Journal of Gerontological Nursing

Age-Related Vision Loss in Older Adults: A Challenge for Gerontological Nurses

Susan Crocker Houde, PhD, RN, CS; Martha A Huff, RN, MS








Vision impairment is a common problem in older adults and occurs in 18% of Americans 70 or older (Nationai Center for Health Statistics, 1999). The incidence increases with aging and rises to 31% in those 85 and older. The prevalence of impaired vision is expected to increase as the population ages. The current number of Americans 65 and older (13%) is expected to increase to 20% by 2030, and 2% of older adults will be 85 years and older (National Center for Health Statistics). These demographic shifts have implications for the role of the gerontological nurse in the support of families and elderly individuals who have impaired vision. The purpose of this article is:

* To review the leading causes of visual impairment in the older adult.

* To review literature on agerelated vision loss, a condition that proposes challenges for gerontological nursing practice and research.






The four most common causes of impaired vision in the older adult are age-related macular degeneration (AMD), glaucoma, cataracts, and diabetic retinopathy. Age-related macular degeneration is the leading cause of visual impairment in the older adult (Quillen, 1999). It is a degenerative process that has no cure and results in the loss of central vision (Elfervig, 1998). Thirteen million people in the United States are estimated to have AMD and 1.2 million are visually impaired because of the disease (Pratt, 1999). As longevity increases, it is expected an increased number of individuals will be diagnosed with AMD (Einer, 1999).

There are two types of AMD: wet (or exudative) and dry. Most cases are the dry form (90%) and there is some controversy about whether this type is caused by age-related atrophy of the macula or if it is pathological (Lewis, 1999). The wet form leads to significant vision loss, and, despite accounting for only 10% of the cases, it results in a much higher incidence of blindness (80% to 90%).

With AMD, round or oval areas of atrophy form in the retina and underlying structures. Degeneration of retinal pigment cells occurs with a decrease in the number of rods and cones. The areas of degeneration enlarge over time, resulting in impaired vision that is usually mild. The amount of visual loss is relative to the degree of abnormalities in the retinal pigment that exist in the center of the macula.

The risk of wet AMD becomes greater as changes from dry AMD become more extensive (Einer, 1999). In dry or nonexudative AMD, there are no scars or hemorrhages in the retina. The wet, or proliferative, type of AMD results in the proliferation of abnormal vessels that leak blood into the macula, resulting in intraretinal and subretinal hemorrhages. This results in abnormal central vision.

Patients may complain of distorted objects, difficulty focusing or reading, problems with sensitivity to glare, the presence of central scotomas, or blurring of central vision, and diminished color vision (Castor & Carter, 1995). The vision loss occurring with macular degeneration usually is not total. Central vision may be impaired, but peripheral vision usually remains intact. Laser photocoagulation therapy may be helpful in managing the wet form of AMD by slowing the progression of the disease. If initiated early, scarring of the fovea can be spared by photocoagulation of blood vessels. Photodynamic therapy also is being studied in the treatment of AMD. A photosensitive dye is injected intravenously, followed by nonthermal laser irradiation to produce vascular occlusion.


The second leading cause of blindness in the United States is glaucoma (Castor & Carter, 1995), accounting for approximately 10% of blindness (Quillen, 1999). It is the leading cause of blindness in Black American elderly adults (Kendrick, 1999). In glaucoma, impaired drainage of aqueous fluid causes increased pressure within the eye, leading to ocular nerve damage. It is not clear why an impairment in aqueous fluid drainage occurs. With aging, changes occur in the eye, including increased extracellular plaque in the anterior chamber angle and a loss of trabecular endothelial cells, as well as changes in the iris and ciliary body. These changes may be accelerated in those who develop glaucoma, which is thought to lead to increased resistance to aqueous outflow. The damage is irreversible, but can be prevented if the eye pressure is controlled (Kendrick, 1999).

Open-angle glaucoma tends to be a health problem that progresses slowly and is usually asymptomatic until the patient notices a peripheral vision loss. Central vision can be adversely affected late in the disease. Other complaints related to vision may include difficulty adapting to darkness and glare, loss of sensitivity to contrasts, and problems functioning in dim lighting (Castor & Carter, 1995). Risk factors associated with open-angle glaucoma include increasing age, severe myopia, diabetes, hypertension, and a positive family history of glaucoma.

Medications are effective in lowering the intraocular pressure in glaucoma. Both topical and systemic medications are used. The topical solutions used in the treatment of glaucoma are systemically absorbed and may have adverse effects (Table 1). Several classes of medications are used to decrease the intraocular pressure. Beta-adrenergic antagonists, alpha2 agonists, and carbonic anhydrase inhibitors reduce the aqueous production. Prostaglandin analogs function by increasing the uveoscleral outflow of aqueous. They have no contraindications and fewer side effects than some other classes of medications, but the long-term effects are not known.

Miotic agents function by constricting the pupil and improving the drainage through the trabecular network, resulting in reduced intraocular pressure. Epinephrine and dipivefrin have been prescribed for glaucoma to increase outflow drainage. If medication therapy is not effective in decreasing the intraocular pressure, surgery is considered. Surgical trabeculectomy is performed by laser to create a new channel for aqueous fluid outflow from the anterior chamber to the subconjunctival space (Quillen, 1999).


Cataracts occur when the lens, which is normally clear, becomes yellow, thick, and cloudy as a result of the aging process. New lens fibers form over old lens cells for many years, resulting in the formation of cataracts. The loss of vision associated with cataracts is typically slow and complaints may consist of a glare or blurring of vision.

Surgery for cataracts is the most common surgery covered by Medicare (Quillen, 1999). It is estimated that more than 1.25 million cataract surgeries are performed in this country every year (Das, 1999). Surgeryshould only be considered when the cataract interferes with the functional level of the patient and adversely affects quality of life. More than 90% of patients having surgery experience improved vision.

Cataract surgery is performed under local anesthesia as an outpatient procedure. The lens is fragmented into small pieces by ultrasound (phacoemulsification) and removed through a small incision. A lens implant is usually inserted in the lens capsule. Factors thought to contribute to the development of cataracts include ocular trauma, tobacco and alcohol abuse, diabetes mellitus, use of corticosteroids, ultraviolet light exposure, and antioxidant deficiencies (Carter, 1994).


Diabetic retinopathy is a leading cause of blindness in older adults with diabetes mellitus. It is the greatest cause of blindness in working-age adults (Einer, 1999). The number of years diabetes has been present is the greatest risk factor. The cause of diabetic retinopathy is unknown, but hyperglycemia for many years is suspected to lead to glycolysation of tissue proteins and tissue damage. The biochemical processes may result in functional and anatomical changes in the retinal vasculature.

There are two types of diabetic retinopathy: proliferative and nonproliferative. In proliferative diabetic retinopathy, ischemia of the retina results in the proliferation of new blood vessels that may cause the detachment of the posterior vitreous and traction of the fibrovascular tissue. These changes can result in vitreous hemorrhage or retinal detachment. In nonproliferative diabetic retinopathy, problems with circulation result in cotton wool exudates, microaneurysms, intraretinal hemorrhages, and other microvascular problems.

Macular edema can result in central vision loss. Strict control of blood sugar has been effective in decreasing the incidence and progression of diabetic retinopathy (The Diabetes and Complications Trial Research Group, 1993). Blood sugar control is thought to increase the flow of oxygen to the tissues (Lewis, 1999). There is no cure for diabetic retinopathy, but laser therapy has been used effectively in its management. Laser photocoagulation to the periphery of the retina (panretinal photocoagulation) has been used to reduce the risk of vision loss with proliferative retinopathy. Macular laser therapy has been effective in preventing vision loss in those with macular edema by decreasing leakage from blood vessels.


Visual impairment can have a negative effect an older adult's ability to interact with others and to function in society. Older adults with vision loss may have difficulty coping with the consequences of their disability. Visual impairment may lead to functional difficulties that could have adverse effects on quality of life. Loss of independence, social isolation, and loneliness may also affect quality of life.

The effects of vision loss on older adults and their families are multidimensional, resulting in changes in societal and familial roles. Support is necessary to assist individuals and families through the transition period of coping with vision loss. In some individuals with vision loss, a sense of fear and a lower level of personal confidence interfere with the ability to compensate for their disability (Conrod & Overbury, 1998). Those who have had contact with someone outside the family who experienced a vision loss, and those with greater knowledge about vision loss and aging, higher education, and higher income were found to have had a more positive attitude about vision loss (Horowitz, Reinhardt, Brennan, & Cantor, 1997).

The quality of life of those with impaired vision may be negatively affected by a diminished ability to participate in normal routines, including self-care activities (Campbell, Crews, Moriarty, Zack, & Blackman, 1999). In fact, older adults with vision loss report quality of life as lower than those with other chronic health problems (Williams, Brody, Thomas, Kaplan, & Brown, 1998). Lower life satisfaction, increased stress, and greater life problems have been reported by visually impaired older adults when compared to those with normal vision (Davis, Lovie-Kitchin, & Thompson, 1995; Horowitz et al., 1997). A decrease in the ability to continue pleasurable leisure activities has also been noted.

In a focus group conducted by the National Eye Institute, participants said reading was the activity most frequently adversely affected by impaired vision (Kupfer, 1999). Having difficulty reading affected the ability to shop, read menus, and travel outside the home. Many consider the loss of their ability to drive as a sign of loss of independence and as having a negative impact on their quality of life (National Eye Health Education Program, 1997).

Functional difficulties associated with visual impairment may have an adverse effect on the quality of life of the older adult. These difficulties may include financial problems resulting from loss of employment, problems with family relationships, and withdrawal from social activities (Bernbaum & Stewart, 1996). Older adults with visual impairment were less likely to eat out in a restaurant or to get together with friends (Campbell et al., 1999).

Loneliness and social isolation are potential outcomes of vision loss in the older adult. Loneliness and social support in older adults with impaired vision have been studied. In a study of 87 visually impaired elderly individuals 65 and older, it was found that those satisfied with their social support network reported less loneliness than those who were not (Barron, Foxall, VonDollen, Jones, & Shull, 1994). No significant difference was reported in level of loneliness according to marital status, but those who were not lonely reported larger support networks. There were no significant differences between the social support network sizes and the loneliness experienced by those who lived alone and those who lived with others (Foxall, Barron, VonDollen, Shull, & Jones, 1993; Foxall, Barron, VonDollen, Shull, & Jones, 1994). The size of the network was not related to loneliness, but rather satisfaction with the support network. Children were reported to be an important part of the social network, especially for those living alone.

Limited research has focused on the psychosocial impact of vision loss in older adults, but social support and a perceived sense of control has been shown to have positive effects on psychological functioning. Higher perceived sense of control has been correlated with lower levels of anxiety and depression, and a higher level of life satisfaction (Kiemschmidt et al., 1995). Supportive friendships and family relationships also contribute to lower levels of depression, better life satisfaction, and improved adaptation to visual impairment. Less functional disability and higher education have also been important predictors of adaptation to vision loss (Reinhardt, 1996).

In a qualitative study of 86 visually impaired older adults in New York City, 26.8% were considered in a state of despair related to their visual loss, 56.9% were having difficulty coping with their vision loss, and 7% were considered in acceptance of their loss (Burack- Weiss, 1991). Factors associated with better initial adaptation to visual impairment include educational level, higher quality of the relationship with the closest family member, and feeling the family member understands one's limitations (Horowitz, Reinhardt, Mclnerny, Balistreri, & Serapio, 1994).

Adaptation over time was affected by the size of one's family network. Success in adapting to one's impairment may be affected by the resources available to family members (Nixon, 1994). In a qualitative study exploring successful adaptation to vision loss, older adults who successfully adapted were proactive, had close relationships with family and friends, used optical aids and assistive devices, and had interactions with professionals who were supportive. (Kleinschmidt, 1999).





Findings from Wahl, Oswald, and Zimprich (1999) suggest that visually impaired elderly individuals who live alone may be more likely to adapt and maintain their activity level outside the home. They propose that this may be related to the need to be more independent when living alone. The researchers also suggest that a stable environment that optimizes light and is highly structured and ordered can assist older adults in adapting to their visual loss. Vision loss services can also help elderly individuals adapt to their environment.

Many older adults with vision impairment do not use services in the community to assist with the adaptation process. Horowitz, et al. (1997) found that only 40% could identify a vision-related agency in their community and only 40% used an assistive device. Knowing a non-relative with impaired vision was the only significant predictor of knowledge about available vision services. Those individuals who use low-vision services have high levels of satisfaction with the services (Scott, Smiddy, Schiffman, Feuer, & Pappas, 1999).

In a 10-year longitudinal study, Mann, Hurren, Tornita, and Charvat (1997) found that most assistive devices used by visually impaired older adults were relatively inexpensive and low tech. Few older adults used print enlargement systems or computer-related systems. It is unclear why few older adults use services and are unaware of the available resources related to their visual impairment. Possible reasons include lack of awareness, poor access to services, and lack of financial resources to procure available resources. Financial issues related to coverage of services for the visually impaired has been a concern.

Financial Issues

Visual impairment in the older adult has serious financial implications, both to society and to the families and elderly individuals who need services to meet their needs as vision declines. Dr. Karl Kupfer, director of the National Eye Institute, National Institutes of Health, estimated that the costs associated with the four leading causes of vision loss in the older adult population are probably between $30 and $40 billion annually when considering both direct and indirect costs (Butler, Faye, Guazzo, & Kupfer, 1997). The reimbursement to individuals for visual rehabilitation has traditionally been limited.

The Rehabilitation Act of 1973 was amended in 1978 (under Tide VII, Chapter 2) to authorize grants to state vocational rehabilitation agencies to provide independent living services to older individuals who are blind and visually impaired. Eligibility criteria for these services include being 55 or older with severe visual impairment which makes competitive employment difficult, but for whom the goal of independent living is feasible (Lidoff & Stephens, 1996). Funding for this program did not occur until 1986. Only 23 states were awarded grants (Branch, Horowitz, & Carr, 1989).

By 1996, every state received a grant ranging from $140,000 to $180,000. The average total state budget in 1995 was $248,672, with two thirds federal funding and one third from state, in-kind, and third party funds. The average cost per recipient in 1995 was $540, with 22,103 receiving services. Of these, 64% were 76 or older and 45% were 81 or older (Lidoff & Stephens, 1996).

The 22,103 individuals who received services in 1995 from the state-administered programs of rehabilitation represent a small percentage of the older adults with impaired vision. Health insurance coverage for basic eye care services, much less vision rehabilitation or optical devices (e.g., magnifiers, telescopes), is lacking among the middle-aged and older Americans with health insurance (Arlene R. Gordon Research Institute, 1995).

Eighty-nine percent of respondents to the Lighthouse National Survey felt vision care and vision rehabilitation coverage should be included in health insurance plans. Ninety-two percent felt rehabilitation for vision loss should be covered in a manner similar to rehabilitation for other age-related conditions, such as hip fractures. In the same survey, only 75% of those with severe vision impairment were covered by a health insurance plan (Arlene R. Gordon Research Institute, 1995).

Although Medicare does not cover vision rehabilitation services, the influx of Medicare HMOs could result in coverage of services not previously covered. The managed care organizations emphasize prevention and are sometimes open to using cost-efficient, nontraditional providers (Lidoff, 1997). Rehabilitation and interventions effective in maintaining functional independence and preventing further disability in older adults with visual impairment may be seen positively by HMO administrators aware of the rising costs associated with disability in the older adult population.

Interventions to Support Older Adults with Vision Loss

Unfortunately, few studies evaluate the outcomes of interventions that assist older adults in adapting to vision loss. One study by Conrod and Overbury (1998) examined the effects of individual and group counseling and perceptual training and found that elderly individuals who participated in individual counseling or perceptual training scored higher on perceptual measures. The older adults who participated in group counseling showed positive longterm effects, including increased independent activity, increased selfconfidence, the initiation of new activities, or the return to previous functioning. However, those participating in educational programs have reported they do not understand all the information presented by professionals (Dahlin-Ivanoff, Klepp, & Sjostrand, 1998). This has implications for the leader of the program who should clarify information presented by professional speakers.

Several programs to support older adults with visual impairment have been described in the literature. The VISIONS program in New York City has had a goal of independent living and integration and equal access to community services for the visually impaired (Ludwig & Schneider, 1991). VISIONS is a multidisciplinary program providing occupational therapy, social services, rehabilitation teaching, orientation and mobility teaching, and publications to the participants, depending on individual needs. Team members collaborate at semi-monthly meetings to discuss individualized plans.

Another program described is an 8-week structured support group for middle age and older adults with vision loss (McCulloh, Crawford, & Resnick, 1994). Topics chosen for weekly sessions included the loss of privacy, issues of mobility, health, finances, family, friends, feelings, self-esteem and self-identity, finding new ways of doing things, and finding substitute pleasures. The first several weeks addressed topics that were less personal and focused more on losses. As the weeks progressed, the sessions became more personal and refocused on positive adaptation.

The support group had an important function in expanding the participants' social network. These programs can serve as models for gerontological nurses who want to develop programs to support older adults with vision loss. Evaluations of existing programs would help nurses understand the strengths and weaknesses of existing programs, and should be considered in the development of new programs.

The Low Vision Education Program was launched by the National Eye Institute in October 1999 (Kupfer, 1999). The program was developed in response to the finding that many individuals do not have adequate information and assistance related to their vision loss. The goal of the program is to improve the transmission of information on vision loss to individuals, families, and friends affected by vision loss, and to health care providers through a media campaign, educational materials, an outreach program, and traveling exhibits.






Educating the public about vision impairment and the resources available is an important step in overcoming the fear of vision loss. For nurses to be effective in the education role, they must be aware of the causes of vision loss, concerns of individuals and families, and resources available to those with impaired vision. Table 2 lists several important resources for those with vision impairment. Encouraging individuals with vision loss and their families to contact available resources may enable them to obtain information that will facilitate their adaptation to visual impairment.

Education by the nurse, using a supportive approach sensitive to the psychological distress associated with vision loss, may also enhance an older adult's ability to cope. Providing support, educating the patient and family about the diagnosis and treatment, and assisting the patient to prepare for and adapt to progressive losses in vision is of paramount importance. Helping patients identify an accessible source for rehabilitation where daily living needs can be evaluated and visual aids can be prescribed will assist older adults with vision loss to maintain their independence and maximize existing function (Faye, 1998). Describing assistive devices available and encouraging older adults to seek rehabilitation is an important role of the gerontological nurse that should increase the number of older adults actively using visual aids.

Gerontological nurses need to assess all patients for new or progressive symptoms of visual impairment and should make recommendations for regular ophthalmic examinations. Additionally, annual physical examinations and mobility assessments are recommended for elderly individuals with visual impairment. A mobility assessment determines functional stability on transferring or walking. Nurses should be actively involved in assessing the size and adequacy of the support network of older adults with visual impairment to help prevent loneliness. Strategies to strengthen the support network by involving friends, church members, and neighbors may help prevent burnout of family members, and is an important function of the gerontological nurse (Barron et al, 1994). Elderly individuals who do not have close family relationships should be identified. Attempts to mobilize a strong social network may facilitate adaptation in this group.

Nurses have an important role in assessing adults with vision loss for depression or adjustment disorders (Leinhaas 8c Hedstrom, 1994), and must assess suicide risk in severe depression. Consultations to appropriate mental health clinicians may be necessary. For individuals with minor emotional distress, nurses have an important role in encouraging participation in activities including church or senior center involvement and hobbies. Lectures, discussion groups, concerts, and support groups may also be appropriate for older adults with vision loss. Participation in activities may be stimulated by promoting positive, creative thinking to overcome obstacles.

Environmental factors can interfere with an older adult's adjustment to vision loss (Thompson, Goldhaber, Amarai, & Ringering, 1992). Therefore, an assessment of the home environment for hazards or obstacles is important so modifications can be made to enhance safety (Table 3). It may also have the positive effect of empowering patients to maintain functional ability and competence in everyday activities. Adequate lighting and the use of color to more clearly define contrasts may enhance quality of life. Hazards in the environment should be identified and eliminated whenever possible (Melore, 1997). Nurses should encourage collaboration between the older adult and family members to create a safe environment for functioning with vision loss.

The advocacy role of the gerontological nurse is a particularly challenging one. Motivating older adults and families to seek services is important because visual loss can create a sense of dis-empowerment that can interfere with the initiative to seek resources. Because of limited reimbursement and strict eligibility requirements, home- and community-based long-term services may be difficult to obtain (Orr, 1998).

Teaching individuals and families advocacy skills may increase their sense of empowerment and help them attain the necessary services. Increasing knowledge about insurance coverage and appropriate public and privately funded agencies may also assist older adults in acquiring needed services. Contacting the state agency serving the blind and visually impaired, as well as private agencies, will provide information about local services available to those with vision loss.

Advocacy efforts by professional nurses in informing legislators about the unmet needs of visually impaired older adults in the community is essential to help legislators make informed decisions about funding issues. Small changes in legislation can improve the allocation of funds for visual rehabilitation services and can make a difference in older adults' ability to adapt to visual loss (Scott & Rogers, 1998).

Gerontological nurses must take a more active role in research evaluating the outcomes of interventions designed to enhance the older adult's adaptation to visual loss. Currently, the data available to evaluate the effectiveness of resources and interventions to support the visually impaired is inadequate. Increased research can provide data to legislators, which may improve allocations of funds for vision rehabilitation services. The role of the nurse in visual impairment is challenging. This role includes increasing public awareness, early disease detection, support of older adults with vision impairment and their family members, providing education about visual loss and resources, political and patient advocacy, and research.


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