Delivery of eye care to the elderly: practical considerations.

The incidence of visual impairment greatly increases with age because most of the commonest blinding conditions occur in older age. Cataract is, of course, the main problem but glaucoma, diabetic retinopathy and macular degeneration are also important. Studies which examine the prevalence of visual impairment according to its causes have been done in both developed and less economically developed countries. They invariably find much unmet need in elderly population samples, in terms of avoidable or treatable conditions. In fact, elderly people often do not express the need to have anything done about their poor eyesight. A memorable example of this occurred during a home visit in a survey we carried out in inner London. The elderly couple were housebound. The husband was glad of our visit because he said his wifeÕs eyes were very bad. We did indeed find this to be so but were surprised to find that he was worse — apparently unaware how poor his eyesight had become. Not surprisingly, cataract was the cause. In many parts of the developing world, a similar situation exists. Areas where the prevalence of blinding cataract is high do not seem to have an overwhelming demand for surgical services. In Aravind Eye Hospital, South India, research has investigated what needs to be done to increase demand and reduce the backlog of avoidable blindness. There, and in Bangladesh, patients who have already had surgery (aphakic motivators) have been employed to increase the demand for cataract surgery, with some success. At the same time qualitative research has been carried out to discover the reasons why less than half the treatable blind come forward for surgery. The reasons will vary from person to person and from place to place but there are common themes shared by the elderly visually impaired across the world. For a prevention of blindness programme to have its desired impact, these issues must be understood and dealt with.