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Blindness in the elderly
Editorial
Oct 9 is World Sight Day, an annual opportunity to recognise the impact of blindness and to draw attention to what can be done to improve the lives of those with partial or complete visual loss. This year, the focus of World Sight Day is on visual impairment in ageing populations. 80% of the world’s blind people are older than 50 years. Cataract is the leading cause of blindness in older people, followed by uncorrected refractive errors, glaucoma, age-related macular degeneration, and diabetic retinopathy. Yet cataract is curable by a simple cost-effective operation, and a sight test followed by prescription of glasses can correct many refractive errors. Preventive measures, such as stopping smoking, have a potentially wide effect on visual loss due to age-related macular degeneration and also cataract. With ageing populations, rising obesity, poor diet, and sedentary lifestyles, diabetic retinopathy is an increasing, yet preventable, cause of new-onset blindness in many countries. Overall, 75% of blindness from all causes is preventable, treatable, or curable. A report produced for World Sight Day by VISION 2020, Eyes on the future: fighting vision impairment in later life, documents some examples of progress in integrating sustainable comprehensive eye-care into national health systems. Launched jointly in 1999 by the International Agency for the Prevention of Blindness and the World Health Organization, VISION 2020’s aim is to eliminate the main causes of avoidable blindness by 2020 and to prevent the projected doubling of avoidable vision impairment between 1990 and 2020. So, for example, the cataract surgical rate—the number of cataract operations per million people in a given area—is used as a measure of the resources for surgery and infrastructure needed. Many developed countries have cataract surgical rates in excess of 6000; the global target set by VISION 2020 is 3000. In the city of Juan José Castelli in Argentina, the cataract surgical rate has increased from zero in 1999 to over 3000 in 2007. In Vanuatu, a Melanesian archipelago of 80 islands, with small, scattered, difficult-to-reach populations, the cataract surgical rate increased from 220 in 2000 to 1330 in 2005. Successes are also documented in rural areas of China, India, and Bangladesh, for example, often because of the dedication of small local surgical teams working with organisations such as Sightsavers and the International Eye Foundation. www.thelancet.com Vol 372 October 11, 2008
In developed countries, age-related macular degeneration is the most common cause of blindness, with as many as two-thirds of people aged older than 80 years showing signs of the disease. In a Lancet Article published early online on Oct 7, susceptibility to age-related macular degeneration was found to be linked to genetic variation in SERPING1, which encodes the C1 inhibitor involved in the classic pathway of complement activation. This new genetic risk factor adds to others previously identified, and helps to build up an understanding of the molecular basis of the disease. Crucially, it now seems that failure of regulation of both the classic and alternative pathways of complement activation can lead to age-related macular degeneration. Ultimately, the hope is that this knowledge will lead to novel treatments. Over the past 2 years, intravitreal injections of vascular endothelial growth factor suppressors (ranibizumab, pegaptanib, and bevacizumab) have revolutionised the treatment of wet or neovascular age-related macular degeneration, which is the most visually disabling form of this disease. However, the long-term safety of these drugs is unknown, and efficacy data for bevacizumab (which is far cheaper than ranibizumab) is limited by lack of clinical trials. In August, the National Institute for Health and Clinical Excellence (NICE) in the UK recommended ranibizumab as a cost-effective treatment for wet age-related macular degeneration, with some limitations, including that the cost beyond 14 injections is met by the manufacturer. NICE decided that pegaptanib is not a cost-effective option for this disease. The reality, however, is that these new and potential drugs are out of reach for most of the world’s ageing blind population. Most of the huge burden of blindness in elderly people worldwide is more readily addressed by providing glasses, cataract surgery, eyedrops for glaucoma, a healthy diet, and stopping smoking. Most people have no access to even the most basic eye-care services, including sight tests. Many elderly blind people live alone, are stigmatised in some cultures, have no help with mobility training or with the use of technical aids, and are therefore at substantial risk of injuring themselves. Building sustainable, affordable eye care into national health systems should be a priority. In the words of VISION 2020, “the Right to Sight has no age limit”. ■ The Lancet
Hugh Rutherford for The Fred Hollows Foundation/Vision2020
Blindness in the elderly
For more on VISION 2020 and its report see http://www. v2020.org For the paper on SERPING1 and age-related macular degeneration see Online/Articles. DOI:10.1016/ S0140-6736(08)61348-3 For more on new treatments for age-related macular degeneration see Comment Lancet 2007; 370: 204–06
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Oct 9 is World Sight Day, an annual opportunity to recognise the impact of blindness and to draw attention to what can be done to improve the lives of those with partial or complete visual loss. This year, the focus of World Sight Day is on visual impairment in ageing populations. 80% of the world’s blind people are older than 50 years. Cataract is the leading cause of blindness in older people, followed by uncorrected refractive errors, glaucoma, age-related macular degeneration, and diabetic retinopathy. Yet cataract is curable by a simple cost-effective operation, and a sight test followed by prescription of glasses can correct many refractive errors. Preventive measures, such as stopping smoking, have a potentially wide effect on visual loss due to age-related macular degeneration and also cataract. With ageing populations, rising obesity, poor diet, and sedentary lifestyles, diabetic retinopathy is an increasing, yet preventable, cause of new-onset blindness in many countries. Overall, 75% of blindness from all causes is preventable, treatable, or curable. A report produced for World Sight Day by VISION 2020, Eyes on the future: fighting vision impairment in later life, documents some examples of progress in integrating sustainable comprehensive eye-care into national health systems. Launched jointly in 1999 by the International Agency for the Prevention of Blindness and the World Health Organization, VISION 2020’s aim is to eliminate the main causes of avoidable blindness by 2020 and to prevent the projected doubling of avoidable vision impairment between 1990 and 2020. So, for example, the cataract surgical rate—the number of cataract operations per million people in a given area—is used as a measure of the resources for surgery and infrastructure needed. Many developed countries have cataract surgical rates in excess of 6000; the global target set by VISION 2020 is 3000. In the city of Juan José Castelli in Argentina, the cataract surgical rate has increased from zero in 1999 to over 3000 in 2007. In Vanuatu, a Melanesian archipelago of 80 islands, with small, scattered, difficult-to-reach populations, the cataract surgical rate increased from 220 in 2000 to 1330 in 2005. Successes are also documented in rural areas of China, India, and Bangladesh, for example, often because of the dedication of small local surgical teams working with organisations such as Sightsavers and the International Eye Foundation. www.thelancet.com Vol 372 October 11, 2008
In developed countries, age-related macular degeneration is the most common cause of blindness, with as many as two-thirds of people aged older than 80 years showing signs of the disease. In a Lancet Article published early online on Oct 7, susceptibility to age-related macular degeneration was found to be linked to genetic variation in SERPING1, which encodes the C1 inhibitor involved in the classic pathway of complement activation. This new genetic risk factor adds to others previously identified, and helps to build up an understanding of the molecular basis of the disease. Crucially, it now seems that failure of regulation of both the classic and alternative pathways of complement activation can lead to age-related macular degeneration. Ultimately, the hope is that this knowledge will lead to novel treatments. Over the past 2 years, intravitreal injections of vascular endothelial growth factor suppressors (ranibizumab, pegaptanib, and bevacizumab) have revolutionised the treatment of wet or neovascular age-related macular degeneration, which is the most visually disabling form of this disease. However, the long-term safety of these drugs is unknown, and efficacy data for bevacizumab (which is far cheaper than ranibizumab) is limited by lack of clinical trials. In August, the National Institute for Health and Clinical Excellence (NICE) in the UK recommended ranibizumab as a cost-effective treatment for wet age-related macular degeneration, with some limitations, including that the cost beyond 14 injections is met by the manufacturer. NICE decided that pegaptanib is not a cost-effective option for this disease. The reality, however, is that these new and potential drugs are out of reach for most of the world’s ageing blind population. Most of the huge burden of blindness in elderly people worldwide is more readily addressed by providing glasses, cataract surgery, eyedrops for glaucoma, a healthy diet, and stopping smoking. Most people have no access to even the most basic eye-care services, including sight tests. Many elderly blind people live alone, are stigmatised in some cultures, have no help with mobility training or with the use of technical aids, and are therefore at substantial risk of injuring themselves. Building sustainable, affordable eye care into national health systems should be a priority. In the words of VISION 2020, “the Right to Sight has no age limit”. ■ The Lancet
Hugh Rutherford for The Fred Hollows Foundation/Vision2020
Blindness in the elderly
For more on VISION 2020 and its report see http://www. v2020.org For the paper on SERPING1 and age-related macular degeneration see Online/Articles. DOI:10.1016/ S0140-6736(08)61348-3 For more on new treatments for age-related macular degeneration see Comment Lancet 2007; 370: 204–06
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