Visuospatial Aging

Fiona Pilate BSN, RN CLP 7934

 Key Terms

 Spatial Ability: a category of reasoning skills that refers to the capacity to think
about objects in three dimensions
 Grid Cells: type of neuron that has been found in the brains of rats and mice;
and it is likely to exist in other animals including humans
 Head direction cells: Neurons which are active only when the animal's head
points in a specific direction within an environment
 Place cells: principal neuron in the hippocampus that exhibit a high rate of
firing whenever an animal is at a specific location in an environment
corresponding to that cell’s place field
Also known as pyramidal or complex spike (CS) cells
 CA1 and CA3 Cells: area in the hippocampus that is densely packed with
pyramidal cells
 Cognitive Map :are a type of mental processing composed of a series of
psychological transformations by which an individual can acquire, code, store,
recall, and decode information about the relative locations and attributes of
phenomena in their everyday or metaphorical spatial environment
 Adaptive Significance of Spatial Ability.
 Variation in hippocampal size (the seat of spatial processing) may be related to
the degree of selection for spatial processing.

 Jacobs et al., (1990) argued that spatial ability should evolve in direct
proportion to the navigational demands that an individual faces in everyday life.

 Gaulin (1992) proposed that cognitive mechanisms underpinning spatial ability

are navigational adaptations.

 Individuals need to be able to find resources, to return to them, and to

remember to avoid dangerous areas.

 This requires the ability to acquire, store, process, manipulate, and retrieve
spatial information.
 Organization of Spatial Behavior

 Spatial behavior
Guides us through space

 Topographic memory
Ability to move through space from one place to the next

 Cognitive Maps
Mental representations we have of space
 Organization of Spatial Behavior
 Body Space
Surface of the body

 Grasping Space
Area around the body

 Distal Space
Space the body moves in and out of

 Time Space
Past and future
 Types of Spatial Behavior

 Route Following
Follow a road or path to a specific object/location

 Piloting
Ability to find a place that is not directly marked by a route or cue
 Types of Spatial Behavior

 Dead Reckoning
Depends on cues generated by one’s own movement
An early form of navigation that uses direction, speed, and travel time
Nonhuman animals
 Self-movement cues for dead reckoning
 Sensory flow
 Movement commands
 Historical Background

 Hughlings-Jackson
Spatial - Perceptual Function for Right Hemisphere
 Unique to humans
 Spatial Deficits

 Egocentric Disorientation
Posterior parietal lobe damage
Deficits in perceiving the relative location of objects

 Heading Disorientation
Posterior cingulate damage
Unable to set a course; “no sense of direction”
 Spatial Deficits

 Landmark Agnosia
Lingual gyrus damage
Unable to use prominent environmental features for orientation

 Anterograde Disorientation
Parahippocampal gyrus lesion
Unable to learn new representations
 Spatial Deficits

 Spatial Learning
Hippocampal damage
Anterograde and retrograde amnesia for spatial content

o Are deficits in spatial learning due to the hippocampus’s role in spatial

navigation or in memory?
Brain Regions Compromised
in Spatial Disorientation
Location of Spatial Cells
 The Dorsal and Ventral Streams

 Dorsal Stream
Actions toward or away from objects
Egocentric

 Ventral Stream
Complex actions that use objects for references
Allocentric
Tasks Used to Study Spatial Behavior
Eight Arm Radial Maze
 Hungry rats will learn
which arms contain
rewards
 Reference Memory
Where
should I
go???  Rats will learn to not
enter an arm more than
once on a given day
 Working Memory

 Hippocampal lesions
produce major deficits
on reference and
working memory
measures
The Maze Study
 Rats with Hippocampal lesions still find the
food, but they aren't very efficient, going
down the same arm repeatedly

 Rats with lesions can learn to avoid the

arms that never have food, but they still
explore the food containing arms
inefficiently and repeatedly

 Inability to use changing information

Hippocampus and Spatial Memory

Morris Water Maze

Pool

“Hidden”
Platform
 Hippocampus and Spatial Memory

Morris Water Maze

Hippocampal
Lesion Rat
Pool

Control Rat

“Hidden”
Platform

Hippocampal lesions impair rats’ ability to learn the location of the platform
 Hippocampus and Spatial Memory
 Hippocampus seems to be
critical for spatial memory, but
why is this?

 Place Cells!
 Cells that fire when the subject
occupies a particular location in
the environment

 Place cells seem to represent a

cognitive component of the
environment
 If the cells fire in a certain pattern,
the rat will behave a certain way
 Hippocampus and Spatial Memory

 Theories of Hippocampal Function

 Cognitive Map Hypothesis

 Hippocampus contains a cognitive map of allocentric space that
can be used to navigate to locations in an environment

 Configural Association Theory

 Hippocampus is critical for learning the significance of
combinations of stimuli (i.e., you will be learning about
neuropsychology of aging in this classroom, not any other topic)

 Spatial Arrangements
 Hippocampus is important for recognizing the arrangement of
objects relative to one another (i.e., the layout of your living room)
 Single-Cell Recording Within the Hippocampal
Formation
 Place Cells

 Head-direction Cells

 Grid Cells
 Place Cells

 Discharge when an animal is in a certain place in an environment

 Maintain activity in the dark

 When the environment is rotated, cells discharge according to new pattern

 Fire in particular places, when the animal is changing direction

 Prefer visual cues

 Place Cells in the Hippocampus

 Neurons in the hippocampus selectively respond when rat is in a

particular location.

 If vision is used to determine place, (like landmarks) cell fires in

response to where the animal thinks he is

 May be responsible for learning radial arm maze

 More than spatial memory is involved

 Hippocampus may control relational memory

 Place cells encode more than just place:
role for hippocampus in episodic memory?

Rats are trained on

alternating T-maze
Wood ER, Dudchenko PA, Robitsek RJ, Eichenbaum H: Hippocampal neurons encode
information about different types of memory episodes occurring in the same location. Neuron
2000; 27: 623-633
 Head Direction Cells

 Discharge when the rat points its head in a particular direction

 Similar to a compass needle; fire as long as the head is facing a direction

 Influenced by surrounding cues

 Continue to fire in the dark

 Can change orientation depending on the cues of the environment

 Head Direction Cells

 Work in the horizontal and vertical plane

 Locked into a constantly active network

 Grid Cells

 Discharge at regular spatial intervals that mark nodes

 Nodes represent points throughout the environment and form a grid

 Orient to different cues and can be influenced by direction

 Temporal Lobes and Spatial Behavior

 Hippocampus as a Cognitive Map

Spatial Mapping
Damage - deficits in piloting and dead reckoning

 Hippocampus and Food-Finding Behavior of Animals

Food Caching in Birds
 Use distal spatial cues to find their caches
 Birds that cache have larger hippocampi
 Changes in hippocampal size correlate with changes in caching
behavior
 Temporal Lobes and Spatial Behavior

Dead Reckoning in Rats

Use room cues and self-movement cues for guidance

Can return home when all auditory and olfactory cues are removed

Damage to the hippocampus disrupts dead reckoning

 Parietal and Frontal Lobes and Spatial Behavior

 Parietal Lobes
Eight visuospatial disorders that result from parietal lobe damage

• Displaced visual attention

• Inability to perceive more than one stimulus
• Defective visual control of movement
• Inability to follow a moving target
• Defective accommodation and convergence.
• Inability to maintain fixation
• Inability to voluntarily gaze towards targets
• Abnormal visual search
 Topographic Disorientation

 Topographic Disorientation
Disability in finding your way around

 Topographic Agnosia
Inability to identify individual landmarks

 Topographic Amnesia
Inability to remember the relationship between landmarks
 Topographic Disorientation

 Retrograde Spatial Amnesia

Loss of ability to navigate in environments that were familiar before the
injury

 Anterograde Spatial Amnesia

Loss of ability to navigate in novel environments
 Individual Differences in Spatial Ability

 Handedness and Spatial Ability

 Left handedness correlated with better spatial ability?
 Reasoning ability and sex also play a role

 Neuropsychological Spatial Tests

Smith and Milner’s Spatial Memory Test
Visualization or Orientation Tests
 Interpretations for role of hippocampus in spatial cognition and memory generally

 Spatial and non-spatial episodic memories involve different

processes; hippocampus does them both, and has evolved to
become more specialized for episodic memory in primates
compared with rodents (Jacobs & Schwenk)

 All experience has a spatial component, and hippocampus

participates in formation/use of episodic memory because of
its role in processing spatial information processing (O'Keefe)

 Spatial cognition involves processes that are also required in

encoding certain other kinds of relations among stimuli;
hippocampus plays a more general role that leads it to
participate in spatial as well as certain non-spatial tasks
(Eichenbaum)
 Spatial Cognition

 “The knowledge and internal or cognitive representation of the structure,

entities, and relations of space; in other words, the internalized reflection
and reconstruction of space in thought” (Hart and Moore, 1973, p. 248)

 3 distinct factors of spatial ability

 Spatial visualization

 Spatial manipulation

 Spatial relations
 Spatial Visualization

• Ability to mentally manipulate spatial objects and configurations without

referring to one’s self as a reference point (Hegarty & Waller, 2005)
 Spatial Orientation

 Ability to imagine how a visual stimulus or configuration looks from a

different perspective (Albert & Golledge, 1993)
 Spatial Relations

 Involves analyzing patterns, shape, layout, hierarchy, and linkage between

individual stimuli within a visual configuration (Albert & Golledge, 1993)
 Spatial Cognition

 Navigation: Finding the way to a goal

 Discriminate different headings (need a sense of direction)

 External directional reference: sun, magnetic field, landmarks
 Internal directional reference: vestibular/inertial cues

 Determine the correct heading (need a sense of position)

 Path integration
 Knowledge of familiar landmarks in home range
 Geographical positioning system (e.g., position relative to large-scale
coordinate system defined by global geophysical features)--migratory
birds, whales, turtles
 Spatial Cognition and Navigation

 Navigational Processes That Use Internally Represented

Spatial Knowledge

 Path integration

 Sun compass

 Landmarks: cognitive maps

What does it mean to have a cognitive map ?
 One operational definition: a representation of spatial relationships that
enables computation of novel shortcuts between known locations
(O'Keefe & Nadel 1978. The hippocampus as a cognitive map)

 Alternative hypotheses:
 Route memory (A--> B already familiar)
 Recognize familiar landmarks associated with goal, even if from novel
vantage point
Varieties of cognitive maps? (Gallistel 1990)
 Broader Definition (Gallistel 1990): ‘A cognitive map is a record in the central
nervous system of macroscopic geometric relations among surfaces in the
environment used to plan movements through the environment. A central question
is what type of geometric relations a map encodes’.

Specific issues:
• Spatial scale (local vs. home-range)
• Geometric content (metric, topological)
• Reference frame (egocentric/view-dependent vs. allocentric/view-
independent)

Evidence:
• People: short cuts in cities and VR (errors); mixed evidence contents of
underlying map
• Rodents: most studies on local scale; mixed evidence on contents
• Insects: on local and home-range scale--metric, egocentric
 Varieties of cognitive maps?
Local Image (Snapshot) Route Maps Global (Metric) Map

F1 F1

N
F2 F2

Experienced
Computed `
Most rodent research Insects (digger wasps, bees) Humans in cities
Humans in rooms Humans in corridors, cities
• Computational models of cognitive maps: need to specify geometric contents (angles, distances, routes,
nodes), reference frames, and operations performed on stored information?

• Humans, but not insects, form Type 3 maps, but insects can flexibly use snapshots and route maps

• Big question is whether map-learning is viewpoint-dependent or viewpoint-independent

 Problems with the "hippocampus-as-cognitive-map"
hypothesis

 May not generalize to humans, because hippocampus is known to play role

in non-spatial episodic memory in humans

 Place cell ensemble in hippocampus is not enough to account for spatial

behavior….encodes current location, but not goals, for example (Andre
Fenton)

 Even in animals, hippocampus is involved in non-spatial tasks (e.g.,

transitive inference)

 Place cells seem to encode something more than just "place"

 Interpretations for role of hippocampus in
spatial cognition and memory generally
 Spatial and non-spatial episodic memories involve different processes;
hippocampus does them both, and has evolved to become more
specialized for episodic memory in primates compared with rodents
(Jacobs & Schwenk)

 All experience has a spatial component, and hippocampus participates in

formation/use of episodic memory because of its role in processing spatial
information processing (O'Keefe)

 Spatial cognition involves processes that are also required in encoding

certain other kinds of relations among stimuli; hippocampus plays a more
general role that leads it to participate in spatial as well as certain non-
spatial tasks (Eichenbaum)
 Working Memory & the Hippocampus

 Hippocampus is involved in memory function for a diverse range of tasks

 Studies of Hippocampal ablation in rats
 Studied “working memory”
 Used a radial maze containing food

Normal rats learn to visit each arm only once

If only some arms are used, they learn only to go down those arms,
and then only once.
 Relational Memory
 Highly processed sensory information comes into the hippocampus &
cortex

 Processing occurs leading to the storage of memories

 All things happening at the same time are stored together

 Thus, remembering one thing brings back related memories

 It's easier to remember events that you had strong feelings about.

 Spatial navigation is based on a spatial map & relational memories

 Background Information

Wilson & McNaughton (1993)

AIM:

 To describe dynamics of ensemble encoding of space in the

hippocampus during a single episode of exploration in a novel
environment

 3 rats were implanted with micro-drive arrays, trained over 10

days to forage small chocolate pellets in a rectangular apparatus

 Ensemble recording were used to accurately predict the rats

movement through their environment
 Orientation & Direction

 In the study by Wilson & McNaughton, direction and orientation

was not controlled for.

 An earlier study done by McNaughton et. al. (1983), shows that

direction and position affect the way in which Complex-Spike cells
are activated.

 Fuhs et al. (2005) conducted a study to assess the effects of

interactions between angular path integration and visual
landmarks on the firing of hippocampal neurons.
 Orientation & Direction
Fuhs et. al. (2005)

In the same-orientation condition, the boxes were connected by a

corridor; in the opposite-orientation condition, the corridor was
removed and the boxes were rotated and joined.
 Age

Shen, et al. (1997)

AIM:
 determine whether experience-dependent expansion of place fields is
altered by age

 young and old rats ran around a rectangular track

 EEG recordings and measurements were taken and combined every 5 laps

o lap 1, 5, 10, 15
 Age (cont’d)

Conclusions: Shen, et al. (1997)

Age affects experience-dependent plasticity

Loss of experience-dependent plasticity in the place fields of old rats

The aged hippocampus fails to show an experience-dependent

increase in the amount of spatial information it transmits
 Age (cont’d)

Wilson, et al. (2005)

AIM:

 Compared spatial firing patterns of CA1 and CA3 neurons in aged rats vs.
young rats as they explored familiar and novel environments

 Place cell recordings taken in a familiar environment and 1 of 3 novel

environments
 Age (cont’d)

Results: Wilson, et al. (2005)

 CA1 cells of aged rats had firing properties similar to those of the young
adults

 Aged CA3 cells had higher firing rates in general & failed to change firing
rates and place fields as much as CA3 cells of young rats in novel
environment
 Age (cont’d)
Wilson, et al. (2005)

 Young CA3 cells created new

spatial representations & often
some were active in only one
environment

 Aged CA3 cells used similar

place field representations for
both environments & scarcely
changed their firing rates
 Age (cont’d)

Conclusion: Wilson, et al. (2005)

 Aged CA3 cells failed to rapidly encode new spatial information

compared to young CA3 cells

 CA3 place cells plays a key role in the age-related changes that
underlie spatial memory impairment.
 Age (cont’d)

What does this all mean..?

 Older rats do not appear to learn new locations as quickly

 Younger rats adapt more quickly and develop greater plasticity

 But rats younger than 50 days do not appear to learn new locations as
quickly
 Age is important in terms of plasticity
 LAST THOUGHTS…

“A friend is someone who knows the song in your heart

and can sing it back to you when you have forgotten
the words.” ~unknown
 Elderly Visual Ability
 Study suggest visual ability get worse after the age of 50 due to physical and
pathological changes.
 General visual ability declinations occurred in (Boyce, 2003; CIBSE , 1997; Sturnieks
2008).
 Visual acuity – ability to focus
 Contrast sensitivity – ability to identify object’s edge.
 Glare sensitivity
 Light-dark adaptation
 Depth perception
 These predicaments causes difficulties in
 Object identification
 Visual search and
 Change detection
 Vision Impairment and Eye Disease
 A major public health problem

 Growing ever larger with the aging of the US population

 Disproportionately incident in underserved and minority populations

 A significant co-morbid condition

 Epidemic of diabetes
 Cardiovascular disease

 Treatments target the end stage of disease

 Accounts for $68 billion in direct costs in the US

 History

 The earliest reference to cataracts can be found in Hindu writings from the
5th century BC

 The word Cataract comes from the Greek word meaning “Waterfall”

 Until the mid 1700’s, it was thought that cataract was formed by opaque
material flowing, like a waterfall into the eye
 Etiology
 Why age-related changes happen to the lens is not known

 One possibility is damage caused by unstable molecules known as free

radicals

 Smoking and exposure to UV light are two sources of free radicals

 General wear and tear on the lens over the years also may cause the
changes in protein fibers
 Cataracts

 Cataracts are the leading cause of blindness world wide.

 Cataract surgery is the most frequently performed surgical procedure in

the US with 1.5 million operations annually

 50% of those over 65 develop vision impairing cataracts.

 Cataracts

•A cataract is a clouding that develops in the crystalline lens of the eye.

•Age-related cataracts are responsible for 48% of world blindness.

•In the United States, age-related cataracts have been reported in 42% of
those between the ages of 52 to 64, 60% of those between the ages 65
and
74, and 91% of those between the ages of 75 and 85.

•Cataract surgery is a common, same-day procedure in the USA.

 Alzheimer’s Disease
•Most common form of dementia. Estimated in 2006 to affect 26.6
million people worldwide.

•Prevalence for ages 65-74 years is 3%, 75-84 years is 18.7%, 85+ is 47%.

•Memory problems are the hallmark of the disease.

•There is growing evidence that vision is affected by Alzheimer’s

Disease.
oHowever, the vision disorders are not commonly known by
physicians.
Alzheimer’s Disease and Peripheral Visual Pathology

Eye
• Lens b-amyloid is present in lens fiber cells
• Aqueous Humor b-amyloid present
• Optic Nerve Nerve degeneration
• Retina Ganglion cell loss; b-amyloid deposition;
reduction in thickness of RNFL

Subcortical Visual Centers

• Lateral Geniculate Nucleus (LGN) b-amyloid plaques
• Pulvinar b-amyloid plaques
• Superior Colliculus b-amyloid plaques &
Neurofibrillary Tangles (NFT)
 Eye Disease in Alzheimer’s Disease
 Glaucoma Incidence of disease is 3 times higher
in AD samples relative to controls
 Macular Degeneration Report of significantly higher incidence of
ARMD in sample of AD patients

 No other eye diseases reported to have higher incidence rate in Alzheimer’s disease
patients.
 Vision in Alzheimer’s Disease
Acuity Normal for age
Color vision Deficits in color discrimination particularly on the blue axis
Stereoacuity Deficits in both monocular and binocular depth perception
Contrast Sensitivity Deficits in seeing both low and high spatial frequencies
Motion Perception Deficit in motion discrimination
Evoked responses Deficits in Flash Visual Evoked Potential (FVEP)
& Pattern Electroretinogram (PERG, particularly for high
temporal frequencies
Normal Vision
Cataract
Alzheimer’s Disease
Cataract and Alzheimer’s Disease
 Cataracts

 Patients often describe trying

to look through a fogged-up
window

 Clouded vision can make it

more difficult to drive a car,
read, or see details
 Cataracts

 Definition and Symptoms of

Cataracts.
 Clouding of the lens which
prevents light from passing
through properly to the retina
 Cataracts

 Clouding of the lens is a normal part of aging

 About half of Americans older than 65 have some degree of clouding of the
lens

 According to one study, after age 75, 39% of men, and 46% percent of
women in the U.S. have visually significant cataracts
 Symptoms

 Blurred vision

 Increasing difficulty with vision at night


 Glare, especially at night

 Halos around lights

 The need for brighter light for reading

 Double vision in a single eye

 Fading or yellowing of colors

 Cataracts

 Symptoms:
 Cloudy vision, glare, halos, decreased night vision, faded colors, double
vision, need for brighter light when reading

 Treatment – can neither be prevented or treated with medications –

surgical only
 Removal of lens and insertion of intraocular lens (permanent)
 Cataracts

 Indications for surgery

 When visual impairment interferes with ADL’s, driving, working,

 Co-existing ocular conditions requiring removal for treatment such as

macular degeneration, diabetic retinopathy, glaucoma
 Age-related Macular Degeneration

 1874 - described in medical literature

 “symmetrical central choroido-retinal disease occuring in senile persons”

 Alternately referred to as “senile,” “diskiform,” or “macular

degeneration.”

 1980 – “age-related maculopathy”

 End stage = “age-related macular degeneration”
 Age-related Macular Degeneration

 Leading cause of irreversible blindness in older individuals in developed

countries.

 In the US and other developed countries around the world it is reaching

“epidemic” levels

 Patients with mild or moderate forms of the disease can develop

metamorphopsia and visual impairment, whereas those with the advanced
stages often experience loss of central vision leading to legal blindness.
 Risk Factors
 Genetic

 Race

 Gender

 Age

 Hypertension/Diabetes

 Refractive error

 Lens opacities

 Sun exposure

 Smoking
 Risk Factors

 Genetic
 Studies have demonstrated familial aggregation.
 ABCR gene (linked to Stargardt’s disease) has been linked to some
cases of AMD.
 Complement factor H Gene
 Proteins in CFH pathway found in drusen deposits
 Two- to four fold increased risk if gene variant is inherited from one
parent
 Five- to seven fold increased risk from 2 parents
 Hagerman studied 3200 eyes with dry AMD
 Genetic component found in 75% of eyes
 Gene accounts for 30% to 50% of overall risk for developing AMD
 Protective form of the gene exists
Blindness from AMD – A Growing Problem

U.S. 2003 2030

Projected
Number of Legally Blind 1.2 Million 6.3 Million

New Cases Annually 200,000 500,000

As the population ages and lives longer, the number of people suffering severe vision loss
will increase dramatically

Pharmacological Treatments for AMD, L. Singerrman, M.D. Review of Ophthalmology, 10/03

Vision Problems in the U.S., Prevent Blindness America, 1994
 AMD Is Directly Related To Age

30%

16%
12%

55 to 64 65 to 74 Over 75

Incidence of AMD Increases With Age

1 Beaver Dam Study

Source: Yanoff: Ophthalmology, First Edition, 1999; Clinical Practice Guidelines, www.aoanet.org; www.allaboutvision.com
 Environmental Risk Factors

Sun exposure – controversial risk factor

 Watermen study revealed a weak association between advanced

AMD and exposure to visible light.
 UV light did not seem to be related in the Beaver Dam, Watermen
and Blue Mountain studies.
 Environmental Risk Factors
 Smoking
 Strong positive association between smoking and the dry and
wet form.

 In the Nurses’ Health Study risk increased as pack years of

smoking increased indicating a dose dependent relationship.
 AMD - Classification

 Nonexudative (geographic, non-neovascular, “dry”)

involves outer retinal complex
 Choriocapillaris
 RPE
 Photoreceptors
 Exudative (neovascular, “wet”)
 Choroidal neovascularization (NV)

 Serous or hemorrhagic neurosensory or RPE detachment

 Both types can lead to visual loss
 Classification & Definition

 2 clinical forms:
 Dry  Exudative

 Both types can lead to visual loss.

 Currently less than 1% is successfully treated
Dry AMD: Natural Course

Drusen
↓
RPE cell change (apoptosis)
↓
2ary atrophy of the
choriocapillaris
↓
2ary atrophy of the outer retina
↓
Geographic atrophy
 Choroidal Neovascular Membrane

 Clinical features
 hemorrhage
 lipid exudation
 serous elevation of retinal pigment epithelium (RPE) and sensory
retina
 subretinal hemorrhage
 gray or green (dirty brown) lesion (appearance as seen through
the RPE)
 Clinical Features of Exudative AMD
 Classic CNVM (30% of CNVM)

• Pattern is mainly differentiated by fluorescein angiography (FA)

findings
• Early phase reveals staining of a well demarcated lesion.
• Late phase reveals leak, at times beyond the lesion borders.
 Clinical Features of Exudative AMD

Occult CNVM (70% of CNVM)

• 2 patterns recognized:
-Fibrovascular pigment epithelial detachment (PED)
-Late leakage of undetermined source
 Glaucoma

 The triad of increased intraocular pressure, degeneration of the optic nerve

head, restricted visual field – open angle glaucoma

 Visual impairment in 0.7% of those over 60, 4% of those over 90

 IOP greater than 17.5 mmHg is associated with a persistent loss of vision
and underscores the need to aggressively treat intraocular pressure
 Glaucoma
 Diagnosed before loss of vision by ophthalmoscopic examination of the
optic nerve to detect cupping.
 Blacks

 Advanced age

 Family history

 Elevated intraocular pressure- Goldman’s tonometer is gold standard –

but the Schiotz indentation tonometer is cheap and easy to use – normal
pressure is 15 to 16 mmHg – those with pressures over 21 are considered
to have ocular hypertension
 Glaucoma
 Dynamics of aqueous humor:
 Produced by ciliary body,
circulates around lens,
through pupil, and anterior
chamber

 Flows out through the

trabecular meshwork into the
venous system –here-in lies
the problem
Diabetic Retinopathy
 RISK FACTORS:

o Duration of diabetes

o Poor control of Diabetes

o Hypertension

o Nephropathy

o Obesity and hyperlipidemia

o Smoking
 The healthy eye
105

 Light rays enter the eye through the

cornea, pupil and lens.

 These light rays are focused directly

onto the retina, the light-sensitive
tissue lining the back of the eye.

 The retina converts light rays into

impulses; sent through the optic
nerve to the brain, where they are
recognized as images.
 What is diabetes?
106

 Diabetes Mellitus is the inability of the body to use and store sugar
properly, resulting in high blood sugar levels.

 Results in changes in veins, arteries and capillaries in the body.

 How does diabetes affect vision?
107

 Could develop cataracts (clouding of the naturally clear lens in the eye).

 May develop glaucoma (a disease of the optic nerve).

 Risk of developing diabetic retinopathy: damage occurs to the fragile blood

vessels inside the retina.
 Diabetic retinopathy epidemiology

 Each year, between 12,000 to 24,000 people lose their sight because of
diabetes.
 Diabetic retinopathy is the most common cause of new cases of blindness
among adults 20-74 years of age.
 During the first two decades of disease, nearly all patients with type 1
diabetes and over 60% of patients with type 2 diabetes have retinopathy.
 WESDR demonstrated that type 1 patients experience a 25% rate of
retinopathy after 5 years of disease, and 80% at 15 years of disease1
 Up to 21% of newly diagnosed type 2 patients have some degree of
retinopathy at time of diagnosis1
American Diabetes Association: Retinopathy in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1):
1

S84-S87, 2004
 Diabetic retinopathy

Two types of diabetic retinopathy:

 Nonproliferative diabetic retinopathy (NPDR)

 Early stage diabetic retinopathy

 Proliferative diabetic retinopathy (PDR)

 Later stage diabetic retinopathy

 Since this course deals with aging I will move forward with the
proliferative type.
 Proliferative diabetic retinopathy
(PDR)

 Later stages of diabetic retinopathy.

 Abnormal blood vessels begin to grow on

surface of retina or optic nerve; can’t
provide retina with normal blood flow
(neovascularization).

 PDR can cause severe visual loss and other

serious complications, such as neovascular
glaucoma and loss of the eye.

Top: Healthy retina

Bottom: Retina with PDR and
neovascularization
 Proliferative diabetic retinopathy
111

With PDR, vision is affected when any of

the following occur:

 Vitreous hemorrhage (new, abnormal

blood vessels bleed into vitreous gel in
center of eye, preventing light rays from
reaching the retina).
 Traction retinal detachment (new,
Vitreous hemorrhage
abnormal blood vessels begin to shrink
and tug on retina; may cause retina to
detach).
 Neovascular glaucoma
(neovascularization occurs in the iris,
causing pressure to build up in the eye,
damaging the optic nerve).
 Diagnosing diabetic retinopathy

 Diabetes can cause vision in both

eyes to change, even if retinopathy is
not present.

 Rapid changes in blood sugar alter

the shape of the eye’s lens, and the
image on the retina will become out
of focus.

 One can reduce episodes of blurred

vision by maintaining good blood
sugar control.
 Treating diabetic retinopathy
113

 Best treatment is to prevent development of retinopathy as much as

possible.

 Diabetes Control and Complications Trial (DCCT) demonstrated that strict

control of blood sugar levels will significantly reduce the long-term risk of
vision loss from diabetic retinopathy.

 Laser surgery is often recommended for people with macular edema, PDR,
and neovascular glaucoma.
Simulation of defective vision as experienced by a
Diabetic whose vision has been affected by Diabetic
retinopathy

Normal Defective
 Losses with age

Examples of tasks that show losses with age are… ƒ

 Free recall of lists of unrelated words ƒ

 Paired-associate learning of unrelated word pairs

ƒ
 Working memory tasks

 Memory for context ƒ

 The original source of some remembered fact ƒ

 Recall of pictures ƒ

 Memory for spatial location

 Losses with age

 Brain does not age uniformly

 Parietal lobe for example remains pretty much intact

 Biggest decline is in the prefrontal cortex, where we think executive

functioning is, explains the drop off in problem solving
Closing Thoughts

The wiser mind

Mourns less for what age takes away
Than what it leaves behind

And often, glad no more,

We wear a face of joy because
We have been glad of yore.

William Wordsworth