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Summary of Recommendation and Evidence

The U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for visual acuity for the improvement of outcomes in older adults (Table 1). I statement.

PopulationAdults 65 years or older
RecommendationGrade I: insufficient evidence
Risk assessmentOlder age is an important risk factor for most types of visual impairment.
Additional risk factors include:
  • For cataracts: smoking, alcohol use, exposure to ultraviolet light, diabetes mellitus, corticosteroid use, and black race

  • For age-related macular degeneration: smoking, family history, and white race

Screening testsVisual acuity testing (e.g., the Snellen eye chart) is the usual method for screening for impairment of visual acuity in the primary care setting. Screening questions are not as accurate as a visual acuity test.
Balance of harms and benefitsThere is no direct evidence that screening for vision impairment in older adults in primary care settings is associated with improved clinical outcomes.
There is evidence that early treatment of refractive error, cataracts, and age-related macular degeneration may lead to harms that are small.
The magnitude of net benefit for screening cannot be calculated because of a lack of evidence.
Other relevant USPSTF recommendationsRecommendations on screening for glaucoma and on screening for hearing loss in older adults can be accessed at http://www.uspreventiveservicestaskforce.org.

Rationale

Importance. Impairment of visual acuity—best-corrected vision worse than 20/50—is a serious public health problem in older adults. The prevalence in adults older than 60 years is approximately 9 percent.

Detection. There is adequate evidence that visual acuity testing does not accurately identify early age-related macular degeneration (AMD). Evidence that screening with a visual acuity test accurately identifies persons with cataracts is inadequate. There is convincing evidence that screening with a visual acuity test identifies persons with refractive error. The USPSTF found convincing evidence that screening questions are not as accurate as visual acuity testing for assessing visual acuity.

Benefits of detection and early treatment. There is inadequate direct evidence that screening and early interventions for impairment of visual acuity by primary care physicians improve functional outcomes in older adults. The USPSTF found adequate evidence that early treatment of refractive error, cataracts, and AMD improves or prevents loss of visual acuity. However, there was inadequate evidence that treatment improves functional outcomes.

Harms of detection and early treatment. There is adequate evidence that early treatment of refractive error, cataracts, and AMD may lead to harms that are small.

USPSTF assessment. The USPSTF concludes that the evidence is insufficient on whether screening older adults for visual impairment improves functional outcomes. The balance of benefits and harms cannot be determined.

Clinical Considerations

Patient population. This recommendation statement applies to adults 65 years or older.

Assessment of risk. Older age is an important risk factor for most types of visual impairment. Additional risk factors for cataracts are smoking, alcohol use, exposure to ultraviolet light, diabetes mellitus, corticosteroid use, and black race. Risk factors for AMD include smoking, family history of AMD, and white race.

Screening tests. A visual acuity test (e.g., the Snellen eye chart) is the accepted 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 is limited on the use of other vision tests, including pinhole testing, the Amsler grid (a chart used to test central vision to detect AMD), or funduscopy (visual inspection of the interior of the eye), in screening in primary care to detect visual impairment caused by AMD or cataracts.

Treatment. Most older adults will need some type of corrective lenses. The treatment for cataracts is surgical removal of the cataract. Treatments for exudative (or wet) AMD include laser photocoagulation, verteporfin, and intravitreal injections of vascular endothelial growth factor inhibitors. Antioxidant vitamins and minerals are treatments for dry AMD, but evidence of their effectiveness is limited.

Other approaches to prevention. This recommendation does not cover screening for glaucoma. The USPSTF review and recommendation statement on screening for glaucoma are available on the USPSTF Web site. The USPSTF is updating the review and recommendation on fall prevention.

This series is coordinated by Joanna Drowos, DO, contributing editor.

A collection of USPSTF recommendation statements published in AFP is available at https://www.aafp.org/afp/uspstf.

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