As I write this editorial, Ontario health care providers and, in particular, those in the Greater Toronto Area are being overwhelmed with cases of Severe Acute Respiratory Syndrome (SARS). Not unexpectedly, the deaths caused by this illness are concentrated in the older age group. This is likely due to the comorbidity that frequently accompanies the aging process. Infectious disease specialists have been warning for many years of the danger of new infectious diseases, but for some reason we did not "see" this outbreak coming until a major public health crisis had already occurred. This is clearly an excellent illustration of the old aphorism that "there are none so blind as those who will not see".

Very real problems with sight, as well as with hearing, are all too common among our elderly patients. Vision and hearing are often grouped together as the "special senses", and they truly are special. Vision and hearing are the means through which we relate to our environment and to other people, and impairments in these spheres result in dysfunction in many areas. In geriatric medicine we know that impaired mobility and falls are closely related to visual loss. Patients with even the mildest cognitive impairment are much more likely to have hallucinations if they have associated visual impairment, while patients with hearing loss are much more likely to have paranoid ideation than those with normal hearing (hardly surprising, as they feel nobody is telling them anything!). Both hearing impairment and visual loss predispose elderly people to delirium when they become ill for any reason, which should come as no surprise as severe sensory deprivation can often provoke a delirium-like state even in young and healthy individuals. Clearly the dysfunction wrought by eye and ear diseases goes well beyond the inability to see and hear.

This issue focuses on eye and ear diseases. Dr. Sohel Somani reviews a topic that has been in the spotlight recently, the role of nutritional supplementation in age-related macular degeneration. I started practising geriatric medicine in 1979, and I believe the greatest advance in the care of elderly patients in the time between then and now has been the development of modern cataract surgery and intraocular lens implantation. Dr. Lorne Bellan reviews the evolution of modern cataract surgery, Dr. Catherine Birt provides an excellent and important article on the diagnosis and management of glaucoma, while Drs. Robert Campbell and William Hodge tackle the issue of the acute red eye in the elderly.

Of course, we cannot forget the ear in this issue. As a geriatrician, I go into "geriatric speak" when I deal with elderly patients almost without realising I'm doing it. I speak more slowly, more distinctly, and louder. The latter is not always necessary, as many older patients remind me not to shout. However, it is very clear that age-related hearing loss is a major public health concern. In our biology of aging column, Drs. Christopher Danner and Jeffrey Harris discuss hearing loss and the aging ear. Drs. Doron Milstein and Barbara Weinstein describe the role of amplification in presbycusis (presumably in a more sophisticated manner than my office shouting), and Marian McLeod provides a description of the Canadian Hearing Society's Hearing Care Counselling Program for our patients.

Please enjoy this issue.

Physiological Aging Occurs throughout the Eye and can bring about the Loss of Vision

Cindy M.L. Hutnik, MD, PhD, FRCSC
Department of Ophthalmology,
University of Western Ontario
Active Staff, St. Joseph's Health Centre, London, ON

Introduction
In 1942, Sir W. Stewart Duke-Elder published his classic ophthalmic text series.¹ The first paragraph eloquently describes his thoughts on the genesis of vision and the evolution of the eye "from remote and lowly origins, far removed in form and in function from the highly specialized mechanism we find in man; indeed, it is no easy matter to decide where its origin lay or when the sense of vision first became a factor in conscious behaviour." He begins by stating that "either in fact or in fiction there are few stories more fascinating than the history of the evolution of the visual apparatus from primitive undifferential protoplasm into a system of the highest delicacy and intricacy of structure." Recognizing the complexity of the human eye, the following is a summary of how this intricate structure withstands the physiological stresses of a normal human life span.

The eye is not exempt from the relentless process of aging. Structurally, changes can be observed in all parts of the eye, both macroscopically and microscopically. The key is to recognize when these structural changes begin to threaten function.

Kim Wilson, BSc, MSc

Cataract patients may now choose to have a multifocal implantable lens which corrects for distance, intermediate and near vision. During surgery, the patient's cataract or cloudy crystalline lens is removed and replaced by the foldable multifocal lens which then unfolds once positioned in the eye.

"This lens is significant to the elderly", said Dr. Allan Slomovic, Clinical Director of the Cornea and External Ocular Diseases at the Toronto Hospital (Western Division), and the Program Director in the Department of Ophthalmology at the University of Toronto. Dr. Slomovic is one of eleven ophthalmologists originally performing this surgery in Canada, and he says "this foldable lens allows for a very small incision of about 3.2 mm, which allows the eye to heal faster and the patient recovers their vision quickly."

Other foldable lenses are available, but the multifocal lens has the added advantage of correcting for distance, intermediate and near vision. The multifocal lens has a series of zones with different refractive powers, allowing the patient to see a range of distances. Each zone has different refractive powers, with zones one, three and five allowing the eyes to focus on objects at a distance, while zones two and four allow focusing of near objects.

The multifocal lens was developed by Allergan Inc. in California.