A Clinic for Complex Visual Problems in Older People
A Clinic for Complex Visual Problems in Older People
Background Visual symptoms in older people can be complex and inadequately explained by eye pathology alone. Psychological and neurodegenerative processes may manifest as complex visual symptoms, and thus some patients may be poorly served by a purely ophthalmic approach. We have developed a novel multidisciplinary clinic with input from neurology, ophthalmology, and psychiatric specialists. Here, we describe the patient population, disease prevalence, and potential impact of this new clinic.
Methods A retrospective audit of paper and electronic records from June 2010 to February 2012 and selected case reports.
Results Between June 2010 and February 2012 48 patients attended the clinic. Notes were available for 47 (98%). Mean age was 76.2 (range 48–92). The main presenting complaints were hallucinations, followed by nonspecific visual deficit, double vision, blurred vision, and visuospatial deficit. Cognitive impairment was noted in 68% (32/47) of patients, of which 16/32 (50%) were new diagnoses. We were able to give a diagnosis to 98% (46/47) of patients; of these, 74% (35/46) were new diagnoses. A total of 6% (3/47) were felt to have presentations attributable to eye pathology alone, whereas 89% (42/47) were felt to have a neuropsychiatric component. Management included referral to other clinics for continuing care in 43% (20/47) and initiation of therapy in 36% (17/47). The three case reports demonstrate cases, where our multidisciplinary approach aided diagnosis and management of patients with complex visual symptoms.
Conclusion A combined clinic with neurological, ophthalmic, and psychiatric input is an effective way to diagnose and manage complex visual problems in older people.
Eye pathology is increasingly common with advancing age and frequently coexists with other morbidity in the older patient population. Complex visual symptoms in such patients may be inadequately explained by eye pathology alone. Neurodegenerative disease, psychotropic medications, and psychological factors may all manifest with or exacerbate symptoms of visual dysfunction. Such multifactorial visual complaints are difficult to diagnose, and may be best approached by a multidisciplinary team.
The Visual Perception Clinic in the Newcastle Eye Centre provides such a multidisciplinary service. The clinic adheres to the following format: (1) Multidisciplinary discussion of each case from the referral letter by clinicians from ophthalmology, old-age psychiatry, and neurology followed by designation of a clinical lead. (2) History and examination by the clinical lead with additional clinical evaluation or investigations as indicated, which may include cognitive assessment, refraction, orthoptic assessment, and imaging. (3) Further multidisciplinary discussion and formulation of management plan, which is relayed back to the patient by the team. The clinic runs in the Eye Department with support from optometrists, orthoptists, and radiologists.
As a novel form of intervention, the Visual Perception Clinic's patient population and clinical impact are uncharacterised. Yet in an aging population with increasing coincidence of ophthalmic and neurodegenerative disease, the need for effective intervention is also increasing. It is therefore important to evaluate the impact of this clinic, which may provide a future model for the management of complex visual symptoms.
Abstract and Introduction
Abstract
Background Visual symptoms in older people can be complex and inadequately explained by eye pathology alone. Psychological and neurodegenerative processes may manifest as complex visual symptoms, and thus some patients may be poorly served by a purely ophthalmic approach. We have developed a novel multidisciplinary clinic with input from neurology, ophthalmology, and psychiatric specialists. Here, we describe the patient population, disease prevalence, and potential impact of this new clinic.
Methods A retrospective audit of paper and electronic records from June 2010 to February 2012 and selected case reports.
Results Between June 2010 and February 2012 48 patients attended the clinic. Notes were available for 47 (98%). Mean age was 76.2 (range 48–92). The main presenting complaints were hallucinations, followed by nonspecific visual deficit, double vision, blurred vision, and visuospatial deficit. Cognitive impairment was noted in 68% (32/47) of patients, of which 16/32 (50%) were new diagnoses. We were able to give a diagnosis to 98% (46/47) of patients; of these, 74% (35/46) were new diagnoses. A total of 6% (3/47) were felt to have presentations attributable to eye pathology alone, whereas 89% (42/47) were felt to have a neuropsychiatric component. Management included referral to other clinics for continuing care in 43% (20/47) and initiation of therapy in 36% (17/47). The three case reports demonstrate cases, where our multidisciplinary approach aided diagnosis and management of patients with complex visual symptoms.
Conclusion A combined clinic with neurological, ophthalmic, and psychiatric input is an effective way to diagnose and manage complex visual problems in older people.
Introduction
Eye pathology is increasingly common with advancing age and frequently coexists with other morbidity in the older patient population. Complex visual symptoms in such patients may be inadequately explained by eye pathology alone. Neurodegenerative disease, psychotropic medications, and psychological factors may all manifest with or exacerbate symptoms of visual dysfunction. Such multifactorial visual complaints are difficult to diagnose, and may be best approached by a multidisciplinary team.
The Visual Perception Clinic in the Newcastle Eye Centre provides such a multidisciplinary service. The clinic adheres to the following format: (1) Multidisciplinary discussion of each case from the referral letter by clinicians from ophthalmology, old-age psychiatry, and neurology followed by designation of a clinical lead. (2) History and examination by the clinical lead with additional clinical evaluation or investigations as indicated, which may include cognitive assessment, refraction, orthoptic assessment, and imaging. (3) Further multidisciplinary discussion and formulation of management plan, which is relayed back to the patient by the team. The clinic runs in the Eye Department with support from optometrists, orthoptists, and radiologists.
As a novel form of intervention, the Visual Perception Clinic's patient population and clinical impact are uncharacterised. Yet in an aging population with increasing coincidence of ophthalmic and neurodegenerative disease, the need for effective intervention is also increasing. It is therefore important to evaluate the impact of this clinic, which may provide a future model for the management of complex visual symptoms.
