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Physicians Update

 
Winter 2012

Primary-Care Physicians Have Important Role to Play in Identifying Vision Problems

Primary-care physicians should pay close attention through patient histories and eye-chart exams to any indication of deteriorating vision, two ophthalmologists at UCLA's Jules Stein Eye Institute suggest. Whether it's an easily treatable problem such as cataracts or warning signs of more serious conditions such as retinal detachment, age-related macular degeneration or glaucoma, a prompt assessment is important.

Whenever there is a decline in vision, it should dictate a referral to an eye-care professional," says Colin McCannel, M.D., a retina specialist and medical director of the Jules Stein Eye Center in Santa Monica. "If it's a gradual decline, it is less urgent but still warrants an evaluation. If it's a more rapid change, it is frequently something serious that needs immediate attention."

Although much can be learned simply by asking patients, Dr. McCannel notes that including an eye-chart exam is optimal and that each eye should be checked separately, since patients may not notice vision loss in one eye if the other eye is compensating.

By far the most common ophthalmologic complaint in primary-care settings, particularly among patients entering their 60s, is gradually reduced vision, typically manifest as more difficulties at night and in dimly lit environments, or changes in the patient's glasses prescription. This is most often due to the development of a cataract - a condition that can be easily treated, notes D. Rex Hamilton, M.D., director of the UCLA Laser Refractive Center, which treats cataract patients with advanced, multifocal lens implants. "It's inevitable that patients will develop cataracts as they get older, but it's not something they should have to live with," Dr. Hamilton says. "The surgery is very safe and takes only 15 minutes, with vision essentially normal by the next day. We can also now use a multifocal lens to give patients distance and near vision without glasses, which is icing on the cake." The center has also begun an effective new treatment for dry eye, which is particularly common among postmenopausal women.

A sudden loss of vision most often indicates macular degeneration, vascular occlusive disease of the eye, or retinal detachment, explains Dr. McCannel. All warrant immediate attention.

When patients have new onset flashes or floaters in their vision, they are likely undergoing a vitreous detachment that is associated with the development of retinal tears, which in turn lead to detachment. "This is very serious," Dr. McCannel says. "Any mention of flashes or floaters that are of sudden onset or that have recently changed should always prompt an urgent eye examination. Treating it early is much simpler than waiting until major surgery is required, and if it is missed altogether for a period of time, it can lead to severe vision loss that would have been preventable." Patients who are nearsighted are at the greatest risk, he adds.

Macular degeneration is characterized by a loss of central vision, often associated with problems reading and, in more advanced stages, difficulty recognizing faces. "It's critical that we catch macular degeneration early, because we are starting to have some effective treatments but by the time it's advanced, there isn't a lot we can do," Dr. Hamilton says. Beyond looking for warning signs, he says, primary-care physicians should make sure patients are aware of their risk. Macular degeneration is most common among fair-skinned, light-eyed individuals of Northern European heritage. Patients with a family history of age-related macular degeneration should begin having regular eye exams at about age 50 to assess whether they have early signs and might benefit from vitamin supplementation, Dr. Hamilton says.

Close-up of the human eyeball with retinal damage caused by glaucomaFamily history and regular eye exams for at-risk patients (particularly African-Americans) are also vital to pick up signs of glaucoma, which tends not to show early visual symptoms but rather requires the instrumentation more common to an eye-care professional. In primary-care settings, Dr. McCannel advises physicians to be aware that the presentation of pain and redness of the eye could simply be conjunctivitis, but - particularly if the pain is severe and associated with nausea and headache - it can be symptomatic of the elevated eye pressure associated with glaucoma. 

Promoting general eye health is important in the primary-care setting, the experts say, whether it's urging patients to protect their eyes from bright sunlight as a way to reduce the progression of cataracts and the risk of macular degeneration, or making sure diabetic patients obtain annual eye exams and have any vision complaints immediately assessed.

"Primary-care physicians should always ask their patients about their vision, and refer if there are any concerns," Dr. Hamilton says. "A lot of people think it's normal to have more difficulties with vision as you get older, and that there's nothing that can be done about it. We need to change that perception."





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