Welcome to question of the day #364

Eyetool question of the day #364

In my community eye care practice I see a lot of older people. Some have dementia and are unable to respond to my questions or cooperate with any subjective tests. Do you have any tips?

I too examine a lot of older people in my clinical work and 5-10% have dementia that prevents me from conducting a traditional eye examination.

Usually, but not always, there is a carer or family member present who can help me with the history and symptoms so I note these in the clinical records with an extra note indicating that the information was not provided by the patient but by someone else. I’m particularly interested in any behaviour which could indicate visual problems such as a sudden loss of interest in TV viewing or reading or an increase in eye rubbing.

Then I examine any current glasses looking for damage to frames and lenses and checking the fit. If I don’t have information on the previous prescription I focimeter the lenses.

I will look for any obvious eye misalignment for distance and near vision.

I check the external features of the eyes for any signs of disease such as blepharitis or conjunctivitis or any other type of inflammation.

If the patient is cooperative enough and I can dim the light in the testing environment (not always possible if the examination is taking place in the patient’s room) I will carry out retinoscopy over the current glasses looking for any prescription change. Sometimes over retinoscopy is not possible because of lack of patient cooperation.

Then I will conduct direct ophthalmoscopy looking for cataract and if possible examine the internal structures of the eyes. If you are licensed to use pupil dilating drugs and you can get consent from the carer and cooperation from the patient then an examination through dilated pupils can be helpful. I am very mindful that instilling dilating drops and the subsequent blurred vision may be very distressing for a patient with dementia. I only consider using dilating drops if I cannot see the retina through undilated pupils.

If the patient needs a reading addition I base the value of the addition on the patient’s age.

I then explain to the family member or carer what I have found and what my recommendations are. If I recommend separate glasses for TV and reading I make sure that the different pairs and their spectacle cases are clearly marked for each different purpose and that the family also understand which pair is for which activity.

This seems to be a limited eye examination but it will pick up any gross abnormalities and ensure that the patient has the best vision possible under the circumstances.