0
Clinical Guidelines |

Screening Older Adults for Impaired Visual Acuity: A Review of the Evidence for the U.S. Preventive Services Task Force FREE

Roger Chou, MD; Tracy Dana, MLS; and Christina Bougatsos, BS
[+] Article and Author Information

From the Oregon Health & Science Center, Portland, Oregon.


Acknowledgment: The authors acknowledge Andrew Hamilton, MLS, MS, for assistance with literature searches; Michelle Pappas, BA, for administrative and formatting assistance; Rongwei Fu, PhD, for statistical assistance; and Rebecca Armour, MD, for her expertise. The authors also thank the Agency for Healthcare Research and Quality Medical Officer Tracy Wolff, MD, MPH, and the U.S. Preventive Services Task Force leads Rosanne Leipzig, MD, PhD; Michael LeFevre, MD, MSPH; Timothy Wilt, MD, MPH; and Diana Petitti, MD, MPH, for their contributions to this report.

Grant Support: By the Agency for Healthcare Research and Quality (contract HHSA-290-2007-10057-I-EPC3, Task Order No. 3).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Roger Chou, MD, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Mail Code BICC, Portland, OR 97239; e-mail, chour@ohsu.edu.

Current Author Addresses: Dr. Chou, Ms. Dana, and Ms. Bougatsos: Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Mail Code BICC, Portland, OR 97239.


Ann Intern Med. 2009;151(1):44-58. doi:10.7326/0003-4819-151-1-200907070-00008
Text Size: A A A

Background: Impaired visual acuity is common in older adults. Screening for impaired visual acuity could lead to interventions to improve vision, function, and quality of life.

Purpose: To update the 1996 U.S. Preventive Services Task Force evidence review on benefits and harms of screening for impaired visual acuity in primary care settings in adults age 65 years or older.

Data Sources: MEDLINE and the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews were searched for studies published in English from 1996 to July 2008.

Study Selection: Randomized trials and controlled observational studies that directly evaluated screening for impaired visual acuity in older adults were selected. To evaluate indirect evidence on screening, investigators included studies of diagnostic test accuracy and systematic reviews, randomized trials, and controlled observational studies of treatments for uncorrected refractive errors, cataracts, and age-related macular degeneration (AMD).

Data Extraction: Details were abstracted about the patient sample, study design, data analysis, follow-up, and results. Quality was assessed by using predefined criteria.

Data Synthesis: Direct evidence on screening and evidence on accuracy of diagnostic tests were synthesized qualitatively. For benefits and harms of treatments, quantitative estimates for treatment effects from good-quality systematic reviews were reported or relative risks using a random-effects model were calculated. Direct evidence shows that screening for vision impairment in older adults in primary care settings is not associated with improved visual or other clinical outcomes and may be associated with unintended harms, such as increased falls. Effective treatments are available for uncorrected refractive error, cataracts, and AMD. A visual acuity test (for example, the Snellen eye chart) is the standard for screening for vision impairment in primary care, but its diagnostic accuracy is uncertain because no studies compare it against a clinically relevant reference standard. There remains no evidence on accuracy of funduscopic examination.

Limitations: A relatively small number of primary studies and methodological shortcomings made it difficult to reach conclusions with a high degree of confidence. In addition, studies not published in English and studies of community- or home-based screening were not included.

Conclusion: More research is needed to understand why direct evidence shows no benefits of screening, even though impaired visual acuity is common and effective treatments are available.

The 2002 NHANES (National Health and Nutrition Examination Survey) estimated an 8.8% prevalence of impaired visual acuity (best-corrected vision of 20/50 or worse) in U.S. adults older than 60 years (1). In addition to having a higher incidence and prevalence of primary ocular disease and systemic diseases associated with ocular disease compared with younger adults, older adults also experience normal age-related changes in vision. Because symptoms may be relatively mild or may progress slowly, older adults may be unaware of or underreport impaired visual acuity or have difficulty recognizing or reporting impaired visual acuity because of comorbid conditions, such as cognitive impairment. Impaired visual acuity is consistently associated with decreased functional capacity and quality of life in older persons and can affect the ability to live independently or increase the risk for falls and other accidental injuries (25).

Uncorrected refractive errors, cataracts, and age-related macular degeneration (AMD) are common causes of impaired visual acuity. In 2000, among U.S. adults older than 65 years, refractive errors, cataracts, and AMD were estimated to affect 6.7 million (6), more than 5 million (6), and 1.5 million persons (7), respectively. Advanced AMD is the most common cause of blindness in older, white U.S. adults, and cataracts are the most common cause of blindness in older black adults (8).

Screening for vision disorders in primary care settings could identify impaired visual acuity in older adults and lead to treatments that correct or prevent vision loss. In 1996, the U.S. Preventive Services Task Force (USPSTF) recommended routine vision screening with a visual acuity test (for example, the Snellen eye chart) for older adults (a grade B recommendation) (9). In 2008, the USPSTF commissioned a new evidence review on the benefits and harms of screening for impaired visual acuity in adults 65 years or older to update its recommendations. The Appendix Figure shows the analytic framework and key questions used to guide our review.

Grahic Jump Location
Appendix Figure.
Analytic framework and key questions.

KQ = key question.

Grahic Jump Location
Data Sources

We searched the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews (through Issue 3, 2008) and MEDLINE databases (1996 to July 2008) for relevant studies (see Appendix Table 1, for the full search strategy). We supplemented these searches with reviews of reference lists of relevant articles, including the previous USPSTF review (9).

Table Jump PlaceholderAppendix Table 1.  Search Strategies
Study Selection

The Figure shows the flow of studies from initial identification of titles and abstracts to final inclusion or exclusion. We selected studies pertaining to screening, diagnosis, and treatment of impaired visual acuity in older adults on the basis of predefined inclusion and exclusion criteria (Appendix Table 2). Two reviewers evaluated each study at the title or abstract and full-text article stages to determine eligibility for inclusion.

Grahic Jump Location
Figure.
Study flow diagram.

AMD = age-related macular degeneration; KQ = key question; RCT = randomized, controlled trial; SR = systematic review; URE = uncorrected refractive error. * Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews. † Identified from reference lists suggested by experts. ‡ Some studies were included for >1 KQ.

Grahic Jump Location
Table Jump PlaceholderAppendix Table 2.  Inclusion and Exclusion Criteria

The target sample was adults 65 years of age or older evaluated in primary care settings who were not known to have impaired visual acuity or had known but inadequately corrected refractive error. We defined impaired visual acuity as worse than 20/40 but better than 20/200. We included studies of vision screening in eye specialty settings but evaluated their applicability to primary care settings. We excluded studies of strictly community- or home-based vision screening but included mixed studies of home and clinic-based screening if 70% or more of patients were evaluated in clinic settings. For diagnosis, we evaluated accuracy of screening questions, visual acuity testing, the Amsler grid, and physical examination. For treatments, we evaluated corrective lenses and photorefractive surgery for uncorrected refractive errors; cataract surgery for cataracts; antioxidants or vitamins for dry AMD; and laser photocoagulation, photodynamic therapy, and vascular endothelin growth factor inhibitors for wet AMD. The full evidence report reviews other interventions (10). Outcomes of interest were visual acuity, vision-related function or quality of life, general function or quality of life, falls, accidents, death, and harms related to screening or treatment. We excluded studies of glaucoma or diabetes (1112). Screening for glaucoma is not based on evaluations of visual acuity and is addressed elsewhere by the USPSTF (11). Screening for diabetic retinopathy typically occurs in patients known to have diabetes.

For diagnostic accuracy, we included studies that compared a screening test with a reference standard. We used randomized, controlled trials (RCTs) to assess the effectiveness and harms of screening and various treatments. If RCTs were not available or evidence was sparse, we also used controlled observational studies. Because many systematic reviews have been conducted on treatments for impaired visual acuity, we included good-quality systematic reviews of randomized trials on the effectiveness or harms of treatment and fair- or good-quality systematic reviews of observational studies when no randomized trials were available (after verifying data abstraction and statistical analyses).

Data Extraction and Quality Assessment

One investigator abstracted data, and another checked the abstracted data. We abstracted details about the patient sample, study design, data analysis methods, follow-up, and results. We used predefined criteria developed by the USPSTF to assess the internal validity of primary studies (13). We independently abstracted and rated all placebo-controlled RCTs, regardless of inclusion status in previously published systematic reviews (14). For randomized trials, we assessed methods of randomization, allocation concealment, and blinding; loss to follow-up; and use of intention-to-treat analysis. For cluster randomized trials (trials that randomly assigned patients in groups according to which clinic they attended), we also evaluated whether the study adjusted for the effects of clustering (cluster-correlation correction) (15). For systematic reviews, we abstracted information on search methods, dates of searches, selection of studies, and data synthesis methods. We rated quality by using criteria described in Appendix Table 3. Two authors independently rated the internal validity of each study as “good,” “fair,” or “poor,” on the basis of the number and seriousness of methodological shortcomings (13). We assessed the potential applicability of studies to primary care on the basis of whether patients were recruited from primary care settings, the proportion of patients with mild to moderate vision impairment, and whether the screening intervention was or could be done in most primary care settings. We resolved discrepancies in quality ratings by discussion and consensus.

Table Jump PlaceholderAppendix Table 3.  Quality Assessment Criteria for Systematic Reviews

For diagnostic accuracy studies, we used the diagti procedure in Stata, version 10 (StataCorp, College Station, Texas), to calculate sensitivities, specificities, and likelihood ratios. We used the cci procedure to calculate diagnostic odds ratios (ORs) with exact CIs. We classified likelihood ratios as “large,” “moderate,” or “small” on the basis of the criteria shown in Table 1(16).

Table Jump PlaceholderTable 1.  Interpretation of Likelihood Ratios
Data Synthesis and Analysis

We assessed the overall strength of each body of evidence by using methods developed by the USPSTF (13). For screening and diagnostic accuracy, we did not attempt to pool results of individual studies owing to heterogeneity in study samples, screening interventions, or diagnostic tests and results. For efficacy of treatments, we reported quantitative estimates for treatment effects from previously published systematic reviews that met quality criteria (14). When we identified RCTs not included in previous reviews, we calculated updated, pooled relative risks (RRs) by using the Mantel–Haenszel random-effects model (Review Manager, version 4.2.8, The Nordic Cochrane Center, Copenhagen, Denmark).

Key Question 1

Does vision screening in asymptomatic older adults result in improved morbidity or mortality or improved quality of life?

Three fair- or fair-to-good–quality cluster randomized trials (n = 4728) evaluated vision screening as part of a multicomponent screening intervention, with high applicability to screening in primary care settings (Table 2) (1719). Methodological shortcomings of all trials included lack of intention-to-treat analysis, unclear blinding status of outcomes assessors, and high loss to follow-up, which was due in part to advanced age and death in enrollees (Appendix Table 4). Only 1 (19) of the 3 trials applied a cluster-correlation correction (15). The screening intervention varied: 1 trial compared universal visual acuity testing (Glasgow acuity chart followed by pinhole testing for persons with visual acuity worse than 6/18) with targeted screening (19), 1 compared immediate with delayed vision screening (17), and 1 compared use of a screening question followed by visual acuity testing if positive with usual care (18). Duration of follow-up ranged from 6 months to 5 years. None of the trials found vision screening to be associated with beneficial effects on vision, likelihood of vision disorders, or functional impairment related to vision.

Table Jump PlaceholderTable 2.  RCTs of Vision Screening in Older Adults
Table Jump PlaceholderAppendix Table 4.  Quality Assessment of Randomized, Controlled Trials of Vision Screening in Older Adults

The highest-quality trial (rated fair to good) also evaluated the largest sample (n = 3249) and followed patients for the longest duration (19). Investigators found that universal vision screening identified about 10 times as many patients with impaired visual acuity and correctable impairment as did targeted screening, yet no difference in likelihood of visual acuity worse than 20/60 after 3- to 5-year follow-up. Reasons for the negative findings are not entirely clear. However, only half of the patients advised to see an eye care provider after vision screening actually received new glasses. Other reasons for lack of benefit in the screening trials may include the high loss to follow-up in all trials, similar frequency of vision disorder detection and treatment in the screening and control groups in 1 trial (18), use of a screening question to identify persons for further testing in 1 trial (18), and low uptake of recommended interventions in 1 trial (17).

A fourth, fair-quality trial was less applicable to primary care because it involved vision screening by an optometrist (visual acuity, contrast sensitivity, and visual field testing; slit-lamp examination; and direct ophthalmoscopy) (20). In frail older adults (n = 309), vision screening did not reduce risk for falls (RR, 1.57 [95% CI, 1.20 to 2.05]) or fractures (RR, 1.74 [CI, 0.97 to 3.11]) after 1 year compared with usual care; in fact, an opposite effect was observed. Screening led to new eyeglasses or referral for further treatment in about half (146 of 309 [47%]) of study participants. Possible explanations for an increased risk for falls could be the need for a prolonged period of readjustment in frail older adults after receiving new eyeglasses or increased activities after treatment of vision impairment that could place persons at higher risk.

No study directly evaluated effects of screening for impaired visual acuity in asymptomatic older adults at different intervals. One cohort study found that after a normal baseline eye examination, the likelihood of experiencing no significant visual field or visual acuity loss after 5 years was 97% in persons age 60 to 69 years, and 93% in persons age 70 to 79 years (21).

Key Question 2

Are there harms of vision screening in asymptomatic older adults?

Potential harms associated with vision screening include anxiety, complications of treatment, or exposure to unnecessary interventions due to false-positive screening test results. However, none of the screening studies in primary care settings evaluated harms associated with vision screening (1719). One study, described above, reported an increased risk for falls after screening by an optometrist (20).

Key Question 3

What is the accuracy of screening for early impairment in visual acuity due to uncorrected refractive error, cataracts, or AMD?

Eight cross-sectional studies evaluated the accuracy of various diagnostic tests or screening questions for impaired visual acuity compared with a reference standard (Appendix Table 5) (2229). All of the studies had at least 2 methodological shortcomings (Appendix Table 6). Only 1 study clearly reported independent interpretation of the reference standard (23), 2 studies clearly applied the reference standard to all patients (2324), and 1 study reported sufficient information to determine that an appropriately broad spectrum of patients was evaluated (25). Four of 8 studies reported diagnostic accuracy specifically in older adults; the remainder enrolled mixed samples of older and younger adults (2326).

Table Jump PlaceholderAppendix Table 5.  Studies of Diagnostic Test Accuracy
Table Jump PlaceholderAppendix Table 6.  Quality Assessment of Studies of Diagnostic Test Accuracy
Screening Questions or Questionnaires

Four studies found various screening questions or questionnaires to have low accuracy for identifying impaired visual acuity compared with visual acuity testing (2426) or a detailed ophthalmologic examination (27) (Table 3). In all studies, positive and negative likelihood ratios were relatively weak (range, 1.19 to 3.23 and 0.23 to 0.78, respectively) because of suboptimal combinations of sensitivity and specificity.

Table Jump PlaceholderTable 3.  Studies of Diagnostic Test Accuracy
Visual Acuity Tests

Four studies found various visual acuity screening tests (near, distance, pinhole, or reading acuity) to have low accuracy compared with a full ophthalmologic examination for identifying the presence of any visual condition (Table 3) (22, 2729). Interpretation of diagnostic accuracy based on this reference standard is a challenge because the clinical significance of visual conditions not necessarily associated with impaired visual acuity is unclear. For 3 of 4 studies, positive likelihood ratios ranged from 1.00 to 8.07 and negative likelihood ratios ranged from 0.32 to 1.00, with diagnostic ORs less than 10 (22, 2728). One study reported diagnostic accuracy of visual acuity testing to specifically identify cataracts or early AMD, with results similar to those for identifying any visual condition (28). No studies compared the Snellen eye chart with a reference standard for impaired visual acuity, possibly because it is often considered the clinical standard for evaluating visual acuity.

Other Screening Tests

One study found that the Amsler grid was associated with poor accuracy as a screening test for identifying any visual condition (Table 3) (22). One very small (n = 50) study found that among patients age 64 to 97 years not known to have eye disease, 100% (9 of 9) of patients with cataracts and 75% (3 of 4) of patients with AMD were correctly identified by a geriatrician compared with an ophthalmologist (23). No study evaluated the accuracy or yield of dilated fundus examination by primary care providers.

Key Question 4

Does treatment of early impairment in visual acuity due to uncorrected refractive error, cataracts, or AMD lead to improved morbidity or mortality or quality of life?

Uncorrected Refractive Error
Corrective Lenses.

In the large, population-based NHANES, more than 60% of persons older than 60 years presenting with visual acuity worse than 20/50 could achieve visual acuity better than 20/40 with refractive correction (1). Because NHANES used a cross-sectional design, the proportion that would have optimal visual acuity at later follow-up is not known. Two fair-quality randomized trials (n = 131 and n = 151) found that immediate correction of refractive error with eyeglasses in older adults (mean age, 80 years) was associated with moderate improvements in short-term (2- to 3-month follow-up), vision-related quality of life or function compared with delayed treatment (3031). In both trials, general vision subscale scores of the National Eye Institute Visual Functioning Questionnaire were improved by a mean of about 10 (of 100) points in the immediate-treatment groups.

Refractive Surgery.

A good-quality systematic review of 157 primarily uncontrolled observational studies found laser in situ keratomileusis (LASIK), laser epithelial keratomileusis (LASEK), and photorefractive keratectomy to be similarly effective at improving refractive errors, with 92% to 94% of persons with myopia and 86% to 96% of persons with hyperopia achieving visual acuity of 20/40 or better (32). Almost half of the observational studies included in this review did not use a prospective design, and most studies did not clearly enroll a consecutive series of patients. Applicability of results to older adults is uncertain because studies generally enrolled younger persons (mean age, 20 to 50 years). Several fair-quality observational studies also found refractive surgery to be associated with improved quality of life (3335).

Cataract
Surgery.

No randomized trial evaluated visual outcomes associated with cataract surgery versus no surgery. A good-quality systematic review of 57 generally lower-quality observational studies published from 1979 to 1991 found cataract surgery associated with postoperative visual acuity of 20/40 or better in 88.9% (CI, 88.1% to 89.8%) of all eyes (n = 17 390) and 95.2% (CI, 94.7% to 95.7%) of eyes without preoperative ocular comorbidity (n = 10 003) after results were weighted by sample size and quality score (36). Only 4 of the studies included in the systematic review used a controlled design. Other common shortcomings included potentially biased methods of patient selection, differential duration of follow-up, and poor description or handling of attrition.

A large, prospective cohort study (n = 4819) found that 85% of persons 85 years or older had improved visual acuity (37). Three good-quality prospective observational studies (n = 45, n = 464, and n = 772) found cataract surgery to be associated with moderate improvements in vision-related quality of life and function (3840). The effect of cataract surgery on functional status or quality of life not directly related to vision was less consistent, with some studies showing no benefits (38, 4042).

One good-quality trial found first cataract surgery to be associated with no significant difference compared with delayed surgery in risk for first fall (hazard ratio, 0.95 [CI, 0.69 to 1.35]) (43). However, the risk for second fall was reduced (hazard ratio, 0.60 [CI, 0.36 to 0.98]), resulting in a lower overall risk for falls (RR, 0.66 [CI, 0.40 to 0.96]). Cataract surgery was also associated with a lower risk for fracture (RR, 0.33 [CI, 0.1 to 1.0]). In another good-quality trial by the same group of investigators, cataract surgery of the second eye was not associated with a reduction in incidence of falls or fractures, although statistical power was limited (44).

A well-designed prospective cohort study of older drivers with cataracts (n = 277) found cataract surgery to be associated with a lower risk for motor vehicle accidents compared with no surgery (RR, 0.47 [CI, 0.23 to 0.94]; absolute risk reduction, 4.74 crashes per million miles driven) (45). Another well-designed prospective cohort study (n = 384) found that patients with cataracts who did not have surgery had increased all-cause mortality risk for up to 6 years of follow-up (6.8 deaths per 100 patient-years) compared with persons with cataracts who had surgery (3.6 deaths per 100 patient-years) or those without cataracts (0.9 deaths per 100 patient-years) (RR, 3.2 [CI, 1.2 to 9.0] for persons with cataracts who did not have surgery vs. those with no cataracts) (46).

Dry (Nonexudative) AMD
Antioxidant Vitamins and Minerals.

The large, good-quality AREDS (Age-Related Eye Disease Study) (n = 3640) (47) found that a multivitamin (vitamins C and E and β-carotene) plus zinc was associated with reduced likelihood of progression to advanced AMD (adjusted OR, 0.68 [CI, 0.49 to 0.93]), although the difference in the likelihood of losing 15 or more letters of visual acuity did not reach statistical significance (adjusted OR, 0.77 [CI, 0.58 to 1.03]) (47). A good-quality systematic review included 9 poor- or fair-quality RCTs (n = 5569) of various antioxidant treatment regimens (48). Results were highly influenced by AREDS, and the systematic review found insufficient evidence to determine efficacy of other vitamin and mineral combinations. A small (n = 101), fair-quality trial not included in the systematic review found the combination of acetyl-l-carnitine, [ohgr ]-3 fatty acids, and coenzyme Q10 was associated with a lower likelihood of deterioration in visual acuity (23% vs. 45%; RR, 0.51 [CI, 0.28 to 0.92]), but effects on clinically significant visual acuity loss were not reported (49).

Wet (Exudative) AMD
Laser Photocoagulation.

A good-quality systematic review found laser photocoagulation to be superior to no treatment for progression of vision loss (loss of ≥6 lines of visual acuity) after 2 years (pooled RR, 0.67 [CI, 0.53 to 0.83]; 5 trials [n = 1413]) (50). We rated all trials poor quality (5155) because of methodological shortcomings (open-label design, incomplete follow-up, and lack of intention-to-treat analysis). In addition, clinical and statistical heterogeneity (I2 = 58%) were present in the pooled analysis. The trials enrolled persons with visual acuity ranging from normal to worse than 20/200, and the proportion of patients with baseline vision worse than 20/200 ranged from 0% to 34%. In addition, the location of choroidal neovascularization (foveal, juxtafoveal, or extrafoveal) varied. Nonetheless, all trials found a benefit in favor of laser photocoagulation.

Photodynamic Therapy With Verteporfin.

Two good-quality systematic reviews of photodynamic therapy found verteporfin to be superior to placebo for preventing loss of visual acuity, based on either 2 (56) or 3 (57) fair- (58) or good-quality (5960) trials. The systematic review that pooled 3 trials (n = 1065) (5860) found that verteporfin reduced the likelihood of 3 or more lines of visual acuity loss after 2 years (RR, 0.22 [CI, 0.13 to 0.30]), with a number needed to treat of 7 (57). Three- and 5-year open-label extension results of 1 of the trials (59) were similar to 2-year results (6162). Quality of life was not assessed in any of the trials.

Intravitreal Injection of Vascular Endothelial Growth Factor Inhibitors.

A good-quality systematic review (63) found pegaptanib at doses of 0.3, 1, or 3 mg to be more effective than placebo at 12 months for visual acuity loss (>15 letters or 3 lines of loss), based on a pooled analysis of 2 fair-quality trials (RR, 0.71 [CI, 0.60 to 0.84]; n = 1186) (64). The number needed to treat to prevent 1 case of visual acuity loss ranged from 7 to 14, depending on the dose evaluated (63). Pegaptanib also reduced the risk for blindness (visual acuity worse than 20/200) compared with placebo (RR, 0.69 [CI, 0.59 to 0.82]). In a pooled analysis of 2 good-quality trials (n = 900), we found that ranibizumab, 0.3 or 0.5 mg, was associated with decreased risk for visual acuity loss (RR, 0.21 [CI, 0.16 to 0.27]) and blindness (RR, 0.35 [CI 0.21 to 0.57]) compared with placebo at 12 months, with a number needed to treat to prevent 1 case of visual acuity loss of about 2.5 (6566). In 1 of the trials, results were sustained through 24 months (66). Vascular endothelial growth factor inhibitors were associated with mild to moderate improvements in vision-related function in 3 good-quality trials, although differences were not always statistically significant (65, 6768).

Appendix Table 7 summarizes trials of interventions for wet AMD versus placebo or no treatment, with quality ratings given in Appendix Table 8.

Table Jump PlaceholderAppendix Table 7.  Randomized, Placebo-Controlled Trials of Interventions for Wet AMD
Table Jump PlaceholderAppendix Table 8.  Quality Assessment of Randomized, Controlled Trials of Wet AMD
Key Question 5

Are there harms of treating early impairment in visual acuity due to uncorrected refractive error, cataracts, or AMD?

Uncorrected Refractive Error
Corrective Lenses.

We identified no studies on harms associated with monofocal eyeglasses. One fair-quality prospective study (n = 87) found that multifocal lenses (bifocals, trifocals, or progressive lenses) were associated with a higher risk for falls in older adults (adjusted OR, 2.09 [CI, 1.06 to 4.92]) (69).

Two large (each enrolled >10 000 persons), fair-quality, prospective observational studies found that the incidence of vision loss due to infectious keratitis ranged from 0.3 to 0.9 cases per 10 000 persons who wore contact lenses, regardless of age (7071). Other fair-quality prospective studies reported a substantially higher risk for keratitis among those who wore extended-wear contact lenses (3.6 [CI, 0.4 to 12.9] cases per 10 000 persons) (72) or found that persons older than 50 years had increased risk for keratitis compared with those 25 years or younger (OR, 2.04 [CI, 1.40 to 2.98]) (73).

Photorefractive Surgery.

A good-quality systematic review of 157 primarily uncontrolled observational studies of photorefractive surgery identified 5 studies, all of LASIK, that reported a median rate of corneal ectasia (bulging forward of the cornea due to weakening of supporting structures) of 0.2% (range, 0% to 0.87%) (32). Rates of infectious keratitis ranged from 0% to 0.16% after LASIK and 0% to 3.4% after LASEK but were reported in only 6 LASIK studies (including 4 reporting no cases) and 4 LASEK studies. Estimates of incidence of glare, visual haloes, or worsened night vision after refractive surgery were inconsistent and were based on sparse evidence, with rates ranging from 0% to more than 50%.

Cataract

Posterior capsule opacification of surgically implanted lens is the most common long-term complication after cataract surgery, but it can usually be treated with a brief external laser procedure. A systematic review of 49 primarily uncontrolled observational studies found a pooled incidence of posterior capsule opacification of 11.8% (range, 9.3% to 14.3%) at 1 year, 20.7% (range, 16.6% to 24.9%) at 3 years, and 28.4% (range 16.6 to 24.9%) at 5 years (74).

A fair-quality systematic review of 215 primarily uncontrolled observational studies found a 0.13% rate of endophthalmitis after cataract surgery (75). Additional analyses found a RR of 2.44 (CI, 2.27 to 2.61) for surgeries completed since 2000 compared with surgeries in earlier decades. This trend temporally coincides with increased use of sutureless, clear corneal incisions.

Other major complications associated with cataract surgery include bullous keratopathy (0.3% [CI, 0.2% to 0.4%]), dislocation of intraocular lens (1.1% [CI, 0.9% to 1.2%]), clinical cystoid macular edema (1.4% [CI, 1.2% to 1.6%]), and retinal detachment (0.7% [CI, 0.6% to 0.8%]) (36).

Dry AMD
Antioxidant Vitamins and Minerals.

The large, good-quality AREDS found treatment with zinc associated with increased risk for hospitalization for genitourinary causes compared with nonuse (11.1% vs. 7.6%; RR, 1.47 [CI, 1.19 to 1.80]) and treatment with antioxidants associated with increased risk for yellow skin compared with nonuse (8.3% vs. 6.0%; RR, 1.38 [CI, 1.09 to 1.75]) (7677). There was no association between antioxidant supplementation and increased hospitalizations, death, or lung cancer. Risk for congestive heart failure was not specifically reported. Other trials of antioxidants for dry AMD found no clear association with adverse events (7879), although assessment and reporting of harms were generally suboptimal.

Wet AMD
Laser Photocoagulation.

A good-quality systematic review found laser photocoagulation to be associated with increased risk for short-term (3 months after treatment) visual acuity loss of 6 or more lines compared with observation (pooled RR, 1.41 [CI, 1.08 to 1.82]; 5 poor-quality trials) (50). However, laser photocoagulation was superior to observation on visual acuity outcomes by 2 years (see Key Question 4).

Photodynamic Therapy With Verteporfin.

A good-quality systematic review of 3 fair- or good-quality trials found verteporfin to be associated with greater risk for acute severe visual acuity loss (20-letter loss within 7 days of treatment) compared with placebo (2% vs. 0.2%; pooled RR, 0.02 [CI, 0.01 to 0.03]; number needed to harm, 50) (57). Verteporfin was also associated with a greater risk for infusion-related back pain compared with placebo (3.4% vs. 0.3%; pooled RR, 6.50 [CI, 1.52 to 27.78]).

Intravitreal Injection of Vascular Endothelial Growth Factor Inhibitors.

A large, good-quality trial reported 5 cases of presumed endophthalmitis, 6 cases of uveitis, and 11 cases of elevated intraocular pressure among 477 patients treated with ranibizumab compared with 0 cases for any of these adverse events among 236 patients treated with sham injections (66).

A study that pooled data from 2 similarly designed, fair-quality trials of pegaptanib (892 patients who received pegaptanib) found a rate of 1.3% for endophthalmitis (0.16% per injection; 1 of 12 cases associated with ≥6 lines of vision loss), 0.6% for traumatic cataract (0.07% per injection; 1 of 5 cases associated with severe vision loss), and 0.7% for retinal detachment (0.08% per injection; no cases associated with severe vision loss) after 1 year of treatment (80). There were no differences between pegaptanib or ranibizumab and placebo in rates of hypertensive or thromboembolic events (66, 80).

The manufacturer of ranibizumab sent a letter to clinicians in January 2007 about preliminary results of an ongoing trial that found increased stroke rates in patients who received higher doses of intravitreal ranibizumab. However, 1-year data reported at a conference in February 2008 showed no difference in stroke rates, regardless of dose (81).

Table 4 summarizes the results of this evidence synthesis, by key question. Compared with the 1996 USPSTF evidence synthesis (9), more direct evidence on vision screening in older adults now exists. Three cluster randomized trials that enrolled more than 4700 patients found vision screening in older adults as part of a multicomponent screening intervention in primary care settings to be no more effective than no vision screening, delayed screening, or usual care (1719). A fourth trial found optometrist screening to be associated with an increased risk for falls in frail elderly patients (20). No studies that evaluate optimal screening intervals exist.

Despite the lack of direct evidence to support vision screening, evidence on effectiveness of treatments for common causes of impaired visual acuity is strong. As the 1996 USPSTF review concluded, a very high proportion of patients have favorable vision-related outcomes after treatment of impaired visual acuity due to refractive error and cataracts (9). For wet AMD, vascular endothelial growth factor inhibitors and photodynamic therapy with verteporfin seem to be effective treatment options with a relatively low incidence of serious harms (57, 63). An important advantage of these treatments is that they are associated with less retinal scarring than laser photocoagulation, which is a particularly important consideration for patients with subfoveal (central) neovascularization. For dry AMD, antioxidant vitamins and minerals seem effective for slowing progression of disease (48), although conclusions are largely based on a single large trial of a specific antioxidant regimen (47). In addition, antioxidants included in the formulation used in this trial have been found to be associated with congestive heart failure (vitamin E [82]) and lung cancer in smokers (β-carotene [8384]) when prescribed for prevention of cancer or cardiovascular disease.

Evidence on accuracy of screening tests for impaired visual acuity (or conditions associated with impaired visual acuity) is difficult to interpret. Although the Snellen eye chart is widely used to measure visual acuity in primary care settings, no studies have evaluated its accuracy against a clinically relevant reference standard. Some studies found testing with the Snellen eye chart to be inaccurate compared with a detailed ophthalmologic examination, but the conditions identified on examination were not necessarily associated with impaired visual acuity. It is unclear whether identification of AMD or cataracts before the development of impaired visual acuity is associated with improved clinical outcomes compared with identification of these conditions after the development of early vision changes. No screening question is similar in accuracy to visual acuity testing (2427), and no studies have assessed the accuracy or utility of pinhole testing, the Amsler grid, visual acuity tests other than the Snellen eye chart, physical examination, or funduscopic examination.

Our evidence review has some potential limitations. First, the relatively small number of primary studies and methodological shortcomings made it difficult to answer most key questions with a high degree of confidence. We did not grade any key question as being supported by good-quality evidence. Second, we excluded studies not published in English, which could introduce language bias. However, we did not identify any relevant non–English-language studies from literature searches or reference lists. Finally, we excluded trials of community- or home-based vision screening. The inclusion of such studies is unlikely to change our conclusions because their results are consistent with no benefit from screening (85).

Impaired visual acuity is common in older adults, and effective treatments are available for common causes of impaired visual acuity. Nonetheless, direct evidence of vision screening in asymptomatic older adults in primary care settings found no effects in improving visual acuity or other clinical outcomes. Additional studies are needed to determine why trials of vision screening have shown no benefit and to clarify the risk for potential unintended harms from screening (such as increased falls). For any vision-screening program to be effective, optimal screening approaches and intervals need to be defined, and older adults with impaired visual acuity need to be effectively linked to appropriate follow-up care.

Vitale S, Cotch MF, Sperduto RD.  Prevalence of visual impairment in the United States. JAMA. 2006; 295:2158-63. PubMed
CrossRef
 
Ivers RQ, Cumming RG, Mitchell P, Attebo K.  Visual impairment and falls in older adults: the Blue Mountains Eye Study. J Am Geriatr Soc. 1998; 46:58-64. PubMed
 
Klein BE, Moss SE, Klein R, Lee KE, Cruickshanks KJ.  Associations of visual function with physical outcomes and limitations 5 years later in an older population: the Beaver Dam eye study. Ophthalmology. 2003; 110:644-50. PubMed
 
McGwin G Jr, Chapman V, Owsley C.  Visual risk factors for driving difficulty among older drivers. Accid Anal Prev. 2000; 32:735-44. PubMed
 
West SK, Munoz B, Rubin GS, Schein OD, Bandeen-Roche K, Zeger S. et al.  Function and visual impairment in a population-based study of older adults. The SEE project. Salisbury Eye Evaluation. Invest Ophthalmol Vis Sci. 1997; 38:72-82. PubMed
 
Eye Diseases Prevalence Research Group.  The prevalence of refractive errors among adults in the United States, Western Europe, and Australia. Arch Ophthalmol. 2004; 122:495-505. PubMed
 
Eye Diseases Prevalence Research Group.  Prevalence of age-related macular degeneration in the United States. Arch Ophthalmol. 2004; 122:564-72. PubMed
 
Eye Diseases Prevalence Research Group.  Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol. 2004; 122:477-85. PubMed
 
U.S. Preventive Services Task Force.  Chapter 33: screening for visual impairment. In: Guide to Clinical Preventive Services. 2nd ed. Rockville, MD: Agency for Healthcare Research and Quality; 1996. Accessed athttp://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat3.chapter.10062on 19 May 2009.
 
Chou R, Dana T, Bougatsos C.  Screening for visual impairment in older adults: systematic review to update the 1996 U.S. Preventive Services Task Force Recommendation. Prepared by the Oregon Evidence-based Practice Center for the Agency for Healthcare Research and Quality under contract 290-2007-10057-I-EPC3. Evidence synthesis no. 71. AHRQ publication no. 09-05135-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; July 2009. Accessed athttp://www.ahrq.gov/clinic/uspstf/uspstopics.htmon 13 May 2009.
 
Fleming C, Whitlock E, Beil T, Smit B.  Primary care screening for ocular hypertension and primary open-angle glaucoma: Evidence synthesis no. 34. Rockville, MD: Agency for Healthcare Research and Quality; March 2005. Accessed athttp://www.ahrq.gov/clinic/uspstf05/glaucoma/glaucsyn.pdfon 13 May 2009.
 
Norris SL, Kansagara D, Bougatsos C, Nygren P, Fu R.  Screening for type 2 diabetes mellitus: update of 2003 systematic evidence review for the U.S. Preventive Services Task Force. Evidence synthesis no. 61. Rockville, MD: Agency for Healthcare Research and Quality; June 2008. Accessed athttp://www.ahrq.gov/clinic/uspstf08/type2/type2es.pdfon 13 May 2009.
 
Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al. Methods Work Group, Third US Preventive Services Task Force.  Current methods of the US Preventive Services Task Force: a review of the process. Am J Prev Med. 2001; 20:21-35. PubMed
 
Whitlock EP, Lin JS, Chou R, Shekelle P, Robinson KA.  Using existing systematic reviews in complex systematic reviews. Ann Intern Med. 2008; 148:776-82. PubMed
 
Campbell MK, Elbourne DR, Altman DG, CONSORT group.  CONSORT statement: extension to cluster randomised trials. BMJ. 2004; 328:702-8. PubMed
 
Jaeschke R, Guyatt GH, Sackett DL.  Users' guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The Evidence-Based Medicine Working Group. JAMA. 1994; 271:703-7. PubMed
 
Eekhof J, De Bock G, Schaapveld K, Springer M.  Effects of screening for disorders among the elderly: an intervention study in general practice. Fam Pract. 2000; 17:329-33. PubMed
 
Moore AA, Siu A, Partridge JM, Hays RD, Adams J.  A randomized trial of office-based screening for common problems in older persons. Am J Med. 1997; 102:371-8. PubMed
 
Smeeth L, Fletcher AE, Hanciles S, Evans J, Wormald R.  Screening older people for impaired vision in primary care: cluster randomised trial. BMJ. 2003; 327:1027. PubMed
 
Cumming RG, Ivers R, Clemson L, Cullen J, Hayes MF, Tanzer M. et al.  Improving vision to prevent falls in frail older people: a randomized trial. J Am Geriatr Soc. 2007; 55:175-81. PubMed
 
Taylor HR, Vu HT, McCarty CA, Keeffe JE.  The need for routine eye examinations. Invest Ophthalmol Vis Sci. 2004; 45:2539-42. PubMed
 
Ariyasu RG, Lee PP, Linton KP, LaBree LD, Azen SP, Siu AL.  Sensitivity, specificity, and predictive values of screening tests for eye conditions in a clinic-based population. Ophthalmology. 1996; 103:1751-60. PubMed
 
McMurdo ME, Baines PS.  The detection of visual disability in the elderly. Health Bull (Edinb). 1988; 46:327-9. PubMed
 
Eekhof JA, De Bock GH, Schaapveld K, Springer MP.  Screening for hearing and visual loss among elderly with questionnaires and tests: which method is the most convincing for action? Scand J Prim Health Care. 2000; 18:203-7. PubMed
 
Hiller R, Krueger DE.  Validity of a survey question as a measure of visual acuity impairment. Am J Public Health. 1983; 73:93-6. PubMed
 
Chu-Ai Teh R, Lim WS, Basri R, Ismail NH.  Utility of a patient-response screening question for visual impairment [Letter]. J Am Geriatr Soc. 2006; 54:370-2. PubMed
 
Wang F, Tielsch JM, Ford DE, Quigley HA, Whelton PK.  Evaluation of screening schemes for eye disease in a primary care setting. Ophthalmic Epidemiol. 1998; 5:69-82. PubMed
 
Ivers RQ, Optom B, Macaskill P, Cumming RG, Mitchell P.  Sensitivity and specificity of tests to detect eye disease in an older population. Ophthalmology. 2001; 108:968-75. PubMed
 
Woods RL, Tregear SJ, Mitchell RA.  Screening for ophthalmic disease in older subjects using visual acuity and contrast sensitivity. Ophthalmology. 1998; 105:2318-26. PubMed
 
Coleman AL, Yu F, Keeler E, Mangione CM.  Treatment of uncorrected refractive error improves vision-specific quality of life. J Am Geriatr Soc. 2006; 54:883-90. PubMed
 
Owsley C, McGwin G Jr, Scilley K, Meek GC, Seker D, Dyer A.  Effect of refractive error correction on health-related quality of life and depression in older nursing home residents. Arch Ophthalmol. 2007; 125:1471-7. PubMed
 
Murray A, Jones L, Milne A, Fraser CM, Lourenco T, Burr J.  A systematic review of the safety and efficacy of elective photorefractive surgery for the correction of refractive error. Aberdeen, United Kingdom: Health Services Research Unit, University of Aberdeen; April 2005. Accessed athttp://www.nice.org.uk/nicemedia/pdf/ip/Finalreport%20010605.pdfon 13 May 2009.
 
McDonnell PJ, Mangione C, Lee P, Lindblad AS, Spritzer KL, Berry S. et al.  Responsiveness of the National Eye Institute Refractive Error Quality of Life instrument to surgical correction of refractive error. Ophthalmology. 2003; 110:2302-9. PubMed
 
Schein OD, Vitale S, Cassard SD, Steinberg EP.  Patient outcomes of refractive surgery. The refractive status and vision profile. J Cataract Refract Surg. 2001; 27:665-73. PubMed
 
Tahzib NG, Bootsma SJ, Eggink FA, Nabar VA, Nuijts RM.  Functional outcomes and patient satisfaction after laser in situ keratomileusis for correction of myopia. J Cataract Refract Surg. 2005; 31:1943-51. PubMed
 
Powe NR, Schein OD, Gieser SC, Tielsch JM, Luthra R, Javitt J. et al.  Synthesis of the literature on visual acuity and complications following cataract extraction with intraocular lens implantation. Cataract Patient Outcome Research Team. Arch Ophthalmol. 1994; 112:239-52. PubMed
 
Lundström M, Stenevi U, Thorburn W.  Cataract surgery in the very elderly. J Cataract Refract Surg. 2000; 26:408-14. PubMed
 
Owsley C, McGwin G Jr, Scilley K, Meek GC, Seker D, Dyer A.  Impact of cataract surgery on health-related quality of life in nursing home residents. Br J Ophthalmol. 2007; 91:1359-63. PubMed
 
Steinberg EP, Tielsch JM, Schein OD, Javitt JC, Sharkey P, Cassard SD, et al.  National study of cataract surgery outcomes. Variation in 4-month postoperative outcomes as reflected in multiple outcome measures. Ophthalmology. 1994;101:1131-40; discussion 1140-1. [PMID: 8008355]
 
Mangione CM, Phillips RS, Lawrence MG, Seddon JM, Orav EJ, Goldman L.  Improved visual function and attenuation of declines in health-related quality of life after cataract extraction. Arch Ophthalmol. 1994; 112:1419-25. PubMed
 
Applegate WB, Miller ST, Elam JT, Freeman JM, Wood TO, Gettlefinger TC.  Impact of cataract surgery with lens implantation on vision and physical function in elderly patients. JAMA. 1987; 257:1064-6. PubMed
 
McGwin G Jr, Li J, McNeal S, Owsley C.  The impact of cataract surgery on depression among older adults. Ophthalmic Epidemiol. 2003; 10:303-13. PubMed
 
Harwood RH, Foss AJ, Osborn F, Gregson RM, Zaman A, Masud T.  Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial. Br J Ophthalmol. 2005; 89:53-9. PubMed
 
Foss AJ, Harwood RH, Osborn F, Gregson RM, Zaman A, Masud T.  Falls and health status in elderly women following second eye cataract surgery: a randomised controlled trial. Age Ageing. 2006; 35:66-71. PubMed
 
Owsley C, McGwin G Jr, Sloane M, Wells J, Stalvey BT, Gauthreaux S.  Impact of cataract surgery on motor vehicle crash involvement by older adults. JAMA. 2002; 288:841-9. PubMed
 
McGwin G Jr, Owsley C, Gauthreaux S.  The association between cataract and mortality among older adults. Ophthalmic Epidemiol. 2003; 10:107-19. PubMed
 
Age-Related Eye Disease Study Research Group.  A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Arch Ophthalmol. 2001; 119:1417-36. PubMed
 
Evans JR, Henshaw K.  Antioxidant vitamin and mineral supplements for preventing age-related macular degeneration. Cochrane Database Syst Rev. 2008; CD000253. PubMed
 
Feher J, Kovacs B, Kovacs I, Schveoller M, Papale A, Balacco Gabrieli C.  Improvement of visual functions and fundus alterations in early age-related macular degeneration treated with a combination of acetyl-L-carnitine, n-3 fatty acids, and coenzyme Q10. Ophthalmologica. 2005; 219:154-66. PubMed
 
Virgili G, Bini A.  Laser photocoagulation for neovascular age-related macular degeneration. Cochrane Database Syst Rev. 2007; CD004763. PubMed
 
.  Argon laser photocoagulation for senile macular degeneration. Results of a randomized clinical trial. Arch Ophthalmol. 1982; 100:912-8. PubMed
 
.  Krypton laser photocoagulation for neovascular lesions of age-related macular degeneration. Results of a randomized clinical trial. Macular Photocoagulation Study Group. Arch Ophthalmol. 1990; 108:816-24. PubMed
 
.  Laser photocoagulation of subfoveal neovascular lesions in age-related macular degeneration. Results of a randomized clinical trial. Macular Photocoagulation Study Group. Arch Ophthalmol. 1991; 109:1220-31. PubMed
 
.  Laser photocoagulation of subfoveal recurrent neovascular lesions in age-related macular degeneration. Results of a randomized clinical trial. Macular Photocoagulation Study Group. Arch Ophthalmol. 1991; 109:1232-41. PubMed
 
.  Treatment of senile disciform macular degeneration: a single-blind randomised trial by argon laser photocoagulation. The Moorfields Macular Study Group. Br J Ophthalmol. 1982; 66:745-53. PubMed
 
Meads C, Salas C, Roberts T, Moore D, Fry-Smith A, Hyde C.  Clinical effectiveness and cost-utility of photodynamic therapy for wet age-related macular degeneration: a systematic review and economic evaluation. Health Technol Assess. 2003; 7:v-vi, 1-98. PubMed
 
Wormald R, Evans J, Smeeth L, Henshaw K.  Photodynamic therapy for neovascular age-related macular degeneration. Cochrane Database Syst Rev. 2007; CD002030. PubMed
 
Azab M, Boyer DS, Bressler NM, Bressler SB, Cihelkova I, Hao Y, et al. Visudyne in Minimally Classic Choroidal Neovascularization Study Group.  Verteporfin therapy of subfoveal minimally classic choroidal neovascularization in age-related macular degeneration: 2-year results of a randomized clinical trial. Arch Ophthalmol. 2005; 123:448-57. PubMed
 
.  Photodynamic therapy of subfoveal choroidal neovascularization in age-related macular degeneration with verteporfin: one-year results of 2 randomized clinical trials—TAP report. Treatment of age-related macular degeneration with photodynamic therapy (TAP) Study Group. Arch Ophthalmol. 1999; 117:1329-45. PubMed
 
Verteporfin in Photodynamic Therapy Study Group.  Photodynamic therapy of subfoveal choroidal neovascularization in pathologic myopia with verteporfin. 1-year results of a randomized clinical trial—VIP report no. 1. Ophthalmology. 2001; 108:841-52. PubMed
 
Treatment of Age-Related Macular Degeneration with Photodynamic Therapy (TAP) Study Group.  Verteporfin therapy for subfoveal choroidal neovascularization in age-related macular degeneration: three-year results of an open-label extension of 2 randomized clinical trials—TAP Report no. 5. Arch Ophthalmol. 2002; 120:1307-14. PubMed
 
Kaiser PK, Treatment of Age-Related Macular Degeneration with Photodynamic Therapy (TAP) Study Group.  Verteporfin therapy of subfoveal choroidal neovascularization in age-related macular degeneration: 5-year results of two randomized clinical trials with an open-label extension: TAP report no. 8. Graefes Arch Clin Exp Ophthalmol. 2006; 244:1132-42. PubMed
 
Vedula SS, Krzystolik MG.  Antiangiogenic therapy with anti-vascular endothelial growth factor modalities for neovascular age-related macular degeneration. Cochrane Database Syst Rev. 2008; CD005139. PubMed
 
Gragoudas ES, Adamis AP, Cunningham ET, Feinsod M, Guyer DR, VEGF Inhibition Study in Ocular Neovascularization Clinical Trial Group.  Pegaptanib for neovascular age-related macular degeneration. N Engl J Med. 2004; 351:2805-16. PubMed
 
Regillo CD, Brown DM, Abraham P, Yue H, Ianchulev T, Schneider S. et al.  Randomized, double-masked, sham-controlled trial of ranibizumab for neovascular age-related macular degeneration: PIER Study year 1. Am J Ophthalmol. 2008; 145:239-248. PubMed
 
Rosenfeld PJ, Brown DM, Heier JS, Boyer DS, Kaiser PK, Chung CY, et al. MARINA Study Group.  Ranibizumab for neovascular age-related macular degeneration. N Engl J Med. 2006; 355:1419-31. PubMed
 
Chang TS, Bressler NM, Fine JT, Dolan CM, Ward J, Klesert TR, et al. MARINA Study Group.  Improved vision-related function after ranibizumab treatment of neovascular age-related macular degeneration: results of a randomized clinical trial. Arch Ophthalmol. 2007; 125:1460-9. PubMed
 
Leys A, Zlateva G, Shah SN, Patel M.  Quality of life in patients with age-related macular degeneration: results from the VISION study. Eye. 2008; 22:792-8. PubMed
 
Lord SR, Dayhew J, Howland A.  Multifocal glasses impair edge-contrast sensitivity and depth perception and increase the risk of falls in older people. J Am Geriatr Soc. 2002; 50:1760-6. PubMed
 
Cheng KH, Leung SL, Hoekman HW, Beekhuis WH, Mulder PG, Geerards AJ. et al.  Incidence of contact-lens-associated microbial keratitis and its related morbidity. Lancet. 1999; 354:181-5. PubMed
 
Nilsson SE, Montan PG.  The annualized incidence of contact lens induced keratitis in Sweden and its relation to lens type and wear schedule: results of a 3-month prospective study. CLAO J. 1994; 20:225-30. PubMed
 
Schein OD, McNally JJ, Katz J, Chalmers RL, Tielsch JM, Alfonso E. et al.  The incidence of microbial keratitis among wearers of a 30-day silicone hydrogel extended-wear contact lens. Ophthalmology. 2005; 112:2172-9. PubMed
 
Chalmers RL, McNally JJ, Schein OD, Katz J, Tielsch JM, Alfonso E. et al.  Risk factors for corneal infiltrates with continuous wear of contact lenses. Optom Vis Sci. 2007; 84:573-9. PubMed
 
Schaumberg DA, Dana MR, Christen WG, Glynn RJ.  A systematic overview of the incidence of posterior capsule opacification. Ophthalmology. 1998; 105:1213-21. PubMed
 
Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM. et al.  Acute endophthalmitis following cataract surgery: a systematic review of the literature. Arch Ophthalmol. 2005; 123:613-20. PubMed
 
Age-Related Eye Disease Study Research Group.  A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E and beta carotene for age-related cataract and vision loss: AREDS report no. 9. Arch Ophthalmol. 2001; 119:1439-52. PubMed
 
Johnson AR, Munoz A, Gottlieb JL, Jarrard DF.  High dose zinc increases hospital admissions due to genitourinary complications. J Urol. 2007; 177:639-43. PubMed
 
Kaiser HJ, Flammer J, Stümpfig D, Hendrickson P.  Visaline in the treatment of age-related macular degeneration: a pilot study. Ophthalmologica. 1995; 209:302-5. PubMed
 
Richer S, Stiles W, Statkute L, Pulido J, Frankowski J, Rudy D. et al.  Double-masked, placebo-controlled, randomized trial of lutein and antioxidant supplementation in the intervention of atrophic age-related macular degeneration: the Veterans LAST study (Lutein Antioxidant Supplementation Trial). Optometry. 2004; 75:216-30. PubMed
 
VEGF Inhibition Study in Ocular Neovascularization (V.I.S.I.O.N.) Clinical Trial Group.  Pegaptanib sodium for neovascular age-related macular degeneration: two-year safety results of the two prospective, multicenter, controlled clinical trials. Ophthalmology. 2006; 113:992-1001.e6. PubMed
 
Avery RL, Ho AC.  Good news for anti-VEGF therapy. Accessed athttp://www.retinatoday.com/issues/0308/0308_01.phpon 7 May 2009.
 
HOPE and HOPE-TOO Trial Investigators.  Effects of long-term vitamin E supplementation on cardiovascular events and cancer: a randomized controlled trial. JAMA. 2005; 293:1338-47. PubMed
 
Omenn GS, Goodman GE, Thornquist MD, Balmes J, Cullen MR, Glass A. et al.  Effects of a combination of beta carotene and vitamin A on lung cancer and cardiovascular disease. N Engl J Med. 1996; 334:1150-5. PubMed
 
.  The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. N Engl J Med. 1994; 330:1029-35. PubMed
 
Lee AG.  Community screening for visual impairment in older people. Community screening for visual impairment in the elderly. J Am Geriatr Soc. 2001; 49:673-5. PubMed
 
National Institute for Health and Clinical Excellence.  The Guidelines Manual. London: National Institute for Health and Clinical Excellence; 2006.
 
Oxman AD, Guyatt GH.  Validation of an index of the quality of review articles. J Clin Epidemiol. 1991; 44:1271-8. PubMed
 
Treatment of Age-Related Macular Degeneration with Photodynamic Therapy Study Group.  Acute severe visual acuity decrease after photodynamic therapy with verteporfin: case reports from randomized clinical trials-TAP and VIP report no. 3. Am J Ophthalmol. 2004; 137:683-96. PubMed
 
Verteporfin In Photodynamic Therapy Study Group.  Verteporfin therapy of subfoveal choroidal neovascularization in age-related macular degeneration: two-year results of a randomized clinical trial including lesions with occult with no classic choroidal neovascularization—verteporfin in photodynamic therapy report 2. Am J Ophthalmol. 2001; 131:541-60. PubMed
 
Visudyne in Minimally Classic Choroidal Neovascularization Study Group.  Verteporfin therapy of subfoveal minimally classic choroidal neovascularization in age-related macular degeneration: 2-year results of a randomized clinical trial. Arch Ophthalmol. 2005; 123:448-57. PubMed
 
Boyer DS, Antoszyk AN, Awh CC, Bhisitkul RB, Shapiro H, Acharya NR, et al. MARINA Study Group.  Subgroup analysis of the MARINA study of ranibizumab in neovascular age-related macular degeneration. Ophthalmology. 2007; 114:246-52. PubMed
 

Figures

Grahic Jump Location
Appendix Figure.
Analytic framework and key questions.

KQ = key question.

Grahic Jump Location
Grahic Jump Location
Figure.
Study flow diagram.

AMD = age-related macular degeneration; KQ = key question; RCT = randomized, controlled trial; SR = systematic review; URE = uncorrected refractive error. * Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews. † Identified from reference lists suggested by experts. ‡ Some studies were included for >1 KQ.

Grahic Jump Location

Tables

Table Jump PlaceholderAppendix Table 1.  Search Strategies
Table Jump PlaceholderAppendix Table 2.  Inclusion and Exclusion Criteria
Table Jump PlaceholderAppendix Table 3.  Quality Assessment Criteria for Systematic Reviews
Table Jump PlaceholderTable 1.  Interpretation of Likelihood Ratios
Table Jump PlaceholderTable 2.  RCTs of Vision Screening in Older Adults
Table Jump PlaceholderAppendix Table 4.  Quality Assessment of Randomized, Controlled Trials of Vision Screening in Older Adults
Table Jump PlaceholderAppendix Table 5.  Studies of Diagnostic Test Accuracy
Table Jump PlaceholderAppendix Table 6.  Quality Assessment of Studies of Diagnostic Test Accuracy
Table Jump PlaceholderTable 3.  Studies of Diagnostic Test Accuracy
Table Jump PlaceholderAppendix Table 7.  Randomized, Placebo-Controlled Trials of Interventions for Wet AMD
Table Jump PlaceholderAppendix Table 8.  Quality Assessment of Randomized, Controlled Trials of Wet AMD

References

Vitale S, Cotch MF, Sperduto RD.  Prevalence of visual impairment in the United States. JAMA. 2006; 295:2158-63. PubMed
CrossRef
 
Ivers RQ, Cumming RG, Mitchell P, Attebo K.  Visual impairment and falls in older adults: the Blue Mountains Eye Study. J Am Geriatr Soc. 1998; 46:58-64. PubMed
 
Klein BE, Moss SE, Klein R, Lee KE, Cruickshanks KJ.  Associations of visual function with physical outcomes and limitations 5 years later in an older population: the Beaver Dam eye study. Ophthalmology. 2003; 110:644-50. PubMed
 
McGwin G Jr, Chapman V, Owsley C.  Visual risk factors for driving difficulty among older drivers. Accid Anal Prev. 2000; 32:735-44. PubMed
 
West SK, Munoz B, Rubin GS, Schein OD, Bandeen-Roche K, Zeger S. et al.  Function and visual impairment in a population-based study of older adults. The SEE project. Salisbury Eye Evaluation. Invest Ophthalmol Vis Sci. 1997; 38:72-82. PubMed
 
Eye Diseases Prevalence Research Group.  The prevalence of refractive errors among adults in the United States, Western Europe, and Australia. Arch Ophthalmol. 2004; 122:495-505. PubMed
 
Eye Diseases Prevalence Research Group.  Prevalence of age-related macular degeneration in the United States. Arch Ophthalmol. 2004; 122:564-72. PubMed
 
Eye Diseases Prevalence Research Group.  Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol. 2004; 122:477-85. PubMed
 
U.S. Preventive Services Task Force.  Chapter 33: screening for visual impairment. In: Guide to Clinical Preventive Services. 2nd ed. Rockville, MD: Agency for Healthcare Research and Quality; 1996. Accessed athttp://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat3.chapter.10062on 19 May 2009.
 
Chou R, Dana T, Bougatsos C.  Screening for visual impairment in older adults: systematic review to update the 1996 U.S. Preventive Services Task Force Recommendation. Prepared by the Oregon Evidence-based Practice Center for the Agency for Healthcare Research and Quality under contract 290-2007-10057-I-EPC3. Evidence synthesis no. 71. AHRQ publication no. 09-05135-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; July 2009. Accessed athttp://www.ahrq.gov/clinic/uspstf/uspstopics.htmon 13 May 2009.
 
Fleming C, Whitlock E, Beil T, Smit B.  Primary care screening for ocular hypertension and primary open-angle glaucoma: Evidence synthesis no. 34. Rockville, MD: Agency for Healthcare Research and Quality; March 2005. Accessed athttp://www.ahrq.gov/clinic/uspstf05/glaucoma/glaucsyn.pdfon 13 May 2009.
 
Norris SL, Kansagara D, Bougatsos C, Nygren P, Fu R.  Screening for type 2 diabetes mellitus: update of 2003 systematic evidence review for the U.S. Preventive Services Task Force. Evidence synthesis no. 61. Rockville, MD: Agency for Healthcare Research and Quality; June 2008. Accessed athttp://www.ahrq.gov/clinic/uspstf08/type2/type2es.pdfon 13 May 2009.
 
Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al. Methods Work Group, Third US Preventive Services Task Force.  Current methods of the US Preventive Services Task Force: a review of the process. Am J Prev Med. 2001; 20:21-35. PubMed
 
Whitlock EP, Lin JS, Chou R, Shekelle P, Robinson KA.  Using existing systematic reviews in complex systematic reviews. Ann Intern Med. 2008; 148:776-82. PubMed
 
Campbell MK, Elbourne DR, Altman DG, CONSORT group.  CONSORT statement: extension to cluster randomised trials. BMJ. 2004; 328:702-8. PubMed
 
Jaeschke R, Guyatt GH, Sackett DL.  Users' guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The Evidence-Based Medicine Working Group. JAMA. 1994; 271:703-7. PubMed
 
Eekhof J, De Bock G, Schaapveld K, Springer M.  Effects of screening for disorders among the elderly: an intervention study in general practice. Fam Pract. 2000; 17:329-33. PubMed
 
Moore AA, Siu A, Partridge JM, Hays RD, Adams J.  A randomized trial of office-based screening for common problems in older persons. Am J Med. 1997; 102:371-8. PubMed
 
Smeeth L, Fletcher AE, Hanciles S, Evans J, Wormald R.  Screening older people for impaired vision in primary care: cluster randomised trial. BMJ. 2003; 327:1027. PubMed
 
Cumming RG, Ivers R, Clemson L, Cullen J, Hayes MF, Tanzer M. et al.  Improving vision to prevent falls in frail older people: a randomized trial. J Am Geriatr Soc. 2007; 55:175-81. PubMed
 
Taylor HR, Vu HT, McCarty CA, Keeffe JE.  The need for routine eye examinations. Invest Ophthalmol Vis Sci. 2004; 45:2539-42. PubMed
 
Ariyasu RG, Lee PP, Linton KP, LaBree LD, Azen SP, Siu AL.  Sensitivity, specificity, and predictive values of screening tests for eye conditions in a clinic-based population. Ophthalmology. 1996; 103:1751-60. PubMed
 
McMurdo ME, Baines PS.  The detection of visual disability in the elderly. Health Bull (Edinb). 1988; 46:327-9. PubMed
 
Eekhof JA, De Bock GH, Schaapveld K, Springer MP.  Screening for hearing and visual loss among elderly with questionnaires and tests: which method is the most convincing for action? Scand J Prim Health Care. 2000; 18:203-7. PubMed
 
Hiller R, Krueger DE.  Validity of a survey question as a measure of visual acuity impairment. Am J Public Health. 1983; 73:93-6. PubMed
 
Chu-Ai Teh R, Lim WS, Basri R, Ismail NH.  Utility of a patient-response screening question for visual impairment [Letter]. J Am Geriatr Soc. 2006; 54:370-2. PubMed
 
Wang F, Tielsch JM, Ford DE, Quigley HA, Whelton PK.  Evaluation of screening schemes for eye disease in a primary care setting. Ophthalmic Epidemiol. 1998; 5:69-82. PubMed
 
Ivers RQ, Optom B, Macaskill P, Cumming RG, Mitchell P.  Sensitivity and specificity of tests to detect eye disease in an older population. Ophthalmology. 2001; 108:968-75. PubMed
 
Woods RL, Tregear SJ, Mitchell RA.  Screening for ophthalmic disease in older subjects using visual acuity and contrast sensitivity. Ophthalmology. 1998; 105:2318-26. PubMed
 
Coleman AL, Yu F, Keeler E, Mangione CM.  Treatment of uncorrected refractive error improves vision-specific quality of life. J Am Geriatr Soc. 2006; 54:883-90. PubMed
 
Owsley C, McGwin G Jr, Scilley K, Meek GC, Seker D, Dyer A.  Effect of refractive error correction on health-related quality of life and depression in older nursing home residents. Arch Ophthalmol. 2007; 125:1471-7. PubMed
 
Murray A, Jones L, Milne A, Fraser CM, Lourenco T, Burr J.  A systematic review of the safety and efficacy of elective photorefractive surgery for the correction of refractive error. Aberdeen, United Kingdom: Health Services Research Unit, University of Aberdeen; April 2005. Accessed athttp://www.nice.org.uk/nicemedia/pdf/ip/Finalreport%20010605.pdfon 13 May 2009.
 
McDonnell PJ, Mangione C, Lee P, Lindblad AS, Spritzer KL, Berry S. et al.  Responsiveness of the National Eye Institute Refractive Error Quality of Life instrument to surgical correction of refractive error. Ophthalmology. 2003; 110:2302-9. PubMed
 
Schein OD, Vitale S, Cassard SD, Steinberg EP.  Patient outcomes of refractive surgery. The refractive status and vision profile. J Cataract Refract Surg. 2001; 27:665-73. PubMed
 
Tahzib NG, Bootsma SJ, Eggink FA, Nabar VA, Nuijts RM.  Functional outcomes and patient satisfaction after laser in situ keratomileusis for correction of myopia. J Cataract Refract Surg. 2005; 31:1943-51. PubMed
 
Powe NR, Schein OD, Gieser SC, Tielsch JM, Luthra R, Javitt J. et al.  Synthesis of the literature on visual acuity and complications following cataract extraction with intraocular lens implantation. Cataract Patient Outcome Research Team. Arch Ophthalmol. 1994; 112:239-52. PubMed
 
Lundström M, Stenevi U, Thorburn W.  Cataract surgery in the very elderly. J Cataract Refract Surg. 2000; 26:408-14. PubMed
 
Owsley C, McGwin G Jr, Scilley K, Meek GC, Seker D, Dyer A.  Impact of cataract surgery on health-related quality of life in nursing home residents. Br J Ophthalmol. 2007; 91:1359-63. PubMed
 
Steinberg EP, Tielsch JM, Schein OD, Javitt JC, Sharkey P, Cassard SD, et al.  National study of cataract surgery outcomes. Variation in 4-month postoperative outcomes as reflected in multiple outcome measures. Ophthalmology. 1994;101:1131-40; discussion 1140-1. [PMID: 8008355]
 
Mangione CM, Phillips RS, Lawrence MG, Seddon JM, Orav EJ, Goldman L.  Improved visual function and attenuation of declines in health-related quality of life after cataract extraction. Arch Ophthalmol. 1994; 112:1419-25. PubMed
 
Applegate WB, Miller ST, Elam JT, Freeman JM, Wood TO, Gettlefinger TC.  Impact of cataract surgery with lens implantation on vision and physical function in elderly patients. JAMA. 1987; 257:1064-6. PubMed
 
McGwin G Jr, Li J, McNeal S, Owsley C.  The impact of cataract surgery on depression among older adults. Ophthalmic Epidemiol. 2003; 10:303-13. PubMed
 
Harwood RH, Foss AJ, Osborn F, Gregson RM, Zaman A, Masud T.  Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial. Br J Ophthalmol. 2005; 89:53-9. PubMed
 
Foss AJ, Harwood RH, Osborn F, Gregson RM, Zaman A, Masud T.  Falls and health status in elderly women following second eye cataract surgery: a randomised controlled trial. Age Ageing. 2006; 35:66-71. PubMed
 
Owsley C, McGwin G Jr, Sloane M, Wells J, Stalvey BT, Gauthreaux S.  Impact of cataract surgery on motor vehicle crash involvement by older adults. JAMA. 2002; 288:841-9. PubMed
 
McGwin G Jr, Owsley C, Gauthreaux S.  The association between cataract and mortality among older adults. Ophthalmic Epidemiol. 2003; 10:107-19. PubMed
 
Age-Related Eye Disease Study Research Group.  A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Arch Ophthalmol. 2001; 119:1417-36. PubMed
 
Evans JR, Henshaw K.  Antioxidant vitamin and mineral supplements for preventing age-related macular degeneration. Cochrane Database Syst Rev. 2008; CD000253. PubMed
 
Feher J, Kovacs B, Kovacs I, Schveoller M, Papale A, Balacco Gabrieli C.  Improvement of visual functions and fundus alterations in early age-related macular degeneration treated with a combination of acetyl-L-carnitine, n-3 fatty acids, and coenzyme Q10. Ophthalmologica. 2005; 219:154-66. PubMed
 
Virgili G, Bini A.  Laser photocoagulation for neovascular age-related macular degeneration. Cochrane Database Syst Rev. 2007; CD004763. PubMed
 
.  Argon laser photocoagulation for senile macular degeneration. Results of a randomized clinical trial. Arch Ophthalmol. 1982; 100:912-8. PubMed
 
.  Krypton laser photocoagulation for neovascular lesions of age-related macular degeneration. Results of a randomized clinical trial. Macular Photocoagulation Study Group. Arch Ophthalmol. 1990; 108:816-24. PubMed
 
.  Laser photocoagulation of subfoveal neovascular lesions in age-related macular degeneration. Results of a randomized clinical trial. Macular Photocoagulation Study Group. Arch Ophthalmol. 1991; 109:1220-31. PubMed
 
.  Laser photocoagulation of subfoveal recurrent neovascular lesions in age-related macular degeneration. Results of a randomized clinical trial. Macular Photocoagulation Study Group. Arch Ophthalmol. 1991; 109:1232-41. PubMed
 
.  Treatment of senile disciform macular degeneration: a single-blind randomised trial by argon laser photocoagulation. The Moorfields Macular Study Group. Br J Ophthalmol. 1982; 66:745-53. PubMed
 
Meads C, Salas C, Roberts T, Moore D, Fry-Smith A, Hyde C.  Clinical effectiveness and cost-utility of photodynamic therapy for wet age-related macular degeneration: a systematic review and economic evaluation. Health Technol Assess. 2003; 7:v-vi, 1-98. PubMed
 
Wormald R, Evans J, Smeeth L, Henshaw K.  Photodynamic therapy for neovascular age-related macular degeneration. Cochrane Database Syst Rev. 2007; CD002030. PubMed
 
Azab M, Boyer DS, Bressler NM, Bressler SB, Cihelkova I, Hao Y, et al. Visudyne in Minimally Classic Choroidal Neovascularization Study Group.  Verteporfin therapy of subfoveal minimally classic choroidal neovascularization in age-related macular degeneration: 2-year results of a randomized clinical trial. Arch Ophthalmol. 2005; 123:448-57. PubMed
 
.  Photodynamic therapy of subfoveal choroidal neovascularization in age-related macular degeneration with verteporfin: one-year results of 2 randomized clinical trials—TAP report. Treatment of age-related macular degeneration with photodynamic therapy (TAP) Study Group. Arch Ophthalmol. 1999; 117:1329-45. PubMed
 
Verteporfin in Photodynamic Therapy Study Group.  Photodynamic therapy of subfoveal choroidal neovascularization in pathologic myopia with verteporfin. 1-year results of a randomized clinical trial—VIP report no. 1. Ophthalmology. 2001; 108:841-52. PubMed
 
Treatment of Age-Related Macular Degeneration with Photodynamic Therapy (TAP) Study Group.  Verteporfin therapy for subfoveal choroidal neovascularization in age-related macular degeneration: three-year results of an open-label extension of 2 randomized clinical trials—TAP Report no. 5. Arch Ophthalmol. 2002; 120:1307-14. PubMed
 
Kaiser PK, Treatment of Age-Related Macular Degeneration with Photodynamic Therapy (TAP) Study Group.  Verteporfin therapy of subfoveal choroidal neovascularization in age-related macular degeneration: 5-year results of two randomized clinical trials with an open-label extension: TAP report no. 8. Graefes Arch Clin Exp Ophthalmol. 2006; 244:1132-42. PubMed
 
Vedula SS, Krzystolik MG.  Antiangiogenic therapy with anti-vascular endothelial growth factor modalities for neovascular age-related macular degeneration. Cochrane Database Syst Rev. 2008; CD005139. PubMed
 
Gragoudas ES, Adamis AP, Cunningham ET, Feinsod M, Guyer DR, VEGF Inhibition Study in Ocular Neovascularization Clinical Trial Group.  Pegaptanib for neovascular age-related macular degeneration. N Engl J Med. 2004; 351:2805-16. PubMed
 
Regillo CD, Brown DM, Abraham P, Yue H, Ianchulev T, Schneider S. et al.  Randomized, double-masked, sham-controlled trial of ranibizumab for neovascular age-related macular degeneration: PIER Study year 1. Am J Ophthalmol. 2008; 145:239-248. PubMed
 
Rosenfeld PJ, Brown DM, Heier JS, Boyer DS, Kaiser PK, Chung CY, et al. MARINA Study Group.  Ranibizumab for neovascular age-related macular degeneration. N Engl J Med. 2006; 355:1419-31. PubMed
 
Chang TS, Bressler NM, Fine JT, Dolan CM, Ward J, Klesert TR, et al. MARINA Study Group.  Improved vision-related function after ranibizumab treatment of neovascular age-related macular degeneration: results of a randomized clinical trial. Arch Ophthalmol. 2007; 125:1460-9. PubMed
 
Leys A, Zlateva G, Shah SN, Patel M.  Quality of life in patients with age-related macular degeneration: results from the VISION study. Eye. 2008; 22:792-8. PubMed
 
Lord SR, Dayhew J, Howland A.  Multifocal glasses impair edge-contrast sensitivity and depth perception and increase the risk of falls in older people. J Am Geriatr Soc. 2002; 50:1760-6. PubMed
 
Cheng KH, Leung SL, Hoekman HW, Beekhuis WH, Mulder PG, Geerards AJ. et al.  Incidence of contact-lens-associated microbial keratitis and its related morbidity. Lancet. 1999; 354:181-5. PubMed
 
Nilsson SE, Montan PG.  The annualized incidence of contact lens induced keratitis in Sweden and its relation to lens type and wear schedule: results of a 3-month prospective study. CLAO J. 1994; 20:225-30. PubMed
 
Schein OD, McNally JJ, Katz J, Chalmers RL, Tielsch JM, Alfonso E. et al.  The incidence of microbial keratitis among wearers of a 30-day silicone hydrogel extended-wear contact lens. Ophthalmology. 2005; 112:2172-9. PubMed
 
Chalmers RL, McNally JJ, Schein OD, Katz J, Tielsch JM, Alfonso E. et al.  Risk factors for corneal infiltrates with continuous wear of contact lenses. Optom Vis Sci. 2007; 84:573-9. PubMed
 
Schaumberg DA, Dana MR, Christen WG, Glynn RJ.  A systematic overview of the incidence of posterior capsule opacification. Ophthalmology. 1998; 105:1213-21. PubMed
 
Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM. et al.  Acute endophthalmitis following cataract surgery: a systematic review of the literature. Arch Ophthalmol. 2005; 123:613-20. PubMed
 
Age-Related Eye Disease Study Research Group.  A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E and beta carotene for age-related cataract and vision loss: AREDS report no. 9. Arch Ophthalmol. 2001; 119:1439-52. PubMed
 
Johnson AR, Munoz A, Gottlieb JL, Jarrard DF.  High dose zinc increases hospital admissions due to genitourinary complications. J Urol. 2007; 177:639-43. PubMed
 
Kaiser HJ, Flammer J, Stümpfig D, Hendrickson P.  Visaline in the treatment of age-related macular degeneration: a pilot study. Ophthalmologica. 1995; 209:302-5. PubMed
 
Richer S, Stiles W, Statkute L, Pulido J, Frankowski J, Rudy D. et al.  Double-masked, placebo-controlled, randomized trial of lutein and antioxidant supplementation in the intervention of atrophic age-related macular degeneration: the Veterans LAST study (Lutein Antioxidant Supplementation Trial). Optometry. 2004; 75:216-30. PubMed
 
VEGF Inhibition Study in Ocular Neovascularization (V.I.S.I.O.N.) Clinical Trial Group.  Pegaptanib sodium for neovascular age-related macular degeneration: two-year safety results of the two prospective, multicenter, controlled clinical trials. Ophthalmology. 2006; 113:992-1001.e6. PubMed
 
Avery RL, Ho AC.  Good news for anti-VEGF therapy. Accessed athttp://www.retinatoday.com/issues/0308/0308_01.phpon 7 May 2009.
 
HOPE and HOPE-TOO Trial Investigators.  Effects of long-term vitamin E supplementation on cardiovascular events and cancer: a randomized controlled trial. JAMA. 2005; 293:1338-47. PubMed
 
Omenn GS, Goodman GE, Thornquist MD, Balmes J, Cullen MR, Glass A. et al.  Effects of a combination of beta carotene and vitamin A on lung cancer and cardiovascular disease. N Engl J Med. 1996; 334:1150-5. PubMed
 
.  The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. N Engl J Med. 1994; 330:1029-35. PubMed
 
Lee AG.  Community screening for visual impairment in older people. Community screening for visual impairment in the elderly. J Am Geriatr Soc. 2001; 49:673-5. PubMed
 
National Institute for Health and Clinical Excellence.  The Guidelines Manual. London: National Institute for Health and Clinical Excellence; 2006.
 
Oxman AD, Guyatt GH.  Validation of an index of the quality of review articles. J Clin Epidemiol. 1991; 44:1271-8. PubMed
 
Treatment of Age-Related Macular Degeneration with Photodynamic Therapy Study Group.  Acute severe visual acuity decrease after photodynamic therapy with verteporfin: case reports from randomized clinical trials-TAP and VIP report no. 3. Am J Ophthalmol. 2004; 137:683-96. PubMed
 
Verteporfin In Photodynamic Therapy Study Group.  Verteporfin therapy of subfoveal choroidal neovascularization in age-related macular degeneration: two-year results of a randomized clinical trial including lesions with occult with no classic choroidal neovascularization—verteporfin in photodynamic therapy report 2. Am J Ophthalmol. 2001; 131:541-60. PubMed
 
Visudyne in Minimally Classic Choroidal Neovascularization Study Group.  Verteporfin therapy of subfoveal minimally classic choroidal neovascularization in age-related macular degeneration: 2-year results of a randomized clinical trial. Arch Ophthalmol. 2005; 123:448-57. PubMed
 
Boyer DS, Antoszyk AN, Awh CC, Bhisitkul RB, Shapiro H, Acharya NR, et al. MARINA Study Group.  Subgroup analysis of the MARINA study of ranibizumab in neovascular age-related macular degeneration. Ophthalmology. 2007; 114:246-52. PubMed
 

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Submit a Comment

Supplements

Supplemental Content
Recommendation Summary

Summary for Patients

Screening Older Adults for Eyesight Problems: U.S. Preventive Services Task Force Recommendation

The summary below is from the full reports titled “Screening for Impaired Visual Acuity in Older Adults: U.S. Preventive Services Task Force Recommendation Statement” and “Screening Older Adults for Impaired Visual Acuity: A Review of the Evidence for the U.S. Preventive Services Task Force.” They are in the 7 July 2009 issue of Annals of Internal Medicine (volume 151, pages 37-43 and pages 44-58). The first report was written by the U.S. Preventive Services Task Force; the second report was written by R. Chou, T. Dana, and C. Bougatsos.

Read More...

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)