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Better fall prevention includes prescribing conservatively in those at higher risk
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To put the significance of falls within the elderly population into perspective, there were 29 million falls, 800,000 hospitalizations and more than 27,000 deaths related to falls in 2014, based on statistics from the CDC, Daniel H. Chang, MD, said in an interview with Primary Care Optometry News.
The risk of tripping increases by 2.3 times with multifocal lens wear, whether bifocal or progressive-addition lenses (PALs), said Chang, who lectures often on the topic and has particular interest in the surgical correction of presbyopia with cataract surgery.
“That’s something we don’t think about as optometrists or ophthalmologists because glasses become a part of our patients’ identity,” he said. “When people trip and fall they tend to blame themselves and not their glasses.”
The economic impact of falls is huge; the CDC reported that in 2014 the total economic impact related to falls was $31 billion, according to Chang.
There is an assortment of risk factors, researcher David Elliott, PhD, MCOptom, FAAO, said in an interview. These include age 75 years and older, female gender, a history of falls, living alone, decreased strength, Parkinson’s disease, stroke, arthritis, diabetes, Meniere’s disease, dementia, taking sedatives and antidepressants, and taking more than four prescription medications per day.
A substantial change in refractive error can also cause problems, he said.
“Although poor vision causes falls, and you would expect that updating refractive correction in glasses would help reduce falls rate, large changes in refractive correction (over 1.00 D) have been shown to increase falls, according to a randomized controlled trial by Cumming et al.,” Elliott added.
To combat this, he recommends prescribing conservatively in older patients, particularly those at a higher risk of falls, and keeping distance refractive changes small – ideally, no more than 0.75 D.
Fall prevention can begin with the patient’s case history and asking older patients if they have fallen in the last year, Elliott said.
In 2014, Tammy Labreche, BSc, OD, took part in a mobility clinic for community-based fall prevention.
“I think we are becoming more aware of falls, but it’s not something that typically comes up in a normal optometric assessment; it’s not really asked about unless the patient is in a rehabilitation situation,” Labreche told PCON.
She recommends paying attention to the other risk factors that impact falls, in addition to ocular health and spectacles. She said more research is needed in this area.
One concern is in regular strength bifocals, as they blur the area where the patients are intending to walk, Labreche said. “It causes a potential misjudgment in their step, which can be avoided with proper head movement. However, if they have a greater fall risk, perhaps the bifocals should be avoided, and patients should strive for making their walking area clear.”
The impact of cataract surgery
Multiple studies have demonstrated that first-eye cataract surgery can reduce the incidence of falls by one-third (Harwood et al., Palagyi et al.), Chang said.
However, the benefit of cataract surgery is more limited than one might expect, according to Elliott.
“Poor vision causes falls, and you would expect that cataract surgery would help reduce falls rate, but there is evidence that second eye surgery has no effect on it (Foss et al.), and first eye surgery seems to improve falls rate only for recurrent falls (Harwood et al.),” he said.
“This appears to be because modern cataract surgery also includes changes in refractive correction, and these can have a negative impact,” Elliott continued. “Large changes in refractive correction after cataract surgery can increase falls rate (Palagyi et al.), as can changing into progressive or bifocal lenses after cataract surgery when they were not worn prior to surgery (Supuk et al.).”
Economic incentive has been a major push for the use of multifocal lenses or extended-depth-of-focus (EDOF) lens technology from a surgical standpoint, Chang added. However, he is striving to change ophthalmology’s motivations for treating presbyopia by highlighting the possible side effects of the traditional spectacle approach to presbyopia correction after cataract surgery with bifocal and PALs, he said.
“As long as we blur the inferior visual field with glasses, the risk of falling remains,” Chang said. “As optometrists and ophthalmologists, we don’t see falling as a problem, because if the patient trips and falls they don’t come and complain to us, they usually go to the hospital ... or a funeral home.”
In the VISIBLE study (Haran et al.), people with bifocal glasses switched to single vision lenses and reduced their fall rate by up to 40%, Chang said.
Sondra Black, OD, FAAO, has firsthand experience, as she is undergoing Symfony IOL (Johnson & Johnson) surgery. She returns to her surgeon, Elizabeth Yeu, MD, for surgery in her second eye in April.
“Being the person that patients are seeing first for cataract surgery, optometrists must spend time educating them on the available options,” Black said.
She added that examining the ocular surface is also crucial for potential cataract surgery patients.
Black had a Lipiflow (Johnson & Johnson) treatment 6 weeks before surgery on her first eye, which changed her measurement by 1.00 D.
“I would have had the wrong power put in if I didn’t have the dry eye treatment,” Black told PCON
Unfortunately, ocular surface issues in cataract surgery are often not treated, she said.
According to a study from William B. Trattler, MD, 88.1% of cataract patients have ocular surface disease going into surgery, and only 22% were treated for dry eye prior to surgery, she added.
Patient environment also a consideration
Chang said the patient’s environment also plays an important role.
“Studies show that if you’re inside your own home, bifocals do not pose as great a risk because you’re familiar with your surroundings,” he said. “If you leave your home, bifocals can pose a greater risk of tripping and falling.”
As such, Chang believes bifocal wear is appropriate in the home, but he suggests patients get a separate pair of single distance vision glasses for outside the home. “It’s less convenient, but safety is improved,” he said.
Chang said the focus on spectacle independence with LASIK has driven our thinking when correcting presbyopia after cataract surgery.
“We push so hard to correct all refractive error when addressing presbyopia,” he said. “However, I think that leaving patients with single distance vision lenses while getting them out of bifocals is an acceptable alternative. While not as convenient because glasses are still needed, that offers an improvement in safety, and I’m more concerned about safety than convenience.”
He recommends that optometrists offer patients information about surgical solutions for presbyopia such as a multifocal or EDOF IOL and try to reduce the need for bifocals after surgery.
“I’ve talked with surgeons who say they offer multifocal IOLs, then have patients wear distance-only lenses for residual refractive error but not need bifocal lenses,” Chang said. “I think it’s a neat approach.”
In his interactions with other surgeons, some like the approach, while others are resistant to the change.
“Every time I have an opportunity to talk about presbyopia, I try to bring up the topic. Our surgical options have their own risks and benefits, but I try to add the risks of bifocal glasses to the conversation,” Chang said.
Prescribing practices to keep in mind
Elliott added that PALs or bifocals should never be prescribed to patients who are used to wearing single-vision glasses and could be categorized as a high fall risk
“PALs, bifocals and monovision correction are hugely convenient, and patients are loathe to change to standard single vision glasses,” he added.
Elliott shared advice for long-term wearers who are identified at high risk for falls based on the results of the randomized controlled trial by Haran and colleagues:
- Long-term wearers of bifocal/PALs with minimal ametropia may be less likely to fall if they remove their glasses when walking outside the home.
- Long-term wearers of bifocal/PALs with significant ametropia who take part in frequent outdoor activities should use distance single-vision glasses when outside the home (unless driving or shopping).
- Prescription single-vision sunglasses may be particularly useful for sunny days and holidays.
- Long-term wearers of bifocal/PALs with significant ametropia who take part in few outdoor activities should continue to wear bifocal/PALs for most activities.
Furthermore, Elliott suggests that patients tuck their chins in when negotiating steps and stairs, to look through the distance vision portion of their PALs or bifocals.
Based on his research, Elliott recommends an alternative strategy to distance single-vision glasses for outside use in long-term PAL/bifocal wearers: Prescribe a PAL/bifocal with an add of intermediate power (about 1.25 D) that provides much less peripheral distortion and much clearer view of steps and stairs and obstacles in the travel pathway so that it provides a lower risk of falls and yet allows spot reading.
Standard addition (about 2.50 D) progressives can be used when seated and reading/performing other near vision tasks for longer, he said.
Labreche said adding a specialty filter to reduce glare and enhance contrast or considering frame parameters that would not contribute to field defects may help. She also advises optometrists not to make quick changes to prescriptions so patients can adapt.
“If somebody presents with concerns of falls risk, monovision is certainly not something that I would recommend if the patient has never experienced it before,” she added.
Communication is another important component in managing fall risk.
“If you are diagnosing someone with formal vision impairment, it’s always a good idea to communicate with other providers to share those findings,” Labreche said.
A lot of good can come from simply asking your patients if they have ever tripped and fallen, according to Chang. Additionally, ask if patients are bothered by their bifocals.
“I now bring it up in my cataract discussion. It’s really common. Go talk to your patients; you’ll be surprised,” Chang said. – by Abigail Sutton
- References:
- Bauman CA, et al. J Can Chiropr Assoc. 2014;58(3)300-311.
- CDC. Falls are leading cause of injury and death in older Americans. https://www.cdc.gov/media/releases/2016/p0922-older-adult-falls.html. September 22, 2016. Accessed February 18, 2019.
- Cumming RG, et al. J Am Geriatr Soc. 2007;doi:10.1111/j.1532-5415.2007.01046.x.
- Dhital A, et al. Eye. 2010;24:1437-1446.
- Elliott DB, et al. Ophthalmic Physiol Opt. 2016;doi:10.1111/opo.12236.
- Foss AJ, et al. Age Ageing. 2006;doi:10.1093/ageing/afj005.
- Haran MJ, et al. BMJ. 2010;doi:10.1136/bmj.c2265.
- Harwood RH, et al. Br J Ophthalmol. 2017;doi:10.1136/bjo.2004.049478.
- Lord SR. Age and Ageing. 2006;doi:1093/ageing/afl085.
- National Council on Aging. Fall prevention facts. https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/. Accessed February 19, 2019.
- Palagyi A, et al. J CataractRefract Surg. 2017;doi:10.1016/j.jcrs.2017.07.029.
- Peel NM. Canadian Journal on Aging. 2011;doi:10.1017/S071498081000070X.
- Supuk E, et al. Ophthalmic Physiol Opt. 2016;doi:10.1111/opo.12243.
- Trattler WB, et al. Clinical study report: Cataract and dry eye: Prospective health assessment of cataract patients ocular surface study. 2010 (unpublished study).
- For more information:
- Sondra Black, OD, FAAO, is head of professional strategy of Surgical Commercial Americas at Johnson & Johnson and based in the Toronto area. She can be reached at: drsblack@yahoo.ca.
- Daniel H. Chang, MD, practices at Empire Eye and Laser Center in Bakersfield, Calif. He can be reached at: dchang@empireeyeandlaser.com.
- David Elliott, PhD, MCOptom, FAAO, is a researcher and professor at the University of Bradford Department of Optometry and Vision Science in Bradford, England. He can be reached at: d.elliott1@bradford.ac.uk.
- Tammy Labreche, BSc, OD, is a clinical associate professor at the University of Waterloo in Ontario and director of the Centre for Sight Enhancement. She can be reached at: tammy.labreche@uwaterloo.ca.
Disclosures: Black is employed by Johnson & Johnson and consults for Shire Canada and Vision Group Canada. Chang consults for and is an investigator for Johnson & Johnson Vision and is an investigator for AcuFocus. Elliott and Labreche report no relevant financial disclosures.