How Old is Too Old?


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You’ve no doubt heard the expression about teaching old dogs new tricks, and by no means is my intent here to disparage the ranks of Medicare patients I will be joining next year!  Rather, my intent is to celebrate the determination of senior citizens who do not accept that old dogma of an upper age limit on the neuroplasticity of the visual system.  Gail S. is one such patient.

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Gail, a 76 year-old female. first came to us on November 28, 2016, referred by her ophthalmologist (you read that correctly) due to constant double vision at distance of which she first became aware on Memorial Day of this year.  She had basically abandoned driving because the only way she could reduce her confusion and attempt to drive was by wearing a pair of glasses with her left lens frosted.  But she knew that this impaired her peripheral vision to the extent that she could no longer drive safely.  It was at that point that her ophthalmologist was ready to prescribe Fresnel prism to neutralize her diplopia, but referred her to me for an opinion on whether I felt optometric vision therapy might be beneficial.

Gail’s medical history is positive for hypertension, diabetes, thyroid disease, asthma, and hypercholesterolemia.  Her medications are Pravastatin, Metformin, Levothroxine, Norvasc, Accupril, Trynenta, Lebatolol, Lasix, and Centrum Silver.  She’s had cataract surgery on both eyes, with a PC IOL OD and an ACL OS.  Unaided VA is 20/30(-) OD and 20/60(-) which improves little upon refraction, and pinhole OS results in monocular diplopia.  OCT is consistent with an epiretinal membrane OS.  Retinoscopy is -0.50-0.75cx10 OD and +0.25-3.25cx67 OS.  The referring ophthalmologist diagnosed sixth nerve palsy and diplopia increases looking downward to the left.

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I wrote an Rx for Fresnel prism to be applied to a plano carrier, 1^BU OD and 4^BO OS through which Gail could fuse comfortably at distance.  I explained that she was a candidate for optometric vision therapy and we set up a schedule for her to come in to the office twice weekly and minimize the need for home therapy.  Our goal was to help her diverge more effectively at distance, guide her on concepts of peripheral awareness, and progressively reduce the dependency on prism to fuse.

Gail has been delightful for our staff to work with, and at her first progress evaluation yesterday already reported that she was driving with more confidence during the daytime with her prism glasses.  She has tried to drive in the early evening now that sundown arrives at 4PM, but is bothered by glare referenced to her left eye.  I found that she could fuse at distance now with 2^ BO OD (instead of 4^) when I had her fixate car lights out the window beyond 20 feet.  Although some of her light scatter OS is influenced by the epiretinal membrane (and uncorrected cylinder), cutting the 4^ Fresnel to 2^, and doing it as a prism grind can only help matters.

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There are senior citizens who we try to work with in vision therapy who prove difficult to please.  They repeatedly dwell on what they can’t do, and question whether therapy is helping them.  But the key here is that attitude isn’t an age, and the determination to help oneself and embracing change as coming from within holds the keys to success.  Gail’s ophthalmologist has referred other senior citizens to us, the ability to maintain independence for driving is a common goal for many of them.  Gail understands that although she has made great strides already, therapy will continue to the point where she can drive confidently under all environmental conditions.  Needless to say, her restored confidence in driving has already made her quite the happy camper!

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5 thoughts on “How Old is Too Old?

  1. Thanks for this reminder, Dr. Press. One of the more inspiring stories I’ve ever been a part of involved a 76 year old woman, who not long before we met her, was diagnosed with a slow moving yet terminal cancer. She refused accept the notion of slowing down because of her age or medical diagnosis, and graduated our program after close to a year of VT. Proof positive that attitude is everything!

    All the best to Gail!

  2. If her diplopia is still worse looking down to her left she will have difficulty using a left side mounted external rear view mirror when she drives. I recommend an oversized rear view mirror internally that mounts over the standard car mirror, and lets her see out to her left by looking up and to the right. This is a nice safety adaptation, cheap and easy, and very fast to learn to use. I most often recommend the 12″ Hercules 20/20 on Amazon. Installation is fast and easy, inexpensive, and the optics are less distorting than many others I have looked at.

    • Good thought, Marsha, and I’ll keep that in mind for other cases. The key here is that she has resumed driving during the day and has no issues with the mirror, so we can factor that out of the equation. My hunch is she has difficulty managing at nighttime because of the impoverished peripheral cues to fusion, and the increased light scatter from lights through her left eye (macular distortion from epiretinal membrane) facing oncoming traffic.

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