Grade: I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in older adults.
Frequency of Service
No information available.
Risk Factor Information
No information available.
This recommendation applies to asymptomatic adults 65 years or older who do not present to their primary care clinician with vision problems.
Suggestions for Practice Regarding the I Statement
Potential Preventable Burden
In 2011, about 12% of US adults aged 65 to 74 years and 15% of those 75 years or older reported having problems seeing, even with glasses or contact lenses.1 The prevalence of AMD is 6.5% in adults older than 40 years and increases with age (2.8% in those aged 40–59 years and 13.4% in those aged ≥60 years).2 About half of all cases of bilateral low vision (ie, best-corrected visual acuity of <20/40) in adults 40 years and older are caused by cataracts. The prevalence of cataracts increases sharply with age; an estimated 50% of US adults 80 years or older have cataracts.1 The prevalence of hyperopia requiring a correction of +3.0 diopters or more ranges from about 5.9% in US adults aged 50 to 54 years, to 15.2% in adults aged 65 to 69 years, to 20.4% in adults 80 years or older.1
Older age is an important risk factor for most types of visual impairment. Additional risk factors for cataracts are smoking, alcohol use, ultraviolet light exposure, diabetes, corticosteroid use, and black race. Risk factors for AMD include smoking, family history, and white race.1
The harms of screening in a primary care setting have not been adequately studied. Overall, the potential for harms from treatment are small to none. Harms of treatment of refractive error include a potential for increased falls with the use of multifocal lenses; infectious keratitis with the use of contact lenses, laser-assisted in situ keratomileusis (LASIK), or laser-assisted subepithelial keratectomy (LASEK); and corneal ectasia with LASIK. Harms of cataract surgery include posterior lens opacification and endophthalmitis. Treatment of AMD with antioxidant vitamins and mineral supplements is not associated with increased risk of most serious adverse events.
Although there appears to be benefit in longer-term outcomes, a systematic review found that treatment of AMD with laser photocoagulation was associated with greater risk of acute loss of 6 or more lines of visual acuity vs no treatment at 3 months (relative risk [RR], 1.41 [95% CI, 1.08–1.82]).3 Pooled estimates report a non–statistically significant association bewteen photodynamic therapy and risk of acute loss of 20 or more letters of visual acuity vs placebo at 7 days (RR, 3.75 [95% CI, 0.87–16]) (3 trials).4, 5 One of 2 trials found that treatment of wet AMD with intravitreal vascular endothelial growth factor (VEGF) inhibitor therapy was associated with greater likelihood of withdrawal vs sham therapy; there were no differences in serious or other adverse events, but estimates were imprecise.1, 4, 6, 7
About half of US adults older than 65 years reported having an eye examination within the last 12 months in a 2007 study.8
A visual acuity test (eg, the Snellen eye chart) is the usual method for screening for visual acuity impairment in the primary care setting. Screening questions are not as accurate as visual acuity testing for identifying visual acuity impairment. Evidence on the use of other tests for vision screening in primary care, such as the pinhole test (a test for refractive error), the Amsler grid (a test of central vision to detect AMD), genetic testing, or funduscopy (visual inspection of the interior of the eye), is lacking.
Several types of treatment are effective for improving visual acuity. Corrective lenses improve visual acuity in patients with a refractive error. Treatment of cataracts through surgical removal of the cataract is effective for improving visual acuity. Treatment of exudative (or wet) AMD includes laser photocoagulation, verteporfin, and intravitreal injections of VEGF inhibitors. Antioxidant vitamins and minerals are an effective treatment for dry AMD.
Other Approaches to Prevention
This recommendation statement does not include screening for glaucoma. The USPSTF’s recommendations on screening for glaucoma and falls prevention are available on its website (www.uspreventiveservicestaskforce.org).
Research Needs and Gaps
More evidence is needed on accurate methods of screening in a primary care setting to identify disorders that do not manifest themselves through loss of visual acuity. More studies are needed that evaluate the link between vision screening in older adults and improved function, quality of life, and independence. Further studies are needed on the association between use of corrective lenses and risk of falls, including possible associations with changes in lens prescriptions and the use of multifocal glasses.
Update of Previous USPSTF Recommendation
This recommendation is an update of the 2009 USPSTF recommendation on screening for impaired visual acuity in older adults, which also concluded that the evidence was insufficient to assess the balance of benefits and harms of screening for visual acuity for the improvement of outcomes in older adults.
Impairment of visual acuity is a serious public health problem in older adults. In 2011, about 12% of US adults aged 65 to 74 years and 15% of those 75 years or older reported having problems seeing, even with glasses or contact lenses.
The USPSTF found convincing evidence that screening with a visual acuity test can identify persons with a refractive error. The USPSTF found convincing evidence that screening questions are not as accurate as visual acuity testing for assessing visual acuity. The USPSTF found adequate evidence that visual acuity testing alone does not accurately identify early age-related macular degeneration (AMD) or cataracts.
Benefits of Detection and Early Treatment
The USPSTF found inadequate overall evidence on the benefits of screening, early detection, and treatment to provide a coherent assessment of the overall benefits. Several studies evaluated the direct benefit of screening and reported no reductions in vision disorders or vision-related function in screened populations; however, these studies had limitations, including differing control interventions, high loss to follow-up, and low uptake of treatment. The USPSTF found adequate evidence that early treatment of refractive error, cataracts, and AMD improves or prevents loss of visual acuity.
Harms of Detection and Early Treatment
The USPSTF found inadequate evidence on the harms of screening. The USPSTF found adequate evidence that early treatment of refractive error, cataracts, and AMD may lead to harms that are small to none.
The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in older adults. The evidence is lacking to provide a coherent assessment, and the balance of benefits and harms cannot be determined.
Recommendations of OthersThe American Optometric Association recommends that asymptomatic adults 61 years and older receive an eye examination every year.28 The American Academy of Ophthalmology recommends a comprehensive eye examination that includes visual acuity testing and dilation every 1 to 2 years for all adults 65 years or older who do not have risk factors or more frequently if risk factors are present.29 This recommendation is based on descriptive studies, case reports, and expert consensus. The American Academy of Family Physicians’ recommendation is consistent with that of the USPSTF statement: the current evidence is insufficient to assess the balance of benefits and harms of screening for impaired visual acuity, or vision impairment, in adults 65 years and older who have not reported problems with vision.30 The American Congress of Obstetricians and Gynecologists recommends that vision assessment be a part of well-woman visits for all women 65 years or older.31