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ORIGINAL ARTICLE
Year : 2021  |  Volume : 3  |  Issue : 1  |  Page : 26

Vision rehabilitation in elderly patients aged 80 years or over: Epidemiological profile and prescription of optical, nonoptical, and electronic devices


1 Instituto de Olhos Ciências Médicas, Belo Horizonte, Minas Gerais, Brazil
2 Clínica de Olhos Luciene Fernandes, Belo Horizonte, Minas Gerais, Brazil

Date of Submission31-May-2021
Date of Acceptance28-Jun-2021
Date of Web Publication24-Aug-2021

Correspondence Address:
Dr. Nadine Fernandes da Silva
Cassiporé Street 271/301, Anchieta, 30310-430 - Belo Horizonte, Minas Gerais
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pajo.pajo_96_21

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  Abstract 


Purpose: The purpose of this study is to investigate the epidemiological profile and prescription of optical, nonoptical, and electronic devices in the elderly aged 80 years or older, in a low-vision rehabilitation center in Belo Horizonte, Brazil.
Methods: This is a retrospective, observational, descriptive study held in a low-vision rehabilitation center in Belo Horizonte, from 1992 to 2016. A total of 448 medical records were analyzed and 375 (83.7%) were included. Age, gender, occupation, diagnosis, ocular and systemic diseases associated, best-corrected visual acuity, refractive error, goal to be achieved, optical, nonoptical, and electronic devices, and visual hallucination were considered.
Results: Of the 375 medical record evaluated, 310 (82.6%) cases were of patients aged 80–89 years old, 218 cases (58.1%) were female and 262 cases (69.8%) were of retired patients. The age-related macular degeneration was the most prevalent disease, 296 (78.9%), followed by glaucoma in 31 patients (8.2%) and diabetic retinopathy in 9 (2.4%). Low myopia was the most prevalent refractive error, present in 148 (39.4%). A severe visual loss occurred in 145 patients (38.6%) while reading was the main goal, with 339 cases (90.4%). Optical and/or electronic devices were prescribed to 361 patients (96.2%), in a total of 418 optical and 66 electronic devices. Among the electronic devices, video magnifiers (CCTV) were indicated for 37 patients (9.8%) and handheld electronic magnifiers for 29 patients (7.7%). Visual hallucinations were reported in 11 cases (2.9%).
Conclusions: This study shows that vision rehabilitation is possible in the elderly.

Keywords: Low vision, low-vision aids, nonoptical and electronic devices, optical, vision rehabilitation, visual hallucination


How to cite this article:
da Silva NF, Fernandes LC, Kanadani FN. Vision rehabilitation in elderly patients aged 80 years or over: Epidemiological profile and prescription of optical, nonoptical, and electronic devices. Pan Am J Ophthalmol 2021;3:26

How to cite this URL:
da Silva NF, Fernandes LC, Kanadani FN. Vision rehabilitation in elderly patients aged 80 years or over: Epidemiological profile and prescription of optical, nonoptical, and electronic devices. Pan Am J Ophthalmol [serial online] 2021 [cited 2021 Dec 5];3:26. Available from: https://www.thepajo.org/text.asp?2021/3/1/26/324522




  Introduction Top


According to the International Classification of Diseases and Related Health Problems, 10th Revision, a person with low vision is the one with a best-corrected visual acuity (BCVA) <0.3 (6/18), but with equal to or better than 0.05 (3/60) and/or visual field <20° around central fixation in the best eye. Blindness is defined as a BCVA <0.05 (3/60) and/or visual field <10° around central fixation in the best eye. The classification refers to BCVA with conventional glasses or contact lenses and the visual field at its greatest diameter in the best eye.[1]

The World Health Organization (WHO, 2010) estimates the number of 285 million visually impaired people in the world, 39 million of whom are blind and 246 million with low vision.[2] Above 82% of the blind are over 50 years old although they represent only 19% of the world's population.[2]

The number of elderly patients in vision rehabilitation centers is growing as a consequence of the growth and aging of the population, the worldwide growth of chronic diseases such as hypertension and Diabetes Mellitus, the impact of technology on the extension of life, and changes in social habits and urbanization.[2],[3]

The impact of visual loss on an individual's life is variable. It may be discrete or represent a complete break in their life. Loss of skills such as reading, driving, working, recognizing people, and watching television (TV) is common; psychological disorders such as depression, loss of self-esteem and independence, social isolation, visual hallucinations, and aggression, as well as risk of accidents, falls, fractures, and change of medication, among many others, can happen.[4] It is necessary to be aware of and be sensitive to daily difficulties of the elderly with low vision referring them to vision rehabilitation as soon as possible, seeking a better quality of life.

The purpose of this study is to analyze the epidemiological profile and prescription of optical, nonoptical, and electronic devices in elderly patients, aged 80 years or over, in a low-vision rehabilitation center in Belo Horizonte, Brazil.


  Methods Top


A total of 448 medical records were analyzed and 375 (83.7%) were included. Age, gender, education level, occupation, diagnosis, ocular and systemic disease associated, best corrected visual acuity, refractive error, goal to be achieved, optical, nonoptical, and electronic devices, and visual hallucination were considered.

This is a retrospective, observational, descriptive study held in a low-vision rehabilitation center in Belo Horizonte. Patients were referred by coworkers from Belo Horizonte, family and friends, or by personal request. Many of them came from cities in the state of Minas Gerais or other Brazilian regions.

Medical records of elderly patients aged 80 years or over were selected, from 1992 to 2016, on their first visit, and the analysis of these data was performed by the authors of the study.

Data obtained and directly related to the study were recorded in an individual protocol. Incomplete medical records and those who failed to complete or had no interest in the treatment were excluded from the review.

To meet the protocol requirements, the following topics were considered:

  • Patient identification: Initials, age, gender, level of schooling, occupation
  • Diagnosis
  • Eye-related disease
  • Associated systemic disease
  • BCVA in the better eye
  • Refractive error
  • Reason for searching for optical aid
  • Prescription of optical aid: distance, intermediate, and near-vision
  • Nonoptical aid
  • Technological devices
  • Visual hallucinations.


For the analysis of data referring to the characteristics studied, the patients were distributed as follows:

Identification

  1. Age: 80–89 years, 90–99 years, and over 100 years
  2. Gender: female and male
  3. Occupation: Homemaker, pensioner, retired, worker, and others.


Diagnosis: Primary cause of visual loss in the better eye

The classification was based on that of the WHO.

  • Age-related macular degeneration (AMD)
  • Cataract
  • Corneal opacities
  • Diabetic retinopathy
  • Glaucoma
  • High myopia
  • Optic atrophy
  • Retinitis pigmentosa
  • Others: Specify.


For classification of AMD, both nonexudative and exudative forms were considered (inactivity, with subretinal neovascular membrane or presence of disciform fibrovascular scar).

Eye-related disease

It was considered the same classification used above. In addition, it was considered whether the patient was phakic, aphakic, or pseudophakic, in each eye.

Associated systemic disease

  • Cardiopathy
  • Cerebrovascular disease
  • Diabetes mellitus (DM)
  • Hearing impairment
  • Ignored: Absence or insufficiency of data
  • None
  • Systemic arterial hypertension
  • Others: Specify.


Best-corrected visual acuity in the right eye and left eye

Visual acuity was recorded using the Snellen notation through the LEA SYMBOLS® Chart for Vision Rehabilitation test (Lea Hyvarinen) chart for illiterate patients and early treatment diabetic retinopathy study (ETDRS) for the literate ones, at distances corresponding to the patient's visual range and standardized by the charts: LEA test at 75 cm, 1.5 m, or 3 m and ETDRS at 50 cm, 1 m, 2 m, or 4 m. When it was not possible to identify optotypes, it was considered: absence of light perception, perception or projection of light, hand movements, figures, and unknown, when the data did not exist.

For the classification of visual acuity, we considered the aspects of visual loss established by the International Council of Ophthalmology (2002)[5] [Table 1].
Table 1: Ranges of vision loss in International Council of Ophthalmology 2002[5]

Click here to view


Refractive error

The refractive error in each eye was retrieved and analyzed, considering ametropy for distance vision. For statistical analysis, we calculated the mean of the spherical equivalent (SE) of the best eye, according to the standard formula: SE = spherical value + 0.5 × cylinder, and distributed it according to the principles below:

  • High myopia: ≤‒6.00 D
  • Moderate myopia: >‒6.00 and ≤‒3.00 D
  • Low myopia: >‒3.00 D and ≤‒0.75 D
  • Emmetropia: >‒0.75 D and >+0.75 D
  • Low hypermetropia: ≥+0.75 D and <+3.00 D
  • Moderate hypermetropia: ≥+3.00 D and <+6.00 D
  • High hypermetropia: ≥+6.00 D.


Reason for seeking optical aid: activity the patient wanted to perform at near, intermediate, and distance vision

  • Reading
  • Writing
  • Crossword puzzles
  • Handicrafts (crochet, knitting, painting, sewing, and others)
  • Daily activities (picking beans and rice, peeling vegetables, cooking, and others)
  • Playing cards
  • Photophobia
  • Goal not defined
  • Others.


Prescription of optical/electronic devices

  • Yes
  • Optical
  • Electronic
  • No.


Type of optical aid

It is important to note that, in the survey of prescribed optical aids, conventional glasses with spherical lenses and addition up to + 4.00 D were also included. We considered as optical aids:

  • Glasses with spherical lenses <+10.00D and special addition >+4.00 D
  • Glasses with aspherical lenses >+10.00D and <+24.00D and special addition >+4.00D
  • Glasses with sphero-prismatic lenses >+12.00 D
  • Glasses with microscopic lenses
  • Handheld magnifier
  • Stand magnifier
  • Telescopic system for near/intermediate vision
  • Telescopic system for distance vision.


Nonoptical aid

  • Magnification
  • Large print playing cards
  • Lighting control
  • Adequate lighting
  • Lens filters: Amber, gray, or brown
  • Contrast in daily activities: Different colors of thread and needle, etc.


Technological devices

  • Video magnifier (known as a closed-circuit television)
  • Handheld electronic magnifier
  • Screen magnification software
  • Others.


Visual hallucination

  • Yes () No ()
  • Type
  • Frequency.


The obtained data were data through frequency distribution, mean, and standard deviation calculations. The study was approved by the ethics committee investigational review board (CEP Number 2862626) and adhered to the principles of the Declaration of Helsinki and Resolution 196/96 of the Ministry of Health, Brazil.


  Results Top


Medical records from a total of 448 patients were analyzed, of which 375 medical records (83.7%) were selected for full review. The remaining records were excluded because the patients did not return to complete the visual assessment/rehabilitation or because they were not interested in the proposed aids.

Demographics such as age, gender, and occupation are described in [Table 2].
Table 2: Distribution of patients submitted to vision rehabilitation according to age, gender and occupation

Click here to view


AMD was the most prevalent primary diagnosis, observed in 296 of the medical records examined (78.9%) followed by glaucoma in 31 patients (8.2%) and diabetic retinopathy in nine patients (2.4%) [Figure 1].
Figure 1: Distribution of patients submitted to vision rehabilitation as the primary diagnosis

Click here to view


Among the associated systemic diseases, in 207 (55.2%) of the medical records, these data were not collected due to the absence or insufficiency of data. In other records, systemic arterial hypertension was observed as the most frequent disorder, 66 patients (17.6%), followed by heart diseases in 34 (9.0%), hearing loss in 32 (8.5%), DM in 31 (8.2%), cerebrovascular disease in 14 (3.7%), depression in 3 (0.8%), and dementia in 1 patient (0.2%). Other diseases not specified above corresponded to 52 cases (13.8%). It was verified that 18 (4.8%) of the patients did not present any systemic disease. Since a patient may have more than one associated systemic disease, the total number of this item outnumbered the total of patients.

The analysis of the associated eye diseases followed the same classification described for primary diagnosis, and it was verified that glaucoma, with 36 cases (9.6%), was the most frequent, followed by AMD with 6 (1.6%). Four patients (1.0%) had diabetic retinopathy and 3 (0.8%) patients had corneal opacities. High myopia was observed in one patient as well as optic atrophy in another patient. Other associated eye diseases, not mentioned above, corresponded to 25 cases (6.6%). In 88 patients (23.4%), there was no eye disease associated or no disease was stated in the medical record. In the same topic, cataract cases were also considered, with 42 cases (11.2%), pseudophakia with 234 cases (62.4%), and aphakia with 12 cases (3.2%).

The BCVA results showed severe visual loss as the predominant one, corresponding to 145 (38.6%) of the records analyzed, followed by moderate visual loss in 125 (33.3%) of the patients and mild visual loss in 63 (16.8%) of the patients. Deep visual loss was reported in 38 (10.1%) of the patients. Finally, near-total visual loss corresponded to 4 (1%) of the records analyzed.

Refractive errors are described in [Figure 2].
Figure 2: Distribution of patients submitted to vision rehabilitation as refractive error

Click here to view


With regard to the reason for seeking visual rehabilitation, many patients had more than one goal. The main one was reading, by 339 patients, corresponding to 90.4% of the patients. Among other objectives, 102 patients (27.2%) had an interest in manual work such as crochet, knitting, painting, and sewing. The desire to watch TV was sought by 64 patients (17.0%) and writing by 45 (12%). Patients who wanted to do crosswords represented 15 cases (4%). The desire to perform daily activities was cited by 24 patients (6.4%). Nine patients would like to play cards (2.4%), and in 16 cases, there was a desire to reduce photophobia (4.2%). Four patients (1%) had no defined goals. Other goals, not mentioned above, were 38 (10.1%) and were also included in the table. In this topic, the same patient can present more than one goal; therefore, the values for goals to be achieved outnumbered the total of patients analyzed. In the analysis of medical records, it was observed that 361 patients (96.2%) had been prescribed some optical/electronic device, and therefore, at least one of their objectives had been reached.

The results obtained concerning the prescription of optical/electronic devices (418 optical and 66 electronic) show that the main aid prescribed was glasses, either with spherical lenses with a special addition, prescribed to 191 patients (50.9% of the patients), aspherical lenses with special addition in 94 cases (25%), microscopic lenses for 36 (9.6%), or sphero-prismatic lenses for 12 patients (3.2%). Handheld magnifier, stand magnifier, and crochet magnifier were prescribed to 32 patients (8.5%). The telescopic system was prescribed for near-vision to two patients (0.5%) and for distance vision to 51 patients (13.6%) [Figure 3]a and [Figure 3]b. The electronic devices [Figure 4] considered were video magnifiers in 37 cases (9.8%) and handheld magnifiers in 29 (7.7%) and screen magnification software, which, in turn, was not prescribed to any patient. It is important to note that the same patient can use more than one type of optical/electronic aid, so the values for prescribed aids surpassed the total number of patients analyzed.
Figure 3: (a and b) Low-vision aids for distance, intermediate, and near-vision

Click here to view
Figure 4: Electronic magnifiers: video magnifier and handheld electronic magnifiers

Click here to view


Among the nonoptical aids, features such as magnification, large print playing cards, magnifying mirrors, contrast in daily activities (different colors of thread and needle, etc.), signature guides, proper lighting, rulers, walking sticks, scanning, and approximation techniques are all resources that can be used in visual rehabilitation. Adequate lighting is a feature that is suitable for all patients. The use of lens filters was indicated to 16 patients with photophobia, as well as for other patients, such as those who had difficult seeing at night. To some patients, more than one nonoptical aid was prescribed, so the total number of this item surpasses the number of patients.

The search for the occurrence of visual hallucinations in patients with low vision is new in this subspecialty, and therefore, it is not questioned in most medical records (95.7%). Visual hallucinations were reported in 11 patients (2.9%), and they were mostly human-like faces, people, lines, ants, grape clusters, tree branches, and monsters. Five patients (1.3%) denied visual hallucinations.


  Discussion Top


Nearly two-third of all visually impaired and blind people in the world are women and this condition may be related to the fact that men have greater access to the eye care and also to the fact that women have more risk factors and have a longer life expectancy than men. The principal causes of visual impairment and blindness were AMD,[7],[8],[9] in accordance with the literature, followed by glaucoma and diabetic retinopathy.

The BCVA in the best eye was distributed according to the classification of the ICO,[5] with the purpose of studying patients with visual acuity better than 20/60 (6/18) and that could not perform their daily activities. The severe visual loss occurred in 145 patients (38.6%) of records reviewed, as also noted by Carvalho et al.[10] and Lucas et al.[11] These findings make us think about a late reference of elderly people to a visual rehabilitation program. Low myopia was the most prevalent refractive error. This fact can be related to the high prevalence of cataract in this population or pseudophakia when a low residual myopia is desired after cataract surgery in low-vision patients.

Reading was the main goal to be achieved, which is justifiable in the elderly, with a great frequency of near tasks. Optical/electronic devices were prescribed to 361 patients (96.2%): optical aids to near-tasks were the most prescribed, with high-plus spectacles more prevalent. Glasses are well accepted, more familiar, and have easier access for elderly persons. In our practice, we observed in the elderly a higher resistance to electronic magnifiers, which Fletcher (1999) refers to as “Technophobia.”[4] This fact has been changing over the years. This study shows a prescription of video magnifiers in 37 cases (9.8%) and handheld electronic magnifier in 29 (7.7%). Nonoptical aids such as improving the lighting, contrast enhancement, and others were prescribed to all the patients. On low vision, prescription is common the patient gets more than one device,[4] which justifies a greater number of devices prescribed than the number of patients.

Visual hallucinations were reported in 11 cases (2.9%) represented by human faces, persons, lines, ants, tree branches, and monsters. It is estimated a prevalence of 11%–13% of visual hallucinations in people with low vision and of 1%–2% in the geriatric population.[12] In the first 10 years of this study, information about visual hallucinations was not required in patients as a routine as it is happens now. Complex visual hallucinations that occur in visually impaired individuals without cognitive impairment, after excluding possible systemic causes, are termed Charles Bonnet syndrome.[12] Hallucinations episodes can last from seconds to hours, and the duration can last from days to years.[12] For many patients, the images are easy to identify as they have peculiar characteristics, and they are viewed in more detail than real objects. The most common characteristics of visions reported by CBS are facial distortion, branching forms, regular, overlapping patterns, hyperchromatopsia, multiple forms of one image, and distortions involving the size of objects.[12] The prevalence of CBS is underestimated due to low disclosure by patients, lack of knowledge among physicians, variable inclusion criteria, and inconsistent depth of questioning.[12] In this study, our objective is only to verify the presence or not of visual hallucinations and their types.

Low vision has a great impact on the quality of life of the elderly population. Studies show that patients with AMD and low vision suffer from anxiety, stress, and depression at levels similar to patients with chronic systemic diseases. This may be a consequence of the abandonment of activities considered important and the need for daily assistance. For the elderly who participate in daily activities, especially in the community, there is a positive impact on quality of life, probably due to the feeling of being useful and respected.[13]


  Conclusions Top


This study allowed a better understanding of the epidemiological profile and characteristics of vision rehabilitation in the elderly aged 80 years and over in a vision rehabilitation center. It is necessary to be attentive and sensitive to the daily difficulties of the elderly with low vision and refer them to vision rehabilitation in the quest for a better quality of life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. International statistical classification of diseases and related health problems. - 10th revision, edition 2010. 3 v.  Back to cited text no. 1
    
2.
Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol 2012;96:614-8.  Back to cited text no. 2
    
3.
Farias N, Buchalla CM. The International Classification of Functioning, Disability and Health: Concepts, Uses and Perspectives. Rev Bras Epidemiol 2005;8:187-93.  Back to cited text no. 3
    
4.
Fletcher DC, ed. Ophthalmology Monographs 12. Low Vision Rehabilitation: Caring for the Whole Person. San Francisco, CA: American Academy of Ophthalmology; 1999.  Back to cited text no. 4
    
5.
The International Council of Ophthalmology. Visual Standards - Aspects and Ranges of Vision Loss. Sydney, Australia; 2002. Available at www.icoph.org/pdf/visualstandardsreport.pdf. [Last accessed on 2021 Apr 20].  Back to cited text no. 5
    
6.
Stevens GA, White RA, Flaxman SR, Price H, Jonas JB, Keeffe J, et al. Global prevalence of vision impairment and blindness: magnitude and temporal trends, 1990-2010. Ophthalmology 2013;120:2377-84.  Back to cited text no. 6
    
7.
Hooper P, Jutai JW, Strong G, Russell-Minda E. Age-related macular degeneration and low-vision rehabilitation: a systematic review. Can J Ophthalmol 2008;43:180-7.  Back to cited text no. 7
    
8.
American Academy of Ophthalmology Vision Rehabilitation Committee. Preferred Practice Pattern Guidelines: Vision Rehabilitation for Adults. San Francisco: American Academy of Ophthalmology; 2013.  Back to cited text no. 8
    
9.
Goldstein JE, Massof RW, Deremeik JT, Braudway S, Jackson ML, Kehler KB, et al. Baseline traits of low vision patients served by private outpatient clinical centers in the United States. Arch Ophthalmol 2012;130:1028-37.  Back to cited text no. 9
    
10.
Carvalho KM, Monteiro GB, Isaac CR, Shiroma LO, Amaral MS. Causes of low vision and use of optical aids in the elderly. Rev Hosp Clin Fac Med Sao Paulo 2004;59:157-60.  Back to cited text no. 10
    
11.
Lucas MB, Leal MO, Tavares SS, Barros EA, Aranha ST. Condutas reabilitacionais em pacientes com baixa visão. Arq Bras Oftalmol 2003;66:77-82.  Back to cited text no. 11
    
12.
Vale TC, Fernandes LC, Caramelli P. Charles Bonnet syndrome: Characteristics of its visual hallucinations and differential diagnosis. Arq Neuropsiquiatr 2014;72:333-6.  Back to cited text no. 12
    
13.
Maués CR, Paschoal SMP, Jaluul O, França CC, Jacob Filho W. Assessment of quality of life: comparison between elderly young and very old. Rev Soc Bras Clín Méd 2010; 8:405-10.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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