Key questions on visual problems in the elderly

Consultant Ophthalmic Surgeon Mr Kamran Saha answers key questions on the common eye problems that present to primary care in older patients. Complete the full module on Pulse 365 today.

The module explores a range of conditions from acute red eye and sudden visual loss to the slow-burn conditions of macular degeneration, glaucoma and cataract, advising on what GPs need to recognise and how to refer and manage.

Learning objectives

 This module will enhance GPs’ understanding of visual problems in the elderly, including:

• How to recognise the sight-threatening causes of an acute painful red eye and when to refer urgently.
• How macular degeneration presents, how it is treated and the urgency of referral for the wet form.
• The current evidence around dietary supplements in age-related macular degeneration.
• When incidentally noted cataracts and ocular hypertension require referral.
• The definitions of sight impairment, the benefits of registration and current DVLA standards.
• The primary care management of amaurosis fugax, dry eye, blepharitis and epiphora.

1. What are the likeliest causes of the acute, painful red eye in the elderly, and how can these be recognised in primary care?

Most red eyes in primary care are caused by benign conditions such as conjunctivitis, blepharitis or subconjunctival haemorrhage. The task is to spot the minority that threaten sight. Two key questions that guide the GP here are: what is the vision like, and what kind of discomfort is it?

The character of discomfort matters as much as its presence. A deep ache or boring pain points towards serious intraocular or scleral disease (angle-closure, uveitis, scleritis), whereas intermittent grittiness, a foreign-body sensation or burning that comes and goes is far more typical of benign ocular surface disease such as dry eye and blepharitis (see Q9 and Q10). A useful rule of thumb is: if vision has dropped and there is genuine pain, it is important to have the eye seen.

Acute angle-closure glaucoma is the classic emergency in older people, commoner in the long-sighted (hypermetropic) eye. It presents with severe aching pain, often nausea and vomiting, a red eye, a fixed mid-dilated pupil, a hazy, steamy cornea and blurred vision with haloes around lights; the eye may feel hard on palpation. This needs same-day referral, as optic nerve damage can occur within hours.

Anterior uveitis (iritis) gives an aching, photophobic red eye with circumcorneal redness and a small or irregular pupil; it would benefit from a same-day assessment but can usually wait a day or two.

A corneal foreign body usually needs review within a day, but the mechanism of injury stratifies risk: a wind-blown speck or a superficial finger graze is low-risk, whereas a high-velocity mechanism such as power tools, grinding or hammering metal raises the possibility of a penetrating injury with an intraocular foreign body, which is an emergency.

Contact lens wear is a red flag in its own right: even with reportedly good hygiene, lenses can harbour aggressive organisms (Pseudomonas, Acanthamoeba), so a lens wearer with a painful red eye should be seen the same day regardless of age.

It is worth knowing your local pathways. Many areas now run a Minor Eye Conditions Service (MECS), in which accredited community optometrists assess recent-onset minor eye problems. Patients self-refer by phoning a participating optician practice (no GP referral needed) and, after triage, are typically seen within 24 hours or a few working days. For many acute red eyes this is faster and more appropriate than a GP appointment or A&E, though a clear-cut emergency such as suspected angle-closure or a penetrating injury still goes straight to the eye unit.

2. How is macular degeneration usually picked up, how is it treated by the specialist team and what is the urgency of referral?

Age-related macular degeneration (AMD) typically presents with painless, gradual loss of central vision, difficulty reading or recognising faces and distortion of straight lines (metamorphopsia). It is often first detected by an optometrist at a routine sight test, but patients also present describing a central blur or missing patch.

The crucial distinction is between dry (non-neovascular) and wet (neovascular) AMD. Dry AMD progresses slowly over years and has no licensed treatment in routine NHS use; management is supportive. Wet AMD, caused by choroidal neovascularisation, can cause severe central vision loss over days to weeks and is an emergency.

The referral route depends on whether the patient is already known to a macular service. A patient already under a macular clinic who develops new distortion or worsening vision can often contact that service directly to arrange their own appointment. This is the quickest route to review, lets the team compare against the patient’s previous retinal scans, and spares the practice from organising a referral.

For a patient not known to a service, the Royal College of Ophthalmologists recommends that suspected wet AMD be assessed and treated within two weeks, so either direct them to an optometrist (including via MECS) to confirm the diagnosis within a few days, or refer to the eye unit promptly, so diagnosis and first treatment both fall inside the two-week window. The clock is about starting treatment, so the referral must move within days.

Wet AMD is treated with intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections, for example ranibizumab, aflibercept or faricimab. The injections are administered directly into the eye, on a repeated, individualised schedule to stabilise and often partially recover vision. GPs should reassure patients that injection is now routine and well tolerated, and that attending for repeat treatment is essential.

3. What general advice can GPs give to help slow progression of AMD? What is the evidence on supplements and vitamins?

The single most valuable modifiable risk factor for both wet and dry AMD is smoking; as such, smoking cessation is the most important advice a GP can give. A cardiovascular-style approach such as blood pressure control, a diet rich in green leafy vegetables and oily fish, weight management and UV protection is also sensible, though the evidence is softer than for smoking. There is evidence that sunglasses that block ultraviolet light can benefit the eyes for several reasons, including reducing retinal damage.

On nutritional supplements, the evidence comes from the AREDS and AREDS2 trials. In AREDS, supplements (including high-dose antioxidants, omega-3 fatty acids and zinc) reduced the risk of progression from intermediate to advanced (advanced dry, or wet) AMD by about 25%.  Crucially, the supplements do not prevent AMD from developing in the first place and have no effect on cataract.

The benefit in the trial was seen specifically in high-risk patients who already had intermediate AMD, or advanced AMD in one eye, for whom progression slowed in the fellow eye.

In practice, however, the general consensus is that supplements are unlikely to do harm and may reduce the risk of progression in patients with dry AMD more broadly, so they are widely recommended for this group.

However, of note the original AREDS formula contained beta-carotene, which increased lung cancer risk in current smokers. AREDS2 substituted lutein and zeaxanthin for beta-carotene, and ten-year follow-up showed it was both safer and was associated with additional slowing of progression.

The practical message here is to recommend an AREDS2-formulation supplement (lutein/zeaxanthin, vitamins C and E, zinc and copper) for patients with established intermediate or advanced AMD, and consider encouraging others with dry AMD to take them too. And, as GPs will already be doing, encourage all patients to stop smoking.

4. GPs often receive letters about incidental cataracts from opticians or retinal screening. When do these need referral?

Cataract is near-universal with age, and an incidental lens opacity is not in itself a reason to refer. The decision should turn on whether the patient is bothered by their vision, not simply whether a cataract is present. If the patient is happy and managing well, they need not be referred for surgery, however the optician’s letter is worded.

Cataract surgery can largely be done at almost any stage, so there is no need to rush an asymptomatic patient. However, it is important not to leave it so long that it causes falls, difficulty driving or trouble managing daily life, or becomes so dense (mature) that surgical complication risk rises. As a rule of thumb, once acuity falls to around the driving threshold of 6/12, many everyday tasks become difficult, and this is a reasonable point at which to discuss referral with a symptomatic patient.

So refer when the patient is symptomatic and willing to consider surgery, when vision affects driving (see Q7), or when the cataract obscures the retinal view needed for other eye disease such as diabetic screening. Local commissioning thresholds vary, so know your integrated care board’s criteria, but NICE is clear that surgery should not be withheld on a visual-acuity limit alone when the cataract is affecting the person’s life.

It is also worth noting that impaired vision and hearing are recognised modifiable risk factors for dementia. Optimising these senses through cataract surgery, glasses and addressing hearing loss is therefore an important part of reducing dementia risk.

Mr Kamran Saha is Consultant Ophthalmic Surgeon at Moorfields Eye Hospital, London

Sources 

• Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS Report No. 8. Arch Ophthalmol 2001;119(10):1417-1436
• Chew E et al; AREDS2 Research Group. Long-term outcomes of adding lutein/zeaxanthin and omega-3 fatty acids to the AREDS supplements on age-related macular degeneration progression: AREDS2 Report 28. JAMA Ophthalmol 2022;140(7):692-698
• Department of Health. Certificate of Vision Impairment: Explanatory Notes for Consultant Ophthalmologists and Hospital Eye Clinic Staff in England. 2017
• NICE. Age-related macular degeneration. [NG82] 2018. (NICE CKS, Macular degeneration – age-related, last revised August 2022, provides a GP-facing summary.)
• NICE. Cataracts in adults: management. [NG77] 2017
• NICE CKS. Red eye. Last revised 2026
• Primary Eyecare Services. Minor Eye Conditions Service (MECS).
• Royal College of Ophthalmologists. Commissioning guidance. Age-related macular degeneration services: recommendations. 2024