Marjan Farid, MD Director of Cornea, Cataract, and Refractive Surgery

Vice-Chair of Ophthalmic Faculty

Gavin Herbert Eye Institute

University of California, Irvine

Relevant Disclosures:

none

1 out of 3 have some visual loss by age 65

Consequences:

Daily activities curtailed

Social isolation, depression

Less mobility; falls and fractures

Loss of Independent living

Visual Loss in the Elderly

Visual Acuity declines

Visual Impairment Increases (contrast

sensitivity, Glare)

Legal Blindness Increases

Effects of Aging on Vision

Yellows:

Color discrimination becomes difficult

Opacifies: Cataract

Hardens

Loss of Accommodation: Presbyopia

Aging and the Lens

Hypertension: Glaucoma

Atherosclerosis/Cholseterol/Heart

Disease: Retinal Vascular Occlusion

Diabetes: Glaucoma, Diabetic

Retinopathy, Cataracts

Systemic Disease and the

Aging Eye

Lid Disease: Blepharitis

Eyelid Laxity:

Eyelid Droop:

Cancers of the Eyelid:

Shingles (Herpes Zoster)

Macular Degeneration

Glaucoma

Cataract

Diabetic Retinopathy

1/3 of new blindness is avoidable

Leading Causes of Vision Loss in the

Elderly:

Most Common Cause of elderly Visual

Loss

Loss of Central Vision

Risk Factors:

Advanced Age

Fair Skin

Family history of macular degeneration

Smoking

Heart Disease

Age Related Macular Degeneration

DRY:

Gradual Visual Loss

Drusen

WET:

Sudden Visual Loss

Abnormal vessels grow underneath the retina

Bleeding and accumulation of fluid under the

retina

Types of Macular Degeneration

Dry Macular Degeneration

EARLY:

Difficulty Reading

Difficulty Driving

Straight Lines may appear crooked

ADVANCED:

Central Blind Spot

Peripheral Vision Remains Intact

Independent Living Skills

Macular Degeneration: Symptoms

Fluorescein Angiography: Sub-Retinal Bleeding

Monitor Vision

Stop Smoking

Control Cardiovascular Disease Cholesterol

Blood Pressure

Diet High in Fruits and Vegetables lowers risk

Antioxidants may be helpful (Zinc, Vit C and E)

Lutein Over the Counter Vitamin Formulations available

Ocular Injections and/or Laser

Macular Degeneration Treatment:

Anterior Segment Device for

Macular Disease

IMT™ by Dr. Isaac Lipshitz

Implantable Telescope Technology

22

Profoundly Reduced Function/Quality of Life

Functional Daily Living Social

End-Stage AMD

Patient Implications

24

Scarred Macula Central Visual Field Projection (Natural Lens/IOL)

CAT CAT

Telescope Implant Central Visual Field Projection

Mechanism of Action

25

20/326 Baseline

20/200 20/127

Source: * Stevenson, **Ebert,† Erber/Osborn

Ability to care for self & others*

More able to perform activities

of daily living**

Face-face communication†

Mean Improvement with 3X model

Statutory Blindness

Efficacy

27

Multidisciplinary Evaluation & Care

CentraSight™ Program

Step Action Practitioner

1 Diagnosis Retina Specialist

2 Candidate Screening Retina Specialist Low Vision Optometrist Occupational Therapist

3 Implantation Cornea/Cataract Surgeon

4 Visual Rehabilitation/Training

Low Vision Optometrist Occupational Therapist

28

Pre-Op Candidacy Assessment

•Diagnosis

•Refer

• Cornea health

•AC depth, other

1 Retina

OT

•Functional Goals

•Rehab Potential

Optom

•Low Vision Eval

•Eye Selection

2 Low

Vision

3 Anterior Segment

29

Second most common cause of visual loss

in the elderly

Affects:

10% African Americans >70 years

2% Caucasians >70 years

Early detection and treatment can prevent

blindness

Glaucoma

High intraocular pressure

African American race

Advanced Age

Family History of glaucoma

Hypertension

Diabetes

Glaucoma Risk Factors

Optic nerves in Glaucoma

Visual Field Testing

1.Halt Visual field loss

2.Prevent further optic nerve damage

3.Use medications to lower intraocular

pressure

4.Assess visual fields and optic nerve

damage 2-3 times per year

Goals of medical treatment:

1. Beta-Blockers:

Timolol (Timoptic), Betagan, Betaxolol

2. Adrenergic Agonists:

Alphagan

3. Cholinergic Agonists:

Pilocarpine

4. Prostaglandin Analog:

Xalatan, Lumigan, Travatan

5. Carbonic Anhydrase Inhibitors:

Trusopt, Azopt

6. Combination drops:

Cosopt, Combigan

Glaucoma medications:

Laser Surgery

Filtering Surgery (trabeculectomy)

Cyclodestructive Surgery

Placement of drainage device

Baerveldt or Ahmed Implant

Trabectome

Surgical treatment of Glaucoma:

Third most common cause of visual loss in

the elderly

Cataract:

Opacification or ‘clouding’ of the natural

crystalline lens

Causes poor focusing and scattering of light

In 90% of cases, this is a consequence of aging

Other risk factors include:

Exposure to UV light

Diabetes Mellitus

Trauma

Medications e.g. steroids

What is a Cataract?

1. Disturbance of Vision

Difficulty with glare at night

Needing more light to read

General haziness

2. Progresses to diminution

3. Cataract size and location determine

impairment

Cataract symptoms:

Cataract elevates crash risk in older drivers

• Cataract surgery reduces this risk by 50% – Owsley et al. Impact of

Cataract Surgery on Motor Vehicle Crash Involvement by Older Adults. JAMA 2002. 288: 841-849.

Surgery indicated if:

Significant visual impairment

Daily activities of living curtailed:

– Problems with driving (especially at night)

– Reading

– Knitting/sewing

– Golfing

No current medical treatment

Cataract Treatment:

95% performed under Topical anesthesia

Patient Awake

+/- IV sedation if necessary

General anesthesia only required in children or

adults with claustrophobia, mental deficiency, or

physically unable to lie still.

Operating time 6-12 minutes

Patients DO NOT need to come off their blood

thinner medications in most cases.

Cataract Surgery

Cataract Surgery:

Standard Monofocal IOL

Patient to decide to refractive goal

– Set for distance (will need reading glasses)

– Set for near (will need distance glasses)

– Set for monovision (dominant eye distance & the other for near)

Toric IOL – treats astigmatism

Presbyopic IOL

Independence from glasses for most of the day

1. Multifocal IOL (Tecnis MTF, ReStor)

2. Accommodating IOL (Crystalens)

Intraocular Lens Implant options:

Presbyopic Lens Options: Multifocal Lens * Tecnis MTF * Restor Crystalens

Patient goes home with a clear shield or no shield

Eye Drops started immediately – (for 4-6 weeks)

Antibiotic

Steroid

Topical NSAID

No lifting over 10-15 lbs for 1 week

No bending from the waist for prolonged periods

No swimming for 1 month

Eye shield at night for the first week to prevent inadvertent rubbing of the eye when asleep

Post-operative Requirements and

Recovery:

>99.9% success rate

Complications infrequent and rare

Infection – 0.01-0.15%

– Drop in vision, pain, severe redness

Transitory intraocular pressure elevation

Retinal tear or detachment - 0.01-0.02%

Posterior capsular opacification – 15%

Treated with non-invasive Nd:Yag laser

capsulotomy in the clinic setting

Outcomes and Complications:

Many conditions are treatable

Early detection and treatment is important

Advancing technology allows excellent

visual and refractive outcomes with current

cataract surgery

Eye Care for the Elderly

Thank You!!