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Conditions and Care of Aging Eyes - Drs. Geeta Lalwani and Heather Gitchell

Currently about 6.5 million Americans over the age 65 have a severe visual impairment. A 2004 National Eye Institute Study confirmed that the risk of visual impairment increases significantly in those over 65. Recently Drs. Geeta Lalwani (Rocky Mountain Retina Associates) and Heather Gitchell (InSight Vision Group) discussed conditions and care of aging eyes for the Aging at Altitude Expo.

Read about the most prevalent eye conditions, signs and symptoms of eye conditions, and what to do to ensure healthy eyes at any age.

What are some of the eye conditions people are at higher risk for as they age?

The most common age-related eye conditions in the population over 65 are:

Glaucoma (about 12% of population over 65)

The risk for glaucoma increases after age 40; glaucoma is called “the silent thief of sight” as there typically are no recognizable symptoms in the early stages of the disease. Glaucoma is a disease that causes a progressive loss of nerve tissue in the back of the eye which eventually results in peripheral vision loss. There are many risk factors associated with glaucoma including elevated eye pressure, diabetes, high blood pressure, sleep apnea, history of migraines and family history. While there is no cure for glaucoma, it can be treated with eye drops, laser procedures or surgery. The only treatment for glaucoma is to lower the eye pressure (even if it is not outside of the normal range at diagnosis). Most often, glaucoma is found as part of an annual eye exam, not because a person noticed a change.

Age-related macular degeneration (ARMD) (about 15% in those 65-80, 35% in those over 80)

The biggest risk factors for age related macular degeneration are: age, light-colored skin, family history, and smoking. Of these, the only modifiable risk factor is smoking cigarettes! Approximately 85% of cases of macular degeneration are considered “dry,” meaning no leaking blood vessels within the macula (a small central area of the retina with the highest density of photoreceptor cells and responsible for central vision). The only treatments for dry macular degeneration are nutritional. A nationwide study completed in 2012 (Age Related Eye Disease Study 2, or AREDS2) showed that a specific formulation of vitamins and minerals slowed the progression of disease in those who have moderate macular degeneration. The AREDS2 Formula of vitamins is currently recommended for anyone with macular degeneration that meets certain criteria. If the patient has high risk characteristics (observed by your eye doctor) or has moderate to severe vision loss in one eye due to ARMD, then it is recommended that they take the AREDS2 formula vitamins. There is no evidence to suggest that patients with mild-moderate ARMD will benefit from the AREDS2 formula vitamins. Evidence does suggest that those patients will benefit from a healthy diet, similar to the Mediterranean diet. As mentioned above, there are not many modifiable risk factors, but an important one is nicotine use. We know that nicotine quadruples to quintuples the risk for macular degeneration. There are ongoing clinical studies looking at other treatments for dry macular degeneration. Regular monitoring, both by your eye doctor and by you at home is important to detect possible conversion to the “wet” form of macular degeneration which requires additional treatment. The treatment for wet AMD in an injection of an anti-vascular endothelial growth factor (anti-VEGF) agent into the eye to stop the blood vessels from leaking. This treatment, while incredibly successful compared to past interventions, is chronic and ongoing. Important to note is that it is not painful! Early diagnosis of wet AMD is crucial.

Diabetic retinopathy (about 20%)

The risk for diabetic retinopathy (bleeding in the retina) increases with the duration of disease as well as with an increase in average blood sugars or hemoglobin A1C (HbA1C). Higher average blood sugars will lead to faster progression of the disease. The vast majority of type I diabetics will have diabetic retinopathy after 15 years with diabetes, with 50% of these progressing to a more serious stage of disease requiring surgical intervention. 60-80% of type II diabetics will have diabetic retinopathy after 15 years with the disease. However, good control of blood sugars starting at the time of diagnosis can lead to a life free of retinal complications of the

disease. If you have diabetes, even well controlled, it is crucial to see an optometrist or ophthalmologist annually because early to mid-stages of the disease often have no symptoms. If there is a significant amount of diabetic retinopathy, you will likely be referred to a retinal specialist for additional evaluation and treatment.

Dry eye (about 30%)

The term “dry eye” oversimplifies the condition. Insufficient tear film can cause frustrating and chronic problems for vision and comfort. The ocular surface is comprised of living cells which require constant bathing in fluids to maintain proper clarity and function. A tear film is a delicate chemistry of three basic layers, each produced by a different part of the eye. Each layer has to be produced in the proper proportions for the tear film to defy gravity, combat the dry Colorado environment and deal with screens of all varieties (all of which cause us to blink less frequently and less completely). Dry eye can be exacerbated by systemic conditions, medications, time and environment.

Floaters (>75%)

When an individual is born, the back chamber of their eye is filled with a gel-like substance called the vitreous. With time, that vitreous liquefies and becomes more mobile. At some point, typically between the ages of 50 and 70, the vitreous separates from the back wall of the eye, termed a posterior vitreous detachment, or PVD. This acute event is often noted by flashes of light followed by floaters. It is a completely normal process, and these floaters often are less symptomatic after several months. However, sometimes when the vitreous separates, it can cause a tear in the retina which can lead to a retinal detachment. A retinal detachment is often perceived as a dark black curtain, coming from any direction, blocking a portion of a person’s peripheral vision. Those at greatest risk of a retinal detachment are those who are highly myopic (nearsighted), even if their vision has been corrected with LASIK, or have a family history.

Cataracts (70% and still the leading cause of blindness world-wide)

Everybody gets cataracts, just as everyone loses focusing ability in their 40s-50s. A cataract is a discolored or clouded lens inside the eye. Not everyone will need cataract surgery in their lifetime, but most people have a clinically recognizable cataract by the decade of 60s. The only treatment for cataracts is to surgically remove the clouded lens. Because cataracts typically progress slowly, we don’t always recognize that vision has changed. Cataracts can cause a general blurring of vision, they can create glare from bright lights (often noticeable when driving at night), or can cause a dimming of vision, making it difficult read without bright light. If or when one’s vision and thus activities of daily living are adversely affected, cataract surgery can be considered. Of the processes listed here, the only one that is completely reversible and treatable is cataracts.

What are some steps people can take to reduce the risks of cataracts, glaucoma, macular degeneration and retina detachments?

UV protection is the only modifiable risk factor for cataracts. When choosing UV protection, you want a lens that blocks 100% UVA and UVB or has a UV400 rating. Even with UV protection, cataracts will progress, but perhaps at a slower rate.

In general, the healthier you keep yourself, the better for your vision and eyes. For example, diabetes and hypertension are risk factors for glaucoma and for certain retinal conditions. Eating

a healthy diet and exercising regularly can reduce your risk for these conditions and potentially decrease your risk for ocular complications associated with them.

Smoking, or using nicotine in any form, is a significant risk factor for macular degeneration. Eating a diet rich in green leafy veggies, antioxidants and Omega-3 fatty acids is recommended to maintain a healthy macula as is UV protection. Supplementing your diet with lutein and zeaxanthin may also be beneficial.

Regular dilated eye examinations are important.

What are some signs or symptoms that people may experience with these various eye conditions?

The most common symptom for any of these of conditions is blur. Many people come in thinking perhaps they need to update their glasses, but there is no change in lenses that can improve vision. However, the acuteness of the symptoms is very helpful in differentiating between the different conditions. Cataracts and glaucoma are slower processes and should rarely cause an acute change in vision. Cataracts are easily treated by removing the clouded lens and replacing it with an artificial lens implant. We can provide varying levels of vision correction as part of cataract surgery based on each individual’s wishes. Glaucoma, on the other hand, does not have a cure. We cannot reverse any damage done by glaucoma, but we can treat it in hopes of slowing down the nerve and vision loss. As mentioned earlier, there typically are not any symptoms associated with glaucoma until late stages of disease.

Both wet macular degeneration and diabetes often cause a distortion of the central vision, with ARMD being much more acute. Over days to weeks, the visual distortion progresses. Both of these conditions are treated with anti VEGF agents which greatly improve the vision. Prompt evaluation and treatment is imperative for both conditions.

As mentioned above, a sudden onset of floaters is most likely related to a posterior vitreous detachment, a normal part of aging. However, it is a very good idea to be examined and rule out a retinal tear which can lead to a retinal detachment. A retinal tear by itself, typically has no symptoms.

What are some of the best things you can do to protect your eye health?

  • UV protection

  • Safety eyewear when working in yard, grinding metal, welding, doing DIY projects or even when participating in sporting activities

  • Don’t smoke

  • Eat a diet rich in green leafy veggies, antioxidants and Omega-3 fatty acids

  • Drink water (2-3 liters daily)

  • Blink regularly and limit screen time (or take regular breaks: 20-20-20 rule)

  • Get annual eye examinations (even if you don’t wear glasses) especially if you have diabetes!


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