Article Figures & Tables
Tables
- Table 1:
Outcomes of screening for impaired vision in community-dwelling adults aged 65 years and older in primary care settings
Outcome and follow-up period No. of studies Cases/screened patients Cases/control patients Relative risk (95% CI) Absolute difference per 1000 (95% CI) Quality of evidence Falls (self-report falls as a proxy for fractures)
Follow-up: range 12 mo to 18 mo2 RCTs Day et al. (28) Any fall* 691/547 757/543 0.88 (0.79 to 0.98) 163 fewer (28 to 292 fewer) ⊕○○○
Very low†Falls requiring medical treatment* 49/547 75/543 0.65 (0.46 to 0.91) 48 fewer (12 to 75 fewer) Newbury et al. (29) Any fall 4/45 3/44 1.30 (0.31 to 5.49) 20 more (48 fewer to 305 more) Vision-related function and quality of life (assessed with NEI-VFQ-25; scale from 0 to 100 (22))
Follow-up: median 3.9 yr1 RCT n = 829 n = 978 – MD 0.4 units higher (1.25 lower to 2.05 higher) ⊕⊕○○
Low‡Change in visual acuity with objective screening (mean change in high-contrast distance visual acuity) (19), (26)– (28)
Follow-up: median 12 mo4 RCTs n = 764 n = 579 – MD −0.01 logMAR better (−0.05 better to 0.03 worse) ⊕⊕⊕○
Moderate§Impaired visual acuity with objective screening (< 20/40 distance visual acuity: bilateral) (22), (26)
Follow-up: range 12 to 47 mo2 RCTs 290/913 394/1054 0.82 (0.66 to 1.02) 67 fewer (from 7 more to 127 fewer) ⊕⊕○○
Low¶Self-reported vision problems (primarily questionnaire-based impairment tests) (20), (21), (23)– (25), (29)– (33)
Follow-up: median 20 mo10 RCTs 1042/3767 (27.7%) 1296/4916 (26.4%) 0.97 (0.90 to 1.05) 8 fewer (from 13 more to 26 fewer) ⊕⊕⊕○
Moderate**Note: CI = confidence interval, MD = mean difference, NEI-VFQ-25 = National Eye Institute Visual Functioning Questionnaire 25, RCT = randomized controlled trial.
↵* The authors of the study (28) of an intervention to prevent falls in older adults, which included a vision component, showed that only 26 of the 547 participants who were assigned the vision component actually received treatment; therefore, it is unlikely that the vision treatment had the effect on falls quoted in this table. In particular, the authors of this study ascribe differences in the rate of falls to the exercise component of the intervention. In addition, visual acuity improved marginally among the control group and not at all among the intervention group. No other differences were seen in vision measures, which makes the conclusion that vision screening had an impact on falls unlikely.
↵† Very serious concerns about an unclear risk of bias, owing to inconsistency from reliance on one trial (28); about indirectness resulting from surrogate outcomes — 75% of participants received an intervention that could have confounded risk; and about imprecision, as the optimal information size was not met.
↵‡ Serious concerns about high risk of bias for not blinding personnel, patients and outcome assessors; about high and differential attrition [42% v. 32% of those alive]; and about inconsistency arising from unknown effects from other studies.
↵§ Moderate concerns about four RCTs (19), (26)– (28) with unclear risk of bias that used multiple objective screening tools and indirectness, as two of the RCTs (19), (26) included many patients who were receiving home care, and one (19) provided an additional intervention that may have influenced results.
↵¶ Serious concerns about inconsistency in one trial (26) and about imprecision, as the optimal information size of about 200 total events with a control event rate of 0.28 was not met.
↵** Moderate concerns about risk of bias for not blinding personnel or patients in any study, about attrition in one study, (23) and about allocation concealment. Although there was some inconsistency (2 CIs did not overlap; I2 = 29%), there were no serious concerns regarding this domain.
- Table 2:
National and international guidelines on screening for impaired vision in older adults in primary care
Organization Recommendation Canadian Task Force on Preventive Health Care (current guideline, 2018) Recommends against screening community-dwelling adults aged ≥ 65 yr for impaired vision in primary care settings (weak recommendation, low-quality evidence). This recommendation applies only to community-dwelling adults aged ≥ 65 yr who are not known to be at increased risk for impaired vision. US Preventive Services Task Force (2016) (36) States that current evidence is insufficient to assess the outcome-based balance of risks and benefits of screening for visual acuity in primary care settings for the improvement of outcomes in asymptomatic adults aged ≥ 65 yr who do not present to their primary care clinician with vision problems. No recommendation made for or against screening. Canadian Ophthalmological Society (2007) (37) Recommends screening in asymptomatic low-risk patients aged > 65 yr at least every two years. Patients aged > 60 yr at higher risk of visual impairment should be assessed more frequently and thoroughly; at least annually. American Academy of Ophthalmology (2015) (38) Recommends comprehensive eye examination that includes visual acuity testing and dilation every one to two years for all adults aged ≥ 65 yr who are not known to be at increased risk for impaired visual acuity and do not have risk factors, or more frequently if risk factors are present. Canadian Association of Optometrists (2013) (39) Recommends annual eye examination for adults aged ≥ 65 yr. American Optometric Association (2015) (40) Recommends annual comprehensive eye and vision examinations for persons aged ≥ 65 yr for the diagnosis and treatment of sight-threatening eye conditions and the timely correction of refractive errors.
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