Download - Vision Lecture
-
7/30/2019 Vision Lecture
1/61
Sensory Function: Vision and Aging"
Marlon Maus MD, DrPH, FACS
UC Berkeley School of Public Health
PH 217C,
Tuesday March 5th, 2013
-
7/30/2019 Vision Lecture
2/61
Introduction
Background
Common roots of Public Health and Built
Environment
Health problems in the 21st Century:
effects on older adults
Vision in older adults
Conclusion
-
7/30/2019 Vision Lecture
3/61
-
7/30/2019 Vision Lecture
4/61
Common Roots of PH and Planning
Schilling, Am J of Prev Med, 2005, The public health roots of zoning: In search of active livings legal genealogy
-
7/30/2019 Vision Lecture
5/61
U.S. Population 1900
-
7/30/2019 Vision Lecture
6/61
-
7/30/2019 Vision Lecture
7/61
-
7/30/2019 Vision Lecture
8/61
Leading Causes Of Death United States: 1900
-
7/30/2019 Vision Lecture
9/61
Of the 30 years of increased life expectancy 1890 -1990
5 years can be attributed to medical care.
The rest has come from:
Infrastructure (including housing, clean water)
Public Health (esp. immunization)
Bunker cited in Prescription for a Healthy Nation Farley and Cohn 2004
-
7/30/2019 Vision Lecture
10/61
Leading causes of death United States:
2000
The real
-
7/30/2019 Vision Lecture
11/61
Obese People WorldwidePeople with Diabetes
Worldwide
Worldwide:
25% Obese
7% Diabetic
-
7/30/2019 Vision Lecture
12/61
Obesity: US Adults
-
7/30/2019 Vision Lecture
13/61
Diabetes: US Adults
-
7/30/2019 Vision Lecture
14/61
Childhood obesity Rates of overweight and obesity have quadrupled among 6-11
year olds in the last three decades Over 9 million American children over the age of 6 are
considered obese
Cuts life expectancy by 15 years, qualys by 22 years.
In CA only 25% of 5th graders met state fitness standards: onemile run, pushups and body mass index measurements
Babey SH, et al. (2009.) Bubbling Over: Soda Consumption and Its Link to Obesity in California.UCLA Center for Health Policy Research. ; http://www.cde.ca.gov/nr/ne/yr11/yr11rel95.asp#tab1
-
7/30/2019 Vision Lecture
15/61
Costs of Diabesity
Diabetes consumes $226 billion or 14% of US
healthcare expenditures (2% of GNP)
Obesity consumes $147 billion or 9.1%
Human cost: increased deaths, cancers,
strokes, heart disease, hypertension and
reduced quality of life
5 million blind, leading cause
82,000 amputations per year
-
7/30/2019 Vision Lecture
16/61
Diabesitythe causes
-
7/30/2019 Vision Lecture
17/61
Hardee's introduces new Mega-Calorie
Monster Thickburger
1410 calories! 107 grams of fat! 7.1 hours of walking!
---All for $5.49---
-
7/30/2019 Vision Lecture
18/61
One 20 Ounce Soda Per Day
17 teaspoons of SUGAR
250 calories
50 gallons per person per year
Children and teens 2 cans perday (25% 4 or more!)
No. 1 source of calories in our
diets Soda portion sizes have
increased dramatically.
-
7/30/2019 Vision Lecture
19/61
High Fructose Corn syrup (HFCS)
HFCS: 63 pounds
consumed per
capita
Most commonsweetener in
processed foods
$$$$$ Corn
subsidies make it
cheap!
-
7/30/2019 Vision Lecture
20/61
Fast food industry spent$4.2 billion inadvertisement
$294 million targetingchildren
Federal 5 A DayCampaign $9.55 million
Center for NutritionPolicy andPromotion.$6.5 million
-
7/30/2019 Vision Lecture
21/61
-
7/30/2019 Vision Lecture
22/61
-
7/30/2019 Vision Lecture
23/61
Exercise for the treatment of
depression and anxiety.
International Journal of Psychiatry and Medicine. 2011;41(1):15-28. Carek, PJ et al
Department of Family Medicine, Medical University of South Carolina, Charleston 29406, USA.
Depression and anxiety most
common psychiatric
conditions
10% of American adults
Leading cause of disability
Physical activity as effectiveas medication for depression
-
7/30/2019 Vision Lecture
24/61
Building Design
UC Berkeley School of Public Health. (1959, Welton and Beckett Building )
-
7/30/2019 Vision Lecture
25/61
Stairs Inspired by???
-
7/30/2019 Vision Lecture
26/61
Celebration, Florida
Walkable
Neighborhoods
-
7/30/2019 Vision Lecture
27/61
Walkable Neighborhoods
Residents weigh 7 poundsless than in suburbs
For every 10 minutes a
person spends in a daily
car commute, time incommunity activities falls
10%.
Benefits to the
environment, our health,our finances, and our
communities.
Paris, France
Key elements:
A center
People
Mixed income, mixed
use
Parks and public space
Pedestrian design
Schools andworkplaces
-
7/30/2019 Vision Lecture
28/61
Health problems in the 21st Century:
Diabesity and depression epidemics
Common roots of Public Health andBuilt Environment
Collaborations between PH and
Planners
What is the relation to vision????
First we shape our buildings;
thereafter, they shape us.Winston Churchill
-
7/30/2019 Vision Lecture
29/61
>80 million people have potentially blinding diseases
Blindness or low vision affects 3.3 million Americans 40 years and older
Economic impact:
>50 billion dollars in 2002 for health care for individuals with visual disorders (bothdirect and indirect costs)
Estimate: by 2030 the number of visually impaired and legally blind individuals inthe US may double
Ranks behind arthritis and CVD as the third most common chronic cause of impairedfunction in persons older than 70 years.
Three fourths of all blindness and vision impairment is either preventable ortreatable
Two-thirds of all blind individuals in the world are female Most are older than 50 years
90% of blind people live in poverty
British Columbia Centre for Epidemiologic & International Ophthalmology (BCEIO), 2000.Healthy People 2010 http://www.healthypeople.gov/document/html/volume2/28vision.htm
Statistics
-
7/30/2019 Vision Lecture
30/61
Behavioral Risk Factor Surveillance System (BRFSS)
Since 1984 survey of civilian, noninstitutionalized U.S. adults aged 18 years
or older
350,000 people surveyed
State-based telephone surveillance system. Vision data collected from 19 states that used the supplemental Vision
Impairment and Access to Eye Care Module (Vision Module)
Provides information about access to eye care, health status, comorbid
conditions among older adults.
Summarizes the prevalence of vision loss and eye diseases reported bypeople aged 65 or older
Statistics BRFSS
-
7/30/2019 Vision Lecture
31/61
Findings:
Prevalence of blindness and vision impairment increases
rapidly with age among all racial and ethnic groups, particularly
among people older than 75 years.
Cases of early age-related macular degeneration are expected
to double by 2050, from 9.1 million to 17.8 million for those
aged 50 years or older
Cases of diabetic retinopathy among people aged 65 or older
are expected to quadruple by 2050, from 2.5 million to 9.9
million
Statistics BRFSS
S i i BRFSS
-
7/30/2019 Vision Lecture
32/61
Statistics BRFSS
-
7/30/2019 Vision Lecture
33/61
Visual Loss is Associated With.
Decreased quality of life
Changes in independent living
Increased injury and falls
Increased depression
Increased isolation
Untreated poor vision is associated with cognitive decline and onset
of dementia
Death
Rogers, MA, Langa KM. Untreated poor vision: a contributing factor to late-life dementia. Am. J.
Epidemiol. 2010 171:728
-
7/30/2019 Vision Lecture
34/61
Visual Impairment and Falls
Falls in older adults Occur in 35-40% of individuals
Responsible for 90% of fractures in the elderly
Clinical risk factors include vision impairment, gait
abnormality and muscle weakness
Fractures associated with
Poor visual acuity in older women
Poor contrast sensitivity Decreased depth perception
Binocular visual field loss
Coleman AL, el al. J Am Geriatr Soc. 2009; 57:1825. Patino CM el
al. Ophthalmology. 2010; 117:199.
-
7/30/2019 Vision Lecture
35/61
23% ignorant that early eye disease
has no noticeable symptoms 27% believe must wait until
symptoms before eyes tested
51.4% believe mostly under 40 y/o
need eyes checked 30% of people surveyed listed
blindness as their greatest fear
second to cancer (43%)
(Vision 2020 Australia)
Misconceptions Among Elderly
-
7/30/2019 Vision Lecture
36/61
Normal Changes of Aging
Physical changes related to Normal aging ARE NOTdisease
Changes occur in most body systems to include:
Sensory SystemBrain and Central Nervous System
Muscles and Bones
Digestion
Heart/Circulatory System
Respiratory System
-
7/30/2019 Vision Lecture
37/61
Vision Not all older people have impaired vision!
Normal visual changes that occur with aging:
Presbyopia: loss of ability to see items that are close upbegins in the 40s
Decreased contrast sensitivity caused by retinal changes
Decreased dark/light adaptation Night vision not as acute
Delayed glare recovery.
Vitreous Humor Haziness Flashing Lights Moving Spots
Color
Lens of eye yellows making it more difficult to see redand green colors
Discrimination as cones
Visual Field Size 1 to 3 degrees per decade
-
7/30/2019 Vision Lecture
38/61
Common Eye Diseases in the United
States Associated with Vision Loss In the U.S., the most prevalent etiologies of
vision loss in persons 40 years and older are:
AMD (Age-Related Macular
Degeneration): 1.6 million age >60 Diabetic Retinopathy: 5.3 million
Cataracts: 20.5 million age >65, most
prevalent eye disease in older persons
and are the leading cause of blindness
worldwide Glaucoma: 2.2 million diagnosed, 2
million NOT diagnosed
Vision Problems in the USA NEI/PBA Report: Eye Diseases
-
7/30/2019 Vision Lecture
39/61
ARMD: leading cause of legal blindness inthe USA
9 million people have some form ofARMD
1.6 million have advanced disease
accounts for 54 % of all blindness
Age is the greatest risk factor
55-64: one percent are affected
65-74: four percent are affected
>75: thirty percent are affected
Age-Related Macular Degeneration
(AMD)
-
7/30/2019 Vision Lecture
40/61
AMD Other risk factors
Smoking. Family history.
Obesity.
Race. Caucasians are more
likely to lose vision fromAMD.
Women tend to live longer
than men, F:M lifetime risk2:1
6% for females
3% for males
-
7/30/2019 Vision Lecture
41/61
AMD Symptoms
Asymptomatic initially
No pain.
Blurred vision.
Loss of central vision (reduced visual acuity causingdifficulties with detail discrimination)
Metamorphopsia (i.e., distortion of objects)
Central scotomas
Increased glare sensitivity
Contrast sensitivity
Decreased color vision.
Key: Peripheral vision remains intact, and the patientdoes not progress to total blindness
-
7/30/2019 Vision Lecture
42/61
-
7/30/2019 Vision Lecture
43/61
AGE-RELATED MACULAR DEGENERATION
Damage of the central retina,or macula
Two types
Nonexudative (DRY ) -
drusen (hyaline deposits)
and areas of alternatingbands of depigmentation/
hyperpigmentation in the
retinal pigmented
epithelium
Exudative (WET) -neovascularization
-
7/30/2019 Vision Lecture
44/61
Treatment options:
Age-related eye disease study (AREDS): high-dose regimen of vitamin
C, vitamin E, beta carotene, and zinc shown to decrease risk of
developing vision loss caused by advanced AMD in patients with
intermediate AMD or advanced AMD in one eye.
Patients without AMD and those with early AMD did not benefit fromsupplementation.
Laser surgery.
Photodynamic therapy and intravitreal injections of antivascular
endothelial growth factor and corticosteroids have shown promise in
treating subsets of patients with macular degeneration. Control of vascular disease risk factors
Exercise to increase circulation
Sunglasses for UV light protection
AMD
-
7/30/2019 Vision Lecture
45/61
AMD
What can you do? Eat a healthy diet
Dont smoke, or stop
smoking Maintain normal
blood pressure
Maintain a healthy
weight Exercise
-
7/30/2019 Vision Lecture
46/61
Increased ocular pressure that can
damage the optic nerve in the eye.
Symptoms:
Loss of peripheral vision that can lead
to decreased central acuity
Difficulty functioning in dim light
Decreased contrast sensitivity
Glare disability
Decreased dark/light adaptation
Glaucoma can develop in one or botheyes.
Primary open-angle glaucoma is the
most common
Glaucoma
-
7/30/2019 Vision Lecture
47/61
Glaucoma
Same scene as viewed by a
person with glaucomaNormal vision
-
7/30/2019 Vision Lecture
48/61
Glaucoma Risk factors: age > 40, hispanic, african
american, family history, diabetes, HTN, eye
injury, myopia, chronic steroids
Treatment: Topical prostaglandins, beta blockers,
adrenergics, carbonic anhydrase inhibitors
Oral medications
Laser therapy
Filtering surgery
About 50% of individuals with glaucoma are
not diagnosed
-
7/30/2019 Vision Lecture
49/61
Glaucoma
What can you do?
People at higher risk
should get a
comprehensive dilated
eye exam every one to
two years or as instructed
by your eye care
professional.
Cataract
-
7/30/2019 Vision Lecture
50/61
Cataract
Cataract prevalence increases with
increasing age 2.6% in the age range 60-69
17% in individuals > 80
Females 20% more likely than
males
1/3 of patients with cataract
had an unmet need for surgery
Surgery for cataract accounts for
60% of Medicare expenses for vision
Richter, CM et al. Ophthalmology. 2009; 116:2327.
Cataract
-
7/30/2019 Vision Lecture
51/61
Cataract Risk factors and associations:
Age
Female sex
Corticosteroid use
Diabetes
Smoking
Myopia,
Ocular UV-B light exposure
Bmi >35
Lack of health insurance
Low education, Income 5 years ago
-
7/30/2019 Vision Lecture
52/61
Cataract Opacifications of the crystalline
lens of the eye
Symptoms:
Decreased visual acuity,
decreased color perception,
decreased contrast sensitivity,and glare disability
Cloudy or blurred vision
Colors that may not appear as
bright as they once did.
Glare
Poor night vision
-
7/30/2019 Vision Lecture
53/61
Cataract
Same scene as viewed by a
person with cataract
Normal vision
C
-
7/30/2019 Vision Lecture
54/61
Treatment:
Alter prescriptions
for eyeglasses or
contacts,
Surgical extraction
What can you do?
Eat a healthy diet.
Wear sunglassesand a brimmedhat whenoutdoors.
Dont smoke.
Cataract
John Taylor, the flamboyant 18th-century
British oculist
-
7/30/2019 Vision Lecture
55/61
Diabetic Retinopathy
Leading cause of new blindness
in U.S. In adults 20 to 74 years of
age.
Rapid increase in chance if
diabetic for 15+ years Retinal vessels weakened by
sorbitol aneurysms
leakage retinal damage
Other complications:
Secondary glaucoma
Retinal detachment
-
7/30/2019 Vision Lecture
56/61
Diabetic Retinopathy
Symptoms
No early warning signs or symptoms
Decreased visual acuity, contrast
sensitivity, color perception, and
dark/light adaptation, glare disability,distortion, and scotomas
Treatment options
Early detection and timely treatment can
reduce the risk of vision loss.
Laser photocoagulation
Surgery
-
7/30/2019 Vision Lecture
57/61
Diabetic Retinopathy
Same scene as viewed by a
person with diabetic retinopathyNormal vision
-
7/30/2019 Vision Lecture
58/61
What can you do?
Control your ABCs - A1C,
blood pressure, and
cholesterol.
Take your medications as
directed.
Maintain a healthy
weight.
Exercise. Dont smoke.
Have a dilated eye exam
at least once a year.
Diabetic Retinopathy
-
7/30/2019 Vision Lecture
59/61
Screening The American Academy of Ophthalmology (AAO)
suggests comprehensive medical eye evaluations:
For non-diabetics
Every 2-4 yrs for patients 40 to 54 years of age
Every 1-3 years for patients 55 to 64 years of age
1 or 2 years for patients older than 65 years.
For diabetics
Normal examination or minimal nonproliferative
retinopathy annually
Mild to moderate nonproliferative retinopathy
without macular edema - every 6 to 12 months
Severe nonproliferative diabetic retinopathy
every 2 to 4 months
E l ti
-
7/30/2019 Vision Lecture
60/61
Evaluation
Check visual acuity usingstandard Snellen chart
An impairment of 20/50 or
worse or a one-line difference
between the eyes shouldwarrant referral
Visual fields
Fundoscopic exam
Amsler Grid
-
7/30/2019 Vision Lecture
61/61
Conclusions