Vision is arguably the most important sense among the five senses. We rely on our sense of sight to interpret up to 80% of all impressions about our surroundings. A good vision is crucial to many of the daily tasks we perform, from reading, driving, keeping safe, to telling a familiar face from that of a stranger, and admiring natural beauty.
With age unfortunately often comes sight impairment. Eye diseases such as age-related macular degeneration, cataract, glaucoma, or diabetic retinopathy are more common among the elderly. A study reports that 1 in 3 adults above the age of 55 has one or more eye problems in at least one eye. The ratio is estimated to increase to 1 in 2 seniors above the age of 75.
In this article, we cover the most common eye diseases affecting the elderly, including causes, symptoms and treatment. We also go over measures to prevent or delay these conditions for seniors, as prevention is better than cure in most cases. Let’s start with finding out how eyesight deteriorates with age.
1. How ageing affects vision
As we get older, your body starts to work more slowly and less efficiently. However healthy we are, we cannot fight the lifelong impact of the wear and tear process. The same principle applies to our vision. Various issues can arise. The lenses in the eyes can become less flexible or turn cloudy and senile, leading to cataracts. Part of the retina may become thinner, altering our vision and increasing the risk of retinal detachment. The amount of rod cells in the eyes can decrease, leading to sluggish adjustment and focus in dim light.
Vision acuity can also be compromised as a result of other medical diseases, often a chronic systemic condition, and medication usage to manage such conditions. Diabetes, which is more common among the elderly than younger adults, can lead to an eye-related complication known as diabetic retinopathy, affecting up to half of the seniors with the condition within 10 years of diabetes diagnosis.
Lifestyle habits can also play a role. Jobs that are visually demanding or involve eye hazards may take a toll on one’s eyesight in older years. Overuse of contact lenses in younger years may damage the eyes later in life. Frequent exposure to strong sunlight can also lead to faster and more severe vision impairment. And smoking has been consistently linked to poorer eye health as one ages.
Visual problems often start in the mid-40s and become more pressing as the years pass. People often notice subtle changes at first, for example it takes longer to adjust your eyesight when you move from a brightly lit room to a dimly lit room. Then you may find reading or identifying details is more comfortable when holding an object further away or with the help of a magnifying glass. In serious cases, vision problems may prompt you to visit the phthalmologist.
2. How impaired vision affects the elderly’s quality of life
Since we perceive the majority of sensory cues through the sense of sight, our quality of life can be negatively affected by visual impairment. Among the elderly, this can pose danger, including the risk of falls and injuries, and even mental health issues.
Older people with impaired vision are almost twice more likely to experience repeated falls and hip fractures. The impact is aggravated by the fact that these seniors are also more likely to reduce their daily activities due to the fear of falling, which increases falling risk.
Adding in other challenges of the aged including gait and balance problems, hearing difficulty, and sarcopenia, it is no surprise that managing personal activities such as bathing, eating, moving around can become overwhelming for seniors with poor vision. Over time, without support from families and loved ones, the fear of embarrassing oneself, getting hurt and the loss of independence and dignity can lead to loneliness, depression and anxiety. This psychological impact of impaired eyesight among seniors has been confirmed by various studies.
3. Common eye conditions among the elderly
Eye conditions can affect people of any age. However, individuals above 50 are disproportionately affected. Very few elderlies can maintain 20/20 vision without the help of spectacles. Some people can see far objects clearly but are unable to read or focus on near objects, this is known as farsightedness or hyperopia. Others can focus on near objects easily but fail to focus on far objects, which is known as near-sightedness or myopia. In addition to vision acuity, changes to the structures of the eyes can create vision problems.
Common eye diseases among the elderly include:
- Age-related farsightedness, or presbysia
- Age-related macular degeneration (AMD)
We will discuss each of them below.
A cataract refers to the formation of a cloudy and dense area in the lens of the eye, due to the clumping of proteins. As a result, light transmitted to the retina through the lens is obscured, hindering the rendition of clear images. The condition often develops slowly and progressively over a number of years, unless it occurs as a result of diabetes.
There are many causes of cataracts, including excessive production of oxidants, UV radiations, trauma, etc. However, age is the most common cause and adults over the age of 50 account for the majority of cases. Doctors refer to cataract caused by ageing as senile cataract.
Cataract is highly prevalent among the elderly in Singapore. It is reported to affect 80% of people above the age of 60, and 95% of people above the age of 70. Though highly treatable, the danger lies in the fact that up to two thirds of those with significant cataracts are unaware of their condition and thus do not seek treatment. Without prompt intervention, cataract can lead to irreversible visual impairment and eventually blindness.
As cataract is severely under-diagnosed, it is important to be aware of the symptoms and seek treatment early. Get an eye check if you experience one of the following symptoms:
- Blurred vision
- Constantly changes in prescription glasses
- Enhanced sensitivity to glaring
- Seeing ‘halos’ around lights
- Double vision
- Faded colours
- Night blindness
To diagnose cataract, an optometrist or ophthalmologist typically conducts the following tests:
- Visual acuity test, to evaluate the sharpness of vision.
- Slit-lamp exam, to look into and detect irregularities in the lens and other small structures of the eye.
- Retinal exam, which involves dilation of the retina with eye drop, to examine the back of the eye.
The doctor will discuss medical history with the patient, to find out if the patient has other systemic condition (e.g., diabetes) or risk factors, before recommending a treatment plan. In complex cases, tests to rule out other causes such as glaucoma may also be performed.
Surgery is the only way to treat cataracts. However, the doctor may suggest non-surgical symptomatic treatments including anti-glare-coated sunglasses and high-power spectacles if symptoms do not interfere with your daily life. However, if the cataract is mature, medicine will not work. Surgery is the only and most efficient option.
There are 2 main types of surgery:
- Phacoemulsification, commonly known as ‘phaco’: a procedure to break the cloudy lens which will then be removed from the eye. An artificial lens will then be inserted
- Extracapsular surgery: the entire cataract is removed and replaced by an artificial lens.
Most patients recover and regain visual acuity within a few days.
A regular eye exam helps in detecting and treating cataracts at an early stage, especially if you experience symptoms or carry risk factors such as diabetes. Eye check-up is important for anyone above the age of 50, even without symptoms and risk factors, as the condition may progress slowly without apparent signs at first. Additionally, a healthy diet and lifestyle can be beneficial for the eyes, including:
- Eating antioxidant-rich fruits and vegetables
- Keeping your weight in check
- Keeping diabetes and other chronic condition in control
- Avoiding or quitting smoking
- Wearing sunglasses to protect eyes from UVB
Glaucoma is an eye condition caused by an abnormally high intraocular pressure, leading to erosion and damage to the optic nerve which provides visual feed to the brain from the eyes. Destruction of optic nerve tissue may lead to decreased visual acuity or even blindness.
The risk of glaucoma increases with age, especially after the age of 60 and heightened among those with diabetes. It is estimated to affect 10% of Singaporeans over the age of 70. In most cases, vision loss often happens slowly and painlessly, resulting in lack of awareness among patients. However, glaucoma may also happen suddenly and be treated as an emergency. In both scenarios, the damages caused by glaucoma are often irreversible. For this reason, if left unmanaged, the disease can cause permanent blindness.
Gradual vision loss, especially peripheral vision (side vision), is the only obvious symptom of glaucoma. Other symptoms are non-specific, which may include:
- Seeing halos around lights
- Sudden and severe pain in eyes
- Redness in eyes
- The abrupt blurring of vision
- Experiencing colored rings around lights
The following tests are usually performed when a person is suspected of having glaucoma:
- Tonometry, to measure pressure inside the eyes.
- Retinal and imaging tests, to check for damages to the optic nerves.
- Perimetry test (visual field test), to check the area of vision loss
- Pachymetry test is a medical device used to measure the thickness of the eye’s cornea
- Other tests to determine the types and extent of glaucoma.
The objective of treatment for glaucoma is to improve fluid drainage from the eye, thereby reducing intraocular pressure and preventing or delaying vision loss. Options vary according to the type and severity of glaucoma, whether it is an emergency incident, and the patient’s medical history. The main treatment includes:
- Eye drops
- Surgery (laser peripheral iridotomy and other techniques)
Regular follow-ups are often required to actively monitor the progression of glaucoma. To successfully manage glaucoma in the long-term, it is important to pay attention to:
- Controlling its causes, e.g., diabetes
- Preventing its complications, such as making home safe to reduce fall risks for your elderly loved ones
- Getting help in daily life activities and to overcome the psychological impact induced by poor vision
Glaucoma can only be prevented by having a regular eye check-up and identifying it at an early stage. Prevention and early detection is highly recommended for individuals with existing diabetes or family history of glaucoma.
6. Presbyopia (Age-related farsightedness)
Presbyopia is the most common eye disorder associated with ageing. It leads to a slow decline in the ability of the eye to focus on near objects. In presbyopia, the lens loses its flexibility, thus fails to bend and focus light properly on your retina.
Ageing may induce changes in the capsule, lens, and zonular fibers in the eyes, leading to presbyopia:
- Lessened elasticity of the lens capsule
- Reduced distance between the lens equator and ciliary muscle
- Sclerosed lens tissue
A misconception exists that people with myopia (short-sightedness) will be less likely to develop farsightedness in old age, or even regain perfect eyesight, because the two conditions cancel each other out. This is not true. A myopic person can still develop presbyopia and will need intervention for both conditions.
Presbyopia can be identified quite easily. When you read or watch TV, you may notice:
- Difficulty reading small print
- Feeling eye strain while reading
- The need for brighter light to read
- Difficulty focusing on near objects
There are a few options to treat and manage presbyopia, ranging from using glasses to surgery:
- Prescription glasses
- LASIK, a non-invasive eye surgery to correct presbyopia using laser
- Conductive keratoplasty, correcting farsightedness using radiofrequency energy
- Intraocular lens implant
Though presbyopia can’t be avoided, you can take measures to detect and correct it early, as well as protecting your eye health in general. From the age of 40, make sure you
- Go for regular eye examination
- Keep a check on blood pressure and diabetes
- Use good light while reading
- Wear the right strength of eyeglasses if you have existing vision problems
- Consume diet that contains antioxidant
7. Age-related macular degeneration (AMD)
Age-related macular degeneration is a chronic eye condition that affects the macula, which contains the light-sensitive cells at the back of the eye. This results in impairment of central vision, which is essential to see shapes, colours, and details clearly. AMD causes difficulty in reading, recognising faces, driving, etc. Vision loss due to AMD is permanent and can lead to blindness eventually.
As the name suggests, age is the primary risk factor for this condition. The majority of cases happen after the age of 60. Other risk factors include smoking, obesity, a diet high in saturated fat, high blood pressure, cardiovascular disease, and a family history of AMD.
Loss of central vision can manifest with any of the following symptoms:
- Gradual decline in the ability to see objects clearly
- Distorted vision (e.g., distorted shapes of objects, straight lines appearing wavy)
- Difficulty in distinguishing colours (e.g., telling one dark colour from another dark colour)
- Blurring, dark or empty area in the centre of vision
Doctors diagnose AMD by taking medical history, conducting a complete eye exam and looking into the back of the eye. One of the key tests is the Amsler grid test which involves showing a grid to the patient. If AMD is present, the patient will see straight lines on the grid appearing wavy or see dark spots or holes on the grid.
Once central vision is lost, it can never be recovered. Only 10% of AMD cases which are categorised as ‘wet AMD’ can be intervened with medical treatment. This type of AMD is caused by leaking of fluids into the macula and can be treated with pharmaceutical drugs (delivered through injections) and/or surgeries. Patients may require a few injections to control the condition.
There is no cure for the remaining 90% cases (known as dry AMD). Patients can use magnifiers to help with their reading. Dietary changes may be recommended to help prevent or delay further vision loss, as evidenced in a number of recent studies. Lutein and zeaxanthin (available in green leafy vegetables and egg), Vitamin C, vitamin E, Zinc are thought to benefit people with AMD. Check with your doctor for the recommended supplements for your case.
As age-related macular degeneration can be caused and aggravated by lifestyle and medical risk factors, it is important to make lifestyle changes and keep a tab on chronic conditions that are associated with AMD.
The best way to prevent AMD is to control risk factors that are in your control, such as quitting smoking, eating an eye-healthy diet, wearing sunglasses when under strong sun, managing your weight and cardiovascular conditions. Similar to other eye diseases, going for eye examination regularly is crucial for early diagnosis. You may also obtain a print of the Amsler grid to self-test your central vision.
8. Takeaway Message
Our eye health is essential to our well-being and quality of life. For elderlies, poor eyesight can pose serious complications, ranging from difficulty moving around to injury risk and mental health disorders.
Awareness of age-related eye conditions and individual’s risk factors, regular eye check-ups are important tools to help mitigate vision related problems among the elderly. Seniors above the age of 60 in Singapore are encouraged to take part in the national program Project Silver Screen to have their eyes examined. Early detection is protection.