‘Vision Loss in Later Life is not Normal’: Vision Loss Projected to Rise in Older Adults

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As people approach 40, rods in the eyes begin weakening, tear ducts don’t work as well leading to dryer eyes, and lenses become more yellow or opaque. Inevitably, vision deterioration affects an individual’s daily lifestyle, from driving and working to reading and cooking. Worse, vision loss in older adults is projected to increase in prevalence in the next few decades.

The Baby Boomer generation, born between 1946 and 1964, is now transitioning into older age. In the year 2029 when all Baby Boomers will be ≥65 years old, the Census Bureau predicts this generation will have a population of 61.3 million.¹

With a greater prevalence of vision loss looming, issues with access to eye care must be addressed. People can either have irreversible vision loss or modifiable conditions that are common causes of vision loss, including uncorrected refractive error, which is when someone needs glasses, and cataract, which is treated with surgery.

Along with uncorrected refractive error and cataracts, diabetic retinopathy and glaucoma—2 common eye diseases—can be prevented with early detection and treatment.

“One of the things I’d like to emphasize and one of the areas of need is greater access,” said Joshua R. Ehrlich, MD, MPH, from the Kellogg Eye Center at the University of Michigan. “And this is true in the United States and globally. There’s really [a need for] greater access to care for these two readily modifiable conditions.”

An individual’s neighborhood, health literacy level, and access to care are all important factors in the association between vision loss and socio-economic status.

Race and ethnicity also affect vision loss. For example, glaucoma is an eye disease common in minority groups in the US. African Americans are 3 to 4 times more likely to have open-angle glaucoma than non-Hispanic whites.² Yet, the reason why glaucoma is more prevalent in African Americans is not completely understood.

“There may be some issues of ancestry or heritability that are at play,” Ehrlich said. “But there may also be issues of exposure, environmental exposures, for example, that differentially affect people from one group or another. What we do know is that the risk of developing certain eye conditions like glaucoma, diabetic retinopathy, for example, is significantly higher in individuals from minority racial and ethnic groups.”

Epidemiological transitions, driven by changing population patterns as more people reach adulthood and extend life expectancy, have contributed to a rise in non-communicable diseases and disabilities, including forms of vision loss.

Global initiatives have set out to address this challenge with an evaluation of evolving vision impairment rates and the prevalence of avoidable blindness.³ The VISION 2020: the Right to Sight initiative was created in 1999 to eliminate avoidable blindness.

Among adults aged ≥ 50 years, the 2020 report found no change in the crude prevalence of avoidable vision impairment between 2010 and 2019, while case numbers increased in that period.

Across the report, nearly half of all global blindness was attributable to cataracts with 15.2 million global cases among nearly 34 million cases of global blindness. Uncorrected refractive error was the greatest contributor to global moderate and severe vision impairment with more than 86 million individuals affected among the 206 million cases.

Although easily treatable through surgical means and glasses, these conditions showed notable regional variability and were not fully addressed in all global regions, including high-income regions. At the same time, eye diseases, including glaucoma, diabetic retinopathy (DR), and age-related macular degeneration (AMD) were linked to more than 19 million global cases of moderate or worse visual impairment in 2020.

“While they’re relatively common conditions in older adults and become more common with each decade of life, their impacts on vision can be quite different in how they affect an individual's functioning,” Ehrlich told HCPLive. “Depending on the disease, there may be treatments to slow down the condition, or at least temporarily give some vision back.”

Other data support these claims, with the global burden of age-related macular degeneration expected to increase globally to 288 million individuals by 2040.⁴ By 2050, the change in disease patterns in the United States is expected to affect approximately 5.4 million adults with AMD.

According to the VISION 2020 report, diabetic retinopathy was the smallest contributor to blindness globally, compared with uncorrected refractive error, cataracts, AMD, and glaucoma.³ However, it was the only cause of blindness that showed a global increase in age-standardized prevalence in those 20 years.

With more than 600 million people expected to be living with diabetes by 2040, and an increase in lifespan for those with the disease, the number of individuals living with diabetic retinopathy and vision impairment will experience a rapid global rise.⁵ Early detection and timely interventions become more and more important as the vast majority of this vision impairment can be avoided with proper care.

“Indeed, we have more and more patients to treat,” Ramin Tadayoni, MD, PhD, the head of ophthalmology at Université Paris Cité and president of EURETINA, told HCPLive. “Thus, having more potent drugs, to have less high intervals or fewer visits for the patient, can decrease the burden for the patient and also on the healthcare system.”

In past decades, the introduction of intravitreal vascular endothelial growth factor (VEGF) inhibitors has led to a revolution of available therapeutic options for retinal diseases, including nAMD.³ The recent approvals of high-dose aflibercept 8 mg (EYLEA HD) from Regeneron and faricimab-svoa (Vabysmo) from Genentech showcase the prioritization of treatment durability, or the extension of treatment intervals, to reduce the burden faced by patients.⁴

Given the need for frequent dosing, anti-VEGF therapies can enact a substantial burden for patients and clinics, from the injection itself to issues with transportation and getting the patient to the clinic.

“Better drugs allow us to treat patients better because the expectations are higher and higher,” Tadayani said. “Everyone wants to have a normal region and that’s our sole goal.”

Even with these treatment advances, the aging Baby Boomer population is expected to lead to dramatically increased demands for ophthalmic health care.⁶ A new projection analysis from the US Department of Health and Human Services has forecasted ophthalmology as one of the medical specialties with the lowest rate of projected workforce adequacy (70%) by 2035.

“There are certainly justifiable concerns that we may not have an adequate number of well-trained eye care providers to care for the number of aging adults who are going to need our help in the decades to come,” Ehrlich said.

The Health Resources and Service Administration (HRSA) Health Workforce Simulation Model has predicted the total ophthalmology workforce supply will experience a 12% decline in full-time equivalent ophthalmologists, while the total demand is projected to increase by 24%, representing a 30% workforce inadequacy.⁶

Regionality also markedly influenced the projections in 2035, with a 77% workforce adequacy expected in metropolitan areas versus 29% in nonmetropolitan locations. Technological innovations may serve to bridge that gap. As telehealth and rapidly more durable treatments become widely available, there may be reduced demand for ophthalmology full-time equivalents concerning disease prevalence.

“On the encouraging side, there are newer technologies on the horizon, including things like artificial intelligence and telehealth, that allow us to take quality care of more people and sometimes from a distance,” Ehrlich added.

Organizations like the National Council on Aging (NCOA) work to improve the lives of older adults. The NCOA provides the service of vision rehabilitation, and Kathleen Cameron, BSPharm, MPH, the senior director of the NCOA’s Center for Healthy Aging, said every state has programs with vision rehab services for people of all ages, not just older adults.

The vision rehab services complete a thorough assessment of an individual’s vision loss and are tailored to their specific needs. The services might train someone on how to use a white cane so they can walk around their community or city, as well as provide assistive devices so they can use the computer or do a simple activity like reading.

“A lot of what the vision rehab will do well, particularly on the vocational vision rehabilitation, is to help people in the workplace,” Cameron said. “So many older adults are continuing to work well past the age of 60.”

The programs pinpoint what adaptions someone might need in the workplace to maintain their employment or find a new job.

Clinicians may be unaware of new assistive technologies to help older adults experiencing vision loss accomplish tasks. Examples of these technologies include screen readers on computers, as well as speech recognition. Speech recognition devices can let people with impaired vision listen to music, hear an audiobook, follow recipes, play games, use grocery delivery services, and create lists by just voicing a command.⁷

“I think a big problem for people who already have vision impairment [is] they might not know about things that can help them live as independently as possible,” Cameron said.

She said the biggest problem is that many people do not understand that significant vision loss is not a “normal part of aging.”

“Yes, we have changes in our vision, but really significant radical changes are due to some type of disease, most likely some type of condition that needs to be treated,” she said.

A 2023 study found adopting a Mediterranean diet can prevent age-related eye diseases such as cataracts, glaucoma, age-related macular degeneration, diabetic retinopathy, and dry eye syndrome.⁸ Other ways to protect vision include getting in physical activity, adequate hydration, quitting smoking, protecting their eyes from sunlight by wearing sunglasses that block the ultraviolet radiation or a wide-brim hat, taking breaks from computers to reduce the eyestrain, and having a good night’s sleep, Cameron said.⁹

Moreover, when asked about the stigma of vision loss and older adults, Cameron said many people view vision loss in older age as normal and they want to deal with it on their own.

“To me there, there shouldn't be any stigma with that—our eyes are no different from our heart,” Cameron said. “If we had a heart condition, we would seek help for it. Most people do. But vision, to me, has such an impact on our quality of life, that the sooner we recognize that there might be an issue and get it, get screening for it, and get it treated is really key to maximizing quality of life for older adults.”

With vision loss projected to increase in prevalence in the year 2050, it is crucial vision loss must be addressed. Other than NCOA, other organizations in the fight against vision loss are the American Academy of Ophthalmology (AAO), the Academy of Optometry, and the American Glaucoma Society. The AAO recommends adults at the age of 40 should get a complete eye examination since this is when early signs of disease may be detected.¹⁰

Ehrlich said how it was rare for many older adults to get regular eye exams since many of the conditions that affect vision become way more common later in life.

“I’d like to emphasize that vision loss in later life is not normal,” Ehrlich said. “We should not expect to lose vision… if one’s vision is declining, it’s important that they seek eye care.”

^References

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7. ^{Trubin, N. Using Voice Recognition Devices for Patients with Low Vision. Fox Rehab. October 3, 2019. https://foxrehab.org/voice-recognition-devices-aid-ot-treatment/#:~:text=With%20the%20help%20of%20voice,being%20used%20with%20voice%20recognition. Accessed February 7, 2024.}
8. ^{Wu Y, Xie Y, Yuan Y, et al. The Mediterranean Diet and Age-Related Eye Diseases: A Systematic Review. Nutrients. 2023;15(9):2043. Published 2023 Apr 23. doi:10.3390/nu15092043}
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