Falls are the leading cause of injury-related morbidity and mortality among older adults. In addition to the resulting physical injury and potential disability after a fall, there are also important psychological consequences, including depression, anxiety, activity restriction, and fear of falling. Fear of falling affects 20 to 43% of community-dwelling older adults and is not limited to those who have previously experienced a fall. About half of older adults who experience fear of falling subsequently restrict their physical and everyday activities, which can lead to functional decline, depression, increased falls risk, and reduced quality of life. Although there is clear evidence that older adults with visual impairment have higher falls risk, only a limited number of studies have investigated fear of falling in older adults with visual impairment and the findings have been mixed. Recent studies suggest increased levels of fear of falling among older adults with various eye conditions, including glaucoma and age-related macular degeneration, whereas other studies have failed to find differences. Interventions, which are still in their infancy in the general population, are also largely unexplored in those with visual impairment. The major aims of this review were to provide an overview of the literature on fear of falling, its measurement, and risk factors among older populations, with specific focus on older adults with visual impairment, and to identify directions for future research in this area.

Purpose To explore the longitudinal impact of central vision loss on concern about falling (CF), over a 12-month period, in people with age-related macular degeneration (AMD). Methods Participants included 60 community-dwelling older people (age, 79.7 ± 6.4 years) with central vision impairment due to AMD. Binocular high-contrast visual acuity, contrast sensitivity, and visual fields were assessed at baseline and at 12 months. CF was assessed at both time points using the Falls Efficacy Scale–International (FES-I). Sensorimotor function (sit to stand, knee extension, postural sway, and walking speed) and neuropsychological function (reaction time, symptoms of anxiety and depression) were also assessed at both time points using validated instruments. Falls data were collected using monthly diaries during the 12 months. Results CF increased by a small but significant amount over the 12-month follow-up (2.1 units; P = 0.01), with increasing prevalence of high levels of CF (FES-I score ≥ 23), from 48% at baseline to 65% at 12 months. Linear mixed models showed that reduced contrast sensitivity was significantly associated with increased concern about falling ( P = 0.004), whereas declines in both visual acuity and contrast sensitivity during the follow-up period were associated with increases in CF over the 12-month follow-up ( P = 0.041 and P = 0.054, respectively), independent of age, gender, falls history, or number of comorbidities. Conclusions Higher levels of CF are common in older people with AMD, and levels increase over time; this increase is associated with declines in both visual acuity and contrast sensitivity. These findings highlight the need for regular assessment of both visual acuity and contrast sensitivity to identify those at greatest risk of developing higher CF. Translational Relevance Routine assessment of visual acuity and contrast sensitivity in older people with AMD will assist in identifying those at risk of developing high CF.

Clinicians regularly face the confronting challenge of differentiating a choroidal naevus from a melanoma. Uveal naevi are a relatively common finding during routine eye examinations: a prevalence of 6.5 per cent has been reported.1 In contrast, malignant melanomata are uncommon, being found in six persons per million population, but they can have devastating implications and consequences. Differential diagnoses can be difficult to make with certainty; any additional information that can assist in this process is advantageous.Optical coherence tomography (OCT) is used extensively in the diagnosis and management of macular pathology and increasingly, in glaucoma. The diverse range of scanning options enables this technology to be adapted easily for the investigation of a wide range of other ophthalmic conditions. For example, it can be a useful tool in the investigation of choroidal naevus, allowing the axial visualisation of potentially important overlying retinal changes. Signs, such as retinal oedema, sub-retinal fluid accumulation, retinal thinning, drusen, retinal pigment epithelial detachment and photoreceptor loss or attenuation, can be indicative of melanoma. Such changes can be difficult to identify with an ophthalmoscopic examination or photography in isolation. 3 A previous study that compared secondary retinal changes in 40 patients with presumed choroidal naevus and 20 patients with untreated choroidal melanoma found a much lower incidence of retinal morphological irregularities in the presumed naevus group (seven per cent), compared with the melanoma cohort (90 per cent).4 Secondary retinal changes, including serous detachment and intraretinal splitting, in the melanoma cohort could be visualised in vivo by using OCT, suggesting that this imaging technique could be highly beneficial in Figure 1. Photograph of the fundus of the right eye, demonstrating the spatial location of a choroidal lesion (white arrow) and a Bergmeister's papilla (green arrow)

Purpose To investigate the prevalence and level of concern about falling (CF) among older people with vision impairment due to age‐related macular degeneration (AMD) compared to a visually normal control group, and to identify determinants of CF for the AMD group. Methods Participants included 133 older people: 77 with AMD (mean age = 80.5 ± 6.2 years), and 56 controls (mean age = 75.4 ± 5.3 years). Binocular visual acuity, contrast sensitivity and visual fields were measured, and CF was assessed using the Falls Efficacy Scale – International (FES‐I). Data were also collected for sensorimotor function (postural sway, sit‐to‐stand, knee extensions, walking speed, proprioception), and neuropsychological function (reaction time, symptoms of anxiety and depression) using validated tests and scales. Results Concern about falling scores were higher for AMD participants compared to control participants (mean ± S.D. 24.6 ± 8.0 vs 21.6 ± 5.7, p = 0.02, respectively), although these findings failed to reach significance when adjusted for age (p = 0.16). Among AMD participants, multivariable models showed that greater CF was associated with reduced contrast sensitivity (p = 0.02), slower sit‐to‐stand times (p < 0.001) and higher anxiety scores (p < 0.001); these factors explained 40% of the variance in CF (p < 0.01). Conclusion Levels of CF in older people with AMD were not found to be elevated by their disease status alone, but rather by the extent of vision loss. Levels of CF in those with AMD were associated with various visual, sensorimotor and neuropsychological factors. These findings will assist clinicians in identifying those at greatest risk of developing high CF and inform the design of future intervention programmes for this population.

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