During my residency, I had the fortune of spending several days in a secondary-care pediatric eye clinic with Scott Richter, OD, of New York. I learned much during my time there, but one notion that stuck with me more than the others was the exam starts as soon as the clinician observes the patient walking down the hallway to the exam room.
Taking note of a patient’s behavior can provide a multitude of clues on the patient’s current condition. Perhaps the most apparent observational feature would be a patient’s gait.
It is often said halfheartedly that looking at a patient’s shins gives ODs more information of visual impairment than looking at the patient’s visual field study. While this statement is factually inaccurate, it does well to point out the notion of observing a patient.
Previously from Dr. Casella: New concepts in diagnosis and treatment
Impact of gait quality
One study suggests compromise of balance control is associated with the severity of one’s glaucoma.1 Study investigators systematically quantified the balance of 24 glaucoma patients and 24 controls. They concluded that the subjects in the glaucoma group tended to have differences in their balance when compared to the control group.
These differences were associated with visual and somatosensory contributions to balance and were more apparent with worsening of glaucoma—as determined by binocular mean deviation scores from Humphrey 24-2 SITA strategy visual field studies.
Another study of 54 open-angle glaucoma patients aged 65 or older produced similar results when examining postural sway.2 This study incorporated retinal nerve fiber layer (RNFL) thickness as measured by optical coherence tomography (OCT). Both metrics had an association with the outcome measures of the study.
A recent, larger study (N=239) looked to determine differences in gait within glaucoma patients and glaucoma suspects.3 The subjects walked at a normal pace on an electronic walkway with and without carrying a cup or a tray. Having a worse visual field was associated with a greater variability in stride and a greater left-to-right drift within subjects carrying a cup or tray while walking.
Findings such as the ones described in these studies point to one significant threat facing individuals with compromised visual fields—the risk of falls.
From a qualitative standpoint, it seems apparent that one would have a higher risk of falling or tripping over an obstacle if one’s vision was diminished. However, quantifications of such occurrences and its risks need to be studied so that proper protocols may be implemented in this sect of an aging population.
Another recent study sought to identify hazards related to falls in the homes of individuals with glaucoma.4 The researchers in this cross-sectional study used data from the ongoing Falls In Glaucoma Study (FIGS) to determine whether or not glaucoma patients and/or glaucoma suspects had adapted their homes to make them safer with respect to falls.
Individuals with worse visual fields were not found to have fewer fall-related hazards in their homes. Bathrooms were found to have the greatest number of hazards, and inadequate lighting conditions were found to be the most common hazards identified.
Higher lighting conditions were not related to visual field states, binocular contrast sensitivity, or visual acuity. However, median income was positively associated with higher lighting conditions. This study does well to point out that individuals tend not to compensate for poorer vision by augmenting their home environments to decrease hazards for falls.
These study outcomes point to a gap in patient care—a gap that may call for interventional care so that falls among an already aging population can be better prevented.
1. Kotecha A, Richardson G, Chopra R, Fahy RT, Garway-Heath DF, Rubin GS. Balance control in glaucoma. Invest Ophthalmol Vis Sci. 2012 Nov 27;53(12):7795-801.
2. Black AA, Wood JM, Lovie-Kitchin JE, Newman BM. Visual impairment and postural sway among older adults with glaucoma. Optom Vis Sci. 2008 Jun;85(6):489-97.
3. Mihailovic A, Swenor BK, Friedman DS, West SK, Gitlin LN, Ramulu PY. Gait Implications of Visual Field Damage from Glaucoma. Transl Vis Sci Technol. 2017 Jun 23;6(3):23.
4. Yonge AV, Swenor BK, Miller R, Goldhammer V, West SK, Friedman DS, Gitlin LN, Ramulu PY. Quantifying Fall-Related Hazards in the Homes of Persons with Glaucoma. Ophthalmology. 2017 Apr;124(4):562-571.