Primary eye care providers are often the first line of defense against sight-threatening disease; however, a new study suggests America's leading cause of vision impairment in older adults might be going underdiagnosed.
Published in May's JAMA Ophthalmology, the study found that 25% of eyes deemed normal by primary care ophthalmologists and doctors of optometry after a dilated eye examination had characteristics of age-related macular degeneration (AMD) upon closer look. Such results reveal just how underdiagnosed AMD may be, further underscoring the challenges of early detection and the necessity for routine eye care.
To examine this prevalence, researchers conducted a cross-sectional study of primary eye care practices in Birmingham, Alabama, and collected data on 644 people (1,288 eyes) over 60 years of age with normal macular health recorded on their most recent dilated eye examination. Upon review using the Clinical Age-Related Maculopathy Staging system based on color fundus photography and masked grader, 968 eyes were confirmed to have no AMD. However, among eyes with AMD that went undetected:
- 249 had small drusen.
- 250 had intermediate drusen.
- 96 had large drusen.
- 43 had hypopigmentation.
- 32 had hyperpigmentation.
These subjects with undiagnosed AMD were more likely to be older and male with less than a high-school education, study authors note, and older eyes were more likely to present with drusen of all sizes. In particular, large drusen made up 30% of undiagnosed eyes, "indicating these patients would have been candidates for therapeutic intervention with nutritional supplements; however, only 3 of 99 eyes with intermediate AMD were from persons taking AREDS formulation nutritional supplements," the study notes.
Although researchers write that ophthalmologists and doctors of optometry were equally likely to miss an AMD diagnosis, advances in retinal imaging technologies could eventually help stem the prevalence of undiagnosed AMD as equipment becomes more affordable for the primary care setting.
AMD in retrospect
Estimated to affect 1.8 million Americans with another 7.3 million at substantial risk for vision loss, AMD is the leading cause of severe vision loss in adults over 50, according to the Centers for Disease Control and Prevention. AMD takes two forms: atrophic (dry) and exudative (wet), the former occurring more commonly but having no known cure. Although any central vision lost to dry AMD cannot be restored, there is a link between nutrition and AMD progression. Such dietary changes and nutritional supplements, such as AREDS, can slow vision loss.
Elizabeth Wyles, O.D., primary care educational coordinator at the Illinois College of Optometry, says this study is particularly interesting in that it quantifies exactly how underdiagnosed dry AMD is in a sample population.
"I think like any early disease process, there are many patients that are probably underdiagnosed by clinicians," Dr. Wyles notes. "I think most optometrists would agree that there are likely early cases of glaucoma, corneal degeneration, amblyopia or other problems that go undetected daily until they produce more signs and symptoms. Technology has made it easier to diagnose some of these problems earlier."
Access the AOA's clinical practice guideline, Care of the Patient with Age-Related Macular Degeneration.
The American Diabetes Association® (ADA) reported, in time for National Diabetes Month in November, that total annual costs of diabetes in 2022 was $412.9 billion, most of it in direct medical costs. How can doctors of optometry help in the fight to lower the prevalence of diabetes?
Doctors of optometry should consider the benefits of adding office-based laser procedures, such as YAG capsulotomy (after cataract surgery) or selective laser trabeculoplasty (SLT, for glaucoma), to their practice.
Doctors of optometry are performing office-based laser procedures in 11 states, as AOA affiliates have seen historic scope expansion wins in the past four years and momentum continues to build. Doctors of optometry are pursuing legislation in other states that would allow them to serve their patients at the highest level of their education and training. Some of these optometrists, who have performed hundreds of laser procedures, share key considerations in providing this care to patients.