Screening for impaired visual acuity in older adults: U.S. Preventive Services Task Force recommendation statement. | National Guideline Clearinghouse

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U.S. Preventive Services Task Force

Screening for impaired visual acuity in older adults: U.S. Preventive Services Task Force recommendation statement. This updates a previously published guideline summary.

Screening for impaired visual acuity in older adults: U.S. Preventive Services Task Force recommendation statement.

The U.S. Preventive Services Task Force (USPSTF) grades its recommendations (A, B, C, D, or I) and identifies the Levels of Certainty regarding Net Benefit (High, Moderate, and Low). The definitions of these grades can be found at the end of the "Major Recommendations" field.

Summary of Recommendation and Evidence

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in older adults. (I statement)

See the Clinical Considerations (below) for suggestions for practice regarding the I statement.

Clinical Considerations

Patient Population Under Consideration

This recommendation applies to asymptomatic adults 65 years or older who do not present to their primary care clinician with vision problems (see Figure 2 in the original guideline document).

Suggestions for Practice Regarding the I Statement

Potential Preventable Burden

In 2011, about 12% of U.S. adults aged 65 to 74 years and 15% of those 75 years or older reported having problems seeing, even with glasses or contact lenses. The prevalence of age-related macular degeneration (AMD) is 6.5% in adults older than 40 years and increases with age (2.8% in those aged 40-59 years and 13.4% in those aged ≥60 years). About half of all cases of bilateral low vision (i.e., best-corrected visual acuity of <20/40) in adults 40 years and older are caused by cataracts. The prevalence of cataracts increases sharply with age; an estimated 50% of US adults 80 years or older have cataracts. The prevalence of hyperopia requiring a correction of +3.0 diopters or more ranges from about 5.9% in U.S. adults aged 50 to 54 years, to 15.2% in adults aged 65 to 69 years, to 20.4% in adults 80 years or older.

Older age is an important risk factor for most types of visual impairment. Additional risk factors for cataracts are smoking, alcohol use, UV light exposure, diabetes, corticosteroid use, and black race. Risk factors for AMD include smoking, family history, and white race.

Potential Harms

The harms of screening in a primary care setting have not been adequately studied. Overall, the potential for harms from treatment are small to none. Harms of treatment of refractive error include a potential for increased falls with the use of multifocal lenses; infectious keratitis with the use of contact lenses, laser assisted in situ keratomileusis (LASIK), or laser-assisted sub epithelial keratectomy (LASEK); and corneal ectasia with LASIK. Harms of cataract surgery include posterior lens opacification and endophthalmitis. Treatment of AMD with antioxidant vitamins and mineral supplements is not associated with increased risk of most serious adverse events.

Although there appears to be benefit in longer-term outcomes, a systematic review found that treatment of AMD with laser photocoagulation was associated with greater risk of acute loss of 6 or more lines of visual acuity vs. no treatment at 3 months (relative risk [RR], 1.41 [95% CI, 1.08-1.82]). Pooled estimates report a non–statistically significant association between photodynamic therapy and risk of acute loss of 20 or more letters of visual acuity vs. placebo at 7 days (RR, 3.75 [95% CI, 0.87-16]) (3 trials). One of 2 trials found that treatment of wet AMD with intravitreal vascular endothelial growth factor (VEGF) inhibitor therapy was associated with greater likelihood of withdrawal vs. sham therapy; there were no differences in serious or other adverse events, but estimates were imprecise.

Current Practice

About half of US adults older than 65 years reported having an eye examination within the last 12 months in a 2007 study.

Screening Tests

A visual acuity test (e.g., the Snellen eye chart) is the usual method for screening for visual acuity impairment in the primary care setting. Screening questions are not as accurate as visual acuity testing for identifying visual acuity impairment. Evidence on the use of other tests for vision screening in primary care, such as the pinhole test (a test for refractive error), the Amsler grid (a test of central vision to detect AMD), genetic testing, or funduscopy (visual inspection of the interior of the eye), is lacking.

Treatment

Several types of treatment are effective for improving visual acuity. Corrective lenses improve visual acuity in patients with a refractive error. Treatment of cataracts through surgical removal of the cataract is effective for improving visual acuity. Treatment of exudative (or wet) AMD includes laser photocoagulation, verteporfin, and intravitreal injections of vascular endothelial growth factor (VEGF) inhibitors. Antioxidant vitamins and minerals are an effective treatment for dry AMD.

Other Approaches to Prevention

This recommendation statement does not include screening for glaucoma. The USPSTF recommendations on screening for glaucoma and falls prevention are available on its Web site (http://www.uspreventiveservicestaskforce.org External Web Site Policy

) (see also the National Guideline Clearinghouse [NGC] summaries of the USPSTF guidelines Screening for glaucoma: U.S. Preventive Services Task Force recommendation statement and Prevention of falls in community-dwelling older adults: U.S. Preventive Services Task Force recommendation statement).

Definitions

What the United States Preventive Services Task Force (USPSTF) Grades Mean and Suggestions for Practice

Grade	Grade Definitions	Suggestions for Practice
A	The USPSTF recommends the service. There is high certainty that the net benefit is substantial.	Offer or provide this service.
B	The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.	Offer or provide this service.
C	The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.	Offer or provide this service for selected patients depending on individual circumstances.
D	The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.	Discourage the use of this service.
I Statement	The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality or conflicting, and the balance of benefits and harms cannot be determined.	Read the "Clinical Considerations" section of the USPSTF Recommendation Statement (see the "Major Recommendations" field). If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

USPSTF Levels of Certainty Regarding Net Benefit

Definition: The USPSTF defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.

Level of Certainty	Description
High	The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.
Moderate	The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by factors such as: The number, size, or quality of individual studies Inconsistency of findings across individual studies Limited generalizability of findings to routine primary care practice Lack of coherence in the chain of evidence As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.
Low	The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of: The limited number or size of studies Important flaws in study design or methods Inconsistency of findings across individual studies Gaps in the chain of evidence Findings not generalizable to routine primary care practice A lack of information on important health outcomes More information may allow an estimation of effects on health outcomes.

Clinical Algorithm(s)

None provided

Scope

Disease/Condition(s)

Impaired visual acuity due to:

Uncorrected refractive errors
Cataracts
Age-related macular degeneration (AMD)

Note: This recommendation statement does not include screening for glaucoma. The U.S. Preventive Services Task Force (USPSTF) recommendations on screening for glaucoma and falls prevention are available on its Web site (http://www.uspreventiveservicestaskforce.org External Web Site Policy

Guideline Category

Screening

Clinical Specialty

Family Practice

Geriatrics

Ophthalmology

Optometry

Preventive Medicine

Intended Users

Advanced Practice Nurses

Health Care Providers

Nurses

Optometrists

Physician Assistants

Physicians

Public Health Departments

Guideline Objective(s)

To update the U.S. Preventive Services Task Force (USPSTF) recommendation on screening for visual acuity impairment in older adults

Target Population

Asymptomatic adults 65 years or older who do not present to their primary care clinician with vision problems

Interventions and Practices Considered

Screening for impaired visual acuity in older adults

Major Outcomes Considered

Key Question 1: Does vision screening in asymptomatic older adults result in improved vision, morbidity or mortality, quality of life, functional status, or cognition?
Key Question 2: Are there harms of vision screening?
Key Question 3: What is the accuracy of screening for early impairment in visual acuity due to uncorrected refractive error, cataracts, or age-related macular degeneration (AMD)?
Key Question 4: Does treatment of early impairment in visual acuity due to uncorrected refractive error, cataracts, or AMD lead to improved visual acuity, morbidity, mortality, vision-related quality of life, functional status, or cognition?
Key Question 5: Are there harms of treating early impairment in visual acuity?

Methodology

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)

Hand-searches of Published Literature (Secondary Sources)

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Note from the National Guideline Clearinghouse (NGC): A systematic evidence review and full report were prepared by the Pacific Northwest Evidence-based Practice Center (EPC) for the U.S. Preventive Services Task Force (USPSTF) (see the "Availability of Companion Documents" field).

Data Sources and Searches

Searches were conducted in Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews from 2008 (searches in the 2009 review were conducted through July 2008) to February 2015 (see Appendix 1 in the evidence review supplement); and reference lists. An updated search conducted on January 6, 2016, using the same databases identified no new studies that would affect the conclusions or understanding of the evidence and therefore the related USPSTF recommendation.

Study Selection

Two reviewers evaluated each study on the basis of predefined criteria. For studies on screening and diagnostic accuracy, the investigators included studies of asymptomatic adults 65 years or older without known impaired visual acuity (based on current corrected vision) who have not sought care for evaluation of vision problems. They included randomized clinical trials (RCTs) of vision screening performed in primary care or community-based settings vs. no screening, delayed screening, or usual care (e.g., targeted screening) and evaluated visual acuity, vision-related quality of life, functional capacity, mortality, cognition, or harms. The investigators included studies of diagnostic accuracy of vision screening tests, questions, or questionnaires performed in primary care or community settings. For treatment, they included RCTs of asymptomatic adults (not restricted to age ≥65 years) with mild to moderate vision impairment (defined as best visual acuity worse than 20/40 but better than 20/200) that evaluated effects on the outcomes described above for corrective lenses, reading aids, or photorefractive surgery due to uncorrected refractive errors; vitamin and oxidants and vascular endothelial growth factor (VEGF) inhibitors for age-related macular degeneration (AMD); or cataract surgery. For screening and treatment, cohort studies were included when evidence from RCTs was insufficient. The investigators excluded studies of screening and diagnostic testing performed in specialty settings and trials of treatment in patients with visual acuity worse than 20/200 or with other causes of vision loss. The selection of literature is summarized in Figure 2 in the evidence review.

Number of Source Documents

Forty-five studies* and reviews were included, 11 from the current search and 34 from the prior review:

Key Question 1: 3
Key Question 2: 0
Key Question 3: 11
Key Question 4: 25
Key Question 5: 17

See the literature flow diagram (Figure 2) in the systematic review (see the "Availability of Companion Documents" field) for a summary of evidence search and selection.

*Studies and reviews may be included for more than 1 Key Question.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Two investigators independently applied criteria developed by the U.S. Preventive Services Task Force (USPSTF) to rate the quality of each study as good, fair, or poor using a consensus process. See the "Description of the Methods Used to Analyze the Evidence" field for further information.

Methods Used to Analyze the Evidence

Meta-Analysis

Review of Published Meta-Analyses

Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Data Abstraction and Quality Assessment

Details about the study design, patient population, setting, screening method, interventions, analysis, and results were abstracted. Two investigators independently applied criteria developed by the USPSTF to rate the quality of each study as good, fair, or poor (see Appendix A5 in the evidence synthesis). Discrepancies were resolved through consensus.

Data Synthesis and Analysis

The aggregate internal validity (quality) of the body of evidence for each Key Question was assessed as good, fair, or poor using methods developed by the USPSTF, based on the quality of studies, precision of estimates, consistency of results between studies, and directness of evidence. Data synthesis was based on evidence from the 2009 review as well as new evidence. A meta-analysis on effectiveness of vascular endothelial growth factor (VEGF) inhibitors vs. placebo for wet age-related macular degeneration (AMD) was performed using a random-effects model with Review Manager 5.2 (Nordic Cochrane Centre) to calculate pooled relative risks (RRs) and absolute risk differences. The meta-analysis was stratified by the vascular endothelial growth factor (VEGF) inhibitor used. Results were considered statistically significant if the P value was less than .05 based on 2-sided testing, and statistical heterogeneity was measured using the I².

Methods Used to Formulate the Recommendations

Balance Sheets

Expert Consensus

Description of Methods Used to Formulate the Recommendations

The U.S. Preventive Services Task Force (USPSTF) systematically reviews the evidence concerning both the benefits and harms of widespread implementation of a preventive service. It then assesses the certainty of the evidence and the magnitude of the benefits and harms. On the basis of this assessment, the USPSTF assigns a letter grade to each preventive service signifying its recommendation about provision of the service (see table below). An important, but often challenging, step is determining the balance between benefits and harms to estimate "net benefit" (that is, benefits minus harms).

U.S. Preventive Services Task Force Recommendation Grid*

Certainty of Net Benefit	Magnitude of Net Benefit
Certainty of Net Benefit	Substantial	Moderate	Small	Zero/Negative
High	A	B	C	D
Moderate	B	B	C	D
Low	Insufficient

*A, B, C, D, and I (Insufficient) represent the letter grades of recommendation or statement of insufficient evidence assigned by the USPSTF after assessing certainty and magnitude of net benefit of the service (see the "Rating Scheme for the Strength of the Recommendations" field).

The overarching question that the USPSTF seeks to answer for every preventive service is whether evidence suggests that provision of the service would improve health outcomes if implemented in a general primary care population. For screening topics, this standard could be met by a large randomized controlled trial (RCT) in a representative asymptomatic population with follow-up of all members of both the group "invited for screening" and the group "not invited for screening."

Direct RCT evidence about screening is often unavailable, so the USPSTF considers indirect evidence. To guide its selection of indirect evidence, the USPSTF constructs a "chain of evidence" within an analytic framework. For each key question, the body of pertinent literature is critically appraised, focusing on the following 6 questions:

Do the studies have the appropriate research design to answer the key question(s)?
To what extent are the existing studies of high quality? (i.e., what is the internal validity?)
To what extent are the results of the studies generalizable to the general U.S. primary care population and situation? (i.e., what is the external validity?)
How many studies have been conducted that address the key question(s)? How large are the studies? (i.e., what is the precision of the evidence?)
How consistent are the results of the studies?
Are there additional factors that assist the USPSTF in drawing conclusions (e.g., presence or absence of dose–response effects, fit within a biologic model)?

The next step in the USPSTF process is to use the evidence from the key questions to assess whether there would be net benefit if the service were implemented. In 2001, the USPSTF published an article that documented its systematic processes of evidence evaluation and recommendation development. At that time, the USPSTF's overall assessment of evidence was described as good, fair, or poor. The USPSTF realized that this rating seemed to apply only to how well studies were conducted and did not fully capture all of the issues that go into an overall assessment of the evidence about net benefit. To avoid confusion, the USPSTF has changed its terminology. Whereas individual study quality will continue to be characterized as good, fair, or poor, the term certainty will now be used to describe the USPSTF's assessment of the overall body of evidence about net benefit of a preventive service and the likelihood that the assessment is correct. Certainty will be determined by considering all 6 questions listed above; the judgment about certainty will be described as high, moderate, or low.

In making its assessment of certainty about net benefit, the evaluation of the evidence from each key question plays a primary role. It is important to note that the USPSTF makes recommendations for real-world medical practice in the United States and must determine to what extent the evidence for each key question—even evidence from screening RCTs or treatment RCTs—can be applied to the general primary care population. Frequently, studies are conducted in highly selected populations under special conditions. The USPSTF must consider differences between the general primary care population and the populations studied in RCTs and make judgments about the likelihood of observing the same effect in actual practice.

It is also important to note that one of the key questions in the analytic framework refers to the potential harms of the preventive service. The USPSTF considers the evidence about the benefits and harms of preventive services separately and equally. Data about harms are often obtained from observational studies because harms observed in RCTs may not be representative of those found in usual practice and because some harms are not completely measured and reported in RCTs.

Putting the body of evidence for all key questions together as a chain, the USPSTF assesses the certainty of net benefit of a preventive service by asking the 6 major questions listed above. The USPSTF would rate a body of convincing evidence about the benefits of a service that, for example, derives from several RCTs of screening in which the estimate of benefits can be generalized to the general primary care population as "high" certainty (see the "Rating Scheme for the Strength of the Recommendations" field). The USPSTF would rate a body of evidence that was not clearly applicable to general practice or has other defects in quality, research design, or consistency of studies as "moderate" certainty. Certainty is "low" when, for example, there are gaps in the evidence linking parts of the analytic framework, when evidence to determine the harms of treatment is unavailable, or when evidence about the benefits of treatment is insufficient. Table 4 in the methodology document listed below (see "Availability of Companion Documents" field) summarizes the current terminology used by the USPSTF to describe the critical assessment of evidence at all 3 levels: individual studies, key questions, and overall certainty of net benefit of the preventive service.

Sawaya GF, Guirguis-Blake J, LeFevre M, Harris R, Petitti D; U.S. Preventive Services Task Force. Update on the methods of the U.S. Preventive Services Task Force: estimating certainty and magnitude of net benefit. Ann Intern Med. 2007;147(12):871-5. [5 references].

I Statements

For I statements, the USPSTF has a plan to commission its Evidence-based Practice Centers (EPCs) to collect information in 4 domains pertinent to clinical decisions about prevention and to report this information routinely. This plan is described in the paper: Petitti DB et al. Update on the methods of the U.S. Preventive Services Task Force: insufficient evidence. Ann Intern Med. 2009;150:199-205.www.annals.org External Web Site Policy

The first domain is potential preventable burden of suffering from the condition. When evidence is insufficient, provision of an intervention designed to prevent a serious condition (such as dementia) might be viewed more favorably than provision of a service designed to prevent a condition that does not cause as much suffering (such as rash). The USPSTF recognized that "burden of suffering" is subjective and involves judgment. In clinical settings, it should be informed by patient values and concerns.

The second domain is potential harm of the intervention. When evidence is insufficient, an intervention with a large potential for harm (such as major surgery) might be viewed less favorably than an intervention with a small potential for harm (such as advice to watch less television). The USPSTF again acknowledges the subjective nature and the difficulty of assessing potential harms: for example, how bad is a "mild" stroke?

The third domain is cost—not just monetary cost, but opportunity cost, in particular the amount of time a provider spends to provide the service, the amount of time the patient spends to partake of it, and the benefits that might derive from alternative uses of the time or money for patients, clinicians, or systems. Consideration of clinician time is especially important for preventive services with only insufficient evidence because providing them could "crowd out" provision of preventive services with proven value, services for conditions that require immediate action, or services more desired by the patient. For example, a decision to routinely inspect the skin could take up the time available to discuss smoking cessation, or to address an acute problem or a minor injury that the patient considers important.

The fourth domain is current practice. This domain was chosen because it is important to clinicians for at least 2 reasons. Clinicians justifiably fear that not doing something that is done on a widespread basis in the community may lead to litigation. More important, addressing patient expectations is a crucial part of the clinician–patient relationship in terms of building trust and developing a collaborative therapeutic relationship. The consequences of not providing a service that is neither widely available nor widely used are less serious than not providing a service accepted by the medical profession and thus expected by patients. Furthermore, ingrained care practices are difficult to change, and efforts should preferentially be directed to changing those practices for which the evidence to support change is compelling.

Although the reviewers did not explicitly recognize it when these domains were chosen, the domains all involve consideration of the potential consequences—for patients, clinicians, and systems—of providing or not providing a service. Others writing about medical decision making in the face of uncertainty have suggested that the consequences of action or inaction should play a prominent role in decisions.

Rating Scheme for the Strength of the Recommendations

What the United States Preventive Services Task Force (USPSTF) Grades Mean and Suggestions for Practice

Grade	Grade Definitions	Suggestions for Practice
A	The USPSTF recommends the service. There is high certainty that the net benefit is substantial.	Offer or provide this service.
B	The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.	Offer or provide this service.
C	The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.	Offer or provide this for selected patients depending on individual circumstances.
D	The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.	Discourage the use of this service.
I Statement	The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality or conflicting, and the balance of benefits and harms cannot be determined.	Read "Clinical Considerations" section of USPSTF Recommendation Statement (see the "Major Recommendations" field). If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

USPSTF Levels of Certainty Regarding Net Benefit

Level of Certainty	Description
High	The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.
Moderate	The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by factors such as: The number, size, or quality of individual studies Inconsistency of findings across individual studies Limited generalizability of findings to routine primary care practice Lack of coherence in the chain of evidence As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.
Low	The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of: The limited number or size of studies Important flaws in study design or methods Inconsistency of findings across individual studies Gaps in the chain of evidence Findings not generalizable to routine primary care practice A lack of information on important health outcomes More information may allow an estimation of effects on health outcomes.

Cost Analysis

The U.S. Preventive Services Task Force (USPSTF) does not consider the costs of providing a service in this assessment.

Method of Guideline Validation

Comparison with Guidelines from Other Groups

External Peer Review

Internal Peer Review

Description of Method of Guideline Validation

Peer Review

Before the U.S. Preventive Services Task Force (USPSTF) makes its final determinations about recommendations on a given preventive service, the Evidence-based Practice Center (EPC) and the Agency for Healthcare Research and Quality (AHRQ) send the draft evidence review to 4 to 6 external experts and to Federal agencies and professional and disease-based health organizations with interests in the topic. The experts are asked to examine the review critically for accuracy and completeness and to respond to a series of specific questions about the document. The draft evidence review is also posted on the USPSTF Web site for public comment. After assembling these external review comments and documenting the proposed response to key comments, the topic team presents this information to the USPSTF in memo form. In this way, the USPSTF can consider these external comments before it votes on its recommendations about the service. Draft recommendation statements are then circulated for comment among reviewers representing professional societies, voluntary organizations, and Federal agencies, as well as posted on the USPSTF Web site for public comment. These comments are discussed before the final recommendations are confirmed.

Response to Public Comment

A draft version of this recommendation statement was posted for public comment on the USPSTF website from July 21 through August 17, 2015. The USPSTF received very few comments on the draft recommendation statement. One respondent requested that the USPSTF clarify that an I statement is not a recommendation against screening; the USPSTF plans to reinforce when communicating this recommendation statement that an I statement is not a recommendation for or against screening.

Comparison with Guidelines from Other Groups

Recommendations for screening from the following groups were discussed: the American Optometric Association, the American Academy of Ophthalmology, the American Academy of Family Physicians, and the American Congress of Obstetricians and Gynecologists.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendation is not specifically stated.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Benefits of Detection and Early Treatment

The U.S. Preventive Services Task Force (USPSTF) found inadequate overall evidence on the benefits of screening, early detection, and treatment to provide a coherent assessment of the overall benefits. Several studies evaluated the direct benefit of screening and reported no reductions in vision disorders or vision-related function in screened populations; however, these studies had limitations, including differing control interventions, high loss to follow-up, and low uptake of treatment. The USPSTF found adequate evidence that early treatment of refractive error, cataracts, and AMD improves or prevents loss of visual acuity.

Potential Harms

Harms of Detection and Early Treatment

The U.S. Preventive Services Task Force (USPSTF) found inadequate evidence on the harms of screening. The USPSTF found adequate evidence that early treatment of refractive error, cataracts, and age-related macular degeneration (AMD) may lead to harms that are small to none.

Qualifying Statements

The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific clinical preventive services for patients without obvious related signs or symptoms.
It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of Agency for Healthcare Research and Quality (AHRQ) or the U.S. Department of Health and Human Services.

Implementation of the Guideline

Description of Implementation Strategy

The experiences of the first and second U.S. Preventive Services Task Force (USPSTF), as well as that of other evidence-based guideline efforts, have highlighted the importance of identifying effective ways to implement clinical recommendations. Practice guidelines are relatively weak tools for changing clinical practice when used in isolation. To effect change, guidelines must be coupled with strategies to improve their acceptance and feasibility. Such strategies include enlisting the support of local opinion leaders, using reminder systems for clinicians and patients, adopting standing orders, and audit and feedback of information to clinicians about their compliance with recommended practice.

In the case of preventive services guidelines, implementation needs to go beyond traditional dissemination and promotion efforts to recognize the added patient and clinician barriers that affect preventive care. These include clinicians' ambivalence about whether preventive medicine is part of their job, the psychological and practical challenges that patients face in changing behaviors, lack of access to health care or of insurance coverage for preventive services for some patients, competing pressures within the context of shorter office visits, and the lack of organized systems in most practices to ensure the delivery of recommended preventive care.

Dissemination strategies have changed dramatically in this age of electronic information. While recognizing the continuing value of journals and other print formats for dissemination, the USPSTF will make all its products available through its Web site External Web Site Policy

. The combination of electronic access and extensive material in the public domain should make it easier for a broad audience of users to access USPSTF materials and adapt them for their local needs. Online access to USPSTF products also opens up new possibilities for the appearance of the annual, pocket-size Guide to Clinical Preventive Services.

To be successful, approaches for implementing prevention have to be tailored to the local level and deal with the specific barriers at a given site, typically requiring the redesign of systems of care. Such a systems approach to prevention has had notable success in established staff-model health maintenance organizations, by addressing organization of care, emphasizing a philosophy of prevention, and altering the training and incentives for clinicians. Staff-model plans also benefit from integrated information systems that can track the use of needed services and generate automatic reminders aimed at patients and clinicians, some of the most consistently successful interventions. Information systems remain a major challenge for individual clinicians' offices, however, as well as for looser affiliations of practices in network-model managed care and independent practice associations, where data on patient visits, referrals, and test results are not always centralized.

Implementation Tools

Mobile Device Resources

Patient Resources

Pocket Guide/Reference Cards

Staff Training/Competency Material

For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness

Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)

U.S. Preventive Services Task Force (USPSTF). Screening for impaired visual acuity in older adults: U.S. Preventive Services Task Force recommendation statement. JAMA. 2016 Mar 1;315(9):908-14. [31 references] PubMed External Web Site Policy

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2016 Mar 1

Guideline Developer(s)

U.S. Preventive Services Task Force - Independent Expert Panel

Guideline Developer Comment

The U.S. Preventive Services Task Force (USPSTF) is a federally-appointed panel of independent experts. Conclusions of the USPSTF do not necessarily reflect policy of the U.S. Department of Health and Human Services or its agencies.

Source(s) of Funding

The U.S. Preventive Services Task Force (USPSTF) is an independent, voluntary body. The U.S. Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF.

Guideline Committee

U.S. Preventive Services Task Force (USPSTF)

Composition of Group That Authored the Guideline

Task Force Members*: Albert L. Siu, MD, MSPH (Chair) (Mount Sinai School of Medicine, New York, New York, James J. Peters Veterans Affairs Medical Center, Bronx, New York); Kirsten Bibbins-Domingo, PhD, MD, MAS (Co-vice Chair) (University of California, San Francisco); David C. Grossman, MD, MPH (Co-vice Chair) (Group Health Research Institute, Seattle, Washington); Linda Ciofu Baumann, PhD, RN, APRN (University of Wisconsin, Madison); Karina W. Davidson, PhD, MASc (Columbia University, New York, New York); Mark Ebell, MD, MS (University of Georgia, Athens); Francisco A. R. García, MD, MPH (Pima County Department of Health, Tucson, Arizona); Matthew Gillman, MD, SM (Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts); Jessica Herzstein, MD, MPH (Independent consultant, Washington, DC); Alex R. Kemper, MD, MPH, MS (Duke University, Durham, North Carolina); Alex H. Krist, MD, MPH (Fairfax Family Practice, Fairfax, Virginia, Virginia Commonwealth University, Richmond); Ann E. Kurth, PhD, RN, MSN, MPH (New York University, New York); Douglas K. Owens, MD, MS (Veterans Affairs Palo Alto Health Care System, Palo Alto, California, Stanford University, Stanford, California); William R. Phillips, MD, MPH (University of Washington, Seattle); Maureen G. Phipps, MD, MPH (Brown University, Providence, Rhode Island); Michael P. Pignone, MD, MPH (University of North Carolina, Chapel Hill)

*Members of the USPSTF at the time this recommendation was finalized. For a list of current Task Force members, go to http://www.uspreventiveservicestaskforce.org/Page/Name/our-members External Web Site Policy

Financial Disclosures/Conflicts of Interest

The U.S. Preventive Services Task Force (USPSTF) has an explicit policy concerning conflict of interest. All members disclose at each meeting if they have a significant financial, professional/business, or intellectual conflict for each topic being discussed. USPSTF members with conflicts may be recused from discussing or voting on recommendations about the topic in question.

Conflict of Interest Disclosures

All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Authors followed the policy regarding conflicts of interest described athttp://www.uspreventiveservicestaskforce.org/Page/Name/conflict-of-interest-disclosures External Web Site Policy

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: U.S. Preventive Services Task Force. Screening for impaired visual acuity in older adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009 Jul 7;151(1):37-43, W10. [26 references]

This guideline meets NGC's 2013 (revised) inclusion criteria.

Guideline Availability

Available from the Journal of the American Medical Association (JAMA) Web site External Web Site Policy

Availability of Companion Documents

The following are available:

Evidence Reviews:

Chou R, Dana T, Bougatsos C, Grusing S, Blazina I. Screening for impaired visual acuity in older adults: updated evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA. 2016 Mar 1;315(9):915-33.
Chou R, Dana T, Bougatsos C, Grusing S, Blazina I. Screening for impaired visual acuity in older adults: a systematic review to update the 2009 U.S. Preventive Services Task Force Recommendation. Evidence Synthesis No. 127. AHRQ Publication No. 14-05209-EF-1. Rockville (MD): Agency for Healthcare Research and Quality; 2016. 111 p.

Available from the U.S. Preventive Services Task Force (USPSTF) Web site External Web Site Policy

Background Articles:

Barton MB et al. How to read the new recommendation statement: methods update from the U.S. Preventive Services Task Force. Ann Intern Med 2007;147:123-7.
Guirguis-Blake J et al. Current processes of the U.S. Preventive Services Task Force: refining evidence-based recommendation development. Ann Intern Med 2007;147:117-22.
Sawaya GF et al. Update on the methods of the U.S. Preventive Services Task Force: estimating certainty and magnitude of net benefit. Ann Intern Med 2007;147:871-5.
Petitti DB et al. Update on the methods of the U.S. Preventive Services Task Force: insufficient evidence. Ann Intern Med. 2009;150:199-205.

Available from the USPSTF Web site External Web Site Policy

The following are also available:

Screening for impaired visual acuity in older adults: clinical summary. Rockville (MD): U.S. Preventive Services Task Force. 2016 Mar. 1 p. Available from the USPSTF Web site .
A continuing medical education (CME) activity is available from the Journal of the American Medical Association (JAMA) Web site .

The Electronic Preventive Services Selector (ePSS) External Web Site Policy

is an application designed to provide primary care clinicians and health care teams timely decision support regarding appropriate screening, counseling, and preventive services for their patients. It is based on the current, evidence-based recommendations of the USPSTF and can be searched by specific patient characteristics, such as age, sex, and selected behavioral risk factors.

Patient Resources

The following is available:

Screening for impaired visual acuity in older adults. Understanding Task Force recommendations. Rockville (MD): U.S. Preventive Services Task Force. 2016 Mar. 3 p. Available from the U.S. Preventive Services Task Force (USPSTF) Web site .

Myhealthfinder is a tool that provides personalized recommendations for clinical preventive services specific to the user's age, gender, and pregnancy status. It features evidence-based recommendations from the USPSTF and is available at www.healthfinder.gov External Web Site Policy

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on August 21, 2009. The information was verified by the guideline developer on November 11, 2009. This summary was updated by ECRI Institute on April 26, 2016. The updated information was verified by the guideline developer on June 17, 2016.

Copyright Statement

Requests regarding copyright should be sent to: Lisa S. Nicolella, Writer/Editor, Office of Communications, Agency for Healthcare Research and Quality, 5600 Fishers Lane, Rockville, MD 20857; E-mail:lisa.nicolella@ahrq.hhs.gov.

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