The leading causes of vision impairment (low vision and blindness) in older Americans are: macular degeneration, glaucoma, cataract and diabetic retinopathy. Age-related visual impairment is second only to arthritis/rheumatism as a cause of disability. Vision loss ranks third after arthritis and heart disease as the reason for impaired daily functioning in people over the age of 70. Given the universality of population aging and the expected growth in the number of seniors as the baby boom generation reaches age 65, projections are that by 2030, as many as 68 million Americans will be over the age of 65 (US DHHS 2003). A significant number of these older Americans will suffer from low vision or blindness.

Vision impairment is associated with a diminished quality of life. Older adults with impaired vision are less able to perform routine activities of daily living, are less mobile, are more isolated, suffer higher rates of depression, and consequently, have a substantially reduced overall quality of life when compared to their normal-sighted counterparts. Impaired vision is a significant independent risk factor for falls and fractures in older people. The ability to travel independently, often linked with issues of quality life, becomes challenging and daunting in the presence of vision loss. Older individuals, especially those with vision impairment, face greater safety risks when crossing busy intersections and when driving. Visually impaired older adults find it difficult, if not impossible, to read for pleasure, watch television, movies and sports for recreation with friends and family, barring them from the most common forms of social engagement, which can further add to a sense of isolation and depression. They confront formidable challenges in using computers and harnessing the internet to access information, to communicate, and to pursue lifelong education through increasingly available online courses. With the aging of the population, the growing number of visually impaired older Americans who are losing the ability to care for themselves further contributes to this major public health concern.

There are several critical barriers to helping visually impaired older Americans attain greater independence and a better quality of life. These barriers range from a generally accepted view that vision decline (as well as other physical abilities) and reduced personal autonomy are a "natural side effect" of growing older, to the compartmentalized way in which different treatments and interventions are administered after diagnosis of an eye disease, and to the traditional approaches to research and development of new treatments for aging eye diseases. Without question, medical, surgical, and technological progress in understanding and treating many aging eye diseases has improved the ability to preserve vision and/or slow down loss of vision. This progress, combined with advances in and the increasing use of low vision aids has helped many visually impaired older persons, but these approaches have not yet fostered the quality or degree of self reliance for the elderly that they desire and that should be possible. Success of a treatment is generally judged by vision benefit that is defined by gains of lines of vision on a high contrast visual acuity chart in controlled clinic-office settings.

Perhaps many of the current treatments will fall short if success were calibrated in terms of maintenance or restoration of independence and quality of life. Assumptions at the individual, societal, public policy and medical levels that any improvement in vision is an acceptable outcome measure of benefit must be overcome and replaced by outcome measures that define benefit of interventions in terms of greater personal freedom and independence of older adults with low vision.

Current state-of affairs: For elderly visually impaired patients, real challenges to their personal autonomy and self sufficiency begin after their physician makes a diagnosis, delivers treatment, and/or prescribes an on-going regimen of medication and/or provides a low vision aid. Current therapy for aging eye diseases often requires daily administration of medications or frequent intraocular injections. Lack of patient compliance with these therapeutic regimens is a well-recognized reason for the failure of treatments, the progression of vision loss and the increased dependence on others associated with loss of vision. The low vision patient now lives with the disease and must manage it while navigating two distinct (and often geographically displaced) systems, one that treats and monitors the disease and another that helps him or her cope with their vision loss through some form of vision rehabilitation. Often, care is provided by multiple, separate providers, billed differently, and may or may not be reimbursed, depending on the patient's insurance coverage and the current Medicare reimbursement policy. Although these systems interact and communicate, they remain separate. It is the patient who forms the bridge between the two, traveling between appointments at various facilities for example. Visually impaired patients who are the least able to drive or use public transportation, read their medical charts and bills or obtain information about novel and alternative treatments and new clinical trials become dependent on physicians, social workers (where they are available), families and friends to help them. Slowly but surely, elderly with vision impairment progressively lose independence.

The Research and Development barrier: Current vision research is largely independent investigator led and disciplinary. The current approach has been highly successful in providing critical breakthroughs that have increased our understanding of disease processes. However, this approach limits goal-driven collaborative efforts, thus creating a barrier to interdisciplinary research efforts to realize the goal of maintaining and restoring independence among visually impaired older Americans. Basic vision science research is largely hypothesis driven with a narrow (albeit important) focus on the mechanisms of individual diseases at the molecular and cellular level. The basic science is conducted by individual investigators pursuing research questions that push the boundaries of what is proven and known in their immediate area of interest to generate new understanding and knowledge of that topic. The paradigmatic limitations of the established ways to conduct basic science research, including the system of rewards adopted by academic research centers and funding agencies, tend to keep information within individual disciplines. As a result, research findings on aging eye diseases by and large is conducted, published and consumed within the scientific community working in the same area. This emphasis on specialized knowledge has numerous negative consequences for advancing the translational research that will foster independence for low vision elderly. First, dissemination of vision science research findings to geriatric researchers, or the reverse, happens infrequently, with few incentives to encourage meaningful interdisciplinary exchange. Thus, the basic scientists with potentially the greatest to offer in terms of discovering the means to stopping a disease process remain focused in their narrow disciplinary specialization. Second, young scientists, like those who have preceded them, will pursue research careers in the highly specialized disciplines; similarly, young clinicians tend to go into established surgical and clinical subspecialties. While the established system of rewards in both the clinical and research domains reinforces specialization, it creates sizeable barriers to examining and pursuing scientific and medical problems from a broad perspective such research in aging eye diseases, and importantly driven by the goal of increasing independence and quality of life in elderly patients who suffer from vision impairment due to these aging eye diseases. Young researchers and physicians starting their careers today may not find well-qualified mentors and role models in these areas.

The Enabling Environment Barrier: The absence of a dedicated "aging eye center of excellence" focused on research on independence from disability resulting from vision loss and aimed at meeting this pressing need to foster independence for the elderly is a critical barrier to improving quality of life for older people with low vision. Adopting the "Aging Eye center of Excellence" model in and of itself presents a sizeable challenge as it requires innovative consideration of the leadership, administrative and oversight structures that will enable both established and young vision researchers and clinician scientists to shift their focus or immerse themselves in translational aging eye research. A sophisticated infrastructure that enables and rewards high impact translational research and encourages the incorporation of the overarching issues of aging into basic science research on specific diseases must be designed and implemented. Further, the lessons of prior and existing centers of excellence indicate the key role played by the synergy between groups from various departments and institutions in their success. Here, too, inherent difficulties in bringing together investigators from different departments and competing institutions must be overcome. These difficulties may interfere with achieving the gains that come from cross-fertilization of the fields of Ophthalmology and Geriatrics and competition between various ophthalmology groups.

The Vision-research Communication barrier: Communication about vision research tends to remain within highly defined disciplinary boundaries, making it difficult for the nonscientific community to access this information. Despite the availability of web-based sources of full text peer-reviewed scientific publications on vision research findings, this information largely remains amongst scientists and clinicians because of restricted pay-per-view or subscription based access. Public domain search engines such as PubMed (National Library of Medicine) limit information display to scientific abstracts. Public policy debate, including decisions about funding to stimulate research for maintaining or restoring independence of older Americans with vision impairment, will be limited unless scientific information is freely accessible to policy makers, businesses and the interested public and communicated in a way that the nonscientific community can readily consume and easily understand.

The Vision-health Dissemination Barrier: Finally, the challenge of disseminating useful information to older visually impaired patients assumes greater significance for a center of excellence organized around the goal of improving the self reliance and self sufficiency of low vision elderly. The most common forms of information dissemination and acquisition require, at minimum, the ability to see. Elderly low vision patients who will benefit most from new research and clinical trials require interventions at the web programming level that will optimize their ability to view and read web-based information. The large print web pages presently offered as an aid to individuals with low vision not only can be difficult to navigate, they do not overcome the particular visual impairments associated with age-related macular degeneration (lost central vision) or diabetic retinopathy (double or wavy vision).

Addressing and Overcoming Critical Barriers to Increasing Independence among Visually Impaired Older Individuals: The combined knowledge, structural, and technical barriers discussed above have greatly impeded progress in aging eye research to foster independence among visually impaired older Americans. The barriers described above are not insurmountable. Emerging technologies have the potential to supplant the present manner of diagnosing, treating and assisting older patients with low vision, especially if they are harnessed with the primary objective of improving independence for aged low vision patients. For example, sustained drug release using nano-particles may change the existing paradigm of clinical practice. Research resources can be dedicated specifically to the development of animal models of aging eye disease, accelerating the translation of basic vision science to clinical applications. Computer programs can be written to optimize viewing by visually impaired older patients and incorporate optional "voice-over". The paucity of role models and mentors in aging eye research or geriatric ophthalmology can be directly addressed through a program that provides faculty advisors from both areas who are committed to translational science and offers structured pedagogic immersion in the methodologies of basic and clinical science, geriatric medicine, gerontology and epidemiology. More challenging are knowledge barriers. Yet, these too can be overcome through the design, implementation and continued employment of novel intellectual concepts that cross traditional disciplinary barriers within and between vision science, ophthalmology and geriatric medicine, identify and support translational methodological approaches, and apply innovations in technology and research tools that address the needs of low vision older individuals.

The Paradigm Shift
Rather than approach translational research by seeking clinical applications for basic research findings that exist, a more effective approach may be to identify the clinical needs of elderly patients with low vision and increased dependency and steer basic science to address these needs.

Just as the paradigm of basic scientific research and discovery with its emphasis on disciplinary specialization has failed to satisfactorily advance research toward clinical applications, traditional hierarchical organizational models will not produce the dynamic leadership needed to ensure a successful organization focused on aging eye disease and attainment of independence. Creating a paradigm shift in the conduct of basic vision research requires an enabling and supportive environment, an incentive system that encourages translational research, and the incorporation of geriatric medicine and geontology into vision science. Further, research resources must be created that support high impact translational studies aimed at increasing the personal autonomy of elderly low vision patients by curing disease, providing diagnostic tools, and developing the next generation low vision aids.

Thank you for interest,

Sandeep Jain, MD
Dimitri Azar, MD

Editors,
The Eye Digest
University of Illinois Eye & Ear Infirmary
1855 W. Taylor Street M/C 648
Chicago, IL 60612
Tel: (312) 996-6590

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