What you should know about: Aging and the eye

Like almost everything else in the body, the eyes naturally change as we age.

Needing reading glasses

The first change for most people is becoming less able to see well up close. This starts to become noticeable after age 40 and continues to worsen until the mid-60s. This happens because the lens naturally hardens as we age and becomes less able to accommodate – that is, change shape so you can see up close. The medical term for this is presbyopia.

Difficulty seeing in low light

Another natural change is that our pupils become a little smaller as we age, so less light gets into our eyes. This may make it more difficult to drive at night. It may also mean you need brighter light to read or do close work. It may also take longer for your eyes to adjust to changes in lighting conditions.

Dry eye

Though younger people can also suffer from dry eye, it becomes more common as we age, particularly for postmenopausal women. If your eyes feel dry or gritty, or if you experience patchy/blurry vision that improves when you blink or when your eyes are less tired, you may have dry eye. Mild dry eye is common and can be treated with measures such as over-the-counter artificial tears (preferably preservative-free) and warm compresses. More severe symptoms require more advanced treatment. Learn more about dry eye.

Sensitivity to glare

As we age, many people experience sensitivity to bright light. This can be due to dry eye and/or to changes in the lens that scatter light more than in younger, clearer lenses. These changes can occur many years before the changes become cataracts that need surgery. Polarized sunglasses can help counteract light sensitivity.

Floaters and flashes

As we age, we may see more “floaters” (spots in the vision) or sometimes flashes of light, particularly in our side vision. The eye is filled with vitreous humour, which has a gel-like consistency, and this gel can detach from the retina, causing an increase in floaters and sometimes flashes. This is called posterior vitreous detachment, and it is common, particularly from the 60s and up. The floaters and flashes usually become less noticeable over the course of several weeks.

Posterior vitreous detachment doesn’t lead to long-term problems – but it can be hard to distinguish from more serious conditions such as a retinal tear or even retinal detachment, which is a medical emergency. If you suddenly experience floaters or flashes in your vision, see an optometrist or ophthalmologist without delay.

Most diseases rise in prevalence as we age. Here are some of the more common ones related to the eye and vision.

Cataracts

Cataracts are a thickening and deepening in colour of the lens in the eye. Everyone develops cataracts if they live long enough. The symptoms of early-stage cataracts can often be mitigated through measures like a new glasses prescription or using brighter lights. Ultimately, however, cataracts need to be treated through surgery that replaces the cloudy lens with an artificial one. Cataract surgery is one of the most common and safest surgeries in Canada. Learn more about cataracts.

Age-related macular degeneration

It’s right in the name – age-related macular degeneration, or AMD, is mainly caused by aging, though lifestyle factors and genetics can influence how fast the disease develops and progresses. AMD is a deterioration of the macular region of the retina, the part of the back of the eye responsible for our sharp central vision. In the early stages, it doesn’t cause any symptoms. As the disease progresses, it may cause loss of central vision, though peripheral vision will remain intact. Regular eye exams can lead to diagnosis and treatment at an early stage, preventing or slowing vision loss. Learn more about macular degeneration.

Glaucoma

Glaucoma is more common in older people, though it can affect younger people too. It’s caused by damage to the optic nerve, which is the connection between the eye and brain. This damage is most often due to high pressure in the eye caused by fluid draining too slowly. Glaucoma doesn’t cause any symptoms in the early stages, though damage is already occurring. In later stages, glaucoma causes vision loss, beginning with peripheral (side) vision. It may progress to central vision without treatment. An optometrist can diagnose glaucoma in the early stages and help prevent vision loss. Learn more about glaucoma.

Dry eye disease

Moderate to severe dry eye can have a significant negative effect on a patient’s quality of life – and symptoms tend to get worse with age. In more severe cases, damage to the cornea (the clear “window” at the front of the eye) can result. Depending on what’s causing your dry eye and how severe your symptoms are, an optometrist can recommend the most appropriate treatments. Learn more about some of the advanced treatments for dry eye disease.

Diabetic eye disease

Anyone with diabetes is at risk for diabetic eye disease. Since diabetes prevalence (particularly type 2) increases with age, so does the prevalence of diseases such as diabetic retinopathy and diabetic macular edema, which can cause vision loss. Poor blood sugar control increases the risk of diabetic eye disease, and the longer blood sugar is poorly controlled, the higher the risk. Learn more about diabetic eye disease.

Stroke

Strokes become more common with age, and vision problems are common in patients who have experienced a stroke. Some people experience a loss of one side of their visual field. Some people experience double vision, difficulty tracking moving objects, eyes becoming misaligned, or repetitive, involuntary eye movements. Optometrists, particularly those with expertise in low vision, brain injuries and/or binocular vision problems (binocular vision is the ability of your two eyes to work together), can help alleviate these symptoms to a significant extent even if full resolution isn’t possible.

Watch out for any changes to your vision, particularly if they have a quick onset. These can include:

• Any sudden changes in vision clarity
• An increase in floaters in your vision
• Seeing flashes of light in your vision
• Dark or blurry spots in your vision
• Loss of peripheral vision or what looks like a curtain falling over part of your vision
• Distorted vision, such as straight lines appearing wavy
• Eye pain

If you experience symptoms such as these, see an optometrist or ophthalmologist as soon as possible. If the changes come on suddenly and you can’t see an optometrist or ophthalmologist right away, go to the nearest hospital emergency room.

Even if the changes to your vision are more gradual, you should still see an optometrist without delay. In general, the sooner eye diseases are treated, the better the outcome.

The best thing you can do to look after your eyesight at any age is to get regular eye exams. This is even more important as you age.

A comprehensive eye exam that includes dilating your pupils using medicated eye drops enables your optometrist to get a good look at the back of your eye. This can reveal signs of conditions such as macular degeneration, glaucoma and diabetic retinopathy – all of which can lead to vision loss if untreated. An optometrist might also see signs of systemic (whole-body) diseases such as diabetes and hypertension in your eyes.

Otherwise, looking after your general health is also looking after your eyesight. Don't smoke. Maintain a healthy, balanced diet including leafy greens. Exercise regularly – anything that helps prevent cardiovascular disease will also help prevent or slow the progression of many types of eye disease.

Protecting your eyes is also important. Wear safety glasses if you’re working someplace like a garden or wood shop. Wear sunglasses labelled “100% UV protection” or “UV400” year round, whenever you’re outside. You can get bifocal or multifocal sunglasses, or lenses that automatically transition from clear to dark when you’re in the sun. High levels of UV exposure can increase your risk of some eye diseases, notably cataracts.

All these tips are useful for younger and middle-aged adults as well as older ones, to prevent or slow down age-related eye disease.

A yearly eye exam is the best practice for people of all ages. Having said that, an optometrist may recommend a different maximum interval depending on your individual health and risk factors. Healthy younger people may be able to get away with having an eye exam every two years, but healthy older people should have a comprehensive eye exam with dilation at least every 12 to 18 months, depending on the optometrist’s recommendation.

If you have diabetes or a known eye disease, are suspected of having an eye disease, or have significant eye disease risk factors, your optometrist will likely recommend a comprehensive eye exam at least once a year, perhaps with follow-ups at shorter intervals.

Important: if you experience a change in your vision, get it checked out as soon as possible – don’t wait for the next regularly scheduled eye exam.

Note that the Ontario Health Insurance Plan (OHIP) covers full eye exams for people 65 and older once every 18 months, plus two follow-ups, if they do not have an eligible medical condition. For adults of any age who do have an eligible medical condition, comprehensive eye exams are covered once a year, plus two follow-ups. Learn more about OHIP eye coverage.

If you’re a caregiver to someone who has dementia or otherwise has difficulty communicating, it can be difficult to separate vision problems from other symptoms. Dementia can cause problems with visual processing in people who don’t have true visual impairments. Nonetheless, signs to look out for include:

• The person looks at you if you speak to them from one side but not the other – or they look at you if you approach from the front but not from the side.
• Clumsiness or apparent difficulty with depth perception.
• Loss of interest in visual activities such as reading, looking at pictures or watching TV – though this may be caused by dementia rather than vision issues.

Research has shown that untreated vision loss is a risk factor for dementia. Though it’s unclear what causes what, visual impairment can lead to worsening of dementia symptoms, while treating eye diseases can improve patients’ quality of life. Learn more from this CBC story.

Once vision loss has occurred, it usually can’t be reversed. However, there is still plenty that can be done to help people maximize the vision they have. Low vision rehabilitation can help in areas such as:

• Suggesting low-tech and high-tech devices that can help people with low vision. These may include higher-powered reading glasses or magnifiers to help with reading and computer programs or apps to help with digital accessibility. You can be trained in the use of these devices.
• Suggesting modifications to your environment to make everyday tasks or work easier.
• Counselling to help patients and their families cope with the emotional impact of vision loss.
• Referrals to community organizations that provide services to people with vision loss.

At the Waterloo Eye Institute, we provide:

• Comprehensive eye exams for all ages.
• Eyewear, including bifocals, multifocals, bifocal/multifocal sunglasses, lenses with therapeutic tints/filters and dry eye spectacles that cup over the eyes. 
• Contact lenses, including bifocal/multifocal contact lenses and specialized lenses for people with conditions such as severe dry eye or corneal scarring.
• Urgent eye care and an after-hours phone line for urgent eye concerns.
• Treatment and management of ocular diseases including dry eye.
• Low vision rehabilitation for people who have experienced vision loss.
• Treatment for people who have experienced brain injuries, including stroke and concussion, and/or who have binocular vision dysfunction.
• Advanced eye imaging to help diagnose and stage diseases, including for patients of other clinics upon referral.

If you have or your loved one has accessibility needs, such as a mobility disability or dementia, let us know when you make the appointment so we’re best prepared to accommodate you.

OHIP covers some eye exams and follow-ups for people over 65. More details are under “How often should an older adult get an eye exam?” Your optometrist may recommend testing or treatments/therapies that are not covered under OHIP. Cost details will be provided in advance.

The University of Waterloo School of Optometry and Vision Science is ranked fifth worldwide in research output for schools of optometry. Our researchers are contributing to knowledge in areas such as cellular aging, dry eye disease, retinal imaging, corneal wound healing, eye drug delivery and more.

If you’re interested in participating in research related to advancing eye and vision care, explore our current studies that are actively looking for volunteers.

Article and video by Karen Kawawada and Kavya Piraba

Reviewed by Dr. Tammy Labreche, OD, FAAO, residency diploma in low vision and geriatrics