Final Research Plan

Impaired Visual Acuity in Older Adults: Screening

June 04, 2020

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

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The analytic framework depicts the relationship between the Key Questions for the systematic review within the context of the populations, interventions, outcomes, and harms of screening and treatment for impaired visual acuity. The far left of the framework describes the target population as asymptomatic adults 65 years of age and older without known vision impairment. To the right of the population is a line representing the diagnostic accuracy of screening leading to the diagnosis of impaired visual acuity (Key Question 3) and instruments for identifying patients at higher risk of impaired visual acuity (Key Question 4), and an additional arrow indicates potential harms of screening (Key Question 2). A subsequent line and area of the framework leads from the impaired visual acuity diagnosis to outcomes from treatment (Key Questions 5 and 6), specifically improved visual acuity, morbidity, mortality, vision-related quality of life, functional status, and cognition. An additional arrow indicates potential harms of treatment (Key Question 7). An overarching arrow leading from the initial screening population to the outcomes represents the direct effects of screening on outcomes (Key Question 1).

*“Asymptomatic” individuals are defined as those without known impaired visual acuity (based on current corrected vision) who have not sought care for evaluation of vision problems.
†Conditions of interest include impaired visual acuity due to uncorrected refractive errors, cataracts, and age-related macular degeneration.
Note: Subpopulations of interest include those defined by age, sex, race/ethnicity, setting (e.g., rural or urban), and functional and cognitive status.

Abbreviation: KQ = key question.

  1. What are the effects of vision screening in asymptomatic older adults versus no screening on visual acuity, morbidity or mortality, general or vision-related quality of life, functional status, or cognition?
  2. What are the harms of vision screening in asymptomatic older adults versus no screening?
  3. What is the diagnostic accuracy of screening for impaired visual acuity due to uncorrected refractive error, cataracts, or age-related macular degeneration?
  4. What is the accuracy of instruments for identifying patients at higher risk of impaired visual acuity due to uncorrected refractive error, cataracts, or age-related macular degeneration?
  5. What are the effects of treatment of wet or dry age-related macular degeneration versus placebo or no treatment on visual acuity, morbidity, mortality, general or vision-related quality of life, functional status, or cognition?
  6. What are the effects of newer (aflibercept or brolucizumab-dbll) versus older vascular endothelial growth factor inhibitors for the treatment of wet age-related macular degeneration on visual acuity, morbidity, mortality, general or vision-related quality of life, functional status, or cognition?
  7. What are the harms of treatment of early impaired visual acuity due to wet or dry age-related macular degeneration?

The Research Approach identifies the study characteristics and criteria that the Evidence-based Practice Center will use to search for publications and to determine whether identified studies should be included or excluded from the Evidence Review. Criteria are overarching as well as specific to each of the key questions.

  Include Exclude
Definition of Disease Impaired visual acuity due to uncorrected refractive errors, cataracts, or age-related macular degeneration for screening and impaired visual acuity due to age-related macular degeneration for treatment Impaired visual acuity due to other conditions
Populations KQs 1–4: Asymptomatic adults age 65 years and older without known impaired visual acuity (based on current corrected vision) and who have not sought care for evaluation of vision problems

KQs 5–7: Asymptomatic adults with vision impairment (current corrected visual acuity worse than 20/40 but better than 20/200) due to uncorrected refractive errors (myopia, hyperopia, astigmatism, or presbyopia), age-related macular degeneration, or cataracts

 KQs 1–4: Persons with known impaired visual acuity based on current corrected vision or those who have sought care for evaluation of vision problems

KQs 5–7: Persons with visual acuity worse than 20/200 or other causes of vision loss
Interventions KQs 1, 2: Vision screening performed in primary care or community-based settings, including multicomponent screening with a distinct vision screening component

KQ 3, 4: Vision screening tests performed in primary care or community-based settings; questions or questionnaires for impaired visual acuity

KQs 5–7: For wet age-related macular degeneration, vascular endothelial growth factor inhibitors (ranibizumab, pegaptanib, aflibercept, brolucizumab-dbll, and bevacizumab); for dry age-related macular degeneration, vitamins and antioxidants

 KQs 1, 2: Vision screening performed in eye specialty settings

KQ 3, 4: Diagnostic tests for vision screening performed in eye specialty settings (including funduscopic examination performed by an eye professional and specialized diagnostic testing)

KQs 5–7: Laser photocoagulation, photodynamic therapy, or treatment for uncorrected refractive error and cataracts
Outcomes KQs 1, 2, 5–7: Visual acuity; vision-related quality of life; functional capacity, including ability to drive and driving outcomes; other measures of morbidity; mortality; cognition; harms, including falls and fractures; and other treatment-related harms

KQ 3, 4: Sensitivity, specificity, positive and negative predictive values, areas under the receiver operating curve, and other measures of diagnostic test accuracy

 KQs 1, 2, 5–7: Reading speed and other tests of vision function
Setting Settings applicable to the United States and relevant to primary care  
Study Designs KQs 1, 2: RCTs and controlled observational studies comparing vision screening with no screening, delayed screening, or usual care (i.e., targeted screening)

KQ 3, 4: Studies evaluating diagnostic accuracy of a screening question or diagnostic test compared with a reference standard

KQs 5–7: RCTs comparing treatment with no treatment (including sham injection); controlled observational studies will be included if evidence on harms from RCTs trials is insufficient

  
Study Quality Fair- or good-quality studies Poor-quality studies

Abbreviation: RCT=randomized controlled trial.

The draft Research Plan was posted on the USPSTF website for public comment from February 13 to March 11, 2020. The USPSTF reviewed the comments and made no changes to the scope or Key Questions, although some edits were made for clarity. The USPSTF revised the inclusion/exclusion criteria to clarify the included and excluded diagnostic tests for glaucoma; tests that are no longer used were excluded.