Patient Care

This vignette provides a good example in older people of the challenges of managing age-related macular degeneration, the most common cause of vision loss in people over age 50 in the United States if left untreated.1 The patient’s complaints, while nonspecific, indicate difficulties with near (reading) and distance (going down stairs in dim light) activities. The patient’s recall of a diagnosis of both cataract and macular degeneration demonstrates not only good communication between the patient and her comprehensive ophthalmologist, but also the challenges of multiple diagnoses in older people. Since some degree of cataract can be ubiquitous, almost any patient over the age of 70 might recall such a diagnosis. A potential danger is that such patients subsequently may ascribe any vision loss to the incorrect perception that the vision loss is from progression of cataract. In this case, the patient believed that recent vision loss ‘‘must’’ be, at least in part, from the cataract. We learn from the physical examination that her cataracts can be seen with a slit-lamp biomicroscope but are not visually significant and not the cause of her recent vision loss. Furthermore, the patient believes that vision loss is an inevitable symptom of aging rather than ascribing a specific diagnosis to her visual impairment. While vision loss may become more common with age, older patients should realize that aging, in and of itself, is not a cause of vision loss. Rather, specific diagnoses that become more prevalent with older age are reasons for vision loss. Older patients should not just accept vision loss as an inevitable sign of aging but should pursue with an ophthalmologist what the cause of vision loss is, especially since most incidents of vision loss in older people can be treated.

The case also demonstrates the anxiety that can come with a diagnosis of agerelated macular degeneration (AMD). Until a few years ago, most people who developed the neovascular or ‘‘wet’’ form of AMD lost substantial vision, first in one eye, and then often in the other eye within a few years, resulting in tremendous loss of function. Because there are approximately 200,000 new cases of neovascular AMD in the United States each year,2 it is common for many older patients to know someone or many people who have lost much of their independence and daily functioning from vision loss due to AMD. Thus, it is important for health care professionals who interact with older people to understand that the risk of vision loss from the neovascular form of AMD can be greatly reduced with the use of certain intravitreal anti-VEGF drugs based on randomized clinical trials evaluating ranibizumab,3,4 so that this information can be relayed appropriately to the older population.

The patient was also taking a dietary supplement formulation (a multivitamin with lutein) that had not been tested in randomized clinical trials to show any efficacy. This situation is also not uncommon but is important for anyone caring for older people to understand. Specifically, the Age-Related Eye Disease Study (AREDS) showed that a specific dietary supplement formulation might reduce the risk of progression to the advanced stage of AMD (usually neovascular