increases with

increasing age 2.6% in the age range 60-69

17% in individuals > 80

Females 20% more likely than

males

1/3 of patients with cataract

had an unmet need for surgery

Surgery for cataract accounts for

60% of Medicare expenses for vision

Richter, CM et al. Ophthalmology. 2009; 116:2327.

Cataract


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Cataract Risk factors and associations:

Age

Female sex

Corticosteroid use

Diabetes

Smoking

Myopia,

Ocular UV-B light exposure

Bmi >35

Lack of health insurance

Low education, Income 5 years ago


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Cataract Opacifications of the crystalline

lens of the eye

Symptoms:

Decreased visual acuity,

decreased color perception,

decreased contrast sensitivity,and glare disability

Cloudy or blurred vision

Colors that may not appear as

bright as they once did.

Glare

Poor night vision


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Cataract


person with cataract

Normal vision

C


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Treatment:

Alter prescriptions

for eyeglasses or

contacts,

Surgical extraction

What can you do?

Eat a healthy diet.

Wear sunglassesand a brimmedhat whenoutdoors.

Dont smoke.

Cataract

John Taylor, the flamboyant 18th-century

British oculist


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Diabetic Retinopathy

Leading cause of new blindness

in U.S. In adults 20 to 74 years of

age.

Rapid increase in chance if

diabetic for 15+ years Retinal vessels weakened by

sorbitol aneurysms

leakage retinal damage

Other complications:

Secondary glaucoma

Retinal detachment


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Symptoms

No early warning signs or symptoms

Decreased visual acuity, contrast

sensitivity, color perception, and

dark/light adaptation, glare disability,distortion, and scotomas

Treatment options

Early detection and timely treatment can

reduce the risk of vision loss.

Laser photocoagulation

Surgery


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person with diabetic retinopathyNormal vision


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What can you do?

Control your ABCs - A1C,

blood pressure, and

cholesterol.

Take your medications as

directed.

Maintain a healthy

weight.

Exercise. Dont smoke.

Have a dilated eye exam

at least once a year.



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Screening The American Academy of Ophthalmology (AAO)

suggests comprehensive medical eye evaluations:

For non-diabetics

Every 2-4 yrs for patients 40 to 54 years of age

Every 1-3 years for patients 55 to 64 years of age

1 or 2 years for patients older than 65 years.

For diabetics

Normal examination or minimal nonproliferative

retinopathy annually

Mild to moderate nonproliferative retinopathy

without macular edema - every 6 to 12 months

Severe nonproliferative diabetic retinopathy

every 2 to 4 months

E l ti


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Evaluation

Check visual acuity usingstandard Snellen chart

An impairment of 20/50 or

worse or a one-line difference

between the eyes shouldwarrant referral

Visual fields

Fundoscopic exam

Amsler Grid


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Conclusions

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