Thursday, November 29, 2007

Providing Eyeglasses a Boon for Nursing Home Residents

By Judith Groch, Senior Writer, MedPage Today

BIRMINGHAM, Ala., Nov. 13 -- The simple expedient of giving glasses to nursing home residents to correct refractive error improved their quality of life and decreased depression, according to researchers here.

Rates of vision impairment for nursing home residents in the U.S. are three to 15 times higher than rates for community-dwelling older adults, Cynthia Owsley, Ph.D., of the University of Alabama at Birmingham, and colleagues wrote in the November issue of Archives of Ophthalmology.

Yet, the researchers said, national surveys have found that only half of nursing homes in the U.S. report having contracts for vision and hearing services, and only 12.6% of nursing homes have optometric services available on site.

To examine the effect of providing glasses for nursing home residents with uncorrected refractive error (myopia, hyperopia, and presbyopia), the researchers undertook a study of 142 such patients, ages 55 or older.

Of these, 78 were randomly assigned to immediate correction with glasses, while 64 were randomized to delayed correction after a two-month follow-up visit. The average age of participants (75% women) was in the late 70s. The residents had an average of five to six chronic medical conditions, and about two-thirds had a diagnosis of a cataract.

They had uncorrected refractive error in one or both eyes for near or far test distances as determined by routine eye examination. Individuals were assessed at baseline and at two-month follow-up.

Distance visual acuity was assessed with the ETDRS chart, while near visual acuity was assessed with the Lighthouse Near Visual Acuity Test (modified ETDRS).

For quality of life, the researchers used the Nursing Home Vision-Targeted Health-Related Quality-of-Life Questionnaire (NHVQoL), which consisted of nine subscales focusing on general vision, reading, ocular symptoms, mobility, psychological stress, activities of daily living, activities and hobbies, adaptation and coping, and social interaction.

Two other questionnaires were used to assess generic health-related quality of life (physical and mental components), and the VF-14 to assess visual activities of daily living.

Depressive symptoms were assessed by the 15-item Geriatric Depression Scale.

At baseline, both groups had similar demographic and medical characteristics and had similar visual acuity and refractive error uncorrected by eyeglasses.

At two months, the immediate correction group compared with the delayed group had higher scores on the NHVQoL subscales for reading, psychological distress, activities and hobbies, and social interaction (all P<0.04)>

They also had fewer depressive symptoms as measured by the Geriatric Depression Scale (P=0.003).

Overall, the researchers said that after providing glasses, intervention scores on the NHVQoL subscales increased dramatically, reaching about 12 points for general vision and reading, with other subscales showing more modest increases of about five points.

Because the average level of uncorrected refractive error at baseline was ± 1.00 D for distance and + 1.25 D for near, these results show that improvement of even modest to moderate levels of optical defocus can benefit the health and well-being of nursing home residents, the investigators said.

Compared with those who did not receive new glasses, residents who received new spectacles not only rated the overall quality of general vision more highly but also reported less difficulty with reading (newspapers, books, wall clocks) and with the performance of activities and hobbies such as writing, using the phone, watching TV, and playing cards.

Optical correction also enhanced psychological well-being. Benefits included less reported psychological distress (worry, frustration, upset), increased social interaction (visiting with fellow residents in their rooms, participating in group activities), and fewer depressive symptoms.

Nursing home residents are at increased risk for depression, which in turn increases their mortality risk over a year. With prevalence estimates in the nursing home for major depression ranging as high as 43%, interventions that successfully reduce depressive symptoms in this population are significant, Dr. Owsley's team said.

Noting the study's limitations, the investigators said that generalizability of conclusions beyond two months of follow-up and to nursing home residents in other geographic areas remains unknown. Also, the study could not address the efficacy of spectacle intervention for nursing home residents with a Mini-Mental State Examination score (MMSE) less than 13.

These findings underscore the need for a systematic evaluation of the factors underlying the pervasive unavailability of eye care for nursing home residents in the U.S., so that steps can be taken to improve service delivery and eye care utilization, the researchers concluded.

Triple Therapy Leads to Lasting Improvement in Macular Degeneration

Triple Therapy Leads to Lasting Improvement in Macular Degeneration
By Charles Bankhead, Staff Writer, MedPage Today


NEW ORLEANS, Nov. 13 -- For many patients with choroidal neovascularization from age-related macular degeneration, a single cycle of photodynamic therapy, bevacizumab (Avastin), and intravitreal steroids led to sustained improvement in visual acuity, German investigators reported here.

After a mean follow-up of 62 weeks, improvement in visual acuity for 104 eyes in 104 patients averaged 2.1 lines (P<0.01),>

Retinal thickness also decreased significantly (P<0.01).

Triple therapy was well tolerated, no severe systemic or optical adverse effects occurred, and intraocular pressure did not increase, he added.

"Ultimately, we must tailor therapy to suit the individual's disease characteristics, ability to visit the clinic, and treatment preference or feasibility," Dr. Augustin concluded.

Age-related macular degeneration has a multifactorial pathogenesis that involves hypoxia, oxidative pressure, inflammatory responses, and an altered balance of pro- and antiangiogenic factors that results in neovascularization, Dr. Augustin noted. An ideal therapy, he said, would include an antiangiogenic agent, an anti-inflammatory, and photodynamic therapy to treat existing choroidal neovascularization.

Dr. Augustin and colleagues have used triple therapy in more than 400 patients, and he reported results for patients who have been followed the longest. Treatment consisted of 70-second photodynamic therapy with verteporfin, followed an average of 16 hours later by intravitreal administration of 800 µg of dexamethasone and 1.5 mg of bevacizumab.

In addition to the improvement in visual acuity, retinal thickness decreased by an average of 195 µm. Five patients required a second cycle of therapy because of persistent choroidal neovascularization activity. Additionally, 23 patients (22%) received a second injection of bevacizumab.

The triple therapy results in significant and sustained improvement in visual acuity, has a good safety profile, is convenient for patients, and is cost-effective over time as compared with indefinite therapy, such as an anti-VEGF agent, Dr. Augustin concluded.