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person's condition. The most important consideration in correcting improper motor coordination of the eyes is the patient himself, his symptoms, his requirements, and his ability to adjust.
EXAMINATION OF THE AGING PATIENT
As the average life span of the American increases, the number of senior citizens also increases. This means that the percentage of patients past the age of 40 will continue to rise. These people require a different approach in many phases of eye care and the diagnostic significance of tests varies considerably. Final prescriptions and recommendations to the senior citizen are based on the physical and mental changes that come with age, as well as the need.
The importance of the physical and visual history of a patient becomes greater with age, for the deficiency of the current visual mechanism often is a result of earlier injury, disease and general physical being. In dealing with aging individuals it has been learned that members of the patient's family can throw a great deal of light on the patient's history, especially in supplying needed details that are lost in the haze of the older individual's memory.
A patient's occupation, hobbies and activities, although perhaps more restricted, take on increased importance after 40. In examining the aging person, details such as location and position of his work, distances and eye levels while engaged in the task are considered. In some cases, actual measurements of working distances are taken. In addition, lighting and general conditions are noted. The amount of fixed attention and prolonged eye use under various conditions are also considered, and often different types of lenses are prescribed for different kinds of visual tasks. It is not unusual for the aging person to require several different types of lenses in order to see more efficiently and comfortably in his varied occupations.
There are a variety of tests used to determine all aspects of the individual's visual acuity and general eye health. Included are external examinations, opthalmoscopic examinations for detailed inspection of the interior of the eye including particularly the lens, retina, nerve head, macular area and vessels; retinoscopy and subjective tests, in order to determine exactly what lenses are needed; phorias and ductions, which are prismatic calculations for correction of neuromuscular disabilities; and, specific near-point tests, which assume increased importance for the patient past 40.
Many optometrists, in taking histories of patients, are surprised to learn that some patients have never had a physical examination, or perhaps haven't had one in several years. It is important to understand that the body is under constant duress and change. A person reaching 40 is at a turning point physically. By working with physicians and geriatric specialists, the optometrist has the opportunity to assist in preventive care. The optometrist is often consulted professionally before other symptoms of aging have appeared. Diseases of the heart and arteries, cancer, nephritis, diabetes and others are best controlled if discovered early.
Decreased vision is found more commonly in the older age groups, and according to Wick, (1960), “Optometry's forte for the older age group lies in helping to make this period of life more worth living. With the reduction of physical stamina, so common to this period, increased use of the eyes is the general rule. Much careless advice has been given to patients with regard to saving their eyesight. There are no statistical data to substantiate any theory to the effect that use of the eyes wears them out. This advice only serves to make visual hypochondriacs of otherwise normal patients".
TIPS TO THE AGING PATIENT Because of a deficiency in both near-point and far-point vision, often the result of natural changes in aging, the senior citizen may require bi-focal or tri-focal glasses. In order to make the adjustment as quickly and conveniently as possible, optometrists will often make a series of simple suggestions:
1. Try not to look at your feet when walking.
2. When reading a newspaper, fold it into half or quarter size, move it, rather than tilt your head upward, until you can read comfortably.
3. Be certain that the lenses are in the right position by making sure the frames are properly adjusted.
4. Wear your bifocals continuously for the first week or two, even though you may not require them for all tasks.
CATARACT AND GLAUCOMA
In considering the problem of aging as related to vision, two pathologies of clinical importance should be noted. They are senile cataract and glaucoma.
The cataract is defined as “any opacity of the crystalline lens". Although there are other manifestations which occur in individuals of all ages, the "cataract" as we generally know it is primarily associated with senility.
The complaint found most frequently among patients suffering cataracts is "my vision blurs" "I can't see as well". The degree of loss depends on the nature, extent, and position of the cataract. In addition, there are other symptoms which include distortion of images, and a change in color values and hues.
Another symptom quite common is the development of "second-sight". This is a characteristic that the uninformed individual becomes quite proud of, because of a newly acquired ability to read or see at certain distances without his glasses. With the senile cataract, this is often the result of a change in the (rystalline lens, which causes the eye to become more myopic or less hyperopic. In such cases, the loss of vision at other distances is often overlooked because of the "improvement" in reading.
Fundamentally the exact causes of the senile cataract are unknown. There are a number of suggested causes, including changes in permeability of the lens capsule, changes in the lens proteins, excessive efforts to accommodate, effect of radiant energy on the lens, inadequate nutrition, and systemic disorders such as Diabetes. Surgery at present is the only effective treatment for cataract.
Glaucoma is defined by Duke Elder (1941) as “that pressure which the tissues of the particular eye in question are unable to withstand without damage to their structure or impairment of their function." Of all ocular pathologies, glaucoma is most important to both the optometrist and ophthalmologist, because it is hardest to detect in early stages, and may eventually result in total blindness.
It is estimated that 1 percent to 2 percent of patients over the age of 40 have glaucoma, that there is three times as much simple glaucoma as acute, that the greatest incidence of adult primary glaucoma occurs in the 60–70 group (although it should be investigated in persons over 40), that males are somewhat more prone to simple glaucoma than females, but females show a definitely higher incidence of acute glaucoma.
Acute glaucoma is seldom found in myopic patients, but chronic simple glaucoma has an incidence which is unrelated to refractive error.
It is generally agreed that heredity may play a role in glaucoma. In a report by Posner and Schossman (1949) of 373 patients with primary glaucoma, 51 had one or more relatives afflicted with the same disease.
Unfortunately, symptoms are not easily detected clinically, except in acute glaucoma where the patient may complain of such symptoms as pain or headache over the eye, visual disturbances or haziness, the seeing of halos around lights, and the seeing of flashes of light.
Other than from diseases, many studies show that loss of visual acuity occurs naturally with age. In the healthy normal adult this loss is very slight, but nevertheless a very real one that often interferes with the aging person's regular activities.
Along with age usually comes a steady decline in the ability of the eyes to resist glare. This creates a problem especially in night driving for a person over the age of 60.
CONTACT LENSES FOR THE OLDER PATIENT The development of the micro-corneal (small) lens has inspired a great popularity in the wearing of contact lenses. Today, approximately 4 million persons are wearing them, as compared to less than 200,000 just six years ago. The majority of today's wearers are females, estimated to be about 60 percent of the total. The great majority are also younger persons, and most are first attracted to contact lenses for cosmetic reasons. In males, it has been found that because of the wide field of vision and the safety and convenience values with contact lenses, they are used a great deal to advantage for sports. Aside from sports and cosmetic uses, there are also benefits in wearing contact lenses for certain vision conditions. Those suffering from keratoconus, irregular astigmatism, corneal scarring, aniridia and monocular aphakia are offered an opportunity through contact lenses to find dramatic improvement not possible with ordinary glasses.
of the patients coming to contact lens specialists, 47 percent are under 25 years old, 45 percent are between 25 and 40 years old and only 8 percent are over 40 years old. The lack of cosmetic incentive to improve one's appearance, a failure to appreciate the optical and physical advantages, and an unwillingness to be inconvenienced during the adaptation period, are no doubt prime reasons for the lack of popularity of contact lenses with older people. Another strong deterrent is the fact that many of these people are presbyopic, which requires glasses in addition to their contact lenses for near-point or reading vision. There are a number of types of bi-focal contact lenses now on the market, and others are in the process of being developed. It is hoped that eventually the advantages of bi-focal correction will be available in a generally acceptable contact lens.
The most spectacular use of contact lenses in later maturity occurs after cataract operations. They are generally superior to spectacle corrections for aphakic patients. Their greatest advantage lies in the fact that they practically eliminate all aberrations found with regular glasses, mainly because they move with the eye, rather than the eye moving behind the lens. From a cosmetic viewpoint, the contact lenses do not give the highly magnified eye appearance that the heavy-plus spectacles do, because of the latter's thick convex lenses. The thickness and weight of aphakic spectacle corrections often cause discomfort to older patients, especially during warm weather. Contact lenses for these same people are light in weight, and found to be comfortable once the patient has become 2dapted to them. Generally, the older aphakic patient becomes adapted to contact lenses faster than the young person, probably because of reduced corneal sensitivity from the incidental severing of some of the corneal nerve fibers during the cataract operation.
The future of vision correction through the use of contact lenses opens vast new areas of progress for the aging as well as for the young.
PARTIAL VISION AND OPTICAL AIDS The degree of visual acuity in the past was the basis of the three classifications of sight. In the normal range was anyone whose vision checked out at 20/70 or better (the first figure represents the distance in feet at which a line of letters on an eye chart is read, while the second figure represents the distance at which it should be read by a person with "normal" vision). In the second group, called "sub-normal”, were those with vision 20/200 or better and less than 20/70. The third was composed of those with vision less than 20/200, and this was called "blindness".
Although this arbitrary classification served a useful purpose in problems relative to vision, a more reasonable approach is one based on the positive aspects of vision. This indicates how much a patient can see in contrast to his loss, rather than vice versa. It is acknowledged and agreed that from "above normal vision” to “blindness", there is an entire range of vision possibilities. Any vision, no matter how much below normal, is an advantage, especially if it can be corrected to provide more useful sight. The preferred term of classification of deficient visual acuity might be “partial vision”, rather than "sub-normal vision” or "blindness".
Practically everyone with vision desires to use the eyes in perception. And with modern techniques, it is the rule, rather than the exception, that partial vision can be improved with optical aids. This is a great boon to the senior citizen, for as he gets older, more and more of his self sufficiency is dependent on vision. Most of the ability to use the knowledge and adeptness gained from a lifetime of experience is controlled by the eyes ... even though in their uncorrected state they might offer only partial vision.
From a legal standpoint, the difference between “blindness" and "vision" is strictly an arbitrary one based on the presence or absence of useful vision. The fallacy of identifying limited vision as "blindness” becomes more evident when the following fact is considered. Only 25 per cent of the “total blind" people have do perception to light, while the remaining 75 per cent have varying degrees of useful vision, from the bare minimum capable only of giving guidance, to sufficient amounts to allow reading. Many of the senior individuals heretofore classified as “blind" have found that what vision they do have can often be mobilized and made more efficient through the use of various optical aids developed by research in optometry. It is for this reason that the diseases and anomalies that cause impaired vision are of deep concern to the modern optometrist.
One of the problems to be coped with by the ophthalmic professions is the "shock” that occurs when an aging person learns that his vision has become impaired. Much of this is due to a lack of understanding or lack of information as to the tremendous strides that have been made in correction and aid.
In perception, those with impaired vision (especially those requiring optical aids) find a problem in habituation and automazation .... getting used to the new visual demands, so to speak. It is a matter of changing one's habits in order to use new “vision”. This is especially difficult in reading and writing where so much is based on making use of “visual cues” (scanning and tip-off words). Until the individual learns to use his optical aid and automatically “see" without requiring conscious analyzation and interpretation, vision is restricted.
Another major problem for the partially-seeing individual is an inadequate rate of perception for meaningful comprehension in reading. It is not at all uncommon to have the rate of perception reduced to individual letters. And since effective reading requires recognition of a group of letters as a word, a group of words as a phrase, a group of phrases as a sentence, and a group of sentences as a paragraph, those with partial vision find reduced ability a difficult handicap, until proper and effective optical correction is made.
Mobility, the capacity of facility for movement is another essential function that creates a problem for the visually handicapped. Mobility has two components: mental orientation and physical locomotion. Lowenfeld (1950) defined mental locomotion as the “ability of an individual to recognize his surroundings and their temporal or spatial relation to himself", and locomotion as "the movement of an organism from place to place by means of its organic mechanism”. Both are essential.
One of the greatest handicaps to the aging person is the loss of mobility. It is considered by many as the most severe single effect of the loss of sight, and creates conflict and frustration. But although good vision is desirable for mobility, it is not always necessary. Even limited sight, skillfully used, maintains orientation and mobility. As a general rule, if visual acuity is better than 20/400, there is little restriction of mobility.
Magnification makes it possible to correct or increase the resolving power of the eye by increasing the size of the retinal image. This is the basis of most compensating lenses. For example, if the best visual acuity of an individual is 20/80, the relationship makes necessary a magnification of 4-times if the individual is to see normally. Correction can be made in only three ways: by decreasing the distance of the object from the eye, by increasing the size of the object (as enlarging the print in a book), and by angular magnification through the use of one or more lenses in front of the eye.
A COMMUNITY RESPONSIBILITY With the trend moving toward a population of older people in our society, it is only natural that aging has become a community responsibility, as well as an opportunity.
There has been a growing interest in the older citizens, in hundreds of communities throughout the United States. This in turn has been transformed into activity designed to cope with the challenge of aging.
All of our fifty states have now established commissions or committees on aging. Scores of conferences have been held, and geriatric organizations and meetings are becoming more prominent.
The American Optometric Association and many individual optometrists are deeply active, for good vision is a deterrent to many of the worst handicaps of age.
Because optometry's interest is so keen and its function so important in alleviating problems of the senior citizen, it is only natural that many community projects are spear-headed by local and state optometric societies. Among those that have proved successful are: Community clinics for the partially sighted
Community vision screenings are conducted at cost to patients. This is a valuable community project because it enables aged individuals who have reduced or limited incomes, because of their physical limitations, to get good vision care.
Many of these clinics are conducted in cooperation with the public health department, service clubs, and other organizations. Vision clinic programs can be arranged in most communities upon request.
Senior citizen plan for the indigent aged
This is a community project in which citizen's groups and local optometrists cooperate for the welfare of the community's indigent aged. The citizen's groups contribute ophthalmic material, while the optometrists contribute their time. This is a very valuable combination that can benefit a large number of otherwise neglected senior citizens. Eye care programs for homes for the aged
As the title suggests, this program is designed specifically to benefit aged individuals in nursing homes, and shut-ins. This is particularly valuable in smaller communities and smaller homes where regular staff optometrists are not retained.
Where this program operates, local optometric societies provide a panel of local optometrists, who are made available to provide visual screening services for the homes. They also offer consultation as to methods of improvement of lighting conditions, general environment, types of printed material to be provided for reading, and other services helpful to comforting and aiding the partially sighted or blind aged patient. Public information
One of the major problems facing any profession is education of the general public to facilities that are available. The more specialized the profession, the greater the problem. It has been found that the general public is usually several years behind in receiving correct information concerning vision care. Often the information is misconstrued or misinterpreted. There are times, too, where the public believes baseless information from an unreliable source, often nothing more than opinion or superstition.
To counteract the lack of reliable information, the American Optometric Association, through its Committee on Vision Care of the Aging, has established a special panel program available for meetings, radio, and television. Available to service clubs and citizen groups, as well as through the broadcasting media, the program presents information in an interesting and easy to understand manner.
Many optometric societies are also active in providing exhibits for meetings and programs sponsored by various senior citizens' organizations, hobby clubs, county and state fair boards, and other groups interested in the care of the aged.
Material and equipment, such as telescopic spectacles, glaucoma screening devices, books and articles on vision care, vision aids for the partially seeing adult, and specialized and unusual types of lens corrections, are shown. This affords the community an opportunity to see a wide variety of the latest ophthalmic devices.
The programs listed above are currently being used in various communities throughout the United States. Unfortunately, a lack of manpower and funds has prevented their adoption in all communities. In many instances, optometric societies have spearheaded such projects, and have volunteered the services of their members. Most optometric societies will assist in any good vision program that provides general benefit to the aged.
Basic research into new methods and techniques in vision care for the aging is at an all-time high. Many public and private organizations are conducting projects or clinical studies to improve and retain the vision of our most valuable generation our senior citizens.
For the past several years, the American Optometric Foundation has sponsored research fellowships in major colleges of optometry. It has been estimated that at least 30 percent of the Foundation's research has been directly related to the study of vision of the aging patient. Among the projects of major importance now under way is an investigation of motorists' vision, part of which is devoted to the problem of night vision of the aged driver.
The American Academy of Optometry has also been quite active. Each year it conducts a program devoted to encouraging the presentation of research papers by practicing optometrists and faculty members of optometric colleges.
In a recent program, over 20 percent of the papers presented related to vision care of the aging patient. Subjects of research were varied, ranging from a longitudinal study of refractive changes with age, to a discussion of special refractive techniques for decreased vision problems in the aged.