Look After Your Eyes as You Age
by: George O. Waring, IV, M.D. and Jerry Reves, M.D.*
People have argued probably as long as they could hear and talk about which of our senses is most important. Without entering that debate, let us simply say that being able to see is very important. Blindness affects about three million people over forty years of age and importantly to our readers, there is a progressive loss of vision as we age. Just as we lose many functions that we had as young people, we can expect as we grow older to have problems with our eyes. It is a normal part of aging to not see as well as we used to, but sudden loss or sudden changes in vision are abnormal and are potentially treatable.
What are the common problems with vision and age?
Normal loss of visual acuity - not seeing things as sharply as we used to occurs over time beginning at around age 40. This is normal and common, and is called presbyopia - the slow loss of ability to see close objects or small print. If you find that you need to move the newspaper further away to read it clearly or that you need magnification to read, then you are one of the many normal people who experience the gradual loss of vision as they age. The most common non-surgical treatment for this is glasses and increased lighting in the environment. These two strategies will usually alleviate the problem. However, for those that are interested in reducing dependence on reading glasses and bi-focals, a number of options for surgical correction are available as well.
Tearing changes occur as we age, particularly in women after menopause. Changes in tearing (keeping the eye moist) can be of more tears or less than we used to have. Sensitivity to light, wind or temperature change can bring more tears or lack of tears can come from blocked tear ducts. Artificial tears can be prescribed for "dry eyes" but because changes in tearing can herald underlying eye disease it is appropriate to see an ophthalmologist to evaluate the eye.
Eyelid problems increase as we age. These can be red or swollen eyelids with crusting of eyelashes during sleep. The eye can be involved and reddens so that "pink eye" develops. Warm eye compresses and gentle eyelid cleaning with water can be effective in treatment of this, but a visit to your physician for prescription medicines including topical antibiotics may be required if symptoms persist.
Cataracts are the gradual impairment of light getting through the lens. Cataracts are the greatest pathologic problem of the eye as we age. By age 65 almost all of us will have some cataract formation, though patients may be symptomatic much earlier due to a ubiquitous disorder known as dysfunctional lens syndrome - or, a pre-cataract. It has been estimated that as many as 30 million Americans will have cataracts in the year 2020 because of the prevalence in older patients. People who are at risk for cataracts have certain diseases like diabetes, or they smoke, excessively alcohol, and or have prolonged/excessive exposure to ultraviolet light. The lens becomes "cloudy" with a yellowish/brownish color protein deposition that adds a brownish tint to vision. Ultimately vision becomes blurred and vision is impaired. The symptoms are cloudy or blurry vision and poor night vision. Glare, for example, headlights, lamps or sunlight may appear too bright or a halo may appear around lights. Some people have double vision or multiple images in one eye. If undiagnosed or left untreated, reversible blindness can develop. Initial therapy is new glasses, anti-glare sunglasses, brighter lighting and magnifying glasses. Surgery is the most common approach to cataracts and involves the extraction (removal) of the cloudy lens with the insertion of a clear plastic lens that is generally an effective therapy in 90% of patients. It is important to not let the cataracts become too large before extraction. Most patients feel the dysfunctional lens or cataract is affecting their quality of life and elect for lens surgery when they have difficulty driving at night or their glasses are not longer working well.
Floaters are tiny streaks or spots that seem to float in the eye as one tries to look at objects. This is generally considered a normal result of getting older and is caused by the liquefying vitreous inside our eyes that pull away from the retina. The floaters tend to disappear but can recur over time. If there are flashes of light this could be a results of a serious problem called macular degeneration (see below) and requires immediate physician consultation.
Age-related macular degeneration (AMD) is the most common cause of blindness in Americans over 50 so it is the biggest cause of blindness in the elderly. AMD blurs the sharp central vision used for reading, driving, sewing and other straight ahead vision. Symptoms include straight lines becoming wavy (wet AMD - macular hemorrhage) or central blurring (dry AMD - macular exudates). Over time as less of the macula functions, central vision decreases and cannot be restored. Risk factors for AMD are smoking, obesity, Caucasian race, female gender and a family history. A variety of treatments exist for AMD including vitamins, antioxidants and zinc supplementation, intra-eye injection or monoclonal antibodies, and laser surgery. Each therapy has to be tailored to the particular patient and the particular pathology (wet or dry AMD).
Glaucoma is multiple processes that go wrong, not a single problem. Approximately 2.2 million patients have this problem. The risk increases with age and is prevalent in African-Americans and Mexican-Americans and those with a family history. Glaucoma occurs when the fluid that normally leaves the eye is diminished. As when fluid in any "closed" system increases (like the eye) so does the pressure. Pressure builds up within the eye, compresses the optic nerve (the nerve that sends vision signals to the brain) and the vision can become impaired. Symptoms include the loss first of peripheral vision - patients fell like they are "looking through a tunnel." Ultimately, if untreated, even central vision is lost to blindness. There are specific medicines used to treat glaucoma and in some cases surgery can be used. Therapy is effective in preventing progression of the disease, but optic nerve destruction cannot be treated, so early diagnosis is essential.
Diabetic retinopathy is a common problem that increases with age and the longevity of patients with diabetes. Of people with diabetes over the age of 40, about 40% have retinopathy and 8% have vision threatened retinopathy. Diabetes causes retinal problems that progress to hemorrhage and this leads to potential vision impairment due to retraction on the retina that can cause blindness. Treatment is limited to vision-enhancing devices that lead to magnification. Enhanced lighting is also a strategy with other vision problems. There is no treatment once blindness occurs.
The diagnosis of eye problems is easy, but is does require one thing. That thing is everyone over 60 should have a complete eye examination at least every two years and some recommend annually. The exam involves measuring reading acuity, having the pressure in the eye measured, and having the eyes "dilated" so that a through examination of the inside (retina and macular) can be completely done. Most of the problems are treatable and the earlier the diagnosis the more successful the treatment. The bottom line is that part of healthy aging involves having an eye exam - a responsibility that each of us must take for our overall welfare and to retain our eyesight.
*George O. Waring, IV, M.D. is Assistant Professor of Ophthalmology, Director of Rrefractive Surgery at MUSC.
Jerry Reves, M.D. is Dean Emeritus of the College of Medicine at MUSC.
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