Evidence profile: visual impairment

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1 Integrated care for older people (ICOPE) Guidelines on community-level interventions to manage declines in intrinsic capacity Evidence profile: visual impairment Scoping question: For older people with visual impairment, does case finding, provision of care or referral produce any benefit and/or harm compared with controls? The full ICOPE guidelines and complete set of evidence profiles are available at who.int/ageing/publications/guidelines-icope Painting: Wet in Wet by Gusta van der Meer. At 75 years of age, Gusta has an artistic style that is fresh, distinctive and vibrant. A long-time lover of art, she finds that dementia is no barrier to her artistic expression. Appreciated not just for her art but also for the support and encouragement she gives to other artists with dementia, Gusta participates in a weekly art class. Copyright by Gusta van der Meer. All rights reserved

2 Evidence profile: visual impairment Contents Background... 1 Part 1: Evidence review... 2 Scoping question in PICO format (population, intervention, comparison, outcome)... 2 Search strategy... 3 List of systematic reviews (and individual studies) identified by the search process... 3 PICO table... 4 Narrative description of the studies that went into the analysis... 5 GRADE table 1: Vision screening and referral compared with standard care for older people... 6 GRADE table 2: Provision of immediate or delayed care (correction) for older people with uncorrected refractive error... 8 Additional evidence GRADE table 3: Expedited compared with routine cataract surgery for older people with cataract Part 2: From evidence to recommendations Summary of evidence Evidence-to-recommendation table Guideline development group recommendation and remarks References Annex 1: Search strategy for vision impairment Annex 2: PRISMA 2009 flow diagrams Screening for vision impairment in community-dwelling older people Screening and provision of care for vison impairment World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution- NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO;

3 1 Evidence profile: visual impairment Background Worldwide, approximately 185 million people aged 50 years and over are visually impaired (1). More than half of all people with visual impairment live in low- and middle-income countries, with India having the highest number of blind people: 8.3 million (2, 3). In older people, visual impairment influences their ability to live an independent life (4), and increases the need for social care (5). Moreover, there is a strong association between vision impairment and undesirable outcomes, including depressive symptoms (6), lower life satisfaction (7), poor quality of life (8, 9) and reduced social interaction and function (10 12). Poor vision in older people increases the risk of falls (13 22) and mortality (23 29). Among the causes of visual impairment, cataract and refractive errors are most common in older people. Cost-effective interventions, such as cataract surgery and provision of corrective glasses, have shown consistent benefit in reducing disability, limitation in activities, anxiety, depression, risk of falls and fractures (30 34). Despite the availability of cost-effective treatments, eye care utilization by older adults has been found to be infrequent: only 10%, 24%, 22% and 37% of older people living in low-, lower-middle-, upper-middle- and high-income countries, respectively, reported having had an eye exam during the preceding year, while approximately 61% of older people living in low-income countries had never had an eye exam. Research evidence suggests that community case-finding and immediate provision of eye care or referral for cataract surgery might reduce the substantial treatment gap for vision impairment in older people. However, the majority of intervention trials were conducted in highincome countries, and the feasibility of implementing this approach in a resource-poor setting is unclear. Further, mass communitybased screening of asymptomatic older people has been reported to produce no benefits in reducing visual impairment (35, 36). The lack of effectiveness found by studies may be due to the absence of immediate provision of a subsequent intervention to treat the detected problem or to the fact that the majority of studies have been carried out in high-income countries, where vision testing is available and accessible, and the unmet need is relatively small. Therefore, this review has been conducted to synthesize the evidence for community case-finding and provision of care or referral for visual impairment in older people.

4 2 Evidence profile: visual impairment Part 1: Evidence review Scoping question in PICO format (population, intervention, comparison, outcome) Population Older people (both male and female) aged 60 years and over with refractive errors or cataract Interventions Case-finding and referral for refractive error or cataract Case-finding and immediate provision of care for refractive error Comparison Usual care control Outcomes Critical: Visual acuity, vision-related quality of life, self-reported improvement Important: Social function, depression Setting Community care/primary care

5 3 Evidence profile: visual impairment Search strategy The search strategy is provided in Annex 1 (page 20). List of systematic reviews (and individual studies) identified by the search process Included in GRADE 1 tables or footnotes Coleman AL, Yu F, Keeler E, Mangione CM. Treatment of uncorrected refractive error improves the vision-specific quality of life. J Am Geriatr Soc. 2006;54(6): (32) Moore AA, Siu Al, Partridge JM, Hays RD, Adams J. A randomized trial of office-based screening for common problems in older persons. Am J Med. 1997;102(4): (33) 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(11): (34) Smeeth LL, Iliffe S. Community screening for visual impairment in the elderly. Cochrane Database Syst Rev. 2006;(3):CD [Review was updated by WHO in 2015]. (35) Laidlaw DAH, Harrad RA, Hopper CD, Whitaker A, Donovan JL, Brookes ST et al. Randomized trial of effectiveness of second eye cataract surgery. Lancet. 1998;352: (37) Harwood RH, Foss AJE, 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. (38) Foss AJE, 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: (39) Excluded reviews and trials Skelton DA, Howe TE, Ballinger C, Neil F, Palmer S, Gray L. Environmental and behavioural interventions for reducing physical activity limitation in community-dwelling visually impaired older people. Cochrane Database Syst Rev. 2013;(6):CD (Reason: no eligible trials were found) (40) 1 GRADE: Grading of Recommendations Assessment, Development and Evaluation. More information:

6 4 Evidence profile: visual impairment PICO table Intervention/ Comparison Outcomes Systematic reviews and individual studies used for GRADE Explanation 1 Visual screening and referral of eye care vs control (usual care) Visual acuity Quality of life Social function Depression Activities of daily living (ADLs) Smeeth LL, Iliffe S. Community screening for visual impairment in the elderly. Cochrane Database Syst Rev. 2006;(3):CD (35) Moore AA, Siu Al, Partridge JM, Hays RD, Adams J. A randomized trial of office-based screening for common problems in older persons. Am J Med. 1997;102(4): (33) Systematic review relevant to the area Individual study relevant to the area 2 Vision screening and provision of service vs control (usual care) Visual acuity Quality of life, Social function, Depression, ADLs 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(6): (32) 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(11): (34) Individual study relevant to the area Individual study relevant to the area

7 5 Evidence profile: visual impairment Narrative description of the studies that went into the analysis Screening and referral The Cochrane systematic review by Smeeth and Iliffe was carried out to assess the effectiveness of community screening for visual impairment in older people for improving vision (35). The authors searched the Cochrane Eyes and Vision Group Trials Register, The Cochrane Library, the National Research Register, MEDLINE, Embase, PubMed, SciSearch and additional sources for published data. There were no language or date restrictions on the search for trials. Also, they contacted investigators to identify additional unpublished studies or further information not included in the published reports of the trials. Both authors worked independently to extract data and assess trial quality. The authors included randomized trials (RCTs) comparing visual or multicomponent assessment for visual impairment with usual care in older adults who were not identified as belonging to a particular risk group. Moore et al. conducted a cluster RCT at a community-based practice in the United States America to evaluate the effectiveness of a 10-minute office-staff administered screening to assess several conditions including visual impairment (33). They enrolled 261 patients aged 70 years and older and compared screening with usual care. The intervention consisted of a question to assess difficulty performing everyday activities followed by use of a Snellen eye chart if impairment was indicated by the answer to the question. Six months after enrolment, authors contacted the participants through a mailed questionnaire that addressed, among others, changes in self-reported vision. No differences were noted between the intervention (screening) and control (usual care) groups regarding changes in self-reported problems with vision. The study by Coleman et al. was carried out in the United States to evaluate the benefits of eyeglasses and magnifiers in elderly patients with uncorrected refractive errors (32). In this RCT, the authors assessed the effects of immediate versus delayed corrective lenses. They enrolled 131 community-dwelling people aged 65 years and older whose distant visual acuity, near visual acuity or both could be improved with eyeglasses, a magnifier or both. The primary outcome of the study was vision-specific functioning, measured using the 25-item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25). Results showed improvements in vision-related quality of life in the participants who received a prescription and voucher for eyeglasses immediately. Moreover, they had significant improvement in perception of their general vision, distance visual acuity, near visual acuity and mental health. The study by Owsley et al. was also an RCT on the effects of immediate versus delayed provision of corrective lenses (34). The authors evaluated 151 patients aged 55 years and older having uncorrected refractive error and residing in nursing homes in the USA. The study reported that dispensing spectacles to treat uncorrected refractive error led to improved vision-targeted healthrelated quality of life, fewer reported difficulties in the visual activities of daily living (ADLs) and decreased depressive symptoms.

8 6 Evidence profile: visual impairment GRADE table 1: Vision screening and referral compared with standard care for older people Author: WHO systematic review team Date: 20 October 2015 Question: What is the effectiveness of vision screening as part of multicomponent screening packages compared with standard care for older people? Setting: Primary care or community Bibliography: Smeeth LL, Iliffe S. Community screening for visual impairment in the elderly. Cochrane Database Syst Rev. 2006;(3):CD (35). [Systematic review was updated by WHO in 2015] Quality assessment Number of patients Effect Number of studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Vision screening as part of multicomp onent screening packages Standard care Relative (95% CI) Absolute (95% CI) Quality Importance Self-reported improvement in vision (follow-up 20 months to 4 years; assessed with direct question) 5 randomized trials serious a not serious serious b not serious none 430/1656 (26.0%) 426/183 8 (23.2%) RR 1.03 (0.92 to 1.15) 7 more per 1000 (from 19 fewer to 35 more) LOW CRITICAL Visual acuity less than 6/18 in either eye (follow-up 3 5 years) 1 randomized trials serious c not applicable serious b not serious none 307/829 (37.0%) 339/978 (34.7%) RR 1.07 (0.84 to 1.36) 24 more per 1000 (from 55 fewer to 125 more) LOW CRITICAL (continued next page)

9 7 Evidence profile: visual impairment Mean composite visual function score (follow-up 3 5 years; assessed with National Eye Institute Visual Functioning Questionnaire 25 item [NEI-VFQ-25]; higher score = better performance) 1 randomized trials serious c not applicable serious b not serious none MD 0.4 higher (1.7 lower to 2.5 higher) LOW CRITICAL CI: confidence interval; MD: mean difference; RR: relative risk. a. Risk of bias: Downgraded once as outcome assessors were not masked in three trials. b. Indirectness: Downgraded once as all included trials were from high-income countries. c. Risk of bias: Downgraded once as high drop-out rates were reported in the trials (response rate to follow-up in the two groups: 57.9% [829/1432] in the intervention group and 67.8% [978/1443] in the control group).

10 8 Evidence profile: visual impairment GRADE table 2: Provision of immediate or delayed care (correction) for older people with uncorrected refractive error Author: WHO systematic review team Date: 10 October 2015 Question: What is the effectiveness of receiving vision correction aids immediately (glasses, magnifier or both) compared with delayed correction (voucher and prescription or glasses) for older people with uncorrected refractive error? Setting: Primary care or community Bibliography: (32) Coleman AL, Yu F, Keeler E, Mangione CM. Treatment of uncorrected refractive error improves visionspecific quality of life. J Am Geriatr Soc. 2006;54(6): (34) 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(11): Quality assessment Number of patients Effect Number of studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Receive vision correction aids immediately (glasses, magnifier or both) Delayed correction (received a voucher and prescription) Absolute (95% CI) Quality Importance Improvement in vision-specific functioning (including near and distance vision; follow-up 2 3 months; assessed with National Eye Institute Visual Functioning Questionnaire 25 [NEI-VFQ-25]; higher score = better performance) 2 randomized trials serious a serious b serious c not serious none SMD 1.03 higher (0.42 higher to 1.65 higher) VERY LOW CRITICAL Social functioning (follow-up 3 months; assessed with NEI-VFQ; higher score = better performance) 1 randomized trials serious d not serious serious c serious d none MD 5.4 higher (1.55 lower to higher) VERY LOW IMPORTANT (continued next page)

11 9 Evidence profile: visual impairment Depression (follow-up 2 3 months; assessed with Geriatric Depression Scale; lower score = better performance) 2 randomized trials serious a not serious serious c not serious none MD lower (-1.23 lower to lower) LOW IMPORTANT CI: confidence interval; MD: mean difference; SMD: standardized mean difference a. Risk of bias: Downgraded once as randomization method was inadequate in one of the included trials and allocation concealment method was unclear in the other trial. b. Inconsistency: Downgraded once as moderate heterogeneity was observed in the meta-analysis (Tau² = 0.16; Chi² = 5.82, df = 1 [P = 0.02]; I² = 83%). Reason for heterogeneity could be the characteristics of the participants: one study recruited older people living in the community and the other recruited from nursing home settings (41, 42). c. Indirectness: Downgraded once as all included studies were from high-income countries and generalizing the evidence to other settings is questionable. d. Imprecision: Downgraded once as sample size was small (smaller than 200).

12 10 Evidence profile: visual impairment Additional evidence GRADE table 3: Expedited compared with routine cataract surgery for older people with cataract Author: WHO systematic review team Date: 20 October 2015 Question: What is the effectiveness of expedited surgery compared with routine surgery for older people with cataract? Setting: Hospital Bibliography: (37) Laidlaw DAH, Harrad RA, Hopper CD, Whitaker A, Donovan JL, Brookes ST et al. Randomized trial of effectiveness of second eye cataract surgery. Lancet. 1998;352: (38) Harwood RH, Foss AJE, 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 (39) Foss AJE, 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: Quality assessment Number of patients Effect Number of studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Expedited surgery Routine surgery Relative (95% CI) Absolute (95% CI) Quality Importance Improvement in visual acuity (follow-up 6 months; assessed with Snellen chart) 3 randomized trials not serious serious a serious b not serious none 328/372 (88.2%) 195/365 (53.4%) RR 7.22 (3.15 to 16.55) 358 more per 1000 (from 249 more to 416 more) LOW CRITICAL CI: confidence interval; OR: odds ratio. a. Inconsistency: Downgraded once as moderate heterogeneity was observed (Chi² = 2.59, df = 1 [P = 0.03]; I 2 value = 78%). b. Indirectness: Downgraded once as all included trials were conducted in high-income countries.

13 11 Evidence profile: visual impairment Part 2: From evidence to recommendations Summary of evidence Outcome Effect size Visual screening as part of multicomponent screening packages vs standard care Screening and immediate intervention for refractive error Expedited compared with routine cataract surgery Self-reported improvement GRADE table 1, Smeeth and Iliffe (35) Visual acuity less than 6/18 in either eye GRADE table 1, Smeeth and Iliffe (35) Mean composite visual function score GRADE table 1, Smeeth and Iliffe (35) RR 1.03 (0.92 to 1.15) LOW RR 1.07 (0.84 to 1.36) LOW MD 0.4 higher (-1.7 lower to 2.5 higher) LOW Improvement in visual function GRADE table 2, Coleman et al. (32), Owsley et al. (34) Social function GRADE table 2, Coleman et al. (32), Owsley et al. (34) SMD 1.03 higher (0.42 higher to 1.65 higher) VERY LOW MD 5.4 higher (1.55 lower to higher) VERY LOW (continued next page)

14 12 Evidence profile: visual impairment Depression GRADE table 2, Coleman et al. (32), Owsley et al. (34) MD lower (-1.23 lower to lower) LOW Improvement in visual acuity GRADE table 3, Laidlaw et al. (37), Harwood et al. (38), Foss et al. (39) RR 7.22 (3.15 to 16.55) 358 more per 1000 (from 249 more to 416 more) LOW MD: mean difference; RR: risk ratio; SMD: standardized mean difference

15 13 Evidence profile: visual impairment Evidence-to-recommendation table Problem Is the problem a priority? Yes No Uncertain Benefits and harms Do the desirable effects outweigh the undesirable effects? Yes No Uncertain Explanation Visual impairment is associated with a risk of significant decline in functional ability in older people, and with several adverse outcomes, including reduced quality of life and functional ability, and increased falls and mortality. Many conditions that contribute to vision impairment can be treated effectively, and loss of vision can be prevented in many older people. Currently, there is huge gap in timely access to comprehensive eye care, which can be improved through community case-finding, and appropriate provision of referral and care at primary or community care settings. Explanation There is no direct evidence on the effectiveness of community case-finding through screening and referral for visual impairment in older people. Six population-based randomized controlled trials (RCTs) were evaluated and found no difference in vision and other clinical or functional outcomes when comparing case-identification through vision screening with visual acuity testing or questions with usual care, no vision screening or delayed screening. Five of the RCTs recruited people aged 70 years and over and were conducted in primary or community care settings (8 12). Vision screening was performed as part of a multicomponent risk assessment of health functioning. Vision screening in four of those trials was conducted in the older person s own home (8 11). Data on self-reported improvements in vision were pooled together in the meta-analysis. The pooled risk ratio of self-reported visual problems for older people in the intervention versus control groups was 1.03 (3494 participants, 95% confidence interval [CI]: 0.92 to 1.15). There was no significant heterogeneity observed in the pooled estimated (χ 2 = 0.88, df = 4, P = 0.93, I 2 = 0%). The reasons for the lack of benefit across the six trials might have included: the high loss to follow-up in all trials; contamination of the intervention; a similar frequency of vision disorder detection and treatment in the screening and control groups in one trial; the use of a screening question to identify people for further testing; and low uptake of recommended interventions. In the Cochrane review, three included randomized trials (n = 3346) of vision screening performed as part of a multicomponent screening intervention in older people (mean age, years) were analysed (35). The trials found no difference between vision screening compared with no vision screening, usual care or delayed screening on vision and other clinical outcomes at follow-up assessment, six months to five years later. One cluster RCT (n = 4340) compared universal screening for vision (continued next page)

16 14 Evidence profile: visual impairment (continued from previous page) Do the desirable effects outweigh the undesirable effects? Yes No Uncertain impairment (using the Glasgow Acuity Card followed by pinhole testing for people with visual acuity worse than 20/60) with targeted screening based on a brief screening questionnaire. Only 34% of vision assessments were carried out in peoples own homes; the rest were undertaken at the general practice surgery. At follow-up, 3 5 years after screening, the risk ratio for visual acuity less than 6/18 in either eye for universal versus targeted screening was 1.07 (95% CI: 0.84 to 1.36, P = 0.58). The mean composite score of the 25-item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) was 85.6 in the targeted screening group and 86.0 in the universal group; the difference of 0.4 was not significant (95% CI: 1.7 to 2.5, P = 0.69). In this trial, only half of the patients who were advised to see an eye care provider after vision screening actually received new glasses, which could have attenuated the potential benefits. There is limited low-quality evidence on the effectiveness of community case-finding and immediate provision of care services for refractive error and cataracts for improving visual acuity in older people. Two RCTs reported that immediate correction of refractive error with eyeglasses for older people 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 (32, 34). In one trial, older people in the intervention arm received prescriptions and vouchers for free eyeglasses, while in the other trial, older people were immediately provided with corrective glasses. Participants in one trial were community-dwelling older people aged 65 years and over, whereas the other trial recruited nursing home residents aged 55 years and over. In both trials, general vision subscale scores of the NEI-VFQ were improved by a mean of about 10 (out of 100) points in the immediate-treatment groups. The pooled mean difference between intervention and control groups was (95% CI: 6.87 to 16.87). We found no RCTs that evaluated cataract surgery versus no surgery. However, we identified three trials that examined the effectiveness of expedited cataract surgery compared with routine cataract surgery. Results showed that the expedited surgery was associated with gains in visual function and reduced visual disability. The benefits of this approach outweighs harms: the adverse consequences associated with community case-finding and immediate provision of care were small or none. (continued next page)

17 15 Evidence profile: visual impairment Values and preferences/acceptability Is there important uncertainty or variability about how much people value the options? Major variability Minor variability Uncertain Explanation Visual impairment is a common and significant public health problem in older people. Many conditions that contribute to vision impairment can be treated efficiently, and loss of vision can often be prevented in older people. Currently, there is a huge gap in timely access to comprehensive eye care, which can be improved through community case-finding and timely provision of referral and care at primary health care or community-based settings. The guideline development group believed that the recommendation would be valued by older people and acceptable to key stakeholders. Is the option acceptable to key stakeholders? Major variability Minor variability Uncertain Feasibility/resource use How large are the resource requirements? Major Minor Uncertain Is the option feasible to implement? Yes No Uncertain Explanation Implementation of community case-finding and immediate provision of care might lead to substantial costs to health care systems. These costs would include opportunity costs for time spent in administering the visual acuity test and providing eyeglasses at primary health care settings or facilitating referral and follow-up. However, in most countries, prevention of blindness comes under the umbrella of the national programme for chronic and noncommunicable diseases. The recommendation can be incorporated into existing national programme budgets with minimal additional cost. The guideline development group firmly believed that the recommendation was feasible to implement in high-, middle- and low-resource health care settings. (continued next page)

18 16 Evidence profile: visual impairment Equity Would the option improve equity in health? Yes No Uncertain Explanation The guideline development group firmly believed that the recommendation would increase equity in health.

19 17 Evidence profile: visual impairment Guideline development group recommendation and remarks Recommendation Older people should receive routine screening for visual impairment in the primary care setting, and timely provision of comprehensive eye care. Strength of the recommendation: Strong Quality of evidence: Low Remarks All of the primary studies available were carried out in high-income countries. The recommendation is applicable to people over 60 years of age (who may or may not visit primary care facilities to present with complaints of low visual acuity). Risk factors, such as diabetes, smoking, alcohol use, corticosteroid use and exposure to ultraviolet light should be considered and addressed. Comprehensive vision rehabilitation should be considered when services are available. Over half of older adults with impaired visual acuity achieve vision better than 20/40 with a refractive correction which can be obtained through non-invasive methods, in most cases with corrective lenses. The accuracy of responses to subjective questions during screening is unclear. Therefore, an objective visual acuity test should be the preferred choice in community case-finding.

20 18 Evidence profile: visual impairment References 1. Pascolini D, Mariotti SP. Global estimates of visual impairment: Br J Ophthalmol. 2012;96(5): Thylefors B. A global initiative for the elimination of avoidable blindness. Am J Ophthalmol. 1998;125(1): Cunningham ET Jr. World blindness: no end in sight. Br J Ophthalmol. 2001;85(3): Haymes SA, Johnston AW, Heyes AD. Relationship between vision impairment and ability to perform activities of daily living. Ophthalmic Physiol Opt. 2002;22(2): Tielsch JM, Javitt JC, Coleman A, Katz J, Sommer A. The prevalence of blindness and visual impairment among nursing home residents in Baltimore. N Engl J Med. 1995;4;332(18): Rovner BW, Zisselman PM, Shmuely-Dulitzki Y. Depression and disability in older people with impaired vision: a follow-up study. J Am Geriatr Soc. 1996;44(2): Brown RL, Barrett AE. Visual impairment and quality of life among older adults: an examination of explanations for the relationship. J Gerontol B Psychol Sci Soc Sci. 2011;66(3): Scott IU, Schein OD, West S, Bandeen-Roche K, Enger C, Folstein MF. Functional status and quality of life measurement among ophthalmic patients. Arch Ophthalmol. 1994;112(3): Rubin GS, Roche KB, Prasada-Rao P, Fried LP. Visual impairment and disability in older adults. Optom Vis Sci. 1994;71(12): Carabellese C, Appollonio I, Rozzini R, Bianchetti A, Frisoni GB, Frattola L, Trabucchi M. Sensory impairment and quality of life in a community elderly population. J Am Geriatr Soc. 1993;41(4): McGwin G Jr, Chapman V, Owsley C. Visual risk factors for driving difficulty among older drivers. Accid Anal Prev. 2000;32(6): 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(4): Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319: doi: /nejm Nevitt MC, Cummings SR, Kidd S, Black D. Risk factors for recurrent non-syncopal falls. A prospective study. JAMA. 1989;261: Cummings SR, Nevitt MC, Browner WS, Stone K, Fox KM, Ensrud KE et al. Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med. 1995;332: Harwood RH. Visual problems and falls. Age Ageing. 2001;30(Suppl 4): Dargent-Molina P, Favier F, Grandjean H, Baudoin C, Schott AM, Hausherr E et al. Fall-related factors and risk of hip fracture: the EPIDOS prospective study. Lancet. 1996;348: Lord SR, Ward JA, Williams P, Anstey KJ. Physiological factors associated with falls in older community-dwelling women. J Am Geriatr Soc. 1994;42: Klein BE, Klein R, Lee KE, Cruickshanks KJ. Performance-based and self-assessed measures of visual function as related to history of falls, hip fractures, and measured gait time. The Beaver Dam Eye Study. Ophthalmology. 1998;105: Lord SR, Clark RD, Webster IW. Visual acuity and contrast sensitivity in relation to falls in an elderly population. Age Ageing. 1991;20: Ivers RQ, Cumming RG, Mitchell P, Attebo K. Visual impairment and falls in older adults: the Blue Mountains Eye Study. J Am Geriatrics Soc. 1998;46: Coleman AL, Stone K, Ewing SK, Nevitt M, Cummings S, Cauley JA et al. Higher risk of multiple falls among elderly women who lose visual acuity. Ophthalmology. 2004;111(5): Cugati S, Cumming RG, Smith W, Burlutsky G, Mitchell P, Wang JJ. Visual impairment, age-related macular degeneration, cataract, and long-term mortality: the Blue Mountains Eye Study. Arch Ophthalmol. 2007;125(7): McCarty CA, Nanjan MB, Taylor HR. Visual impairment predict 5 year mortality. Br J Ophthalmol. 2001;85(3): Lee DJ, Gomez-Marin O, Lam BL, Zheng DD. Visual acuity impairment and mortality in US adults. Arch Ophthalmol. 2002;120(11): Freeman EE, Egleston BL, West SK, Bandeen-Roche K, Rubin G. (continued next page)

21 19 Evidence profile: visual impairment Visual acuity change and morality in older adults. Invest Ophthalmol Vis Sci. 2005;46(11): Knudtson MD, Klein BE, Klein R. Age-related eye disease, visual impairment, and survival: the Beaver Dam Eye Study. Arch Ophthalmol. 2006;124(2): Reuben DB, Mui S, Damesyn M, Moore AA Greendale GA. The prognostic value of sensory impairment in older persons. J Am Geriatr Soc. 1999;47(8): Thompson JR, Gibson JM, Jagger C. The association between visual impairment and mortality in elderly people. Age Ageing. 1989;18: Universal eye health: a global action plan Geneva: World Health Organization; 2013 ( accessed 27 July 2017). 31. Vela C, Samson E, Zunzunegui MV, Haddad S, Aubin MJ, Freeman EE. Eye care utilization by older adults in low, middle, and high income countries BMC Ophthalmol. 2012;12: 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(6): Moore AA, Siu Al, Partridge JM, Hays RD, Adams J. A randomized trial of office-based screening for common problems in older persons. Am J Med. 1997;102(4): 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(11): Smeeth L, Iliffe S. Community screening for visual impairment in the elderly. Cochrane Database Syst Rev. 2006;(3):CD The U.S. Preventive Services Task Force (USPSTF). Screening for Visual Impairment in Older Adults: Systematic Review to Update the 2009 U.S. Preventive Services Task Force Recommendation. Report No.: EF-1. Rockville (MD): United States Agency for Healthcare Research and Quality; Laidlaw DAH, Harrad RA, Hopper CD, Whitaker A, Donovan JL, Brookes ST et al. Randomized trial of effectiveness of second eye cataract surgery. Lancet. 1998;352: Harwood RH, Foss AJE, 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(1): Foss AJE, 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(1): Skelton DA, Howe TE, Ballinger C, Neil F, Palmer S, Gray L. Environmental and behavioural interventions for reducing physical activity limitation in community-dwelling visually impaired older people. Cochrane Database Syst Rev. 2013;(6):CD Vela C, Samson E, Zunzunegui MV, Haddad S, Aubin MJ, Freeman EE. Eye care utilization by older adults in low, middle, and high income countries. BMC Ophthalmol. 2012;12: Vetter NJ, Jones DA, Victor CR. Effect of health visitors working with elderly patients in general practice: a randomised controlled trial. Br Med J (Clin Res Ed). 1984;288(6414):

22 20 Evidence profile: visual impairment Annex 1: Search strategy for vision impairment MEDLINE database (1946 to September 2015) 1. randomized controlled trial.pt. 2. (randomized or randomised).ab,ti. 3. placebo.ab,ti. 4. dt.fs. 5. randomly.ab,ti. 6. trial.ab,ti. 7. groups.ab,ti. 8. or/ exp animals/ 10. exp humans/ not (9 and 10) not 11 13, exp vision screening/ 14. exp vision tests/ 15. ((vision or visual$) adj5 (screen* or assess* or test* or diagnos* or surveill*)).tw. 16. or/ exp aged/ 18. "Aged, 80 and over"/ 19. exp health services for the aged/ 20. (old$ adj5 (age$ or people or person$)).tw. 21. (geriatric$ or elderly or senior$).tw. 22. or/ exp eye diseases/ 24. exp visual acuity/ 25. exp macular degeneration/ 26. macula$ degenerat$.tw. 27. (eye$ or vision or ophthalmic or glaucom$ or cataract$ or presbyop$).tw. 28. or/ and 22 and and limit 30 to yr= Embase database (1980 to first week of October 2015) 1. exp randomized controlled trial/ 2. exp randomization/ 3. exp double blind procedure/ 4. exp single blind procedure/ 5. random$.tw. 6. or/ (animal or animal experiment).sh. 8. human.sh and not not exp clinical trial/ 13. (clin$ adj3 trial$).tw. 14. ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$)).tw. 15. exp placebo/ 16. placebo$.tw. 17. random$.tw. 18. exp experimental design/ 19. exp crossover procedure/ 20. exp control group/ 21. exp latin square design/ 22. or/ not not exp comparative study/ 26. exp evaluation/ (continued next page)

23 21 Evidence profile: visual impairment 27. exp prospective study/ 28. (control$ or prospectiv$ or volunteer$).tw. 29. or/ not not (11 or 23) or 24 or exp vision test/ 34. ((vision or visual$) adj5 (screen* or assess* or test* or diagnos* or surveill*)).tw. 35. or/ exp aged/ 37. exp senescence/ 38. exp elderly care/ 39. (old$ adj5 (age$ or people or person$)).tw. 40. (geriatric$ or elderly or senior$).tw. 41. or/ exp eye disease/ 43. exp visual acuity/ 44. exp retina macula degeneration/ 45. macula$ degenerat$.tw. 46. (eye$ or vision or ophthalmic or glaucom$ or cataract$ or presbyop$).tw. 47. or/ and 41 and and l imit 49 to yr= Search terms (MEDLINE) for interventions (1946 to September 2015) 1. randomized controlled trial.pt. 2. (randomized or randomised).ab,ti. 3. placebo.ab,ti. 4. clinical trails.ab,ti. 5. randomly.ab,ti. 6. trial.ab,ti. 7. groups.ab,tw. 8. or/ exp animals/ 10. exp humans/ not (9 and 10) not exp vision disorders/ 14. exp visually impaired persons/ 15. ((low$ or handicap$ or subnormal$ or impair$ or partial$ or disab$) adj3 (vision or visual$ or sight$)).tw. 16. or/ exp rehabilitation/ 18. ((rehabilitat$ or assess$) adj4 low vision).tw. 19. exp activities of daily living/ 20. risk assessment/ 21. risk factors/ 22. risk management/ 23. safety management/ 24. (home adj3 safety$).tw. 25. (hazard$ adj3 (home or environment$)).tw. 26. home care services/ 27. occupational therapy/ 28. exercise therapy/ 29. physical therapy modalities/ 30. (behavio$ adj3 modif$).tw. 31. (program$ adj3 (home or exercise$ or modif$)).tw. 32. or/ and and 33

24 Screened Included Eligible Identified 22 Evidence profile: visual impairment Annex 2: PRISMA flow diagrams Screening for vision impairment in community-dwelling older people Records identified through MEDLINE and Embase database searching (n = 6789) Records after duplicates removed (n = 5066) Records screened (n = 5066) Records excluded (n = 5053): Target population or intervention different (n = 3217) Conference abstract (n = 123) Participants aged under 60 years (n = 1713) Full-text articles assessed for eligibility (n = 13) Full-text articles excluded: Outcome data not reported (n = 8) Studies included in qualitative synthesis (n = 5) Studies included in quantitative synthesis (meta-analysis) (n = 5) 2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). For more information:

25 Screened Included Eligible Identified 23 Evidence profile: visual impairment Screening and provision of care for vison impairment Records identified through database searching (n = 5454) Records after duplicates removed (n = 4467) Records screened (n = 4467) Records excluded (n = 4453): Not eligible (intervention) (n = 3267) Wrong population (n = 1134) Not published in English (n = 52) Full-text articles assessed for eligibility (n = 14) Studies included in qualitative synthesis (n = 2) Full-text articles excluded, with reasons (n = 12): Outcome not reported (n = 6) Target population aged under 50 years (n = 3) Study design not randomized controlled trial (n = 3) Studies included in quantitative synthesis (meta-analysis) (n = 2)