Screening for Impaired Visual Acuity in Older Adults
Authors: Roger Chou, Tracy Dana, Christina Bougatsos, Sara Grusing, Ian Blazina
Journal: JAMA (2016)

<h3>Importance</h3> Impaired visual acuity is common among older adults and can adversely affect function and quality of life. <h3>Objective</h3> To update a 2009 systematic review on screening for impaired visual acuity among older adults for the US Preventive Services Task Force (USPSTF). <h3>Data Sources</h3> Ovid MEDLINE (2008 to January 2016), Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. <h3>Study Selection</h3> Randomized clinical trials of screening; diagnostic accuracy studies of screening tests in primary care settings; and randomized clinical trials of treatment vs placebo or no treatment for uncorrected refractive errors, cataracts, and dry (atrophic) or wet (exudative) age-related macular degeneration (AMD). Studies of screening and diagnostic accuracy were limited to asymptomatic adults 65 years or older; studies of treatment included asymptomatic adults of any age. <h3>Data Extraction and Synthesis</h3> One investigator abstracted data, a second checked data for accuracy, and 2 investigators independently assessed study quality using predefined criteria. Random-effects meta-analysis was used to estimate the relative and absolute benefits of vascular endothelial growth factor inhibitors (anti-VEGF) for wet AMD. <h3>Main Outcomes and Measures</h3> Visual acuity, vision-related function, functional capacity, harms, and diagnostic accuracy. <h3>Results</h3> Three trials (n = 4728) from the 2009 USPSTF review found that screening for impaired visual acuity was not associated with improved visual or clinical outcomes. In 1 good-quality trial (n = 3346), universal screening identified 27% of persons with impaired visual acuity and correctable impairment vs 3.1% with targeted screening, but there was no difference in the likelihood of visual acuity worse than 20/60 after 3 to 5 years (37% vs 35%; relative risk [RR], 1.07; 95% CI, 0.84-1.36). The 2009 review found that effective treatments are available for uncorrected refractive errors and cataracts. Ten-year trial results of dry AMD found an antioxidant/zinc combination was associated with decreased risk of visual acuity loss (46% vs 54%; odds ratio, 0.71; 95% CI, 0.57-0.88). An updated meta-analysis found anti-VEGF for wet AMD was associated with greater likelihood of having vision 20/200 or better vs sham injection (4 trials; RR, 1.47; 95% CI, 1.30-1.66;<i>I2</i> = 42%; absolute risk difference, 24%; 95% CI, 12%-37% after 1 year). New evidence on the diagnostic accuracy of visual acuity screening tests was limited and consistent with previous findings that screening questions or a visual acuity test was associated with suboptimal accuracy. <h3>Conclusions and Relevance</h3> Screening can identify persons with impaired visual acuity, and effective treatments are available for common causes of impaired visual acuity, such as uncorrected refractive error, cataracts, and dry or wet AMD. However, direct evidence found no significant difference between vision screening in older adults in primary care settings vs no screening for improving visual acuity or other clinical outcomes.