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Wilson et al recently published a guideline for family practitioners recommending against vision screening, defined as either asking a question about vision health or vision testing such as visual acuity, for Canadians 65 years or older based on ‘low-quality evidence’.1 The methodology of the review is not being challenged. However, the conclusions are not supported and are being questioned by the Canadian Ophthalmological Society for several reasons.
The literature on which this guideline was based is from studies outside of Canada. Health care policies such as public funding of routine eye examinations differ by region and this should be considered in making recommendations. In Canada routine eye exams performed by optometrists or ophthalmologists for seniors are not government-funded in Saskatchewan, New Brunswick, Newfoundland & Labrador and Prince Edward Island which represents 460,700 of Canadians (7.4%) aged 65+ relying on family practitioners as the entry point for eye care.2 Wilson et al referenced the 2005 Canadian Community Health Survey and reported that 59% of adults 65+ consulted an eye care professional in the previous year.1, 3 This statistic is misleading since it also included those with a known eye condition. For those without a known eye condition only 51% of seniors living in a province with government-insured eye examinations had seen an eye care professional in the preceding year and this decreased to 42% for those seniors living in the 4 provinces without government coverage.3 The prevalence of eye disease increases with age so in this vulnerable population more than 50% have not seen an eye care professional and are at risk especially for initially asymptomatic eye disease.
Not highlighted in the guideline were some exclusions such as individuals with ‘a condition known to predispose to vison impairment, such as glaucoma or diabetes’. The problem however is that a practitioner would not be aware of these exclusions unless they asked about vision issues. In addition, some potentially treatable eye diseases may not be known to the patient. For example up to 50% of those with glaucoma in the industrialized world are unaware that they have the disease and are not receiving care.4-6 It was recently reported that nearly half of newly diagnosed Canadians with open-angle glaucoma had moderate or advanced disease at the time of diagnosis and more than half of these patients were asymptomatic.7 Instead of recommending family practitioners ignore vision health we should be encouraging family practitioners to educate patients about common risk factors for eye disease and the importance of routine eye exams.
Given that the authors acknowledged there was no evidence of harm associated with screening adults for impaired vision and the evidence overall for this analysis was ‘low-quality’, we believe a recommendation of “against” screening seems to be extreme. Furthermore, the cost to simply inquire about a patients’ vision health is low. For many seniors a family practitioner may be their only contact to the health care system and denying this opportunity to diagnose a vision related health care issue is misguided. The Canadian Ophthalmological Society suggests that the recommendations of the US Preventative Services Task Force (2016), namely no recommendation for or against screening, be adopted instead.8
References
1. Wilson BJ, Courage S, Bacchus M, et al. Screening for impaired vision in community-dwelling adults aged 65 years and older in primary care settings. CMAJ 2018 May 14;190:E588-94. Doi:10.1503/cmaj.171430
2. An overview of provincial health coverage for optometric care in 2016. Available: https://opto.ca/sites/default/files/resources/documents/prov_health_cove... (accessed 2018 May 29)
3. Canadian Community Health Survey — Healthy aging (CCHS). Ottawa: Statistics Canada; 2010 May 12. Available: http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=5146 (accessed 2018 May 29)
4. Sommer A, Tielsch JM, Katz J, et al. Relationship between intraocular pressure and primary open angle glaucoma among white and black Americans. The Baltimore Eye Survey. Arch Ophthalmol 1991;109:1090–5.
5. Mitchell P, Smith W, Attebo K, Healey PR. Prevalence of open angle glaucoma in Australia—The Blue Mountains Eye Study. Ophthalmology 1996;103:1661–9.
6. Anraku A, Jin YP, Butty Z, et al. The Toronto epidemiology glaucoma survey: a pilot study. Can J Ophthalmol. 2011;46(4):352-7.
7. Buys YM, Gaspo R, Kwok K, and the Canadian Glaucoma Risk Factor Study Group. Referral source, symptoms, and severity at diagnosis of ocular hypertension or open-angle glaucoma in various practices. Can J Ophthalmology 2012;47(3):217-22.
8. US Preventive Services Task Force (USPSTF); Siu AL, Bibbins-Domingo K, Grossman DC, et al. Screening for impaired visual acuity in older adults: US Preventive Services Task Force recommendation statement. JAMA 2016;315:908-14.