Vision Impairment Has Implications for Aging and Health Outcomes, Beyond Ophthalmology

The latest recommendations from the US Preventive Services Task Force (USPSTF) found insufficient information to recommend for or against impaired visual acuity screening for uncorrected refractive error, cataracts, and age-related macular degeneration (AMD) in asymptomatic adults aged 65 years or older in primary care settings.^1,2 An “I statement” remains, as was the case for the 2016 USPSTF recommendations,³ implying that there continues to be a dearth of evidence on the balance of benefits and harms of impaired visual acuity screening for this population. This latest USPSTF recommendation^1,2 is based on a rigorous set of criteria and applies specifically to adults aged 65 years and older; individuals who are asymptomatic, defined as those without known impaired visual acuity (based on current corrected vision) who have not sought care for evaluation of vision problems; 3 conditions of interest (uncorrected refractive errors, cataracts, and AMD); and screening in a primary care setting.

The USPSTF is an independent body of primary care clinicians and preventive medicine experts that provides evidence-based recommendations about clinical preventive services to improve the health of people in the US. The USPSTF is supported by Department of Health and Human Services and Agency for Healthcare Research and Quality. Their recommendations are based on an exhaustive systematic review of the literature and consider the magnitude of the net benefit of impaired visual acuity screening. The USPSTF recommendations^1,2 have great influence, as they are followed by payers and care professionals, with significant influence on health policy and insurance coverage. As a result, an impaired visual acuity screening recommendation is considered when there is at least moderate certainty that the net benefit would be substantial.

The continued insufficiency of evidence highlights a need for well-designed studies to formally test the potential benefits of impaired visual acuity screening among older adults. Vision screening is key to linking patients to vision care. During the life course, many people will experience vision impairment, and the risk of vision loss increases with age.^4,5 Approximately 1% of adults aged 50 to 54 years in the US have visual acuity impairment or are blind, but this estimate increases to more than 20% of those 85 years and older.⁶ Almost 80% of vision impairment and 25% of blindness in the US is preventable or treatable with prescription eye glasses and surgical cataract treatment, interventions with high clinical- and cost-effectiveness.⁴ For eye diseases that lead to irreversible vision loss, such as AMD, early interventions can be critical.⁷ Yet, the USPTSF recommendation found that there was not enough interventional data showing the downstream benefits of impaired visual acuity screening for averting or reversing vision loss.

To generate this body of evidence, research efforts must move beyond the confines of clinical ophthalmology. There is established evidence of the associations between vision impairment and physical, cognitive, psychological, and social functioning, as well as independence, and well-being.^8-14 Longitudinal studies have shown that vision impairment is a risk factor associated with cognitive decline,⁸ reduced physical activity,⁹ increased falls and fratures,¹⁰ depression,¹¹ social isolation,¹² frailty,¹⁵ and mortality.¹³ Our previous work conceptualizing a model on how vision impairment challenges successful aging highlights how the impact of vision impairment on aging outcomes can be addressed at multiple intervention points.¹⁴ While there are established temporal associations of vision impairment with these adverse health outcomes, there is still a lack of interventional data showing that impaired visual acuity screening and subsequent treatment of vision impairment from eye diseases, such as AMD, will actually affect these outcomes. Among the few exceptions are studies demonstrating that surgical cataract treatment is associated with approximately 50% reduced incidence of falls¹⁶ and 30% reduced risk of dementia.¹⁷ There is also limited evidence for the potential positive impact of AMD treatments on patient mobility and falls.⁷ Additional interventional research is needed to test the downstream nonophthalmic gains of screening for vision impairment among older adults.

Generating evidence on the value of impaired visual acuity screening for older adults will require robust collaboration. With the aging of the US population, the proportion of US adults aged 65 years and older is expected to increase from 16% of the population in 2019 to 22% of the population by 2040.¹⁸ Consequently, 6.6 million people aged 60 years and older are projected to have vision impairment or blindness in 2050, up from 3.3 million in 2020.¹⁹ The increasing number of people with vision impairment and the associated adverse health outcomes have far-reaching social and economic implications for older adults, family caregivers, health care practitioners, government, and policy makers.^4,6,20 Therefore, interventional studies examining the effect of impaired visual acuity screening to stave off these effects will be best conducted with a team of experts: ophthalmologists, optometrists, and vision scientists will need to work alongside researchers in geriatrics, disability, and health policy to fill current evidence gaps that could move the needle on this USPSTF recommendation.^1,2

To maximize the impact of any potential future changes in USPSTF recommendations, forward-looking health care policy must also track alongside vision screening research. Currently, traditional fee-for-service Medicare does not reimburse most vision services, and beneficiaries in need of these services incur out-of-pocket expenses or must enroll in Medicare Advantage plans with supplemental vision benefits.^21,22 Accordingly, vision services are not accessible to many people in the US. Access to eye care for older adults is critical for diagnosis and treatment of preventable causes of vision loss, such as refractive error and cataract, as well as for early detection and intervention for eye diseases, such as AMD. But for many older adults, barriers to care go beyond insurance coverage and can be magnified for marginalized groups, including women and Black and Hispanic individuals.²² Eye care coverage strategies are needed to support both the impaired visual acuity screening and subsequent eye care costs of refractive services and prescription lenses and frames in older adults.

There are some nuances to be kept in mind when considering the USPSTF recommendation.^1,2 The American Academy of Ophthalmology recommends a comprehensive eye examination every 1 to 2 years for adults 65 years and older without risk factors, and the American Optometric Association recommends an annual examination for adults older than 60 years. Various factors likely underlie the differences between the USPSTF^1,2 and professional organization recommendations. Within the eye health and research community, there is growing recognition that the association between vision impairment and declines in functioning is not driven by visual acuity alone. Impairments in near acuity (including due to presbyopia), contrast sensitivity, visual fields, and stereoacuity also can affect daily functioning^8,9,14,23 and must be assessed to comprehensively characterize visual impairment in older adults. However, primary care settings, the focus of this USPSTF recommendation,^1,2 are not currently equipped to administer a full battery of vision tests. Yet technological developments, such as tablet-based tests that incorporate multiple tests of visual function, offer new opportunities to collect visual acuity and other data more readily in primary care settings and could change the landscape of vision screening in the future.²⁴

Vision research must refocus on the health and well-being of older adults to ensure that when the USPSTF next revisits this recommendation,^1,2 it will no longer be based on a lack of evidence. Meeting this goal will require funding innovative interventional research, supporting interdisciplinary collaborations that include the patient perspective and the expertise of researchers from outside of vision science, and establishing health care policy provisions for affordable vision services. This rigorous research must take a wide view of the impact of vision screening on the health and well-being of older adults. It is incumbent on the vision research community to lead the charge in filling these important data gaps.

Published: May 24, 2022. doi:10.1001/jamanetworkopen.2022.14610

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Varadaraj V et al. JAMA Network Open.

Corresponding Author: Bonnielin K. Swenor, PhD, MPH, Johns Hopkins Disability Health Research Center, Johns Hopkins University, 525 N Wolfe St, Room 530P, Baltimore, MD 21287 (bswenor@jhmi.edu).

Conflict of Interest Disclosures: Dr Ehrlich reported receiving personal fees from MetLife outside the submitted work. No other disclosures were reported.