Screening eye exams in older adults

Just yesterday I posted about the United States Preventive Services Task Force (USPSTF) and the fine line they walk between providing evidence-based recommendations for screening tests and making medical specialist groups happy.

Sometimes it just doesn’t happen.

The task force recently gave an “I” grade to vision screening in patients over 65. An I grade, or Insufficient evidence, means that the task force can’t definitively say that the benefits of vision screening in older adults outweigh the possible harms.

The American Academy of Ophthalmology (AAO) doesn’t agree.

Specifically, the task force reviewed the evidence for primary care doctors screening for three vision problems: refraction (the need for glasses), cataracts, and age-related macular degeneration.

They released their findings in last week’s edition of the Journal of the American Medical Association (JAMA).

The USPSTF reviewed the evidence on screening for visual acuity impairment associated with uncorrected refractive error, cataracts, and age-related macular degeneration among adults 65 years or older in the primary care setting; the benefits and harms of screening; the accuracy of screening; and the benefits and harms of treatment of early vision impairment due to uncorrected refractive error, cataracts, and age-related macular degeneration.

This recommendation applies to asymptomatic adults 65 years or older who do not present to their primary care clinician with vision problems.

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in older adults. (I statement)

In an editorial in JAMA Ophthamology, the CEO of the AAO, wrote:

Millions of elderly Americans could benefit from a quick and reliable visual acuity test and referral to an eye care clinician.

The American Academy of Ophthalmology believes the ‘I’ recommendation will be a barrier to improve identification of elderly individuals in primary care settings at risk for vision loss and lifetime functional impairment and to refer them for effective treatment.

The AAO is arguing that primary care doctors should perform simple vision screening exams on all their patients, even if the patient isn’t complaining of any eye trouble.

On one hand, some vision problems would be caught and treated.

On the other hand, this would result in more referrals to ophthamologists, and possibly more overtreatment of those vision problems. (This is why specialists aren’t allowed to be part of the task force.)

The USPSTF is simply saying there is not enough evidence to show that the benefit of catching a few problems sooner would outweigh the harms of treating too many patients unnecessarily.

The chair of the USPSTF qualified their position in an interview with an online medical journal:

Older adults who are having problems seeing should talk to their primary care doctor or an eye specialist. Primary care doctors can explore the various causes of vision problems and do an eye exam to check for refractive error. An eye specialist can do a full eye exam to look for and treat refractive errors and other eye conditions that affect vision, such as cataracts and age-related macular degeneration (AMD).

He also urged primary care doctors to “use their clinical judgment” when deciding whether to screen their older patients.

So what does all this mean for the patient??

Medicare does not pay for routine eye exams. Most insurance plans (other than specific vision plans) don’t pay for annual eye exams. I haven’t had an eye exam covered by insurance in over 20 years!

If the task force had given a more positive recommendation to vision screening, an A or B grade, it’s possible future exams would have been covered (that is, free) under the preventive health benefits of the Affordable Care Act.

Medicare patients do get a free annual “wellness visit,” but these are designed to be very short and there is little enough face-to-face time with the doctor, even without doing a quick eye exam.

Related post: Annual exams vs. wellness visits

To save time, most primary care doctors will heed the USPSTF’s decisively indecisive recommendation and not screen. But if you are having a problem with your vision, speak up!

Medicare does pay for eye exams if you already have a diagnosis of cataracts or glaucoma or macular degeneration. Prescriptions for new glasses or contacts are not covered, except for one pair of glasses following cataract surgery.

This latest ruling by the USPSTF isn’t going to have much of an impact.

The AAO recommends that everyone age 65 and over have an eye exam every one to two years, or as directed by your ophthamologist or optometrist. I think that’s good advice.

An eye specialist has the time, skills and tools to more adequately look for and diagnose eye problems, anyway.

Just be aware that you might have to pay part or all of the exam’s cost.

Sláinte,

Frugal Nurse

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