Treating visual impairment to improve dementia status

Large retrospective studies have demonstrated that visual impairment is a risk factor for developing cognitive impairment, including dementia.

Cataracts, age-related macular degeneration and diabetic eye disease are directly correlated to dementia, but visual impairment from other causes can exacerbate the disease. Poor acuity in dementia patients increases dementia symptoms, including disability and dependency, negative emotions and abnormal behaviors. It also reduces their participation in hobbies and social engagement and makes them more likely to go to the hospital.

Although strong relationships exist between visual and cognitive function, we are still trying to fully understand the impacts of concurrent age-related diseases. However, the eye care practitioner’s role in helping these patients is quite clear: If there are treatable causes of vision loss, we can intervene and mitigate the effects of dementia, perhaps delaying the onset of severe disease.

Assessing visual, cognitive function

To assess a patient’s overall health and cognitive ability, I take in their entire presentation, such as how they enter the room and interact visually and verbally. In more advanced dementia, the face has a blank stare, the blink rate is markedly lower, and in many cases the response to stimuli is reduced by corneal neuropathy. As a result of neuropathy and cognitive impairment, these patients often don’t complain about vision problems or discomfort.

To understand how visual impairment is affecting their lives, I focus my questions on function, durability and sustainability. Are patients still reading, doing crosswords, playing cards and watching TV normally or less frequently? Do their eyes get tired in the evening (a simple surrogate for functional compromise)? If improving visual function can increase patients’ time engaged in social and intellectual activities, we can delay further loss of cognitive function.

Presentation, treatment of eye disease

People who have cognitive impairment may present later in the course of a treatable disease such as cataracts, AMD, glaucoma or diabetic retinopathy, making it common to see advanced disease. Diabetic disease has the strongest correlation to dementia, with a risk 61% higher than patients who aren’t diabetic (Cao et al).

Poorly controlled diabetes causes microvasculopathy, peripheral neuropathy that strongly correlates to depressed corneal nerve function and retinopathy with irreversible vision loss. We need to collaborate with caregivers and medical colleagues to ensure their diabetes is well-managed.

Cataracts are correlated to dementia, and their extraction significantly lowers the risks of this disease, yet patients with dementia are less likely to get timely cataract surgery. Thus, patients with dementia are more likely to have complex cataract surgery — lasting longer than 30 minutes — yet they do well and have average rates of complications (Pershing et al). After cataract surgery, my patients with dementia as well as their families report improved engagement in the activities they enjoy.

Although glaucoma is not correlated to dementia risk, delayed diagnosis and visual field loss can exacerbate dementia. MIGS and selective laser trabeculoplasty can help ensure that glaucoma is controlled while reducing the burden of self-treatment for patients and caregivers. In nonsurgical cases, dry eye therapy can help ease the toxic effects of topical medications.

Simple dry eye therapy for clearer vision

Dry eye disease (DED) is well-known to decrease visual acuity, reading longevity and contrast sensitivity, but it can be overlooked for dementia patients, who are at high risk for DED. They often display reduced blink rate, experience neuropathy, use topical glaucoma medications, take systemic medications or have diabetes. Because most treatments for DED rely on at-home care, I keep the regimen as simple as possible and give patients a list of specific products to use.

Mild cases do well with nutritional supplements, artificial tears, a warm compress and a lid scrub. Supplements such as HydroEye (ScienceBased Health) or Blink NutriTears (Bausch + Lomb) work well.

A durable, preservative-free artificial tear is important for chronic use in older patients, so I recommend iVizia (Thea), a povidone drop with hyaluronic acid and trehalose. Its multidose bottle is easy for my patients with dexterity problems to use accurately. Other excellent options are Refresh (AbbVie), Systane (Alcon), Blink (Bausch + Lomb) and TheraTears (Prestige).

For hygiene, OcuSoft lid scrub is effective, easy to use and easy to find in drugstores, as is iVizia micellar eyelid cleanser. Patients also can order a hyaluronic acid spray like Optase Protect (Scope) online, as well as a Bruder mask.

In more severe cases, caregivers or nursing home staff can help patients use prescription medications such as Xiidra (lifitegrast ophthalmic solution 5%, Bausch + Lomb) or Vevye (cyclosporine ophthalmic solution 0.1%, Harrow), Tyrvaya (varenicline solution nasal spray 0.03 mg, Viatris), Miebo (perfluorohexyloctane ophthalmic solution, Bausch + Lomb), and Xdemvy (lotilaner ophthalmic solution 0.25%, Tarsus).

Punctal occlusion with plugs or cautery is especially useful in potentially noncompliant patients.

Gauging the outcomes

Like the patient’s initial evaluation, an assessment of outcomes depends on asking the right questions about visual function and durability. Are they reading again? Can they watch their shows a few hours longer at night? Are caregivers seeing better participation in group conversations?

I often hear positive responses that tell me patients are not only seeing better, but also enjoying the increased intellectual and social stimulation they need to thrive and slow the progression of dementia.

References:

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John D. Sheppard, MD, MMSc, FACS, is division medical director at EyeCare Partners and senior founding partner at Virginia Eye Consultants, as well as professor of ophthalmology, microbiology and molecular biology at Eastern Virginia Medical School in Norfolk.

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Disclosures:
Sheppard reports financial relationships with AbbVie, Bausch + Lomb, Harrow, Oasis, Oyster Point, Tarsus, Thea and Viatris.

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