Improving vision can help quality of life in LTC
Mark Milner, M.D.
Despite recent projections estimating that in the United States the number of individuals with age-related macular degeneration will reach 20 million in 2020, new survey results reveal that nearly 75% of Americans still don't know that AMD is the leading cause of legal blindness in older adults.
AMD dramatically impacts quality of life, manifesting in greater social dependence, challenges maintaining independence and early admission to nursing homes.
As macular degeneration progresses, central vision can deteriorate to the point where patients are challenged to see fine detail and images in their center zone. While treatment options for AMD have improved over the past 10 years with the use of intravitreal anti-VEGF medications for neovascular AMD, some patients inevitably progress to advanced AMD, in which central vision is often poor or completely blocked in both eyes. Advanced, or end-stage, AMD is associated with increased depression and stress.
Although some AMD patients in the long-term care setting may have serious co-morbid conditions that must be prioritized, many patients who are simply less ambulatory or relatively healthy could benefit immensely from active treatment for advanced AMD. Of course, effective treatment for AMD is largely dependent on a facility's ability to provide patients access to treatment and, if needed, visual rehabilitation. But the quality of life improvements to be gained may outweigh logistical challenges.
AMD treatment strategies
Typically, macular degeneration is divided into early, intermediate and end-stages. Atrophic, or dry AMD, is more common and is characterized by the presence of drusen (dots of yellow fatty deposits that develop within the macula) and thinning of the macula, which reduces the central vision and can affect color perception. Ten percent of patients will experience neovascular, or wet, AMD, which is caused by the development of excess blood vessels that scar the macula when they leak.
Early stage AMD
Patients may not even realize they have AMD at its earliest stages. Symptoms might include lines looking crooked (like telephone poles appearing bent) or wavy. Annual monitoring by an ophthalmologist is vital to ensure the disease isn't progressing, and there are services in the community that can provide vision assistive devices such as reading glasses with high-powered lenses, video magnifiers, computer aids and more.
At this point, patients may experience blurred or partially blocked central vision in one or both eyes. There are several treatments that may slow progression, but will not cure AMD.
Vitamin therapy: Published in 2013 to evaluate the impact of nutritional supplements, AREDS2 remains the largest, high-profile study to evaluate the impact of vitamins on the development and progression of AMD. The researchers demonstrated that adding dietary carotenoids lutein and zeaxanthin can slow the progression of dry AMD.
Injections: intravitreal anti-VEGF injections (Macugen (pegaptanib sodium), Lucentis (ranibizumab) and Eylea (aflibercept) are a mainstream, first-line treatment approach for neovascular AMD. In some patients, regular injections can slow or stabilize and even reverse neovascularization, as well as improve and restore visual acuity.
Other treatment options for neovascular AMD might include photodynamic therapy, a “cold” laser treatment used in combination with drug treatment and laser surgery, which involves aiming an intense “hot” laser at the abnormal blood vessels in the eyes to destroy them.
Advanced (or End-stage AMD)
Inevitably, some patients progress to end-stage AMD in both eyes, which is uncorrectable by any other treatment including glasses, vitamins, drugs or cataract surgery. (Though commonly recommended as a “last resort” to improve contrast and/or peripheral vision, studies show gains in visual acuity following cataract surgery are modest, at best, for the end-stage patient.)
Certain patients may benefit from an FDA-approved telescope implant, which has been demonstrated to restore vision and improve quality of life in patients with the most severe form of the disease. Smaller than a pea, the device is surgically implanted into one eye in an out-patient procedure. Combined with the cornea's optics, the implant creates a telephoto system that magnifies objects in front of the eye by approximately 2.7 times and, then, projects those images seen in a patient's central vision onto healthy areas of the retina. Studies show that motivated patients can better see faces and return to activities requiring central vision, such as reading, watching TV or other tasks requiring detailed vision.
The pre-operative evaluation, the post-operative visual rehabilitation, and support from family, friends and other health providers, such as those supporting the patient living in a nursing home or long term care facility, are as critical for success as a well-performed surgery. Beyond meeting specific eye health criteria for surgery, being at least 65 years old and having a cataract in place in the eye receiving the telescope, patients will also be evaluated to see how they tolerate the magnified image using an external telescope simulator. The patient must also commit to working with an occupational therapist to learn how to use their new vision, and this rehabilitation process may take months. Therefore, the long term care specialist (and the institution) would have a role to play in motivating the patient to practice with their new vision.
Vision is important in maintaining quality of life
Older adults do not realize how their vision impacts their quality of life until it begins to deteriorate. As the boomer population ages, more patients entering nursing homes or long-term care facilities will develop macular degeneration. Understanding and helping patients access AMD treatments and tools that improve their ability to see will help these patients realize more independence and likely reduce their risk for depression, anxiety and stress.
Mark S. Milner, M.D., FACS, is the co-founder and co-medical director of Precision LASIK Group and Associate Clinical Professor at Yale University School of Medicine.