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Screening for Impaired Visual Acuity in Older AdultsUpdated Evidence Report and Systematic Review for the US Preventive Services Task Force

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Abstract

Importance  A 2016 review for the US Preventive Services Task Force (USPSTF) found that effective treatments are available for refractive errors, cataracts, and wet (advanced neovascular) or dry (atrophic) age-related macular degeneration (AMD), but there were no differences between visual screening vs no screening on visual acuity or other outcomes.

Objective  To update the 2016 review on screening for impaired visual acuity in older adults, to inform the USPSTF.

Data Sources  Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews (to February 2021); surveillance through January 21, 2022.

Study Selection  Randomized clinical trials and controlled observational studies on screening, vascular endothelial growth factor (VEGF) inhibitors (wet AMD), and antioxidant vitamins and minerals (dry AMD); studies on screening diagnostic accuracy.

Data Extraction and Synthesis  One investigator abstracted data and a second checked accuracy. Two investigators independently assessed study quality.

Results  Twenty-five studies (N = 33 586) were included (13 trials, 11 diagnostic accuracy studies, and 1 systematic review [19 trials]). Four trials (n = 4819) found no significant differences between screening vs no screening in visual acuity or other outcomes. Visual acuity tests (3 studies; n = 6493) and screening question (3 studies; n = 5203) were associated with suboptimal diagnostic accuracy. For wet AMD, 4 trials (n = 2086) found VEGF inhibitors significantly associated with greater likelihood of 15 or more letters visual acuity gain (risk ratio [RR], 2.92 [95% CI, 1.20-7.12]; I2 = 76%; absolute risk difference [ARD], 10%) and less than 15 letters visual acuity loss (RR, 1.46 [95% CI, 1.22-1.75]; I2 = 80%; ARD, 27%) vs sham treatment, with no increased risk of serious harms. For dry AMD, a systematic review (19 trials) found antioxidant multivitamins significantly associated with decreased risk of progression to late AMD (3 trials, n = 2445; odds ratio [OR], 0.72 [95% CI, 0.58-0.90]) and 3 lines or more visual acuity loss (1 trial, n = 1791; OR, 0.77 [95% CI, 0.62-0.96]) vs placebo. Zinc was significantly associated with increased risk of genitourinary events and beta carotene with increased risk of lung cancer in former smokers; other serious harms were infrequent.

Conclusions and Relevance  This review found that effective treatments are available for common causes of impaired visual acuity in older adults. However, direct evidence found no significant association between vision screening vs no screening in primary care and improved visual outcomes.

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Article Information

Corresponding Author: Roger Chou, MD, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: BICC, Portland, OR 97239 (chour@ohsu.edu).

Accepted for Publication: April 5, 2022.

Published Online: May 24, 2022. doi:10.1001/jama.2022.6381

Correction: This article was corrected on August 9, 2022, for an incorrect reference (reference 10).

Author Contributions: Dr Chou had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data.

Concept and design: Chou, Jonas.

Acquisition, analysis, or interpretation of data: Chou, Bougatsos, Jungbauer, Grusing, Blazina, Selph, Tehrani.

Drafting of the manuscript: Chou, Bougatsos, Jungbauer, Grusing, Blazina.

Critical revision of the manuscript for important intellectual content: Chou, Blazina, Selph, Jonas, Tehrani.

Statistical analysis: Chou, Blazina.

Obtained funding: Chou, Bougatsos, Jonas.

Administrative, technical, or material support: Bougatsos, Jungbauer, Grusing, Blazina, Jonas, Tehrani.

Supervision: Chou, Bougatsos, Jonas, Tehrani.

Conflict of Interest Disclosures: None reported.

Funding/Support: This research was funded under contract HHSA-290-2015-00011-I, Task Order 75Q80119F32015, from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, under a contract to support the US Preventive Services Task Force (USPSTF).

Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the scope, analytic framework, and key questions for this review. AHRQ had no role in study selection, quality assessment, or synthesis. AHRQ staff provided project oversight, reviewed the report to ensure that the analysis met methodological standards, and distributed the draft for peer review. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript findings. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.

Additional Contributions: We thank the following individuals for their contributions to this project: Pacific Northwest Evidence-based Practice Center Librarian, Tracy Dana, MLS; Agency for Healthcare Research and Quality Medical Officer, Justin Mills, MD, MPH; as well as the US Preventive Services Task Force. We also acknowledge past and current USPSTF members who contributed to topic deliberations. The USPSTF members, external reviewers, and federal partner reviewers did not receive financial compensation for their contributions.

Additional Information: A draft version of this evidence report underwent external peer review from 4 content experts (April Maa, MD, Emory University School of Medicine, Emory Eye Center; Atlanta VA Medical Center; Nancy Weintraub, MD, David Geffen School of Medicine at University of California at Los Angeles; Jennifer Evans, PhD, MSc, London School of Hygiene and Tropical Medicine; and 1 nondisclosed reviewer) and federal partners representing the Centers for Disease Control and Prevention. Comments were presented to the USPSTF during its deliberation of the evidence and were considered in preparing the final evidence report.

Editorial Disclaimer: This evidence report is presented as a document in support of the accompanying USPSTF Recommendation Statement. It did not undergo additional peer review after submission to JAMA.

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