TOPIC 2: GERIATRIC EYE EXAMINATION

Question 1

What are some common ocular side effects of medications taken by the elderly? (no need to know the medication names, but should know things like vortex keratopathy, maculopathy dry eyes etc)

Answer 1

-Beta-blockers prescribed for systemic hypertension can cause dry eyes
-Antiarhythmic medications can cause vortex keratopathy in cornea
-Reduced accommodation for the age
-Deposits on cornea or crystalline lens
-pigmentary changes in macula
-Poor tear quality (can also be due to meibomian gland dysfunction)
-Colour vision deficiency / change in colour perception
-Both red/green and blue/yellow deficiencies may manifest.
-The presence of a CV deficiency may indicate maculopathy, since that’s where the cone photoreceptors are found.

Question 2

What is radical retinoscopy useful for?

Answer 2

The reflex from the patient’s pupil may be difficult to observe due to the presence of media opacity and pupil miosis
radical ret can overcome this (shorten WD)

Question 3

How to compensate the final retinoscopy result if you performed retinoscopy without a working distance lens?

Answer 3

Always subtract the Working distance value from the neutralized lens power to get the final value

WD lens calc: 1/WD (in m)

e.g
NR= -3.00DS; WD= +1.50 DS
GR= (-3.00) - (+1.50)= -4.50DS

Question 4

What modifications can we make to subjective refraction procedure if our patient is elderly?

Answer 4

-Ask patient to read out only specific letters (e.g. letters they got wrong the first time) when you are deciding whether to give/remove the lens.

• be sensitive to how quickly the patient reads out the letters. The more hesitant he is, the less clear the letters are.

-Use +/- 0.50Ds instead of +/- 0.25Ds
miotic pupils have increased depth of focus so the patient may not notice any diff if you use +/-0.25D steps.

• avoid using duochrome
  In elderly, miotic pupils and cataract produce unreliable results

-Use a longer presentation time for JCC to allow them more time to compare
If your hands are unstable, try to use “O” or “C”, or a phoropter
Ensure the O or C letters are 2 lines above patient’s threshold.
For example, VA = 6/9. The JCC target should be around 6/15 size or else it is too difficult for patient to appreciate the diff

-Binocular balancing is not necessary if the patient has no accommodation.

-For near addition, only switch on near light if that is the patient’s habitual practice. Remember to check range of clear vision and refine the near add.

Question 5

How to prescribe optical rx for elderly? understand why patients may complain about a new rx

Question 6

How to modify rx for adaptation purposes

Answer 6

• Any changes to rx (i.e. possibly due to cataract) can cause adaption problems to the elderly and increase the risk of falling. Therefore limit rx changes to 0.75D or less

-Changes in cylinder power should be LIMITED to no more than 0.75DC and preferably 0.50DC if possible.

-Give the reduced cyl in spherical equivalent. E.g.:
Habitual: +0.50/-1.00 x 170
Subj Refraction: +1.00/-2.00 x 170
Prescribe: +0.75/-1.50 x 170

-When checking near add, always refer to these information:
Patient’s age
Current distance and near rx
Near working distance and the type(s) of correction they are using or intending to use
(e.g. SVN, PAL lens)

-Educate your patient on potential adaptation issues (e.g. “swim” effect, less bright and clear etc.)

-For PALs, remember that even if patient orders the same design of PAL as his current pair, a change in distance or near prescription, or a change in frame can also affect the overall ‘feeling’.

-There is an increased risks of falls in elderly with progressive lenses. Thus, do NOT recommend progressive lenses unless they are existing users.