Blindness in the Elderly

Prevalence increases exponentially

with advancing age
One of the most common disabilities
Eye disease ranks 3rd after arthritis and
heart disease as the most common
cause of functional impairment in
elderly population

Most feared

Visual Impairment
& Blindness in Elderly
Negative impact on quality of life
Increased
Accidents
Falls
Road traffic accidents

Mortality (34X higher; life expectancy

reduced by 4 years)

Decreased
Productivity
Functional independence increased
depression

Importance of
Age-related Eye Diseases
Increase in
Life expectancy
Proportion of elderly in population

Corresponding increase in agerelated eye diseases important

and major public health problem

Schematic Diagram
of the Eye

The Eye
Worlds best camera!

Retina
Two parts
Macula (5%)
Responsible
for sharp
central vision

Peripheral retina
(95%)

The Macula
Oval area of the
retina at the
posterior pole of
the eye
5 mm diameter
Responsible for
sharp central
vision

Examining the Macula

Direct ophthalmoscopy
Indirect ophthalmoscopy
Slit lamp biomicroscopy
Fundus photography

Age-related Macular Degeneration

(AMD)
Most common cause of blindness in
persons > 60 years of age in Western
developed countries
Major public health problem

AMD in Singapore
Exact prevalence unknown
27% among 574 people aged 60 yrs in
one community-based study* (response
rate = 22.2%)
As life expectancy and the proportion of
elderly people in our population increase,
AMD is expected to become a major cause
of visual impairment in Singapore
*Ho T, Law NM, Goh LG, Yoong T. Eye diseases in the elderly in Singapore.
Singapore Med J 1997;38:149-55.

AMD: WHO Statement

Most common disorder in the group
of non-avoidable causes of visual
disability
8 million worldwide are blind or
severely visually disabled because of
AMD
Affects 25% of persons aged 80
years and older

AMD
Some form of AMD affects 25-30
million people worldwide
Number expected to triple over the next
25 years

Yet awareness of AMD remains low

Survey on Eye Tests,

Awareness and AMD
Conducted by EOS Gallup Europe for
AMD Alliance International
Study details
11 countries
Approx. 1000 respondents in each
country
18 y.o. and above
Survey from 2-23 Jun 2003

Frequency of Eye Tests

Familiarity with AMD

AMD
Deterioration of the health of the
macula related to ageing
Cause unknown
Affects both eyes
Loss of vision can be
Gradual
Rapid and dramatic

Definition of AMD
(AMD Alliance International)
AMD is a sight-threatening retinal
disease, predominantly macular, that
is usually progressive
It generally occurs at age 55 or older
and is associated with multiple
environmental and genetic factors
AMD is divided into early and late
stages

Definition of AMD
(AMD Alliance International)
Early AMD is of the dry type,
characterised by relatively good
visual function and the presence of
drusen and/or pigment epithelial
changes with a variable risk of
progression to late disease

Definition of AMD
(AMD Alliance International)
Late AMD can be either of the dry or
the wet type and is usually
characterised by significant loss of
vision
The clinical signs are geographic
atrophy, neovascularisation or
pigment epithelial detachment

AMD: Types
2 types
Dry non-neovascular, nonexudative
Wet neovascular, exudative

AMD
2 types
Dry
Yellow deposits called drusen

Wet
Abnormal new blood vessels under macula
Leaks
Fluid
Blood

Scarring of macula

Dry AMD
Drusen (singular =
druse)
Small, discrete,
yellow-white,
slightly elevated
spots
Increase in
numbers and size
with advancing age

Hyper- and hypopigmentation

Dry AMD
90% of all AMD
10% of blindness
due to AMD
Gradual mild to
moderate
impairment of vision
over months to years
Slow and progressive
atrophy of RPE and
photoreceptors

Dry AMD:
Geographic Atrophy
Most severe form of dry AMD
Causes severe visual loss if fovea
affected

Wet AMD
Characterised by
choroidal
neovascularisation (CNV)
beneath the macula
Causes impaired and
distorted vision
Visual loss may be
sudden
10% of all AMD
90% of blindness due to
AMD

Wet AMD
Early stage
Abnormal new blood vessels under
macula
Leaks fluid and blood
Potentially treatable

Late stage
Scarring occurs destruction of
photoreceptors
No treatment

2 Forms of AMD
Causing Severe Visual Loss

Dry AMD
(Geographic atrophy)

Wet AMD

Vision with AMD

AMD affects central sharp reading

vision but does not usually cause
total blindness

Monitoring AMD

Normal

Significant Distortion

Preferential
Hyperacuity Perimetry (PHP)

AMD Primary Prevention

Primary prevention preventing
disease from occuring in the first
place
Quit smoking
Diet rich in fruits and vegetables
Currently no strong scientific evidence
for people with healthy eyes to take
nutritional supplements

AMD Secondary Prevention

Secondary prevention Preventing
disease from getting worse after
onset of disease
Eye screening
Early detection
Timely intervention

Who to Screen?
AMD Alliance International
As part of an overall health package for vision,
the Scientific Advisory Panel of the AMD
Alliance International recommends that people
55 years of age or older should have regular
dilated fundus examinations performed by a
qualified eye health professional every two
years
People age 55 or older who have loss of vision
or distorted vision should immediately have an
eye examination by a qualified eye health
professional and should follow his or her advice
regarding follow-up

Dry AMD: Management

Past
No active intervention

Now
Monitoring for progression
Amsler grid
Preferential hyperacuity perimetry (PHP)

Cessation of smoking
Secondary prevention with antioxidants
and zinc lutein
Blue-blocker artificial lens for cataract
surgery

AMD Risk Factors

Age
Race/ethnicity
Heredity
Smoking - modifiable
Micronutrients modifiable
Antioxidants
Zinc
Lutein

Au Eong KG, Haller JA. Risks

factors of age-related macular
degeneration and choroidal
neovascularisation. In: Lim JI
[Ed]. Age-related macular
degeneration. New York: Marcel
Dekker, Inc. 2002, Ch 20, pp
355-406.

Smoking & AMD

Cigarette smoking is a/w increased
risk of AMD in dose-dependent
fashion
Potential benefits of preventing
progression of early AMD to late AMD
or severe visual loss by targeting
antismoking education to people who
are current smokers and have signs
W et al. Smoking & Age-Related Maculopathy: The
of early AMD Smith
Blue Mountains Eye Study. Arch Ophthal 1996, 114:15181523

The Eye Disease Case-Control Study Group. Risk factors

for neovascular AMD. Arch Ophthalmol 1992;110:1701-

AREDS AMD Trial

Age-Related Eye Disease Study
11-centre double-masked clinical trial
3640 participants (AMD trial)
55-80 yrs
Average follow-up = 6.3 yrs
2.4% lost to follow-up

Age-Related Eye Disease Study Research Group. A randomised,

placebo-controlled, clinical trial of high-dose supplementation with
vitamins C and E, beta carotene, and zinc for AMD and vision loss.
AREDS report no. 8. Arch Ophthalmol 2001;119:1417-1436.

AREDS AMD Trial

Participants randomised to
Antioxidants (beta-carotene 15mg,
vitamin C 500mg and vitamin E 400IU)
Zinc 80mg as zinc oxide (+ copper 2mg
as cupric oxide)
Antioxidants + zinc
Placebo

AREDS AMD Trial

Risk reductions:
Antioxidants alone: 17%
Zinc alone: 21%
Antioxidants plus zinc: 25%

Group with benefit: extensive intermediate

drusen, large drusen, noncentral GA in 1
or both eyes or advanced AMD or VA
<20/32 attributable to AMD in 1 eye
Smokers avoid beta-carotene
No statistically significant serious adverse
effect was a/w any of the formulations

The Macula: Histology

Histologically,
region of the
retina
containing a
yellow
pigment
xanthophyll
and >1 layer
of ganglion
cells

Macular Pigment
Macular pigment consists of 2 hydroxycarotenoids
Lutein
Zeaxanthin

Powerful antioxidants
Blue light filter
Protect against blue light damage

Guo Qi Zi (Lycium barbarum)

Highest concentration of lutein & zeaxanthin

Macular Pigment
Some dietary sources of macular
pigments
Guo Qi Zi (Lycium barbarum)
Highest concentration of lutein
& zeaxanthin

Green leafy vegetables

E.g. spinach

Macular Pigment
Macular pigment decreased in
Advanced age (ageAMD)
Female gender (femaleAMD)
Cigarette smoking (smokingAMD)
Fellow eye in AMD (fellow eyeAMD)
Light iris colour (light iris colourAMD)

Macular Pigment
Individuals with high dietary intakes
and blood levels of Z & L have
significantly lower rate of exudative
AMD [Arch Ophthalmol (1993)111:104-109 ;JAMA (1994) 272:1413-1420.]
Autopsy study: AMD eyes have lower
levels of macular pigments relative
to controls [Adv Pharmacol (1997)38:537-556]

Macular Pigment
Possible to raise carotenoid levels
within the macula by dietary
manipulation and through
nutritional supplements
Adv Pharmacol (1997)38:537-556 ; IOVS (1997)38: 1795-1801

Lutein supplementation
potentially useful

UV and Visible Light

UV-C

UV-B

UV-A

200-290

290-315

315-400

Filtered
by
Ozone

Filtered by
Cornea

Filtered by
Lens

Visible
400-550

Light
550-700

Hazard
Blue Light: Visible light, rangingRetinal
from
400
Zone
500 nm
Prolonged exposure to visible blue light
rays is widely thought of as a causative
factor for damage to the retina and
macula, and is believed to be a primary
contributor to AMD

Advances in
Artificial Lens Design
Artificial lens designed to
mimic the light absorption
characteristics of the
human crystalline lens
Provides a filter to restrict
hazardous blue light from
reaching the retina
Potential benefits for
prevention of AMD

Dry AMD - Summary

Regular monitoring
Daily Amsler grid monitoring
Preferential hyperacuity perimetry

Stop smoking
Nutritional supplements
Antioxidants & zinc
E.g., B&L Ocuvite Preservision, Ocuvite Lutein
Smoker avoid beta-carotene

Lutein
E.g., B&L Ocuvite with lutein
Lycium barbarum (Guo Qi Zi)

Blue-blocker IOL for cataract surgery

Wet AMD - Treatment

Aim to destroy abnormal new blood
vessels under retina
2 proven treatments
Laser photocoagulation
Photodynamic therapy (PDT)

Other treatments
Macular translocation
Transpupillary thermotherapy (TTT)

Laser Photocoagulation
Thermal (hot) laser
Destroys abnormal new blood vessels
below retina as well as the retina
Results in a blind spot
Not for abnormal new blood vessels
affecting centre of macula

Photodynamic
Therapy (PDT)
Light-activated drug (verteporfin)
Non-thermal (cold) laser
2-stage process

Verteporfin:
Mechanism of Action

Circulating verteporfin
complexes with LDL

Verteporfin accumulates
in neovascular tissue
which is rich in LDL
receptors

Verteporfin:
Mechanism of Action
Reactive
oxygen
products

Endothelial cell damage

and thrombus formation

Light-activation of
verteporfin

Possible occlusion
of abnormal
vessels

Verteporfin Therapy:
A Two-Step Process
10 mins

Step 1

5 mins

Step 2
83 secs

Future:
Visual Prosthesis?

Visual Prosthesis
Au Eong KG, et al. Retinal
prosthesis. In: Lim JI [Ed].
Age-related macular
degeneration. New York:
Marcel Dekker, Inc. 2002,
Ch 23, pp 441-456.
Dagnelie G, Au Eong KG, et
al. Vision enhancement
systems. In: Atala A, Lanza
RP. [Eds]. Methods of tissue
engineering. San Diego:
Academic Press 2002,
Chapter 100, pp 11071125.
Scribner D, Margalit E, Au
Eong KG, et al. Intraocular
retinal prostheses and
related signal processing.
In: Hung G [Ed]. Models of
the visual system. New
York: Kluwer
Academic/Plenum

Visual Prosthesis

From Au Eong KG, Weiland JD, Margalit E, de Juan E, Jr, Humayun

MS. Retinal prosthesis. In: Lim JI [Ed]. Age-related macular
degeneration. New York: Marcel Dekker, Inc. 2002, Ch 23, pp
441-456.

Wet AMD - Summary

Abnormal new blood vessels outside
centre of macula
Laser photocoagulation

New blood vessels under centre of macula

PDT
Others
Macular translocation
Submacular surgery
TTT

No treatment

Low Vision Aids

To maximise existing visual potential

at any stage of disease

Low Vision Aids

Primary Prevention
of Age-related Eye Diseases
Primary prevention preventing disease
from occurring in the first place
Currently no primary preventive approach
of proven effectiveness for many agerelated eye diseases
Reduce risk factors
Sunglasses cataract
Diabetes control diabetic retinopathy
Smoking cataract & AMD

Secondary Prevention
of Age-related Eye Diseases
Secondary prevention prevent disease
from getting worse after onset of disease
More valuable approach than primary
prevention
Early detection and timely intervention
Decreases visual impairment and blindness
Improves quality of life
Decreases associated morbidity and mortality

S.E.E. Project
S.E.E. = Sight & Eye Evaluation
Free community eye screening
programme for elderly population in
Singapore
Part of Alexandra Hospitals
community outreach
Organised by Ophthalmology &
Visual Sciences, AH

S.E.E. Project
Aim
Early detection and timely intervention
of sight-threatening eye conditions
Decreases visual impairment and blindness
Improves quality of life
Decreases associated morbidity and
mortality

S.E.E. Project
Who
Anyone 55 years or older not seen previously
in the last one year by an eye specialist

When
Monthly or more frequently

Where
Clinic C, Ophthalmology & Visual Sciences, AH

How
By appointment (call tel:6476 8828)

S.E.E. Project
Screening

Eyesight (visual acuity) measurement

Autorefraction
Eyeball pressure measurement
Retinal photography
Clinical examination

Pick up common conditions

Cataract
Macular degeneration
Glaucoma
Diabetic retinopathy

What S.E.E. Project is Not

Not a comprehensive examination - cannot
pick up all eye diseases
Screening only
No treatment
No glasses prescription

Not a consultation service

Not for patients with symptoms
Not for second opinion
Not for patients already on follow-up with other
eye specialists

S.E.E. Project - Summary

Call tel:6476 8828 for appointment
State cleary you are calling for S.E.E.
project
Free of charge

L.O.V.E. (Loss Of Vision

Evaluation) Project
Partner
Geriatric Centre

Opportunistic screening of visual

acuity in patients 55 years and older