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Re: Falls risk assessment in patients with rheumatoid arthritis: more to it than meets the eye

Dear Editor,

In their recent report, Armstrong and colleagues highlight the high prevalence of falls in patients with rheumatoid arthritis (RA)[1], show that falls increase with functional disability and antidepressant use, and comment that fracture prevention extends beyond the pharmacological treatment of osteoporosis. This concurs with current guidelines for the management of steroid induced osteoporosis[2], which also recommend falls risk assessment. However, they did not address another important risk factor for falls i.e. visual impairment.

Older people with visual impairment are seven times more likely to fall and sustain an injury[3] and the risk of hip fracture is doubled by poor or moderately impaired vision.[4] Visual impairment (classified as binocular visual acuity (VA) of <6/18[5]) affects 12.4% of the population aged 75 years or more[6], while 30% of the over 65s have reduced binocular VA to <6/12.[7] The latter study assessed people wearing their spectacles, thus measuring day-to-day vision. In three quarters of these cases vision was potentially remediable.

Visual impairment may have implications beyond fall risk, including potentially reduced safety of medication-taking, social isolation, depression, reduced functional status and quality of life[8], features also well recognised in RA patients.[9] The cumulative effects of both could be devastating.

We investigated the prevalence of impaired VA in patients with RA attending routine outpatient clinics. 75 RA patients were examined (78.7% female). The mean age was 58.9 years (SD 11.73), disease duration 14.8 years (range 1-48 years), HAQ 1.62 (SD 0.8). 39.7% had a VA of <6/18 in either eye, which was corrected with the patients’ spectacles in all except 2 patients who did not use them (1 of which had amblyopia, the 2nd patients vision corrected with pin-hole which signifies potential for good eyesight). 84% of patients had had an eye test within 18 months. Patients with normal vision were less likely to have had a recent test (c2=6.15; p<0.05).