Eye Care Among US Adults at High Risk for Vision Loss in the United States in 2002 and 2017

Barriers to the uptake of eye care services: A cross-sectional survey from rural and urban communities

PURPOSE

To explore the barriers to the uptake of eye care services in urban and rural communities in Papua New Guinea.

METHODS

This was a population-based cross-sectional descriptive study and involved multi-stage sampling. Communities were randomly selected from each of the three clusters of Madang District for free eye care outreaches from June to September 2022. A structured questionnaire was used to collect data from the outreach patients. The study excluded attendees who refused to consent. Responses were rated from 1 (not a barrier) to 10 (a very strong barrier). The p-value significance was set at ≤ 0.05.

RESULTS

The majority of the 972 participants (60.2%) were from rural communities. The mean age of participants was 40.82 ± 13.14 years. Almost two-thirds of the participants (61.4%) never had an eye examination before this study was conducted. All the participants reported that time constraint, insufficient income, good vision in the fellow eye, not considering their eye conditions as serious issues and cultural beliefs were personal barriers to accessing eye care services. Provider-related challenges included long waiting periods at eye clinics and fear of procedure complications. There were differences in barriers with respect to the participants' demographic clusters.

CONCLUSION

There are major personal- and service-related barriers to eye care services in Madang. These barriers could be overcome through strategic human resource development, health education, school screening programs, and establishing eye care centres in the communities to improve the uptake of eye care services in Madang and more widely across the country.

Evaluating the Correlation between Eyeglass-Type Wearable Device Measurements and Subjective Physical Activity Assessments

Introduction Wearable trackers are instrumental in monitoring various health indicators, notably daily physical activity, which is crucial for managing chronic diseases and improving overall health. This study examined the relationship between physical activity levels measured using JINS MEME, an eyeglass-type wearable device equipped with motion sensors, and subjective activity assessments reported through the International Physical Activity Questionnaire (IPAQ). Methods Healthy volunteers aged 20-60 were recruited for an observational study. Participants wore the JINS MEME throughout the day for one week, and data on walking activity were collected and analyzed alongside IPAQ responses to evaluate subjective physical activity levels. The correlation between the two sets of data was evaluated using the nonparametric Spearman's rho (ρ) correlation coefficient for both the assessed metabolic equivalents (METs) score of the JINS MEME and the IPAQ. Similarly, the relationship between the IPAQ questionnaire items and the measurements from the JINS MEME. Results The study included 42 participants and revealed a strong correlation (R=0.719, P<0.01) between the metabolic equivalents (METs) calculated from the JINS MEME and IPAQ scores, especially for walking activities. Similarly, a significant association was found between the IPAQ data and walking speed (R=0.129, P=0.02). METs showed significant relationships with all physical activities, except sitting or reclining time. Conclusion This study validated the use of eyeglass-type wearable devices, such as the JINS MEME, to accurately assess physical activity levels, demonstrating a strong correlation with subjective assessments using the IPAQ. This highlights the potential of wearable devices in comprehensive health monitoring and management strategies.

The Sleep Health of Individuals with Visual Impairments: A Scoping Review

PURPOSE

Amidst the global aging population and an increasing prevalence of visual impairment across all age groups, this study aims to investigate the current state of research on sleep health in visually impaired populations.

METHODS

A scoping review was conducted to synthesize the existing literature on sleep health and visual impairment. We employed conceptual mapping to identify key research topics, analyzing data from four databases: PubMed (n = 290), CINAHL (n = 81), Scopus (n = 117), and PsycInfo (n = 96). A total of 83 peer-reviewed articles, published from 1977 to August 2023, were included in the review.

RESULTS

Our analysis identified 11 distinct eye health conditions including blindness, glaucoma, diabetic retinopathy, low vision, cataract, retinitis pigmentosa, macular degeneration, optic neuropathy, visual field defects, ocular hypertension, and retinal vein occlusion. Additionally, 8 major sleep problems were recognized: abnormal sleep duration, daytime sleepiness, insomnia, Non-24-Hour Sleep Wake Disorder, sleep apnea, sleep disorders, sleep disturbances, and sleep disordered breathing. The dominant research themes were (1) poor sleep quality in individuals with visual impairments and ophthalmic diseases, (2) high prevalence of sleep issues in patients with ophthalmic diseases, (3) sleep apnea in patients with ophthalmic conditions, and (4) circadian rhythm disruptions in blind individuals.

CONCLUSION

This review highlights research gaps that, when addressed, could greatly enhance our comprehension of the interplay between visual impairment and sleep health. Bridging these gaps promises to lead to more holistic care strategies, potentially improving vision functioning and rehabilitation outcomes for individuals with visual impairments.

Factors Influencing Vision Health and Eye Care among Older Adults in Northeast Tennessee

OBJECTIVES

The purpose of this study was to examine the factors associated with vision impairment (VI), age-related eye disease (ARED), and frequency of eye examinations among older adults.

METHODS

A cross-sectional study (N = 166) was designed to identify barriers in vision and eye care services among adults 50 years and older in four counties in Appalachian Tennessee. Surveys were administered in March 2023. Simple and multiple logistic regression analyses were used to determine the risk factors of VI and ARED and the frequency of eye examinations.

RESULTS

In two out of the three regression models, predictors such as traveling >10 mi to an eye care provider, barriers to eye care, and a lack of exposure to eye health information emerged as significant factors. Individuals who traveled >10 mi to an eye care provider were more than twice as likely than individuals who traveled shorter distances to have VI and not maintain routine eye care (adjusted odds ratio [AOR] 2.69, 95% confidence interval [CI] 1.08-6.75; AOR 2.82, 95% CI 1.05-7.55, respectively). Reporting barriers to eye care doubled the odds of ARED (AOR 2.33, 95% CI 1.02-5.34) and substantially increased the odds of reporting a 3-year or longer interval since the last eye examination (AOR 7.45, 95% CI 1.85-29.96) compared with having no barriers to eye care. Moreover, limited exposure to eye health information tripled the odds of VI (AOR 3.26, 95% CI 1.15-9.24) and not maintaining routine eye care (AOR 3.07, 95% CI 0.97-9.70) compared with more exposure to eye health information. Other predictors also were uncovered in the analysis.

CONCLUSIONS

This study contributes to the scarce literature on risk factors associated with vision health among older adults in Appalachia.

Machine Learning Methods Using Artificial Intelligence Deployed on Electronic Health Record Data for Identification and Referral of At-Risk Patients From Primary Care Physicians to Eye Care Specialists: Retrospective, Case-Controlled Study

BACKGROUND

Identification and referral of at-risk patients from primary care practitioners (PCPs) to eye care professionals remain a challenge. Approximately 1.9 million Americans suffer from vision loss as a result of undiagnosed or untreated ophthalmic conditions. In ophthalmology, artificial intelligence (AI) is used to predict glaucoma progression, recognize diabetic retinopathy (DR), and classify ocular tumors; however, AI has not yet been used to triage primary care patients for ophthalmology referral.

OBJECTIVE

This study aimed to build and compare machine learning (ML) methods, applicable to electronic health records (EHRs) of PCPs, capable of triaging patients for referral to eye care specialists.

METHODS

Accessing the Optum deidentified EHR data set, 743,039 patients with 5 leading vision conditions (age-related macular degeneration [AMD], visually significant cataract, DR, glaucoma, or ocular surface disease [OSD]) were exact-matched on age and gender to 743,039 controls without eye conditions. Between 142 and 182 non-ophthalmic parameters per patient were input into 5 ML methods: generalized linear model, L1-regularized logistic regression, random forest, Extreme Gradient Boosting (XGBoost), and J48 decision tree. Model performance was compared for each pathology to select the most predictive algorithm. The area under the curve (AUC) was assessed for all algorithms for each outcome.

RESULTS

XGBoost demonstrated the best performance, showing, respectively, a prediction accuracy and an AUC of 78.6% (95% CI 78.3%-78.9%) and 0.878 for visually significant cataract, 77.4% (95% CI 76.7%-78.1%) and 0.858 for exudative AMD, 79.2% (95% CI 78.8%-79.6%) and 0.879 for nonexudative AMD, 72.2% (95% CI 69.9%-74.5%) and 0.803 for OSD requiring medication, 70.8% (95% CI 70.5%-71.1%) and 0.785 for glaucoma, 85.0% (95% CI 84.2%-85.8%) and 0.924 for type 1 nonproliferative diabetic retinopathy (NPDR), 82.2% (95% CI 80.4%-84.0%) and 0.911 for type 1 proliferative diabetic retinopathy (PDR), 81.3% (95% CI 81.0%-81.6%) and 0.891 for type 2 NPDR, and 82.1% (95% CI 81.3%-82.9%) and 0.900 for type 2 PDR.

CONCLUSIONS

The 5 ML methods deployed were able to successfully identify patients with elevated odds ratios (ORs), thus capable of patient triage, for ocular pathology ranging from 2.4 (95% CI 2.4-2.5) for glaucoma to 5.7 (95% CI 5.0-6.4) for type 1 NPDR, with an average OR of 3.9. The application of these models could enable PCPs to better identify and triage patients at risk for treatable ophthalmic pathology. Early identification of patients with unrecognized sight-threatening conditions may lead to earlier treatment and a reduced economic burden. More importantly, such triage may improve patients' lives.

Visual Impairment from Uncorrected Refractive Error among Participants in a Novel Program to Improve Eye Care Access among Low-Income Adults in Michigan

PURPOSE

To assess the rate of visual impairment (VI) from uncorrected refractive error (URE) and associations with demographic and socioeconomic factors among low-income patients presenting to the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine (MI-SIGHT) program.

DESIGN

Cross-sectional study.

PARTICIPANTS

Adults ≥ 18 years without acute ocular symptoms.

METHODS

MI-SIGHT program participants received a telemedicine-based eye disease screening and ordered glasses through an online optical store. Participants were categorized based on refractive error (RE) status: VI from URE (presenting visual acuity [PVA], ≤ 20/50; best-corrected visual acuity [BCVA], ≥ 20/40), URE without VI (PVA, ≥ 20/40; ≥ 2-line improvement to BCVA), and no or adequately corrected RE (PVA, ≥ 20/40; < 2-line improvement to BCVA). Patient demographics, self-reported visual function, and satisfaction with glasses obtained through the program were compared among groups using analysis of variance, Kruskal-Wallis, chi-square, and Fisher exact testing.

MAIN OUTCOME MEASURES

PVA, BCVA, and presence of VI (defined as PVA ≤ 20/50).

RESULTS

Of 1171 participants enrolled in the MI-SIGHT program during the first year, average age was 55.1 years (SD = 14.5), 37.7% were male, 54.1% identified as Black, and 1166 (99.6%) had both PVA and BCVA measured. VI was observed in 120 participants (10.3%); 96 had VI from URE (8.2%), 168 participants (14.4%) had URE without VI, and 878 (75.3%) had no or adequately corrected RE. A smaller percentage of participants with VI resulting from URE reported having a college degree, and a larger percentage reported income < $10 000 compared with participants with no or adequately corrected RE (3.2% vs. 14.2% [P = 0.02]; 45.5% vs. 21.6% [P < 0.0001], respectively). Visual function was lowest among participants with VI from URE, followed by those with URE without VI, and then those with no or adequately corrected RE (9-item National Eye Institute Visual Function Questionnaire composite score, 67.3 ± 19.6 vs. 77.0 ± 14.4 vs. 82.2 ± 13.3, respectively; P < 0.0001). In total, 71.2% (n = 830) ordered glasses for an average cost of $36.80 ± $32.60; 97.7% were satisfied with their glasses.

CONCLUSIONS

URE was the main cause of VI at 2 clinics serving low-income communities and was associated with reduced vision-related quality of life. An online optical store with lower prices made eyeglasses accessible to low-income patients.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The influence of simulated visual impairment on distance stereopsis

The intricate interrelationships between visual acuity (VA) and stereopsis depend on an array of factors, incorporating the nature of vision impairment, its manifestation (monocular versus binocular), and the classification of stereopsis test symbols used. The objectives of this study were to methodically dissect these multifaceted interactions by simulating a diverse range of vision loss conditions. Thirty medical students with normal vision were subjected to simulated vision loss through opacification and blurring methodologies. Stereopsis was assessed at a distance using both contour-based and random-dot-based symbols under equal binocular and varied monocular VA conditions. In this study, opacification consistently affected stereopsis more than blurring at equivalent VA reductions. However, this difference was absent in contour-based symbols under binocular vision impairment conditions. Significant differences in stereopsis emerged between monocular and binocular vision within the opacification contour-based groups. These differences were less evident in the opacification and blurring groups using random-dot-based patterns. In terms of symbols, the contour-based test demonstrated superior results to the random-dot-based test, particularly under decreased VA. In sum, the method of VA reduction and the choice of stereogram significantly impact distance stereopsis outcomes. This understanding can guide clinical assessments of stereopsis in individuals with varying visual impairments.

The Impact of Social Determinants of Health on Vision Loss From Cataracts and Cataract Surgery Utilization in the United States-A National Health Interview Survey Analysis

PURPOSE

To investigate the association of social determinants of health (SDOH) factors and cataract-related outcomes disparities.

DESIGN

Cross-sectional, with a nationally representative sample.

METHODS

We used publicly available data from the 2008, 2016, and 2017 National Health Interview Survey data sets. Outcome measures included self-reported prevalence for ever been diagnosed with cataract, vision loss secondary to cataracts, and the likelihood of undergoing cataract surgery. Survey-weighted, multivariable logistic regression models, adjusted for age, race and ethnicity, and other relevant covariates, were used to examine the association between SDOH factors and cataract-related outcomes.

RESULTS

A total of 81,551 participants were included, who were predominantly between 18 and 44 years of age (49.6%), female (51.7%), and White (74.8%). Multivariable regression models with age as a covariate showed that individuals who were not working were more likely to report having cataracts than those who were working (P < .001). Those who needed but could not afford medical care in the past year were more likely to report vision loss secondary to cataracts than their counterparts (P < .001). Uninsured participants were less likely to report undergoing cataract surgery than those with private insurance (P = .03). Individuals with higher income (poverty-income ratio: 1.00-2.99 vs <1.00) were more likely to report undergoing cataract surgery (P = .04).

CONCLUSIONS

Several SDOH factors were associated with disparities in rates of cataract-related outcomes. These findings highlight the importance of ophthalmologists screening for social risks in patients with cataract, as these social factors are important barriers for access to care.

Predicting Internet Use and Digital Competence Among Older Adults Using Performance Tests of Visual, Physical, and Cognitive Functioning: Longitudinal Population-Based Study

BACKGROUND

The rapidly increasing role of the internet in obtaining basic services poses challenges, especially for older adults' capabilities of getting the services they need. Research on the predictors of older adults' internet use and digital competence is especially relevant given that people are living longer than before, and the age profile of many societies is changing rapidly.

OBJECTIVE

We aimed to examine the associations of objective measures of physical and cognitive impairment with the nonuse of the internet for services and low digital competence among older adults.

METHODS

A longitudinal population-based design was used that combined data from performance tests and self-rated questionnaires. Data were gathered in 2017 and 2020 among 1426 older adults aged between 70 and 100 years in Finland. Logistic regression analyses were used to examine the associations.

RESULTS

Those who had poor near (odds ratio [OR] 1.90, 95% CI 1.36-2.66) or distant vision (OR 1.81, 95% CI 1.21-2.71), restricted or failed abduction of upper arms (OR 1.81, 95% CI 1.28-2.85), and poor results from the word list memory (OR 3.77, 95% CI 2.65-5.36) or word list delayed recall (OR 2.12, 95% CI 1.48-3.02) tests had greater odds for nonuse of the internet for services than their counterparts. Moreover, those who had poor near (OR 2.18, 95% CI 1.57-3.02) or distant vision (OR 2.14, 95% CI 1.43-3.19), poor results from the chair stand test (OR 1.57, 95% CI 1.06-2.31), restricted or failed abduction of upper arms (OR 1.74, 95% CI 1.10-2.76), and poor results from the word list memory (OR 3.41, 95% CI 2.32-5.03) or word list delayed recall (OR 2.05, 95% CI 1.39-3.04) tests had greater odds of low digital competence than their counterparts.

CONCLUSIONS

According to our results, older adults' impaired physical and cognitive functioning may hamper their possibilities of accessing internet services such as digital health care services. Our results should be considered when planning digital health care services intended to be used by older adults; that is, digital solutions should also be suitable for older adults with impairments. Furthermore, face-to-face services should be provided for those who cannot use digital services, even if they are assisted properly.

Association of Gaps in Health Insurance Coverage With Unmet Needs for Vision Care Among Adults in Ohio

Importance

Access to vision care is vital to diagnose and treat vision impairment and diseases. Previous studies found that currently uninsured adults have limited access to vision care. It is unclear whether a recent history (past 12 months) of gaps in insurance coverage likewise adversely affects access to vision care.

Objective

To determine whether gaps in insurance coverage within the past 12 months are associated with higher risk of unmet needs for vision care among adults in Ohio.

Design, Setting, and Participants

This cross-sectional study analyzed data for adults in Ohio from the 2021 Ohio Medicaid Assessment Survey (OMAS), which is conducted via web, telephone, and mail. Participants were residents 19 years or older who reported needing vision care or eyeglasses within the past 12 months.

Exposures

Insurance coverage over the past 12 months, classified as continuous private, continuous public, gap in coverage, or year-round uninsured.

Main Outcomes and Measure

Self-reported unmet need for vision care over the past 12 months.

Results

Based on a sample of 19 036 participants, we calculated that 4% of adults experienced recent coverage gaps (weighted total in the population, 180 259 of 4 518 841) while another 4% were year-round uninsured (187 552 adults). Unmet needs for vision care were reported by 13% (590 015 adults). On multivariable logistic regression, adults with gaps in coverage were at a higher risk of unmet vision care needs compared with adults who had continuous private coverage (odds ratio [OR], 2.9; 95% CI, 2.1-3.9; P < .001) or continuous public coverage (OR, 1.7; 95% CI, 1.3-2.4; P = .001).

Conclusions and Relevance

This study found that gaps in health insurance coverage were associated with increased risk of unmet vision care needs among adults in Ohio compared with continuous private or public coverage. Policies that protect the continuity of health insurance coverage may help reduce the rate of unmet needs for vision care.

Primary Care Provider Familiarity and Compliance With Preferred Practice Patterns for Comprehensive Eye Examinations

PURPOSE

To assess primary care practitioners' (PCPs) familiarity with American Academy of Ophthalmology Preferred Practice Pattern (PPP) guidelines on the frequency of comprehensive eye examinations (CEEs), and to explore their opinions and practices on counseling and referring patients for CEEs.

DESIGN

Cross-sectional study.

METHODS

Between February 1, 2019, and June 25, 2019, an anonymous survey was emailed to clinicians holding an MD, DO, PA, or NP degree, and residents at Brigham and Women's Hospital and the University of Oklahoma. Descriptive statistics of participants' responses were reported.

RESULTS

Regarding patient counseling on CEEs, 15.4% of PCPs reported "always," 48.1% "usually," and 36.5% "seldom" or "never" doing so. Few PCPs (11.1%) reported being able to describe the guidelines, and 63.9% were unaware of their existence. A strong majority of PCPs (90.7%) correctly referred a type 2 diabetic patient at their time of diagnosis, but a similar majority (77.8%) prematurely referred a newly diagnosed type 1 diabetic patient. One in 7 PCPs (13.4%) would refer a patient with family history of glaucoma only upon developing visual/ocular symptoms. Compared to other providers, PAs/NPs were more likely to recommend unnecessary CEEs for low-risk individuals (P = .009), whereas residents counseled patients less frequently (P = .003), were less likely to be familiar with PPP guidelines (P = .026), and were less likely to recommend appropriate follow-ups for patients with family history of glaucoma (P = .004).

CONCLUSIONS

PCPs' awareness of and familiarity with AAO CEE guidelines is variable and improves with provider age and experience. Efforts to improve PCP guideline awareness may be especially well suited to residents and mid-level practitioners.

Perioperative Ischemic Optic Neuropathy after Cardiac Surgery: Development and Validation of a Preoperative Risk Prediction Model

OBJECTIVE

Previous studies identified risk factors for ischemic optic neuropathy (ION) after cardiac surgery; however, there is no easy-to-use risk calculator for the physician to identify high-risk patients for ION before cardiac surgery. The authors sought to develop and validate a simple-to-use predictive model and calculator to assist with preoperative identification of risk and informed consent for this rare but serious complication.

DESIGN

Retrospective case-control study.

SETTING

Hospital discharge records.

PATIENTS

A total of 5,561,177 discharges in the National Inpatient Sample >18 years of age, with procedure codes for coronary artery bypass grafting, heart valve repair/replacement, or left ventricular assist device insertion.

INTERVENTIONS

All patients had undergone cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

Known preoperative risk factors for ION after cardiac surgery were assessed to develop a risk score and prediction model. This model was validated internally using the split-sample method. There were 771 cases of ION among 5,561,177 patients in the National Inpatient Sample. The risk factors for ION used in the model were carotid artery stenosis, cataract, diabetic retinopathy, macular degeneration, glaucoma, male sex, and prior stroke; whereas uncomplicated diabetes decreased risk. With the internal validation, the predictive model had an area under the receiver operating characteristic curve of 0.66. A risk score cutoff ≥3 had 98.4% specificity.

CONCLUSIONS

This predictive model, based on previously identified preoperative factors, predicted risk of perioperative ION with a fair area under the receiver operating characteristic curve. This predictive model could enable screening to provide a more accurate risk assessment for ION, and consent process for cardiac surgery.

Perioperative Care of the Patient with Eye Pathologies Undergoing Nonocular Surgery

The authors reviewed perioperative ocular complications and implications of ocular diseases during nonocular surgeries. Exposure keratopathy, the most common perioperative eye injury, is preventable. Ischemic optic neuropathy, the leading cause of perioperative blindness, has well-defined risk factors. The incidence of ischemic optic neuropathy after spine fusion, but not cardiac surgery, has been decreasing. Central retinal artery occlusion during spine fusion surgery can be prevented by protecting eyes from compression. Perioperative acute angle closure glaucoma is a vision-threatening emergency that can be successfully treated by rapid reduction of elevated intraocular pressure. Differential diagnoses of visual dysfunction in the perioperative period and treatments are detailed. Although glaucoma is increasingly prevalent and often questions arise concerning perioperative anesthetic management, evidence-based recommendations to guide safe anesthesia care in patients with glaucoma are currently lacking. Patients with low vision present challenges to the anesthesia provider that are becoming more common as the population ages.

Disparities in Vision Health and Eye Care

Significant disparities in vision health and eye care exist. To achieve health equity, we must understand the root causes and drivers of health disparities and inequities, including social determinants of health and systemic racism.

The relationship between sensory loss and health literacy in older adults: A systematic review

OBJECTIVES

As sensory loss may impact the ability to receive and apply health information, a relationship between sensory loss and health literacy may exist. The purpose of this systematic review was to explore the relationship between hearing, vision and dual sensory loss and health literacy in older adults.

METHODS

Studies examining the relationship between sensory loss and health literacy in older adult populations using a validated health literacy instrument were included. The search was conducted in the CINAHL, PubMed, Scopus, AgeLine and REHABdata databases in May-June 2021.

RESULTS

Nine studies were included. Findings revealed a positive association between hearing and vision loss and low health literacy.

DISCUSSION

This review highlights a relationship between hearing and vision loss and low health literacy. The small number of studies and overall heterogeneity of study methods limits strength of this evidence. Individuals with sensory loss may benefit from additional clinician support in receiving and applying health information.

Improving Access to Eye Care: A Systematic Review of the Literature

PURPOSE

The goals were to develop a working and inclusive definition of access to eye care, identify gaps in the current system that preclude access, and highlight recommendations that have been identified in prior studies. This manuscript serves as a narrative summary of the literature.

CLINICAL RELEVANCE

Health care disparities continue to plague the nation's well-being, and eye care is no exception. Inequities in eye care negatively affect disease processes (i.e., glaucoma, cataracts, diabetic retinopathy), interventions (surgical treatment, prescription of glasses, referrals), and populations (gender, race and ethnicity, geography, age).

METHODS

A systematic review of the existing literature included all study designs, editorials, and opinion pieces and initially yielded nearly 2500 reports. To be included in full-text review, an article had to be US-based, be written in English, and address 1 or more of the key terms "barriers and facilitators to health care," "access," and "disparities in general and sub-specialty eye care." Both patient and health care professional perspectives were included. One hundred ninety-six reports met the inclusion criteria.

RESULTS

Four key themes regarding access to eye care from both patient and eye care professional perspectives emerged in the literature: (1) barriers and facilitators to access, (2) utilization, (3) compliance and adherence, and (4) recommendations to improve access. Common barriers and facilitators included many factors identified as social determinants of health (i.e., transportation, insurance, language, education). Utilization of eye care was largely attributable to having coverage for eye care, recommendations from primary care professionals, and improved health status. Geographic proximity, age, and lack of transportation surfaced as factors for compliance and adherence. There were a variety of recommendations to improve access to eye care, including improving presence in community health clinics, reimbursement for physicians, and funding of community-based programs such as DRIVE and REACH.

CONCLUSIONS

The eye care profession has abundant evidence of the disparities that continue to affect marginalized communities. Improving community-based programs and clinics, addressing social determinants of health, and acknowledging the effects of discrimination and bias on eye care serve as ways to improve equity in this field.

Screening for Impaired Visual Acuity in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

A 2016 review for the US Preventive Services Task Force (USPSTF) found that effective treatments are available for refractive errors, cataracts, and wet (advanced neovascular) or dry (atrophic) age-related macular degeneration (AMD), but there were no differences between visual screening vs no screening on visual acuity or other outcomes.

Objective

To update the 2016 review on screening for impaired visual acuity in older adults, to inform the USPSTF.

Data Sources

Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews (to February 2021); surveillance through January 21, 2022.

Study Selection

Randomized clinical trials and controlled observational studies on screening, vascular endothelial growth factor (VEGF) inhibitors (wet AMD), and antioxidant vitamins and minerals (dry AMD); studies on screening diagnostic accuracy.

Data Extraction and Synthesis

One investigator abstracted data and a second checked accuracy. Two investigators independently assessed study quality.

Results

Twenty-five studies (N = 33 586) were included (13 trials, 11 diagnostic accuracy studies, and 1 systematic review [19 trials]). Four trials (n = 4819) found no significant differences between screening vs no screening in visual acuity or other outcomes. Visual acuity tests (3 studies; n = 6493) and screening question (3 studies; n = 5203) were associated with suboptimal diagnostic accuracy. For wet AMD, 4 trials (n = 2086) found VEGF inhibitors significantly associated with greater likelihood of 15 or more letters visual acuity gain (risk ratio [RR], 2.92 [95% CI, 1.20-7.12]; I2 = 76%; absolute risk difference [ARD], 10%) and less than 15 letters visual acuity loss (RR, 1.46 [95% CI, 1.22-1.75]; I2 = 80%; ARD, 27%) vs sham treatment, with no increased risk of serious harms. For dry AMD, a systematic review (19 trials) found antioxidant multivitamins significantly associated with decreased risk of progression to late AMD (3 trials, n = 2445; odds ratio [OR], 0.72 [95% CI, 0.58-0.90]) and 3 lines or more visual acuity loss (1 trial, n = 1791; OR, 0.77 [95% CI, 0.62-0.96]) vs placebo. Zinc was significantly associated with increased risk of genitourinary events and beta carotene with increased risk of lung cancer in former smokers; other serious harms were infrequent.

Conclusions and Relevance

This review found that effective treatments are available for common causes of impaired visual acuity in older adults. However, direct evidence found no significant association between vision screening vs no screening in primary care and improved visual outcomes.

Demographics, clinical interests, and ophthalmology skills confidence of medical student volunteers and non-volunteers in an extracurricular community vision screening service-learning program

BACKGROUND

Medical school curricular hours dedicated to ophthalmology are low and declining. Extracurricular ophthalmology activities, such as participation in community vision screenings, may serve an important adjunctive role in medical school curricula. The Johns Hopkins University (JHU) Vision Screening In Our Neighborhoods (ViSION) Program is an example of a voluntary medical student-directed community service-learning program.

METHODS

We used a mixed-methods cross-sectional approach, including an online survey and semi-structured interviews. JHU School of Medicine students enrolled in MD or MD/PhD programs during the 2019-2020 academic year were surveyed regarding demographics, career and service interests, involvement in ophthalmology-related activities, and confidence in their ophthalmology-related skills. Survey responses were compared between ViSION volunteers and non-volunteers using Fisher's exact chi-square tests. Semi-structured interviews were conducted via webconference with 8 prior or current ViSION volunteers and responses analyzed using inductive thematic analysis. Data were collected when ViSION volunteers were in variable stages of their medical education and involvement with the ViSION program.

RESULTS

A total of 118 medical students were included, representing an overall response rate of 24.6% of JHU medical students. ViSION volunteers reported greater involvement in ophthalmology-related research (42% vs. 4%, p < 0.001), intent to apply to ophthalmology residency programs (35% vs. 1%, p = 0.001), and confidence with multiple ophthalmology knowledge and clinical skill domains. In particular, ViSION volunteers were more likely to feel confident estimating cup-to-disc ratio using direct ophthalmoscopy (20% vs. 0%, p < 0.001). In open-ended survey and interview questions, most volunteers attributed at least some degree of their ophthalmology skill development and desire to pursue ophthalmology and public health careers to their ViSION experience.

CONCLUSIONS

Medical students who volunteered with a student-led community vision screening program were more likely to have a prior interest in ophthalmology than those who did not volunteer, but only 1/3 of volunteers planned to pursue a career in ophthalmology. Overall, volunteers reported higher confidence performing ophthalmology-related clinical skills, suggesting that student-led community vision screening programs may provide an important avenue for medical students to explore public health aspects of ophthalmology, while practicing ophthalmology exam skills and learning about common ophthalmic pathologies, regardless of their career intentions.

How can basic research on spatial cognition enhance the visual accessibility of architecture for people with low vision?

People with visual impairment often rely on their residual vision when interacting with their spatial environments. The goal of visual accessibility is to design spaces that allow for safe travel for the large and growing population of people who have uncorrectable vision loss, enabling full participation in modern society. This paper defines the functional challenges in perception and spatial cognition with restricted visual information and reviews a body of empirical work on low vision perception of spaces on both local and global navigational scales. We evaluate how the results of this work can provide insights into the complex problem that architects face in the design of visually accessible spaces.