Mohamed Morgan
Introduction
Falls are a leading cause of morbidity and mortality in the older population. Approximately half of people aged 80 and over experiencing at least one fall per year. Falls place a significant burden on the NHS, costing an estimated £2 billion per year (1). Visual impairment is a well-documented, modifiable risk factor for falls amongst older adults, increasing the likelihood of recurrent of falls and subsequent hospitalisations.
In the UK, over two million people live with sight loss, 59% of whom are aged 75 or over. It is estimated that by 2050, the number of people with sight loss in the UK will double, reaching over four million (2). Notably, nearly 60% of these cases are attributed to cataracts and uncorrected refractive errors – both of which are readily treated through corrective lenses or cataract surgery (2).
Despite this, visual assessments are often overlooked in the management of older adults presenting with falls. This article explores the reasons behind this oversight, outlines a practical approach to assessing vision, and highlights the benefits of integrating visual assessments into routine clinical care.
Why are visual assessments overlooked?
Given the prevalence of both visual impairment and falls in older adults, it is surprising that visual assessments are not routinely undertaken in fall evaluations. Several factors contribute to this gap:
Time constraint in acute care settings
In emergency and inpatient settings, immediate concerns such as fractures, head injuries, and acute medical issues often take precedence. Once addressed, visual assessments may be forgotten or not prioritised. Additionally, many patients presenting with falls can often also develop delirium, making it difficult to assess their vision.
Lack of standardised guidelines
Currently, there are no standardised guidelines on how to perform a visual assessment in older patients presenting with falls. Without clear protocols, visual assessments may be omitted because clinicians are unsure on how to perform them or simply forget.
Assumptions about vision
There is a tendency to presume that patients keep up to date with visits to their optometrist, particularly those who already wear glasses. However, many older people do not notice their visual impairment if it is longstanding and may not notice gradual deterioration in vision. This can lead to significant impairments going unnoticed unless actively assessed.
Components of a visual assessment
A “visual assessment” can vary in scope, but practical bedside evaluation should typically include four key components:
Taking a visual history
A simple but crucial step is asking the patient whether they experience any issues with their vision. Questions should cover recent changes in eyesight, difficulty in seeing in low light, trouble navigating steps, when they last visited an optician, and whether they still drive.
Identify past ophthalmic history
This is equally important to identify the patient’s past ocular diagnosis and surgeries. This includes whether they have any common conditions such as cataracts, refractive errors, glaucoma, macular degeneration, and diabetic retinopathy. IT is also important to identify whether they have sought treatment for their diagnosis.
Test visual fields
Testing visual fields can be performed quickly at the bedside. Sit at eye level to the patient, approximately arm’s length away. Ask the patient to cover their eye while you cover your corresponding eye. Move your fingers from the periphery toward the centre and ask the patient to indicate when they see movement. Repeat with the other eye.
Testing visual acuity
While formal visual acuity testing is typically done using a Snellen chart at the optician’s or in the ophthalmology department, there are practical alternatives to examine visual acuity in the ward setting. There are several mobile apps which can be used to test visual acuity at the end of the bed. Some of which have been shown to be comparable to the official Snellen’s chart (3). The American Academy of Ophthalmology also suggests using a printed Snellen’s chart on an A4 piece of paper to be done as an “at home” test (4). This can be printed out on the ward and held at roughly 3 meters away from the patient. The patient should read the chart with their best corrected vision.
Interpreting the Snellen’s chart
The result would typically be read as 20/20 – 20/200. The first number being what the patient can see at 20 feet, and the second number being what an average healthy adult can see at 20 feet. A reading of 20/60 means the patient can see at 20 feet, what a healthy adult can see at 60 feet.
Mild visual impairment is considered 20/30 to 20/60. Moderate visual impairment was considered 20/70 to 20/160. Severe visual impairment is considered 20/200 or worse (5).
Benefits of visual assessments
Introducing routine visual assessments in patients presenting with falls offers several significant benefits.
Early identification
Over 70% of adults aged over 85 have cataracts and 54% of people aged 40-69 have refractive errors (6, 7). Performing visual assessments can identify new or previously undiagnosed visual impairments.
Timely referrals and management
Research suggests up to 2.5 million UK adults over 65 years old have had their eyes checked in the last 1 years (8). Following a visual assessment, once visual impairment has been identified, patients can be referred to the optometrist or ophthalmology services to initiate appropriate treatment
Improved patient outcomes
Addressing visual impairments can lead to better patient outcomes. This includes mobility, increased confidence, and even reduced risk of falls and injuries.
One study conducted in Nottingham particularly highlights the importance of identifying and addressing visual impairments, specifically cataracts, to help reduce falls risks in older patients. This study concluded that patients with cataracts who underwent surgery had a 34% reduction in rate of falls compared to patients with cataracts who did not undergo surgery. Furthermore, these patients were at a 77% reduction in rates of fractures, which is comparable to the use of bisphosphonates (9).
Long-term cost effectiveness
Reducing rate of falls and fracture rates will ultimately result in long-term cost savings for the NHS. A study evaluating the cost-effectiveness of first eye cataract surgery compared to no surgery from a health service perspective found that over the patient’s remaining lifetime, the procedure would be cost-effective, through reduction in falls and fracture risk (10).
Recommendations
1) Education
Ophthalmology is often underrepresented during medical school, leaving many clinicians with little experience in performing and interpreting visual assessments. Implementing vision screening workshops into the undergraduate curriculum can help bridge this gap.
2) Clinical tools
Highlighting available easy-to-use tools for assessing visual acuity can facilitate the smooth integration of visual assessments. These include printed out Snellen’s charts and mobile phone app versions.
3) Policy and protocols
National and local guidelines should formally include visual assessments as part of a comprehensive falls risk assessment. This should also highlight referral pathways available.
Conclusion
Despite their prevalence, visual impairment is a significant but often missed contributor to falls in older adults. Many causes of impairment are easily treatable yet remain undiagnosed and untreated in hospital settings. By integrating visual assessments within a comprehensive falls risk assessment, we can identify this modifiable risk, initiate timely management, and ultimately improve patient safety and quality of life.
References
- Hospital Episode Statistics (HES) and Office for National Statistics (ONS) – Mid Year Population Estimates.
- Pezzullo L, Streatfield J, Simkiss P, and Shickle D (2018) The economic impact of sight loss and blindness in the UK adult population. BMC Health Services Research, 18:63; Deloitte Access Economics (2019). The economic impact of sight loss and blindness in the UK adult population. RNIB.
- Ansell, K., Maconachie, G. and Bjerre, A. (2020) ‘Does the EyeChart App for iPhones Give Comparable Measurements to Traditional Visual Acuity Charts?’, British and Irish Orthoptic Journal, 16(1), p. 19–24. Available at: https://doi.org/10.22599/bioj.146
- American Academy of Ophthalmology (2025) Home vision tests for children and adults, American Academy of Ophthalmology. Available at: https://www.aao.org/eye-health/tips-prevention/home-eye-test-children-adults.
- American Optometric Association (no date) Low vision and vision rehabilitation, AOA.org. Available at: https://www.aoa.org/healthy-eyes/caring-for-your-eyes/low-vision-and-vision-rehab
- Reidy, A., Minassian, D.C., Vafidis, G., et al. (1998) Prevalence of serious eye disease and visual impairment in a north London population: population based, cross sectional study. BMJ 316(7145), 1643-1646.
- Cumberland PM, Bao Y, Hysi PG, Foster PJ, Hammond CJ, Rahi JS; UK Biobank Eyes & Vision Consortium. Frequency and Distribution of Refractive Error in Adult Life: Methodology and Findings of the UK Biobank Study. PLoS One. 2015 Oct 2;10(10):e0139780. doi: 10.1371/journal.pone.0139780. PMID: 26430771; PMCID: PMC4591976.
- Young, K. Research suggests 19 million British people missing routine eye tests, AOP. Available at: https://www.aop.org.uk/ot/news/2024/09/24/research-suggests-19-million-british-people-missing-routine-eye-tests
- Harwood RH, Foss AJ, Osborn F, Gregson RM, Zaman A, Masud T. Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial. Br J Ophthalmol. 2005 Jan;89(1):53-9. doi: 10.1136/bjo.2004.049478. PMID: 15615747; PMCID: PMC1772474.
- Sach TH, Foss AJ, Gregson RM, Zaman A, Osborn F, Masud T, Harwood RH. Falls and health status in elderly women following first eye cataract surgery: an economic evaluation conducted alongside a randomised controlled trial. Br J Ophthalmol. 2007 Dec;91(12):1675-9. doi: 10.1136/bjo.2007.118687. Epub 2007 Jun 21. PMID: 17585002; PMCID: PMC2095519.