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 Practical Vision: Telescope Implants Score Large

Some assisted living or skilled nursing residents with macular degeneration may be eligible for a surgical procedure that could turn their lives around.

 



Vision changes are common as people age, and reaching for reading glasses is not unusual. But many older adults find their vision is further impeded by the onset of age-related macular degeneration (AMD), which can result in severe impairment of their straight-ahead (central) vision. Tasks that used to be simple, like selecting the right coffee brand or recognizing the face of a neighbor, become increasingly challenging as the disease progresses.
 
Despite the high prevalence of AMD, a recent survey conducted by Wakefield Research found that nearly 75 percent of Americans still don’t know that age-related macular degeneration is the leading cause of legal blindness in older adults, affecting millions of Americans.
 
Although some people with macular degeneration who reside in skilled nursing care centers, assisted living communities, or other long term care settings may have serious co-morbid conditions that must be prioritized, many patients who are healthy, but simply less ambulatory, could achieve meaningful improvements in their quality of life if they actively commit to treatment.

Macular Degeneration Targets Seniors

As age-related macular degeneration progresses, central vision can deteriorate to the point where patients are challenged to see fine detail, images, and even recognize faces. A blind spot develops that patients cannot see around, and their remaining peripheral vision is not clear enough to provide meaningful information.

The good news is that there are now new treatments that can help slow or stabilize the disease in some individuals. For example, the availability of intravitreal anti-VEGF injections for neovascular (wet) AMD may be able to help patients retain some of their central vision.

Yet, inevitably, some patients will progress to having either geographic atrophy or disciform scarring involving the fovea in both eyes, leading to significant limitations in the treatment of age-related macular degeneration by glasses, vitamins, drugs, or cataract surgery. Called advanced, or End-stage, AMD, this severe form is associated with increased depression and stress, according the A.E. Bennion, et al., in a 2012 issue of Social Science & Medicine. Approximately 2 million Americans have the End-stage form of AMD with associated vision loss.

Tiny Telescope

A relatively new treatment option for End-stage AMD patients is the Implantable Miniature Telescope (IMT from VisionCare Ophthalmic Technologies). The telescope implant, which is Medicare-eligible and approved by the Food and Drug Administration (FDA), is available to patients aged 65 years and older living with bilateral, End-stage AMD.

Only the size of a pea, the device utilizes wide-angle micro-optics that, in combination with the optics of the cornea, create a telephoto system that magnifies objects in view by approximately 2.7x and projects those images to undamaged sections of the retina.

The telescope does not eliminate the blind spot (scotoma)—and therefore is not a cure for AMD—but it reduces its impact on the central vision by making it appear smaller to the patient. The IMT has been demonstrated to restore vision and improve patients’ quality of life, according to pivotal studies.

What The Procedure Consists Of

Telescope implant success is highly dependent on selecting the right candidate. Patients must be motivated to undergo regular occupational therapy in order to learn how to use the device and understand their new vision.

The CentraSight treatment program, which includes the telescope implant procedure, incorporates a team-based provider approach to manage each patient case. To identify a patient candidate, there are five main steps:
  1. Diagnosis by a retina specialist.
  2. Vision evaluation, including external telescope simulations by a low-vision optometrist.
  3. Evaluation of therapeutic motivation (willingness to participate in post-implantation therapy) by an occupational therapist.
  4. Evaluation and implantation by a cornea, fellowship-trained cataract surgeon.
  5. Post-implantation visual rehabilitation with the low-vision optometrist and occupational therapist.
There are advantages to encouraging the patient with End-stage AMD to consider a surgical treatment, which is performed as an outpatient procedure. Notably, because the telescope becomes part of the patient’s visual system, there is a reduced reliance on hand-held or mounted external vision appliances, which is more convenient for the patient. The telescope allows a recipient to use natural eye movements to scan their environment and practice focusing on central images that are near, far, and during movement. Within a few weeks or months (depending on the patient), individuals find that they can rejoin activities that they may have given up due to vision loss.

Improved Vision Enhances Quality Of Life

In a pivotal clinical trial reviewed by FDA, 67 percent of patients who received the telescope implant achieved a three-line or more improvement in best-corrected distance visual acuity (on the eye chart), compared with 13 percent of fellow eye controls (the second eye, which did not receive the implant), which is a noteworthy improvement.

But what may be a more meaningful finding is that patients also reported improved quality of life as measured by the National Eye Institute Visual Functioning Questionnaire.

This study found that telescope patients were less dependent on others, less worried or frustrated with their visual acuity, less limited in their activities, and better able to recognize facial expressions following implantation.
In the post-operative visual rehabilitation period, the patient will require support from family and friends as well as facility health care providers.

Given the vital role occupational therapy plays in patients’ ability to use their new vision for tasks such as reading, watching TV, or recognizing faces, the long term care specialist and the assisted living or skilled nursing center have a role to play in motivating patients to practice with their new vision.

Good vision isn’t truly appreciated until it begins to diminish. Age-related macular degeneration dramatically impacts quality of life, manifesting in greater social dependence, challenges maintaining independence, and early admission to skilled nursing centers, according to M. Yuzawa et al. in the July 2013 issue of Clinical Ophthamology.
Vincent Hau, MD, PhD
Understanding and helping these patients access macular degeneration treatments and tools that improve their ability to see will help them realize more independence and likely reduce their risk for depression, anxiety, and stress.
 
Vincent Hau, MD, PhD, is a board-certified ophthalmologist who works for Kaiser Permanente in Riverside, Calif. He can be reached at vincent.s.hau@gmail.com.

revised July 7, 2016
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