Health

Out of Sight

Experts see a crisis looming in age-related vision loss

Cheryl Hawkes December 4 2000
Health

Out of Sight

Experts see a crisis looming in age-related vision loss

Cheryl Hawkes December 4 2000

Out of Sight

Health

Experts see a crisis looming in age-related vision loss

Cheryl Hawkes

In May, 1999, Sherrie Kitcher was on her way to play golf when she stopped off for an eye appointment. The St. Catharines, Ont., elementary school secretary had been experiencing blurred vision and figured she just needed stronger reading glasses. Instead, her optometrist told her she was “going blind” and should find herself a surgeon. “I cried all the way home,” recalls Kitcher. At 47, she had cataracts—a condition in which the lens of the eye loses its transparency. Left untreated, it can lead to blindness. The solution is replacement of the natural lens of the eye with a clear plastic implant, or interoccular lens—a surgical procedure lasting as little as 15 minutes.

But it wouldn’t be that simple. Kitcher’s appointment on the operating table to remove the first cataract didn’t come

up until August this year—a 15-month wait, while her vision worsened. “My son was getting married in September. I was going crazy thinking I wasn’t going to see the wedding.” At school, barely able to see, she relied on layers of magnifying devices to read her work and on a volunteer to manage the rest of her job. “We just muddled through.” With her truck-driver husband on the road most of the time, she couldn’t drive and needed help grocery shopping. Today, with one cataract removed, and just five-per-cent vision remaining in her other eye, she faces a wait of another year or more for her next procedure.

Canada, say the experts, is on the verge of a crisis in vision health care. Looming large is the coming surge in volume of visually handicapped Canadians, as baby boomers—the 10

million Canadians born between 1946 and 1965—move into old age. The boomers, accustomed to finding a solution for almost everything, are in for a shock as they come to terms with cataracts, macular degeneration, glaucoma and other age-related threats to their vision. And experts are advising them to start protesting now if they don’t want to be shunted aside. “Making noise is what’s going to do it,” says Martin Steinbach, head of the Vision Science Research Program at Toronto Western Hospital. “And I don’t want that noise to be the tapping of thousands of blind people with their white canes on Parliament Hill.”

At 65, the chances of going blind or becoming “visually impaired”—unable to see clearly, even with the best prescription glasses—are about one in 10. At age 80, those chances are one in four. Increased life expectancies mean that Canada’s blind and visually impaired will be reliant longer on a health-care system that is shrinking, not expanding to meet their needs. And while seniors of previous generations accepted failing vision as a natural outcome of old age, the elderly of the future will no longer be content to simply fade to black.

The trends are already evident. In the past 15 years, the number of people reliant on the Canadian National Institute for the Blind, the volunteer agency that helps the blind and visually impaired live independently, has more than doubled. Agency officials expect that to almost double again in the next

The CNIB’s client list has doubled in 15 years and will almost do so again by 2015

15 years. CNIB vice-president Gerrard Grace estimates the agency works with 90 per cent of Canada’s blind population. “Right now,” he says, “our typical client is older and very grateful for our services. As we deal with boomers, we’re going to get demands for more and better services than we’re able to provide right now. That kind of pressure will be on the health professions as well.”

In many respects, those professions are ill-prepared to offer solutions. Apart from the challenge of coping with mushrooming demand, eye specialists are often simply unable to offer many solutions. Kitcher and the thousands of other Canadians waiting a year or more for cataract operations would find it bitterly ironic that cataracts, the cause of about three per cent of new cases of blindness each year, are vision care’s biggest success story. The other eye ailments that hit the elderly hardest remain only treatable, not curable or preventable. Those patients can only hope to stop or slow down

their loss of vision. “There is no magic bullet,” says Vancouver epidemiologist Paul Courtright.

The most widespread eye disease plaguing the elderly is agerelated macular degeneration, a loss of central vision, which accounts for about half of all new cases of blindness. Others are diabetic retinopathy, a consequence of diabetes; glaucoma, a buildup of pressure in the eye resulting in nerve damage and vision loss; and cataracts, still a leading cause of blindness in nursing homes. Most common in people over the age of 60, cataracts can be sparked by certain medications, such as the prednisone Kitcher was taking for a lung infection.

Another issue is the gender imbalance in vision impairment. “Women have a 20to 40-per-cent greater chance of acquiring AMD,” says Courtright. “In the industrialized world generally, two-thirds of all the folks who go blind are women.” While Courtright cautions that scientists have yet to nail down the biological links between women and increased vision loss, the CNIB’s Grace says longer life expectancies and higher poverty levels among women may partly explain the discrepancy.

The trends the rest of the country will eventually face are already evident wherever large concentrations of seniors live. In Victoria, the city with the largest proportion of seniors in Canada—18.2 per cent of the population—the wait for cataract surgery is a year long. In Ontario’s Niagara region, where over-65s make up 16 per cent of the population, Kitcher’s eye surgeon, George Beiko, will need about two years to get to the 650 people, most of them seniors, on his waiting list. “I threatened to go to another doctor,” says Kitcher, “but it was the same story everywhere, unless I wanted to pay to have it done in the States.”

Beiko says the Ontario health ministry “suggested we send our patients to Hamilton.” But that city, 50 km to the west, shares the country’s third highest concentration of over-65s with Winnipeg—13.5 per cent—and its eye surgeons are overbooked themselves. “Our patients are frustrated,” says

Many ophthalmologists are retiring, working part time or doing no more surgery

Beiko. “They want to get on with their lives. Older patients want to enjoy what time they have left. Patients in their 40s and 50s need to work.”

Dr. Graham Trope, head of ophthalmology at the University of Toronto, sees a crisis in the making. “Patient access to the system,” he says, “is the No. 1 problem.” The profession itself is aging—one-third of the 1,000 ophthalmologists practising in Canada are over 65. Countering that, Canadian medical schools graduated just 28 new ophthalmologists last June, compared with 45 to 50 a decade ago.

Many ophthalmologists are retiring, electing to work part time, shutting down the surgical end of their practices or moving increasingly into lucrative, non-insured areas like laser eye surgery. “If patients can’t even get in to see an eye specialist,” says Trope, “it’s really irrelevant if there’s a cure on the horizon or not.”

Vision researchers are feeling squeezed, too, frustrated by a lack of funding at home and tempted by offers to go to the United States to work. “Less than one per cent of all medical research dollars in Canada go to vision research,” says Grace. “We’re simply not pulling our weight.” By Steinbach’s reckoning, that totals about $ 14 million a year. “The eye institute of the U.S. National Institutes of Health alone has an annual budget of $450 million [U.S.],” he says.

A new Canadian-developed technology offers some relief on one front—AMD, the eye disease that affects almost half of the client base of the CNIB. AMD progresses to its blinding “wet” form only in a small portion of cases. Among those patients, about one-third have the particular vision patterns that make them eligible for the new process, called photo-dynamic therapy. And even among that select group it does not work for everyone.

At roughly $15,000, the therapy is expensive. Ophthalmologists who offer it need a $60,000 piece of equipment to laser-activate a drug called Visudyne, which is injected into the patient’s arm and prevents the growth of the abnormal blood vessels that destroy sight. Still, with cases of AMD expected to triple over the next 25 years, the therapy could have significant value. “There’s no question this treatment will save a large number of Canadians from losing their sight,” says Dr. Michael Potter, a Vancouver ophthalmologist involved in Visu-

200,000

150,000

100,000

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CREEPING DARKNESS

Numbers of Canadians served by the Canadian National Institute for the Blind

1970 1975 1980 1985 1990 1995 2000 2005 2010 2015

The view when vision fails

CATARACT

GLAUCOMA

MACULAR DEGENERATION

Diseases and conditions cause specific problems for patients. Cataracts produce a blurriness, macular degeneration diminishes central vision and glaucoma reduces peripheral vision.

dyne’s clinical trials. “The majority of patients who have it are helped considerably.”

Given the inevitability of vision loss for a growing group of Canadians, experts like Courtright argue that more attention should be paid to developing innovative ways to help people adjust to losing their sight. “We have to seriously consider the burden of rehabilitation,” he says, noting that the visual expectations of elderly baby boomers will put enormous pressure on the healthcare system. At Kingston’s Hotel Dieu bïospital, ophthalmologist and epidemiologist Sanjay Sharma is researching cost-effective ways to deliver vision health care. Sharma says his studies of elderly patients blinded by AMD show doctors often underestimate how much patients with vision loss suffer. “People who are profoundly blind,” he says, “told us that if they had 10 years left to live, they’d give up six if they could have four years of restored vision. This is similar to people living with severe stroke.” Adds Potter: “I think the fear of vision loss runs so deep that people are unwilling even to consider it, unless they’re forced to.”

Sherrie Kitcher knows how precious sight is. These days, she spends a lot of time at her kitchen table, counting the trees in the schoolyard across the street from her house. “Before it was just a mass of grey shadows.” She has a new understanding of the upside-down world of vision health. “I have a friend who decided she didn’t want to wear glasses anymore,” Kitcher says. Two weeks later, she saw a laser eye surgeon and both eyes were fixed. Meanwhile, people who really need surgery so they can see have to wait. “It’s not fair,” Kitcher says. “Eyesight isn’t cosmetic.” EU