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Should We Be Screening all Patients Over 50 for Age-Related Macular Degeneration?

Should We Be Screening all Patients Over 50 for Age-Related Macular Degeneration?

A growing public health issue for older adults is impaired sight. In fact, in 2011, 12% of US adults aged 65 to 74 years reported trouble with their vision, even with the use of glasses or contact lenses; in those aged 75 years and older, this increased to 15%.

One prominent condition impacting sight in older adults is age-related macular degeneration (AMD), which results in central vision loss (peripheral vision generally is unaffected) and significantly impacts quality of life. In the US alone, AMD affects more than 1.5 million older adults, and is the leading cause of blindness in White adults. As central vision is required for everyday activities such as reading, driving, watching television, and recognizing people, its loss is extremely impactful on quality of life, especially as elderly patients are already concerned with losing independence and mobility. In addition, loss of central visual acuity increases the risks of falls and fractures.

Unfortunately, there is no cure for AMD, but patients who are able to be referred to an ophthalmologist and begin treatment early in the disease course have better outcomes and less progression to severe disease. As primary care providers, we can play a pivotal role in early recognition and treatment of AMD in our patients.

Though early detection is key, persons with early and intermediate stages of AMD usually are asymptomatic and may be totally unaware of their diagnoses. While there is not yet a cure for AMD, therapies for those at risk do exist: The Age-Related Eye Disease Study (AREDS) and AREDS-2 supplements. These supplements consist of antioxidant vitamins and minerals, and in studies of persons with AMD who have used the supplements for 5 years, an approximate 25% reduction in risk of progression to late AMD was seen.

The 25% reduction is quite impactful, especially when you consider that 8 million people in the US currently have intermediate AMD. If all 8 million were to appropriately use the supplements, nearly 300,000 would avoid progression to severe disease—particularly those with neovascular ("wet") AMD.

Symptoms of AMD include the following:

  • Blurred or decreased central vision
  • Blind spots (scotomas), partial loss of vision
  • Distorted vision (metamorphopsia): Straight lines may appear wavy or bent
    • This can be checked with an Amsler grid
  • Inability to see in dim light
  • Objects appearing suddenly smaller when viewed with 1 eye versus the other

A simple screening question for all adults can be very helpful in early recognition of AMD: "Have you noticed a change in your vision over the past year?" If the answer is yes, they should be instructed to make an appointment with their optometrist or ophthalmologist. Currently, it is recommended that all adults older than 45 have an exam with an optometrist or ophthalmologist every 2 years. Asking about vision changes may help to encourage patients to have that exam done as recommended.

References
  • Chew EY, Schachat AP. Should we add screening of age-related macular degeneration to current screening programs for diabetic retinopathy? Ophthalmology. 2015;122:2155.
  • Fong DS. Age-related macular degeneration: Update for primary care. Am Fam Physician. 2000;61:3035.

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Filed under: Miscellaneous, Preventive Medicine

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