Building a basis for action: enhancing public health surveillance of vision impairment and eye health in the United States

Trends in Geographic Distribution of Visual Disability - United States, 2010-2019

PURPOSE

We aimed to describe changes in the geographic distribution of self-reported visual impairment (VI) over the last decade (2010-2019) in the U.S.

METHODS

Our study was an analysis of publicly available data collected between 2010 and 2019 from the Census Bureau American Community Survey.

RESULTS

The mean overall prevalence of self-reported VI from 2010 to 2019 was 2.31% in the United States, and there was a significant increase in VI over the past decade from 2.25% in 2010-2014 to 2.37% in 2015-2019 (p < .001). VI was significantly higher in rural counties (3.58%), compared to urban (3.10%) or metropolitan counties (2.18%) (p < .001). In terms of geographic region, the South of the United States had the highest rate of VI (2.63%) (p < .001). For age groups > 17-years-old in the 2010-2019 data, women had higher rates of VI compared to men.

CONCLUSIONS

Prevalence of self-reported visual impairment has risen and disproportionately affects certain communities. This includes individuals living in the South, in rural counties, and women.

Prevalence of Eye and Vision Disorders in the Military Health System, Fiscal Year 2018

INTRODUCTION

Eye and vision disorders are estimated to impact 7.08 million people in the United States, including 1.62 million under the age of 40. This study uses the Vision and Eye Health Surveillance System (VEHSS) case definitions to assess the burden of eye and vision disorders in a universally insured, nationally representative population.

MATERIALS AND METHODS

This retrospective, cross-sectional study applied the VEHSS case definitions to TRICARE claims data collected from the Military Health System Data Repository and Defense Enrollment Eligibility Reporting System during 2018. Beneficiaries aged 0-64 years during the fiscal year 2018 were identified with inpatient and outpatient codes matching to the VEHSS diagnostic case definitions, which were organized into 17 categories of eye and vision disorders classified by the ICD-10. Beneficiaries were recorded only once per category but allowed to match to multiple categories. Analyses included descriptive statistics of patient demographics and prevalence of eye disorders.

RESULTS

We identified 4,548,897 TRICARE Prime/Plus beneficiaries (54.86% men and 45.14% women), of whom 22.93% were diagnosed with at least one disorder in 2018. Of those with a diagnosis, the majority were men (50.13%), adults (74.91%), and of or sponsored by a senior enlisted rank (57.83%), used as socioeconomic proxy. Disorders of refraction and accommodation were most prevalent, followed by infectious and inflammatory diseases. Potentially preventable and treatable conditions, including amblyopia and strabismus, infectious and inflammatory disease, and diabetic complications, affected up to 22% of those with vision disorders.

CONCLUSIONS

This study represents the first use of VEHSS measures in a universally insured, socioeconomically diverse population. Identification of potentially treatable or preventable conditions indicates significant opportunity to mitigate the burden of eye and vision disorders in the Military Health System.

Risk Factors for Vision Loss among Nursing Home Residents: A Cross-Sectional Analysis

OBJECTIVE

Approximately 2% of older adults currently live in nursing homes. It is important that the risks for vision loss be characterized to ensure appropriate vision care is provided for nursing home patients. Our objective was to evaluate the association of age-related eye diseases (AREDs) and multimorbidities with vision loss.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

This is a cross-sectional analysis of comprehensive eye examination records for 7753 residents of 74 North Carolina nursing homes who were ≥65 years of age at time of the initial patient visit.

METHODS

Complete data on vision and associated factors were included from the standardized Centers for Medicare and Medicaid Services eye examination. We defined vision impairment and blindness respectively as best-corrected visual acuity between 20/40 and 20/200, and 20/200 or worse. Clinical diagnoses of AREDs were defined by the attending clinician. Data were extracted from electronic health records, and all analyses were conducted in SAS v 9.4. We used descriptive statistics to summarize the resident characteristics and AREDs and logistic regression analysis to examine independent risk factors for vision impairment.

RESULTS

A total of 7753 initial eye examination records with complete data were included in the analysis. Overall, 34% of the residents had normal vision, 43% had vision impairment, and 23% were blind. Among participants with various AREDs, the prevalence of vision impaired/blind ranged from 63% to 76%, while blindness ranged from 23% to 53%. We found correction of refractive error alone served to reduce vision impairment or blindness.

CONCLUSIONS AND IMPLICATIONS

Comprehensive eye examinations showed vision impairment and blindness affected 66% of nursing home residents, overall. This study substantiates the positive impact of comprehensive eye examinations to promote visual, systemic, and cognitive health and well-being and the need that eye care service be used to inform policy and practice to improve patient functioning and independence.

Association between Vision Impairment and Physical Quality of Life Assessed Using National Surveillance Data

SIGNIFICANCE

Physically unhealthy days assessments in national health surveillance datasets represent a useful metric for quantifying quality-of-life differences in those with and without vision impairment. Disproportionately poorer physical health in the visually impaired population provides further rationale for the inclusion of vision care in multidisciplinary approaches to chronic disease management.

PURPOSE

This study aimed to assess the association between vision impairment and health-related quality of life using data from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System.

METHODS

Data from each of the 50 states were extracted from the 2017 Behavioral Risk Factor Surveillance System data set. Self-report of difficulty seeing was used to categorize visually impaired versus nonvisually impaired populations. Self-report number of physically unhealthy days in the previous 30 days was used to quantify quality of life. The number of unhealthy days was calculated for the visually impaired and nonvisually impaired cohorts for each state. The ratio of the number of physically unhealthy days in the visually impaired versus nonvisually impaired population was calculated for each state and for different age cohorts.

RESULTS

Mean numbers of physically unhealthy days among persons with and without severe vision impairment across all states were 10.63 and 3.68 days, respectively, and demonstrated considerable geographic variability. Mean ratios of physically unhealthy healthy days in the visually impaired versus the nonvisually impaired population were 2.91 in the 18- to 39-year-old cohort, 2.87 in the 40- to 64-year-old cohort, and 2.16 in the ≥65-year-old cohort.

CONCLUSIONS

National surveillance data demonstrate a greater number of physically unhealthy days in the visually impaired population, indicating a need to improve our understanding of causes that lead to reduced physical health among those with vision impairment. Additional research is needed to better understand how individuals perceive vision as part of their overall health.

Do You See What Eye See? Measurement, Correlates, and Functional Associations of Objective and Self-Reported Vision Impairment in Aging South Africans

Objectives: Our study investigates measurement, correlates, and functional associations of vision impairment (VI) in an aging population in rural South Africa. Methods: 1582 participants aged 40-69 reported on near (NVI) and distance vision impairment (DVI) and completed objective vision tests. Logistic and linear regression were used to evaluate sociodemographic, health, and psychosocial correlates of VI and assess relationships between VI and cognitive and physical function. Results: VI prevalence was considerably higher according to objective testing (56%) versus self-reports (18%). Older adults were especially likely to underreport impairment. Objective VI was associated with age, education, cardiometabolic disease, and female sex. Conversely, self-reported VI was associated with psychosocial factors. Objective NVI and both types of DVI were associated with worse visual cognition and slower gait speed, respectively. Discussion: Self-reported and objective VI measures should not be used interchangeably in this context. Our findings highlight extensive burden of untreated VI in this region.

Visual and Ocular Conditions among a Homeless Adult Population of Boston

SIGNIFICANCE

The eye care needs of the homeless population in the United States are not well known. This study elucidates those needs for health care for the homeless programs and eye care practitioners. This information could result in an increase in the provision of necessary eye care services.

PURPOSE

The purpose of this study was to assess the extent of visual and ocular conditions, the frequency of eyeglass orders and receipt of eyeglasses, and the frequency of ophthalmology referrals and receipt of ophthalmological care in an adult homeless population in Boston.

METHODS

A cross-sectional retrospective chart review was conducted for patients of the Boston Health Care for the Homeless Program's Pine Street Inn eye clinic from September 26, 2016, to December 31, 2017. Data on sociodemographics, medical history, comprehensive eye examination findings, glasses orders and receipt, and ophthalmology referrals and receipt of care were collected and analyzed.

RESULTS

A total of 424 patients were included in the study. The mean age of the study population was 52.7 (interquartile range, 46 to 60), and the majority were male (74%). The most common systemic conditions were hypertension (40.6%) and diabetes (23.8%). The most common refractive error was presbyopia (67.7%), followed by astigmatism (38.9%), hyperopia (34.0%), and myopia (30.7%). The most common ocular conditions were dry eye (28.6%), visually or clinically significant cataract (20%), and glaucoma/glaucoma suspicion (13.9%). Refractive correction was indicated for 356 patients (84%), but 82 (29%) did not receive ordered eyeglasses. Ophthalmology referrals were placed for 61 patients (14.4%), yet only 20 (32.8%) of those referrals were completed.

CONCLUSIONS

A significant need for refractive correction and a large gap for ophthalmological care were found among the study population. Health care for the homeless programs and eye care practitioners should be aware of the visual and ocular needs of this patient population so as to better meet their needs.

[Self-reported vision in (gerontological) health services research and practice-an opening plea]

The use of self-reported vision is an integral part of most population surveys and is primarily used for healthcare monitoring. Since the patient's assessment is not always consistent with the objectively measured clinical parameters, the majority of the literature looks critically at the adequacy of self-reported vision, particularly with respect to answering epidemiological questions; however, it is often misunderstood that self-reported vision measures far more than the directly derived information show. This article shows the complexity of self-reported vision and discusses the importance of health services research and practice, with a special focus on the topic of vision in old age. From the explanations it becomes clear that the self-estimation of vision by a person is determined by various factors apart from the pure organ function and that the need for action and diagnostic conclusions can only be derived from self-reports. This is essential if vision is to be understood as a multifactorial condition and empirically practiced using different survey instruments. The article shows that self-reported vision is a good indicator of the quality of care in its entirety.

Eye Health Information Systems in Selected Countries

One of the important factors for achieving “Vision 2020” targets is the availability and accessibility of eye health information systems. This study aimed to describe eye health information systems in selected countries. The status of eye health information systems in Australia, the United States, and England was reviewed. Data were gathered from the PubMed, Scopus, and ScienceDirect databases. The main key terms used included, but were not limited to “National Action plan”, “Eye Health Information System”, “Database”, and “Registery”. Also, the websites of the World Health Organization, the International Agency for the Prevention of Blindness, and Departments of Health in the selected countries were accessed. Fifty documents and articles of 170 retrieved references related to the research goals were used in this study. In all three countries, the issue of eye health is considered to be a national health priority. Concerning data gathering, the most common point in these countries was data gathered directly (health information systems, eye registries) and indirectly (studies, projects, and surveillance systems) by the organizations that participated in eye health programs. Producing accessible, timely, and highly quality information about eye health is one of the most important goals in the formation of eye health information systems in the selected countries, which facilitates achievement of the goals of the “Vision 2020: The Right to Sight” initiative.

Impact of Retinitis Pigmentosa on Quality of Life, Mental Health, and Employment Among Young Adults

PURPOSE

To determine the relationship between visual function and quality of life, education, mental health, and employment among young adults with retinitis pigmentosa (RP).

DESIGN

Cross-sectional study.

METHODS

Inclusion of 148 patients (mean age 38.2 ± 7.1 years) diagnosed with RP, living in France. Quality of life was assessed using the National Eye Institute Visual Function Questionnaire (VFQ-25), mental state with the Hospital and Anxiety and Depression Scale (HADS), and employment with a specifically designed questionnaire.

RESULTS

Limited visual impairment was noted in 22.3%, low vision in 29.7%, and legal blindness in 48.0%. There was a correlation between quality-of-life scores and residual visual field (P < .0001). Mental health scores were suggestive of anxiety in 36.5% and depression in 15.5%. The rates did not increase with disability level (P = .738, P = .134). The percentage of subjects with higher education did not significantly decrease with disability level (P = .113). The employment rate did not significantly decrease with disability level (P = .276). It was lower in subjects reporting depression (P = .0414). Self-rated impact of RP on employment increased with disability level (P = .02642).

CONCLUSIONS

Our results differ from previous results showing lower education rates and employment rates in young adults with RP. Further research is warranted focusing on the impact of mental health, education, workplace conditions, and employment aids on employment rate vs age- and education-matched normally sighted controls to guide visual disability strategies in RP.

Clinical and Economic Burden of Visual Impairment in an Aging Society of South Korea

Whereas the incidence of visual impairment and blindness (VI&B) is decreasing, the total number of VI&B is increasing due to the growth of elderly population. To compare the clinical and economic outcomes of patients with and without VI&B (ie, cases and controls) in Korea, a case–control study was performed using the Health Insurance Review and Assessment Service–National Patients Sample data. Cases had higher prevalence for all of the Charlson Comorbidity Index components, depression, fracture, and injury as well as eye diseases compared to age- and sex-matched controls. In regression after adjustment of concomitant diseases, cases had 2.7 times (95% confidence interval = 2.3-3.2) higher medical expenditure than controls. The results of this study confirm that patients with VI&B have significantly higher direct medical expenditures and concomitant diseases than those without VI&B and highlight the need for a public health strategy to reduce potentially avoidable costs attributed to VI&B.

Assessment of a rapid method to determine approximate visual acuity in large surveys and other such settings

PURPOSE

To evaluate the efficacy of an iPod application developed to rapidly measure approximate visual acuity (VA).

DESIGN

Prospective, cross-sectional study.

METHODS

One hundred four subjects (104 eyes) with a wide range of VA underwent both Early Treatment Diabetic Retinopathy Study (ETDRS) VA testing and iPod application testing. The application presented 4 randomized ETDRS letters at the Snellen equivalent of 20/40 and 20/200 each. In separate analyses, sensitivity and specificity of the iPod test were determined using the ETDRS VA testing results as the gold standard and defining "failure" to see as identifying 1, 2, 3, or all 4 letters incorrectly out of 4 trials. The minimum number of iPod trials necessary to maintain high accuracy was determined by defining a "failure" as getting the first, first 2, first 3, or all trial letters incorrect. In 13 subjects, the time necessary to perform the testing was determined.

RESULTS

Forty-six subjects had an ETDRS Snellen equivalent VA ≥20/40; 45 had a VA <20/40 and ≥20/200; and 13 had a VA <20/200. The mean ± SD testing time for the 3 groups was 43 ± 13, 60 ± 15, and 72 ± 25 seconds, respectively. The highest sensitivity and specificity combination was observed when a "failure" was defined as getting all letters incorrect for both the 20/40 (sensitivity = 98.3%/specificity = 93.5%) and 20/200 (sensitivity/specificity both 92.3%) cutoffs.

CONCLUSIONS

An iPod application requiring about a 1-minute testing time provides an objective, portable, rapid, and low-cost method to determine approximate VA, allowing VA testing to be performed efficiently in large surveys and other settings where approximate VA should be measured.

Use of electronic health records and administrative data for public health surveillance of eye health and vision-related conditions in the United States

PURPOSE

To discuss the current trend toward greater use of electronic health records and how these records could enhance public health surveillance of eye health and vision-related conditions.

DESIGN

Perspective, comparing systems.

METHODS

We describe 3 currently available sources of electronic health data (Kaiser Permanente, the Veterans Health Administration, and the Centers for Medicare & Medicaid Services) and how these sources can contribute to a comprehensive vision and eye health surveillance system.

RESULTS

Each of the 3 sources of electronic health data can contribute meaningfully to a comprehensive vision and eye health surveillance system, but none currently provide all the information required. The use of electronic health records for vision and eye health surveillance has both advantages and disadvantages.

CONCLUSIONS

Electronic health records may provide additional information needed to create a comprehensive vision and eye health surveillance system. Recommendations for incorporating electronic health records into such a system are presented.