Disparities in Vision Health and Eye Care

Representation Quotients to Examine Diversity in Ophthalmology Residency Applicants and Matriculants

Importance

A diverse ophthalmic workforce is key to equitable care, and identifying areas of underrepresentation is important in tackling vision care disparities.

Objective

To evaluate the diversity of applicants and matriculants in ophthalmology residency programs relative to medical school graduates and analyze the intersection of race and gender within this pathway.

Design, Setting, and Participants

This retrospective cross-sectional study conducted from 2022 to 2024 used representation quotients (RQs) using reports from the Association of University Professors of Ophthalmology and San Francisco Match, along with demographic data from the Association of American Medical Colleges from 2008 to 2021. RQs measure equity by dividing a racial, ethnic, or gender group's proportion in a specific population by its proportion in a larger reference population. Individuals who graduated from US medical schools from 2008 to 2021 or who applied to or matriculated into US ophthalmology residency programs from 2015 to 2021 and from 2008 to 2021, respectively, were eligible for inclusion.

Exposure

Applying to or matriculating into ophthalmology residency.

Main Outcomes and Measures

The primary outcome was median RQs and trends among racial, ethnic, and gender groups for ophthalmology applicants (RQapp) and matriculants (RQmat), with RQ differences evaluated using Mann-Whitney U tests.

Results

Among total applicants (n = 5304) and matriculants (n = 6139), 36% and 42% of applicants and matriculants, respectively, were female (applicants: 28% Asian, 4% Black, 7% Hispanic, and 47% White; matriculants: 31% Asian, 3% Black, 5% Hispanic, and 57% White). Self-identified Black individuals had the lowest median (IQR) RQs (RQapp, 0.604 [0.437-0.771]; RQmat, 0.469 [0.341-0.597]). Regression analysis revealed increased representation for male applicants (slope, 0.036; 95% CI, 0.015-0.057; P = .007) and matriculants (slope, 0.009; 95% CI, 0.002-0.016; P = .02), but decreased representation for female applicants (slope, -0.031; 95% CI, -0.010 to -0.102; P = .01) and matriculants (slope, -0.009; 95% CI, -0.016 to -0.002; P = .02). Black (RQapp, 0.604 vs RQmat, 0.469; P = .047) and Hispanic (RQapp, 1.46 vs RQmat, 1.04; P = .03) groups experienced a decrease between applicant and matriculants.

Conclusions and Relevance

This cross-sectional retrospective study found persistent underrepresentation of Black and female individuals in ophthalmology residency programs, with increases in Black and Hispanic applicants failing to translate into higher matriculation rates. Barriers that female or Black medical students face when applying or matriculating into ophthalmology residency may contribute to their underrepresentation in the field.

Social Determinants of Uncorrected Distance and Near Visual Impairment in an Older Adult Population

Purpose

Uncorrected visual impairment (VI) significantly impacts life quality and exacerbates age-related health issues. Social determinants of health (SDOH) are associated with uncorrected VI, but quantitative evidence is limited. This study investigated the link between SDOH and uncorrected VI among aging adults to identify disparities and improve vision care.

Methods

We used data from the Atherosclerosis Risk in Communities (ARIC) study visits 4 and 6 and the ancillary Eye Determinants of Cognition (EyeDOC) study. We included subjects who were >70 years old and extracted their sex, race, residence, household income, education level, having an eye doctor, health insurance status, and Area Deprivation Index (ADI) and vision outcomes. Uncorrected VI was categorized into uncorrected distance (UDVI) or near visual impairment (UNVI). Associations between SDOH indicators and VI were evaluated using logistic regressions.

Results

Among 967 adults (mean ± SD age, 78.6 ± 4.35 years; 37.9% male), UDVI was found in 293 and UNVI in 186. Living in Jackson, MS, was associated with lower odds for UNVI (adjusted odds ratio [aOR] = 0.36; 95% CI, 0.20-0.65). Higher odds for UNVI were associated with male sex (aOR = 2.01; 95% CI, 1.41-2.87), low educational attainment (aOR for not completing high school = 2.32; 95% CI, 1.37-3.92; aOR for high school only = 1.92; 95% CI, 1.26-2.92), no eye doctor (aOR = 1.58; 95% CI, 1.05-2.39), and having government health insurance only (aOR = 1.48; 95% CI, 1.00-2.17). Associations between SDOH factors and UDVI were weaker or non-existent.

Conclusions

This study links SDOH factors to uncorrected VI among older adults.

Translational Relevance

SDOH should be considered when designing interventions to reduce VI in vulnerable communities.

Use and Costs of Supplemental Benefits in Medicare Advantage, 2017-2021

Importance

Nearly all Medicare Advantage (MA) plans offer dental, vision, and hearing benefits not covered by traditional Medicare (TM). However, little is known about MA enrollees' use of those benefits or how much they cost MA insurers or enrollees.

Objective

To estimate use, out-of-pocket (OOP) spending, and insurer payments for dental, hearing, and vision services among Medicare beneficiaries.

Design, Setting, and Participants

This cross-sectional analysis used pooled 2017-2021 Medical Expenditure Panel Survey (MEPS) and Medicare Current Beneficiary Survey (MCBS) data for MA and TM beneficiaries (excluding those also covered by Medicaid). The analysis was performed from September 10, 2023, to June 30, 2024.

Exposures

MA compared with TM coverage.

Main Outcomes and Measures

The main outcome was receipt of eye examinations, corrective lenses, hearing aids, optometry and dental visits, and MA and TM enrollees' and insurers' spending for such services. MEPS and MCBS data were weighted to be nationally representative.

Results

We included 76 557 non-dually eligible Medicare beneficiaries, including 23 404 from the MEPS and 53 153 from the MCBS. Weighted demographic characteristics of MA and TM beneficiaries were similar (54.7% and 51.9% female; 39.8% and 35.2% older than 75 years, respectively). Only 54.2% (95% CI, 52.4%-55.9%) and 54.3% (95% CI 52.2%-56.3%) of MA beneficiaries were aware of having MA dental and vision coverage, respectively. MA enrollees were no more likely to receive eye examinations, hearing aids, or eyeglasses than TM enrollees. After adjustment for demographic differences, MA and TM enrollees paid OOP $205.86 (95% CI, $192.44-$219.27) and $226.12 (95% CI, $212.02-$240.23), respectively, for eyeglasses (MA - TM difference, -$20.27 [95% CI, -$33.77 to -$6.77] or -9.0% [95% CI, -14.9% to -3.0%]); $226.82 (95% CI, $202.24-$251.40) and $249.98 (95% CI, $226.22-$273.74) for dental visits, respectively (MA - TM difference, -$23.16 [95% CI, -$43.15 to -$3.17] or -9.3% [95% CI, -17.3% to -1.3%]); and no less for optometry visits or durable medical equipment (a proxy for hearing aids). Nationwide, MA plans' annual spending on vision, dental services, and durable medical equipment totaled $3.9 billion (95% CI, $3.3-$4.4 billion), while enrollees spent OOP $9.2 billion (95% CI, $8.2-$10.2 billion) annually for these services and other private insurers covered $2.8 billion (95% CI, $2.7-$3.0 billion).

Conclusions and Relevance

In this cross-sectional study of 2 nationally representative surveys, MA beneficiaries did not receive more supplemental services than TM beneficiaries, possibly because of cost-sharing and limited awareness of benefit coverage.

Relationship between Neighborhood-Level Social Risk Factor Measures and Presenting Glaucoma Severity Utilizing Multilevel Modeling

Purpose

The neighborhood and built environment social determinant of health domain has several social risk factors (SRFs) that are modifiable through policy efforts. We investigated the impact of neighborhood-level SRFs on presenting glaucoma severity at a tertiary eye care center.

Design

A cross-sectional study from August 2012 to May 2022 in the University of Michigan electronic health record (EHR).

Participants

Patients with a diagnosis of any open-angle glaucoma with ≥1 eye care visit at the University of Michigan Kellogg Eye Center and ≥1 reliable visual field (VF).

Methods

Participants who met inclusion criteria were identified by International Classification of Diseases ninth and tenth revision codes (365.x/H40.x). Data extracted from the EHR included patient demographics, address, presenting mean deviation (MD), and VF reliability. Addresses were mapped to SRF measures at the census tract, block group, and county levels. Multilevel linear regression models were used to estimate the fixed effects of each SRF on MD, after adjusting for patient-level demographic factors and a random effect for neighborhood. Interactions between each SRF measure with patient-level race and Medicaid status were tested for an additive effect on MD.

Main Outcome Measures

The main outcome measure was the effect of SRF on presenting MD.

Results

In total, 4428 patients were included in the analysis who were, on average, 70.3 years old (standard deviation = 11.9), 52.6% self-identified as female, 75.8% self-identified as White race, and 8.9% had Medicaid. The median value of presenting MD was -4.94 decibels (dB) (interquartile range = -11.45 to -2.07 dB). Neighborhood differences accounted for 4.4% of the variability in presenting MD. Neighborhood-level measures, including worse area deprivation (estimate, β = -0.31 per 1-unit increase; P < 0.001), increased segregation (β = -0.92 per 0.1-unit increase in Theil's H index; P < 0.001), and increased neighborhood Medicaid (β = -0.68; P < 0.001) were associated with worse presenting MD. Significant interaction effects with race and Medicaid status were found in several neighborhood-level SRF measures.

Conclusions

Although patients' neighborhood SRF measures accounted for a minority of the variability in presenting MD, most neighborhood-level SRFs are modifiable and were associated with clinically meaningful differences in presenting MD. Policies that aim to reduce neighborhood inequities by addressing allocation of resources could have lasting impacts on vision outcomes.

Financial Disclosures

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

Sociodemographic Factors Associated With Emergent Eye-Related Emergency Department Visits: A Multicenter Analysis

OBJECTIVE

To compare sociodemographic factors in patients presenting to the emergency department (ED) with emergent and nonemergent eye-related concerns.

DESIGN

Cross-sectional multicenter study.

SUBJECTS

60,677 patients with eye-related concerns who visited EDs at Bascom Palmer Eye Institute, Wills Eye Hospital, Massachusetts Eye and Ear, and Johns Hopkins Hospital/Wilmer Eye Institute from January 1, 2019, until December 31, 2019.

METHODS

Descriptive statistics were performed using Stata, version 17.

MAIN OUTCOME MEASURES

(1) Sociodemographic factors associated with emergent diagnoses, (2) visit patterns across ED settings (ie, standard ED vs eye ED), and (3) the most common emergent and nonemergent diagnoses.

RESULTS

A total of 60,677 eye-related ED encounters were included in the study, including 22,434 at Bascom Palmer Eye Institute, 16,124 at Wills Eye Hospital, 15,487 at Massachusetts Eye and Ear, and 6632 at Johns Hopkins Hospital/Wilmer Eye Institute. Most patients had nonemergent diagnoses (56.7%). Males (odds ratio [OR] 1.85, 95% CI 1.79-1.92) were more likely to have an emergent diagnosis than females. Patients with private or employer-based insurance (OR 0.88, 95% CI 0.81-0.96), Medicare (OR 0.80, 95% CI 0.72-0.87), and Medicaid (OR 0.81, 95% CI 0.74-0.89) were all less likely to have an emergent diagnosis than uninsured patients. Those with Veteran or military insurance (OR 1.08, 95% CI 0.87-1.34) were equally likely to have an emergent diagnosis compared with uninsured patients. Non-White Hispanic patients (OR 1.26, 95% CI 1.12-1.42) were more likely to present with an emergent condition than White patients. Patients seen in the standard ED setting were more likely to have emergent diagnoses than those who visited standalone eye EDs (P < .001). The most common emergent diagnoses were corneal abrasion (12.97%), extraocular foreign body (7.61%), and corneal ulcer (7.06%). The most common nonemergent diagnoses were dry eye (7.90%), posterior vitreous detachment (7.76%), and chalazion (6.57%).

CONCLUSIONS

ED setting was associated with the acuity of patient diagnoses. Lack of insurance coverage and non-White Hispanic race or ethnicity were associated with emergent eye-related ED visits. Improving access to ophthalmic care in these populations may reduce the incidence of preventable eye emergencies related to untreated chronic conditions. This combined with measures to redirect nonemergent issues to outpatient clinics may alleviate ED overload.

Association between metabolic syndrome and the risk of glaucoma: a meta-analysis of observational studies

BACKGROUND

The potential link between metabolic syndrome (MetS) and the risk of glaucoma has been proposed but remains inconclusive. This meta-analysis aimed to systematically evaluate the association between MetS and the risk of glaucoma.

METHODS

We conducted a comprehensive search of PubMed, Embase, and Web of Science from inception to August 12, 2024, for observational studies assessing the relationship between MetS and glaucoma risk. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to estimate the association. Heterogeneity was assessed using I² statistics, and a random-effects model was applied.

RESULTS

Nine studies involving 2,258,797 participants were included. The pooled results showed that MetS was significantly associated with an increased risk of glaucoma (OR: 1.34, 95% CI 1.15-1.55, p < 0.001; I² = 75%). Subgroup analyses according to the individual component of MetS suggested that hypertension and hyperglycemia were significantly associated with glaucoma, but not for obesity or dyslipidemia, although the difference among subgroups was not significant (p = 0.05). Further subgroup and meta-regression analyses suggested that the results were not significantly affected by study design, average age, sex, method of glaucoma diagnosis, or glaucoma subtype (primary open-angle glaucoma or normal-tension glaucoma). Sensitivity analysis confirmed the robustness of the findings.

CONCLUSIONS

This meta-analysis suggests that MetS is significantly associated with an increased risk of glaucoma. These findings highlight the need for heightened awareness and potential screening strategies for glaucoma in individuals with MetS. Further studies are required to elucidate underlying mechanisms and causality.

Infectious keratitis in Western New York: a 10-year review of patient demographics, clinical management, and treatment failure

Background

Infectious keratitis (IK) is a blinding disease and an important cause of ocular morbidity. Understanding regional trends in IK are important to understand the epidemiology and clinical outcomes of this disease.

Methods

In this 10-year retrospective review, patient characteristics including sociodemographic factors, medical history, and ocular history were collected as well as the clinical course and outcomes. This study particularly focused on these characteristics as it relates to treatment failure in IK, as defined as requiring more than 2 weeks to heal or surgical intervention, likelihood of having microbiology cultures collected, surgical intervention, and presenting disease severity.

Results

935 cases of IK were identified at the University of Rochester. Age (p=0.004), history of prior corneal transplant (p=0.009), severe vision loss on presentation (p<0.001), large ulcer size (p=0.001), and fungal (p=0.001) or protozoan (p=0.009) infections were all significantly associated with treatment failure. Both ulcer size (p<0.001) and severity of vision loss (p<0.001) were associated with a higher likelihood of having microbiology cultures as well as surgical intervention. Patients' whose home address was greater than 60 miles from the University were also more likely to present with a more severe ulcer (p<0.001) and undergo a surgical intervention (p=0.05). In studying the impact of race and ethnicity, Black patients were less likely to receive corneal cultures compared to White patients (p=0.02).

Conclusions

This study defined the patient characteristics and clinical course of patients with IK over 10 years at the University of Rochester providing insight into regional trends of the patient population as well as clinical outcomes.

Loss to Follow-Up in Patients With Proliferative Diabetic Retinopathy or Diabetic Macular Edema

Importance

Effective management of proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME) requires reliable patient follow-up to prevent disease progression.

Objective

To investigate the sociodemographic and clinical factors associated with being lost to follow-up (LTFU) among individuals with PDR or DME treated with anti-vascular endothelial growth factor (VEGF) intravitreal injections (IVIs) or panretinal photocoagulation (PRP).

Design, Setting, and Participants

This cohort study included a multicenter, retrospective review of patients with PDR or DME treated in Toronto, Canada, from January 1, 2012, to December 31, 2021. Data were analyzed from February 1 to May 31, 2024.

Exposures

All patients received at least 1 anti-VEGF IVI or PRP session.

Main Outcomes and Measures

The primary outcome was the LTFU rate, defined as the absence of an ophthalmic visit or intervention in the 1-year period following an individual's last visit with the treating retinal specialist. Univariable and multivariable logistic regression models were conducted to evaluate associations between sociodemographic and clinical factors with the LTFU rate.

Results

Overall, 2961 patients with PDR or DME (mean [SD] age, 71 [13] years; 1640 [55.4%] male) were included, of whom 507 (17.1%) were LTFU over a mean (SD) follow-up period of 61 (22) months. In the multivariable analysis, older patients (age ≥85 years vs age <65 years: odds ratio [OR], 0.58; 95% CI, 0.40-0.81; P = .002), those with worse baseline visual acuity (>20/200 Snellen vs 20/40 Snellen or better: OR, 0.68; 95% CI, 0.48-0.97; P = .04), those with DME (OR vs no DME, 0.60; 95% CI, 0.43-0.83; P = .003), those with frequent clinic visits (≥6 visits vs <6 visits: OR, 0.78; 95% CI, 0.62-0.98; P = .04), and those with a high anti-VEGF IVI burden in the first year (OR vs low anti-VEGF burden, 0.40; 95% CI, 0.21-0.76; P = .006) were less likely to be LTFU. In contrast, males (OR vs females, 1.23; 95% CI, 1.04-1.52; P = .04), patients living further from the point of care (>200 vs ≤20 km OR, 2.65; 95% CI, 1.85-3.76; P < .001), and those treated with PRP (OR vs anti-VEGF IVIs, 2.10; 95% CI, 1.24-3.55; P < .001) were more likely to be LTFU. Compared with White patients, Black patients (OR, 2.10; 95% CI, 1.50-2.95; P < .001) and Hispanic patients (OR, 1.54; 95% CI, 1.05-2.21; P = .03) were more likely to be LTFU.

Conclusions and Relevance

This cohort study found multiple factors associated with LTFU rates. Identifying individuals at higher risk of LTFU and developing targeted strategies may reduce disease progression and vision loss in individuals with PDR.

Health disparities in ocular oncology

Social determinants of health (SDH) play a crucial role in shaping health outcomes. Few studies have explored the impact of SDH in ocular oncology, looking at differences in disease presentation, treatment choices, and outcomes based on race, ethnicity, socioeconomic status (SES), and insurance status. Retinoblastoma exhibits disparities in survival, with lower-income countries experiencing substantially lower rates compared to high-income countries. In the U.S., racial and SES disparities exist, impacting treatment choices and outcomes in children with retinoblastoma. Disparities in treatment modalities based on race and SES have been reported in uveal melanoma, with non-White and economically disadvantaged patients more likely to undergo primary enucleation. Ocular surface squamous neoplasia (OSSN) exhibits racial and socioeconomic disparities in treatment outcomes. Black patients with OSSN face higher mortality, independent of tumor size, eye laterality, or tumor behavior. Given the rarity, there is no data on disparities in vitreoretinal lymphoma management. When using primary central nervous system lymphoma as a surrogate, management and survival outcomes vary based on factors such as race, socioeconomic status, and insurance status. This article aims to review current literature on disparities in ocular oncology, highlighting the need for granular data to better understand existing gaps in care within ocular oncology.

An Exploratory-Descriptive Qualitative Study on Accessing Eye Health Services at the Community Level in the Gamo and Gofa Zones, Southern Ethiopia

Background and Aims

Access to eye health care, which has a substantial influence on quality of life, is crucial for preventing and treating vision impairments. The determinants of access to eye health care in Ethiopia, especially in the Gamo and Gofa Zones in southern Ethiopia, are not well known. Therefore, this study aimed to identify barriers to accessing eye health services at the community level.

Methods

A community-based, exploratory descriptive qualitative study was conducted among adult women and men residing in two zones from June 2 to July 10, 2023. A purposive sampling technique was utilized to collect qualitative data. In-depth interviews and FGDs were included among the purposefully selected study participants. During the interviews and discussions, digital audio recording was carried out. The data were analysed via the inductive thematic analysis technique and direct quotations from participants' opinions. The respective themes and subthemes provided a detailed overview of the findings, and the Atlas software was used to support the analysis.

Findings

Nine FGDs were conducted among 90 participants. Moreover, a total of 26 in-depth interview participants were included. The mean (±SD) age of the participants in the in-depth interviews was 32.96 ± 4.8 years. The most commonly cited barriers (1) poor awareness and misperception, financial constraints and community-based health insurance implementation gaps; (2) lack of social support; (3) lack of healthcare accessibility, shortage of basic medical equipment; (4) cultural eye care practices and (5) poor road access, rough topography, and difficulty reaching areas, which are identified as obstacles for accessing eye health services.

Conclusion

This study identified pertinent barriers that hinder access to eye health care in the study area. Therefore, tailored strategies are needed to tackle the challenges. This approach is helpful for the local context and offers actionable insights for health policymakers and program designers.

Contributions and Legacies of Selected Black Pioneers in Ophthalmology and Institutional Milestones

PURPOSE

Establishing a record of key contributions of early Black ophthalmologists can help illuminate future generations. We aimed to identify major physician pioneers in ophthalmology, delineate their contributions, and place their ascendance in a historical context to understand the institutional and cultural barriers they overcame to achieve success.

METHODS

PubMed and other databases were searched, along with death notices and archeological records, using "Black," "African American," "eye surgeon," "Negro," "Journal of the National Medical Association" and other search terms. Librarians from the Library of Congress, National Institutes of Health, and key ophthalmology training institutions were consulted, as were the American Academy of Ophthalmology and American Board of Ophthalmology. Family members and colleagues of selected deceased pioneers were interviewed.

RESULTS

Many early pioneers emerged from historically Black institutions, as Black students and practitioners were then typically excluded elsewhere. Mentorship is a key theme that emerged in the careers of many pioneers and the Black ophthalmologists they trained.

CONCLUSIONS

Black ophthalmologists have contributed tremendously to eye-care practice, education, and innovation. Efforts to recruit and train Black ophthalmologists should include highlighting the roles of Black pioneers, increasing educational and training access for the underrepresented in medicine at the institutional level, and expanding pathway and mentorship programs. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Racial and Gender Disparities for Glaucoma Treatment Rates in Upstate New York

Introduction: Glaucoma is one of the leading causes of irreversible blindness around the world. Black individuals are two times more likely to be diagnosed with glaucoma compared to White individuals. In 2019, the prevalence of glaucoma in Monroe County was highest amongst older individuals aged 85 and non-Hispanic Blacks. This study seeks to explore differences in glaucoma treatment rates that may be exacerbating disease severity and prognosis for individuals most acutely affected by glaucoma in Monroe County, NY. Methods: We used data from the Center for Disease Control's National Vision and Eye Health Surveillance System (VEHSS) to assess the rates of glaucoma treatment for different racial, gender, and age demographic groups in Monroe County, NY. The source data were from individuals enrolled in Medicare who filed a claim. We stratified the data based on the glaucoma treatment type: laser glaucoma surgery, glaucoma drainage devices, other glaucoma surgery, or glaucoma prescription drugs. The main outcome variable was the prevalence rate of various types of glaucoma treatment in Monroe County, NY. The data were analyzed by potential risk covariates such as race/ethnicity, age, and gender. A descriptive data analysis was performed to assess for demographic trends. Results: The most common form of glaucoma treatment in Monroe County, NY was prescription drug therapy (36.82%), which was predominant across all racial, gender, and age groups. This was followed by laser surgery (3.26%), glaucoma drain (1.47%), and other forms of glaucoma surgery (0.58%). Women displayed a higher incidence of laser surgery, glaucoma drainage, and other glaucoma surgeries (3.58%, 1.77%, and 0.69%, respectively) with a lower incidence of prescription drug usage (36.14%) compared to men. Black non-Hispanic patients had a higher incidence of laser surgery and prescription drug usage (3.39% and 47.20%, respectively), but a lower incidence of glaucoma drainage and other glaucoma surgeries (1% and 0%, respectively) compared to other racial groups. Conclusions: This study elucidates the differences in glaucoma treatment types across different racial, gender, and age groups in Monroe County, NY. The results underscore the disparities in treatment rates for Medicare patients diagnosed with glaucoma in Monroe County. The results justify the need for increased interventions to increase access to a variety of glaucoma treatment options to mitigate disparities in glaucoma outcomes.

Associations between School-Based Vision Program Outcomes and School Characteristics in 410 Schools

PURPOSE

School-based vision programs (SBVPs) deliver care to students at school, addressing disparities in access to pediatric vision care. We aimed to evaluate the associations between SBVP outcomes and school-level characteristics.

DESIGN

Retrospective cross-sectional data analysis.

PARTICIPANTS

Public schools with at least 50 SBVP-enrolled students 5 to 22 years old with complete demographic data. Schools with less than 60% of total grade levels served by the SBVP were excluded, creating a sample of 410 schools.

METHODS

Vision screening and eye examination data were extracted from 2016-2022 Helen Keller International's United States Vision Program dataset. Individual student data were aggregated to characterize each school's SBVP outcomes and were analyzed with schools' publicly available socioeconomic and demographic data (student body race and ethnicity composition, proportion of students qualifying for free and reduced-price meals [FARM], and proportion of English language learners). Fractional regression models were used to understand associations between SBVP outcomes and school characteristics.

MAIN OUTCOME MEASURES

SBVP outcomes were rates of vision screening failure, prescriptions for eyeglasses, and community eye care referral among each school's SBVP-enrolled students.

RESULTS

We evaluated 151 elementary schools (36.8%), 155 middle schools (37.8%), and 104 high schools (25.4%), with a median proportion of students qualifying for FARM of 87.4% and a plurality of Hispanic students in 61.0% of schools. Median rates of vision screening failure, eyeglasses prescription, and referral were 38.4%, 25.2%, and 5.4%, respectively. High schools were associated with increased screening failure and eyeglasses prescription rates and a decrease in referral rate compared with elementary schools. In multivariable analysis, each 10% increase in proportion of students qualifying for FARM was associated with a 2.6% (95% confidence interval [CI]: 1.54%-3.65%), 1.8% (95% CI, 0.87%-2.74%), and 0.86% (95% CI, 0.36%-1.36%) increase in screening failure, prescriptions for eyeglasses, and referral rates, respectively.

CONCLUSIONS

Significant vision care demand exists among public schools, especially those with students from lower socioeconomic backgrounds. School-based vision programs are important in improving pediatric vision care access. Our findings demonstrated opportunities to allocate personnel and equipment resources according to schools' anticipated needs, thus maximizing SBVPs' impact.

FINANCIAL DISCLOSURE(S)

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

Baseline Characteristics and Clinical Outcomes of Patients Seen Through the Free Diabetes Screening (FDS) Program

Purpose

To characterize the baseline characteristics and clinical outcomes of patients seen through the Free Diabetic Screening (FDS) program, a free diabetic retinopathy screening program for uninsured patients, in the ophthalmology resident clinic at the Wilmer Eye Institute.

Patients and Methods

This retrospective longitudinal cohort study included uninsured patients ≥18 years with diabetes mellitus seen through the FDS clinic from 2013 to 2023. Data extraction was performed using manual chart review of the first FDS visit, and automated extraction of the data warehouse related to all other office visits. Patient demographic and clinical characteristics at presentation, treatments, and follow-ups were collected.

Results

A total of 422 patients were included in this study (mean age 52 years; 59% female; 47% Hispanic; 49% Spanish as primary language). One-third of patients had some form of diabetic retinopathy or diabetic macular edema, and 12% had vision-threatening diabetic retinopathy at presentation. In all, nearly 10% of patients were referred for further specialty care, and 71% of these patients completed at least one follow-up visit. The majority of patients (55%) returned for care as recommended and were followed for a mean length of 200 weeks and 10 office visits.

Conclusion

The FDS clinic provided much needed diabetic retinopathy screening and treatment for uninsured patients in Baltimore City and surrounding areas. This study highlights the need for strong integration between initial screening and downstream services, as nearly 10% of patients require further sub-specialty intervention or care.

The reporting of equity-relevant sociodemographics in the Canadian ophthalmology literature

OBJECTIVE

To determine the quality and extent of sociodemographic reporting in the contemporary Canadian ophthalmology literature.

STUDY DESIGN

Cross-sectional study.

METHODS

All full-length primary studies involving human participants published in the Canadian Journal of Ophthalmology from January 2020 to December 2022 were included.

RESULTS

A total of 669 studies were screened, and 213 studies were eligible for inclusion. Sociodemographic information reported in eligible studies included age (97.18%), sex (88.26%), comorbidities (25.35%), level of education (5.16%), socioeconomic status (2.82%), and occupation (1.14%). Of the relevant studies, 54 (25.35%) included racial or ethnic data. Canadian studies were 1.84 times less likely than studies conducted outside Canada to report race or ethnicity (p = 0.018), but 13 times more likely to report level of education (p < 0.001). Few articles provided information on how racial or ethnic data were collected (12.96%), why the racial or ethnic classification reported in the study was used (5.56%), why race or ethnicity was assessed in the study (24.07%), whether the classification options used were defined by the investigator or the participant (5.56%) or defined the variable race (1.85%). Some studies reported Indigenous participants (18.52%), and no studies with Indigenous participants reported engagement with Indigenous interest holders in the research process.

CONCLUSIONS

Most studies reported age and sex or gender, while the reporting of other equity-relevant sociodemographic data was low. In particular, the reporting of racial or ethnic data was limited. Improved sociodemographic reporting may help stakeholders better identify and address national disparities in ocular health.

Parents' Knowledge and Attitudes Toward Pediatric Ophthalmic Disorders in Saudi Arabia: A Cross-Sectional Study

Recognizing pediatric eye health issues at an early stage, along with ensuring that parents are well informed, is crucial. This study measures parents' knowledge and perspectives on pediatric ophthalmic disease. The study utilized a cross-sectional design, and participants included Saudi parents of children residing in Saudi Arabia. Data were collected using a pre-validated self-administered questionnaire with a scoring system. Sociodemographic characteristics and factors associated with knowledge/attitude were collected and analyzed. Initially, 425 respondents participated in this study. Excluding the participants whose work was related to healthcare and those with incomplete data yielded 370 responses on which the subsequent analyses were performed. The analysis revealed that only half of the parents recognized the need for annual eye examinations for children. Most of them showed gaps in knowledge regarding the frequency of routine eye exams and indicators of visual problems. Notably, parents with good/excellent knowledge were more proactive in their eye care practices, such as adherence to recommended eye examination schedules and accepting corrective measures like glasses for common conditions such as refractive errors and amblyopia. However, parental willingness to permit surgical interventions did not correlate significantly with their level of knowledge, signaling the influence of other factors. In conclusion, this study underscores the need for enhanced public health education to improve parental awareness of pediatric eye diseases in Saudi Arabia. Given the link between knowledge and proactive eye health practices, targeted interventions should distribute comprehensive, culturally sensitive information accessible to all demographics.

Incidence, Mechanisms, and Clinical Characteristics of Traumatic Iritis: A Population-Based Analysis

PURPOSE

To describe the incidence, mechanisms, and clinical characteristics of patients diagnosed with traumatic iritis in a U.S. Midwestern county population.

METHODS

Retrospective population-based cohort of all residents of Olmsted County, Minnesota diagnosed with traumatic iritis from January 1, 2006, to December 31, 2015. The medical records of patients with traumatic iritis were identified using the Rochester Epidemiology Project database, which contains virtually all medical care in the county. Medical records were reviewed for demographics, presentation, and follow-up data. Incidence rates were calculated per 100,000 per year.

RESULTS

There were 156 incident diagnoses of traumatic iritis during the 10-year study period, yielding an age- and sex-adjusted incidence rate of 10.7 per 100,000 per year. Traumatic iritis disproportionately occurred in male (p < 0.001) and Black (p < 0.001) patients. The mean age of diagnosis was 33 years (range: 4-96 years), mean number of traumatic iritis-specific follow-up visits was 2.1 (range: 0-26), and median duration of traumatic iritis-specific follow-up was 11 days (range: 1 day-1.6 years). There were 155 (99.4%) patients with unilateral disease. The most frequent mechanisms of traumatic iritis were sports-related (N = 29, 18.6%), assault-related (N = 23, 14.7%), scratch (N = 22, 14.1%), and work-related (N = 21, 13.5%) injuries. The mean initial and final best-corrected visual acuity (BCVA) of the affected eye was 20/40 and 20/30, respectively. Loss of follow-up was more frequently observed in Black patients (p < 0.001) and patients with smoking history (p = 0.004).

CONCLUSION

Traumatic iritis was most frequently observed in younger males and Black patients. Common mechanisms included sports, assault, scratch, and work-related injuries.

Racial Disparities in Microinvasive Glaucoma Surgery for Management of Primary Open-Angle Glaucoma: A Propensity-Matched Cohort Study

PURPOSE

To evaluate racial and ethnic differences in the use of microinvasive glaucoma surgery (MIGS) for the management of mild-moderate primary open-angle glaucoma (POAG) in the United States.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients with a diagnosis of mild or moderate POAG, as defined by Current Procedural Terminology (CPT) codes, were included. The experimental group comprised African American (AA) patients, and the control group consisted of patients without an AA designation in the TriNetX database.

METHODS

Propensity scoring was used to match cohorts for age at diagnosis, Charlson Comorbidity Index, sex, nicotine dependence, glaucoma medications, family history of POAG, body mass index, and weight. Outcome was incidence of MIGS over 1 year of follow-up. Odds ratios were calculated between cohorts.

MAIN OUTCOME MEASURE

Incidence of MIGS over 1 year of follow-up post-POAG diagnosis.

RESULTS

A total of 63,418 POAG patients were included (50% AA, 50% non-AA). AA patients were found to undergo MIGS at a significantly lower rate (1,268 of 31,709) compared with non-AA patients (1,508 of 31,709) (odds ratio 0.834, 95% CI 0.773-0.900).

CONCLUSION

Although POAG is understood to be more prevalent among African Americans, these patients display lower use of MIGS, suggesting a possible nationwide racial disparity in the management of POAG.

Racial and Ethnic Disparities in Receipt of Retinal Imaging Among Patients With Diabetes

This cohort study examines racial and ethnic differences in varieties of advanced retinal imaging received among patients with diabetes at a single tertiary care institution.

Eye Care in Federally Qualified Health Centers

PURPOSE

To assess changes in vision care availability at Federally Qualified Health Centers (FQHCs) between 2017 and 2021 and whether neighborhood-level demographic social risk factors (SRFs) associated with eye care services provided by FQHCs.

DESIGN

Secondary data analysis of the Health Resources and Services Administration (HRSA) data and 2017-2021 American Community Survey (ACS).

PARTICIPANTS

Federally Qualified Health Centers.

METHODS

Patient and neighborhood characteristics for SRFs were summarized. Differences in FQHCs providing and not providing vision care were compared via Wilcoxon-Mann-Whitney tests for continuous measures and chi-square tests for categorical measures. Logistic regression models were used to test the associations between neighborhood measures and FQHCs providing vision care, adjusted for patient characteristics.

MAIN OUTCOME MEASURES

Odds ratios (ORs) with 95% confidence intervals (CIs) for neighborhood-level predictors of FQHCs providing vision care services.

RESULTS

Overall, 28.5% of FQHCs (n = 375/1318) provided vision care in 2017 versus 32% (n = 435/1362) in 2021 with some increases and decreases in both the number of FQHCs and those with and without vision services. Only 2.6% of people who accessed FQHC services received eye care in 2021. Among the 435 FQHCs that provided vision care in 2021, 27.1% (n = 118) had added vision services between 2017 and 2021, 71.5% (n = 311) had been offering vision services since at least 2017, and 1.4% (n = 6) were newly established. FQHCs providing vision care in 2021 were more likely to be in neighborhoods with a higher percentage of Hispanic/Latino individuals (OR, 1.08, 95% CI, 1.02-1.14, P = 0.0094), Medicaid-insured individuals (OR, 1.08, 95% CI, 1.02-1.14, P = 0.0120), and no car households (OR, 1.07, 95% CI, 1.01-1.13, P = 0.0142). However, FQHCs with vision care, compared to FQHCs without vision care, served a lower percentage of Hispanic/Latino individuals (27.2% vs. 33.9%, P = 0.0007), Medicaid-insured patients (42.8% vs. 46.8%, P < 0.0001), and patients living at or below 100% of the federal poverty line (61.3% vs. 66.3%, P < 0.0001).

CONCLUSIONS

Vision care services are available at a few FQHCs, localized to a few states. Expanding eye care access at FQHCs would meet patients where they seek care to mitigate vision loss to underserved communities.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Loss to Follow up in Patients with Proliferative Diabetic Retinopathy Treated with Anti-VEGF Therapy and/or Panretinal Photocoagulation in the United States

PURPOSE

To determine the rate of loss to follow up (LTFU) in patients with proliferative diabetic retinopathy (PDR) treated with anti-VEGF therapy and/or panretinal photocoagulation (PRP) in the United States.

DESIGN

Retrospective cohort study using the national IRIS® (Intelligent Research in Sight) Registry data.

SUBJECTS

A total of 73 595 eyes of 56 590 patients with PDR diagnosed between 2013 and 2015 and treated between 2013 and 2018.

METHODS

Multivariable logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

MAIN OUTCOME MEASURES

Loss to follow up was no follow up within 12 months from last treatment.

RESULTS

For patient eyes treated for PDR, 11.7% (95% CI, 11.5-12.0) were LTFU. Among patients with PDR treated with anti-VEGF therapy alone, PRP alone, and anti-VEGF and PRP, the rates of LTFU were 12.3% (95% CI, 11.8-12.7), 12.6% (95% CI, 12.1-13.0), and 10.8% (95% CI, 10.4-11.1), respectively. Risk factors for LTFU include Black or African American race/ethnicity (odds ratio [OR], 1.26; 95% CI, 1.13-1.41; P < 0.001), Hispanic ethnicity (OR, 1.28; 95% CI, 1.16-1.42; P < 0.001), Native American/Alaska Native or Native Hawaiian/Other Pacific Islander race/ethnicity (OR, 2.69; 95% CI, 2.14-3.38; P < 0.001), and unilateral disease (OR, 2.05; CI, 1.88-2.23; P < 0.001). Odds for LTFU were higher with patients with baseline vision of 20/50 to 20/200 (OR, 1.25; 95% CI, 1.15-1.36; P < 0.001) and with vision worse than 20/200 (OR, 1.22; 95% CI, 1.05-1.42; P = 0.01) than for patient eyes with a baseline visual acuity of 20/40 or better. Odds for LTFU were lower for Medicare Fee-for-Service (OR, 0.71; 95% CI, 0.64-0.79; P < 0.001) and Medicare Managed (OR, 0.66; 95% CI, 0.56-0.78; P < 0.001) compared with private insurance. Odds for LTFU were lower for patients treated in the Midwest (OR, 0.72; 95% CI, 0.64-0.81; P < 0.001) and West (OR, 0.83; 95% CI, 0.74-0.94; P = 0.003) compared with in the South region.

CONCLUSIONS

The rate of LTFU is between 10% and 12% among patients with PDR who were treated with anti-VEGF injections and/or PRP. Risk factors include Black or African American race/ethnicity, Hispanic ethnicity, baseline vision worse than 20/40, private insurance, South region, and unilateral disease.

FINANCIAL DISCLOSURE(S)

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

Retinitis Pigmentosa Associated With EYS Gene Mutations in Puerto Rico: A Case Series

BACKGROUND

Mutations in the EYS (eyes shut homolog) gene are a known cause of autosomal recessive retinitis pigmentosa (arRP). Pathogenic variants in EYS have been associated with a more severe clinical course compared to mutations in other retinitis pigmentosa (RP)-related genes. The prevalence of EYS-related arRP varies among different populations. To date, no studies have described the presence of EYS mutations in Puerto Rican patients. This case series aims to report and characterize EYS mutations in RP patients from Puerto Rico.

METHODS

This retrospective case series was conducted at two major ophthalmology clinics in Puerto Rico from 2019 to 2023. A chart review was performed to identify RP patients who had mutations in the EYS gene, identified through the Invitae Inherited Retinal Disease Panel, which evaluates more than 300 genes. Collected data included demographic information (age and gender), ocular and medical history, clinical presentation of RP, best corrected visual acuity (BCVA), and genetic testing results.

RESULTS

Seven Puerto Rican patients, three females (43%) and four males (57%), with a clinical diagnosis of RP, were found to have pathogenic EYS variants. Among them, four patients (57%) carried the c.5928-2A>G variant, two (29%) had c.6794del, one (14%) had c.1211dup, and one (14%) had c.3443+1G>T. Compound heterozygosity in the EYS gene was observed in two patients. Additionally, three variants of unknown significance (VUS) were identified. Patients exhibited a wide range of visual acuity; however, those older than 40 were found to be legally blind.  Conclusions: This study provides evidence of EYS-related RP in Puerto Rican patients. Four truncating mutations in the EYS gene were identified, with c.5928-2A>G being the most frequent. Additionally, the novel EYS variant c.9263G>A (p.Gly3088Glu), classified as VUS, was identified in one patient.

Challenges and Opportunities of Vision Screening and Refractive Error Management for Underserved Children in the United States

Uncorrected refractive error is a key cause of childhood visual impairment in the United States. As pediatric vision issues are often asymptomatic, vision screenings are essential to identify children's eye problems. Despite the importance of vision for children's health, well-being, and academic achievement, challenges remain in ensuring that children have equitable access to vision screenings and follow-up eye care. Children of racial and ethnic minorities experience a greater burden of myopia, while longstanding disparities in eye care access have been observed across both race and socioeconomic status. Collaborations with schools and community organizations may represent effective strategies to increase children's access to eye care in underserved communities. By providing services directly at schools, school-based vision programs have demonstrated success in addressing children's refractive error and need for eyeglasses. Future work for community-based programs may engage schools, eye care professionals, and other community stakeholders in collaborations to address children's unmet eye care needs.

Potential Gaps in Eye Care Based on Evaluation of Federally Qualified Health Centers

Importance

Federally qualified health centers (FQHCs) are federally funded community health clinics that provide comprehensive care to underserved populations, making them potential opportunities to offer eye care and address unmet health care needs. Evaluating the presence of eye care services at FQHCs in Florida is important in understanding and addressing possible gaps in care for the state's large uninsured and underserved populations.

Objective

To determine whether FQHCs in Florida are currently offering eye care services, where they are available, what services are being offered, and who provides them.

Design, Setting, and Participants

This study used a cross-sectional design conducted within 1 year (from November 2023 to February 2024). FQHCs listed in the US Health Resources and Services Administration database were contacted by telephone to inquire about the presence of eye care services. The FQHCs were located in both urban and rural areas in Florida to assess accessibility of eye care services in the state. School-based health centers and nonophthalmic specialty care health centers were excluded. A total of 437 FQHCs were included.

Main Outcomes and Measures

Primary outcomes included the presence of eye care services, types of services offered, clinician type (optometrists or ophthalmologists), frequency of services, and availability of pediatric services.

Results

Among 437 FQHCs contacted, only 39 (8.9%) reported offering eye care services. These services primarily included vision examinations, glasses prescriptions, and dilated eye examinations. Optometrists were the primary providers of services at all clinics, with no clinics reporting care by ophthalmologists. The frequency of services varied considerably, ranging from daily to bimonthly. Thirty-seven (94.9%) of the 39 clinics offered pediatric eye care services.

Conclusions and Relevance

The low prevalence of FQHCs with eye care services and the absence of ophthalmologist-provided care highlight a gap in access to eye care for underserved populations in Florida. These findings support investigations into implementing eye care services and interventions at FQHCs that might enhance access and equity in eye care.

Seeing in Color: Inclusion and Characterization of Hereditary Eye Disease in African Americans

Purpose

Hereditary eye diseases (HEDs) are individually rare but affect millions globally. The era of molecular genetics has ushered major advances in the study of these disorders; however, the inclusivity and population diversity of this research is unknown. Questions on the accuracy and applicability of these findings in diverse populations, especially African American patients, came up consistently during counselling sessions. This also raised the possibility of missed opportunities for broader understanding of these rare diseases. We conducted a literature review to measure the representation of African Americans in genomic research surrounding nine HEDs.

Methods

A detailed literature search using a predetermined set of search terms for each of nine HED categories was performed across PubMed, Embase, Web of Science, and Scopus focusing on studies published between Jan 1990 and July 2021. Predetermined inclusion criteria were applied to filter the sources.

Results

We identified 46 studies clearly reporting HED characterization in African Americans. Analysis of these inclusive studies revealed unique findings demonstrating the known usefulness of including diverse cohorts in genomics research.

Conclusions

HED characterization in diverse participants, specifically African Americans, is identified as a knowledge gap area. Genomic research is more applicable to patients when conducted in populations that share their ancestral background. Greater inclusion of African Americans in ophthalmic genetics research is a scientific imperative and a needed step in the pursuit of the best possible patient care for populations of all ancestries.

Translational Relevance

This work reveals gaps in genomic research in African Americans with HEDs.

Examining barriers to dental, medical, mental, and vision healthcare access, attitudes towards seeking healthcare, and internalized racism among Black Americans

Structural barriers, which impede access to healthcare, are often seen as tangible expressions of structural racism. Those who experience more structural barriers to healthcare access are likely to experience poor health. Expanding on this notion, our research integrated the Internalized Racism Framework (James, 2022) with the Structural Vulnerability Framework (Bourgois et al., 2017; Metzl and Hansen, 2014) to explore how encountering barriers to healthcare access influences healthcare seeking attitudes across four health domains: mental, medical, dental, and vision. Our study included a sample of 780 Black American adults (average age = 37.68) who were recruited to participate in an anonymous web-based cross-sectional survey. Our findings revealed that internalized racism explained the direct effect of healthcare access structural barriers on healthcare attitudes in the mental, medical, and vision health domains, but not in the dental health domain. Specifically, the experience of more structural barriers in accessing healthcare (mental, medical, and vision) correlated with heightened internalized racism, which, in turn, was associated with more negative attitudes towards seeking (mental, medical, and vision) healthcare. Notably, our results also showed variations in the frequency and types of structural barriers encountered across the four health domains, along with differences in participants' positive healthcare seeking attitudes. Our findings underscore an urgent need for targeted interventions addressing both structural and internalized racism. Removing healthcare access barriers is crucial for fostering equitable healthcare access for Black Americans. Future research should explore additional factors influencing healthcare seeking attitudes, as well as strategies that mitigate the negative effects of racism on said attitudes.

2023 Global Survey of Optometry: Defining Variations of Practice, Regulation and Human Resources Between Countries

Purpose

To provide information on the demographics of optometrists and regulation of the optometry profession in countries who were members of the World Council of Optometry (WCO) during the period 2022-2023.

Methods

A non-random, purposive sampling and a key informant strategy was employed to conduct a survey-based cross-sectional study on the professional landscape and distribution of optometrists; educational landscape; legislative aspects of the profession; and the scope of optometry practice in countries who were members of WCO during the period 2022-2023. Key informants were identified by WCO country members' leadership.

Results

In the 39 countries surveyed, one optometrist serves 23,200 persons on average. Only 46.2% of the countries met the internationally suggested 1:10,000 optometrist-to-population ratio. The average male-to-female ratio was 45% males/55% females, with a division of average age as follows: under 45 years of age 46% as compared to above 45 years of age 54%. It was reported that optometry is not regulated in France, Portugal, India, Kenya and Cameron. Thirteen countries (33%) do not require a Bachelor's degree as a minimum to practice optometry. Use of diagnostic drugs is prohibited in 20% of the countries, with 25% of the countries limiting the use of therapeutic pharmaceutical agents.

Conclusion

Many countries where optometry is recognized struggle to have an adequate number of optometrists; this hinders access to eye care. This is compounded by unregulated minimum levels of education for entry-level optometric practitioners. In addition, several countries limit or prohibit many optometric procedures that restrict the ability of optometrists to provide eye care and vision health services at the primary care level.

Diversity gaps among practicing ophthalmologists in Canada: a landscape study

OBJECTIVE

Outline geographic disparities in access to language-and gender-concordant ophthalmologic care in Canada.

DESIGN

Cross-sectional.

PARTICIPANTS

Practicing ophthalmologists in Canada (September 2023).

METHODS

Data on ophthalmologists, including demographics, languages spoken, and practice locations, were collected from provincial regulatory body websites. Population data were extracted from the 2021 Statistics Canada Census. Ratio of ophthalmologists-to-potential patients and mean distances (absolute, population-weighted) to gender- and language-concordant care were calculated. The five most common languages spoken in the included provinces were analyzed.

RESULTS

There were 986 and 1338 ophthalmologists in the language and gender analysis, respectively. Few ophthalmologists spoke non-official languages in Saskatchewan, Manitoba, and Nova Scotia. In a population-weighted analysis, the distance to a language-concordant ophthalmologist were 4.55 times greater for Spanish speakers compared to their English counterparts. Cantonese speakers had the shortest distances to language-concordant care but were still had 40% greater distance than English speakers in the same regions. Despite French-speaking ophthalmologists being the most prevalent per 100 000 speakers, francophones outside Quebec endured distances over double that of anglophones to access language-concordant care. Females in Newfoundland and Saskatchewan faced the longest distances to access gender-concordant care. In Ontario, females may face 3 times the distance to gender-concordant ophthalmologists compared to males. Quebec approaches gender parity with a male-to-female ratio of 55:45.

CONCLUSIONS

The results highlight the disparities in accessibility to non-English ophthalmologic care and the underrepresentation of female ophthalmologists across Canada. These disparities underscore the need for targeted strategies to ensure that the ophthalmologic workforce mirrors the demographic of the population it serves.

Disparities in Healthcare-Seeking Behavior and Decision Preference Among Hispanics: A Comparative Study Across Races/Ethnicities, SES, and Provider Types

Purpose

Hispanics, the largest minority in America, have increased risk of several medical issues and face noteworthy health disparities. This study compares care-seeking behaviors and choice experience among Hispanics, Asians, Blacks, and Whites, considering SES (income, education, and insurance status) and across five healthcare provider (HCP) types. Concurrent analysis provides a comprehensive view of how and where inequity manifests in healthcare.

Methods

A cross-sectional online survey assessed 1485 adults (Hispanic=314, Asian=313, Black=316, White=542, recruited through a panel agency) of the frequency of visiting primary care providers, dentists, optometrists, gynecologists, and specialists for chronic conditions. Participants also rated the importance of self-selecting a HCP and difficulty in finding one.

Results

Whites visited each HCP most regularly. Compared to Asians, more Hispanics saw specialists regularly (45.1% vs 56.5%, p=0.042), and Blacks saw dentists less (47.0% vs 38.3%, p=0.028) and gynecologists more often (21.2% vs 33.1%, p=0.024). No other frequency differences were observed among minorities. Low-income participants across four races saw dentists and gynecologists with comparable infrequency. Hispanics and Asians assigned similarly significantly lower self-choice importance and experienced more difficulty relative to Whites or Blacks. Participants with lower income or education visited HCPs less regularly yet perceived the same choice importance as higher-SES peers (p>0.05). Notably, discrepancies in visit frequency between Whites and minorities were more pronounced in higher-SES than lower-SES group. Differences in experiencing care-seeking difficulty were associated with income (p=0.029) and insurance type (p=0.009) but not education (p>0.05).

Conclusion

Higher income and education increase healthcare utilization; however, racial disparities persist, particularly among higher-SES groups. Despite similarities among minorities, the extent of disparities varied by SES and provider type. The findings help explain evident inequity in healthcare access and health outcomes. Tailored patient education, culturally-specific navigation support, and more inclusive services are needed to address barriers faced by minorities and disadvantaged populations.

Assessing The Relationship Between Demand And Accessibility For Pediatric Ophthalmology Services By State In The United States

Purpose

To investigate the relationship between public demand for pediatric ophthalmology services and the accessibility of such services on a statewide basis in the United States, focusing on strabismus care.

Methods

Using Google Trends data, search volumes for "strabismus" were analyzed from January 2014 to December 2023. Pediatric ophthalmologist availability was assessed via the American Academy of Ophthalmology directory, normalized for state population size to create a relative demand index. Additional metrics from the United States Census Bureau and Centers for Disease Control and Prevention provided socioeconomic and health data. Correlation coefficients were used to explore relationships between search volumes, specialist availability, vision screening, socioeconomics, and demographic factors.

Results

The data revealed variability in public interest in pediatric ophthalmology across states, with Alaska showing the highest relative search volume for strabismus. The data also indicated notable disparities in pediatric ophthalmologist density, with North Dakota, Vermont, and Wyoming having no pediatric ophthalmologists. A significant correlation was identified between pediatric ophthalmologist availability and vision screening (R = 0.486, p < 0.001). Negative correlations were observed between the relative demand index and urbanization (R = -0.388, p = 0.007), as well as the strabismus prevalence (R = -0.455, p = 0.001), indicating that urbanization and specialist distribution influence eyecare demand and access.

Conclusion

The findings highlight disparities in accessibility and demand for pediatric ophthalmology services across the US, influenced by urbanization and distribution of healthcare professionals. The study underscores the need for targeted interventions to improve access to care and bridge gaps in pediatric ophthalmology service provision.

Gender, Race, and Ethnicity of US Academic Ophthalmology Faculty and Department Chairs From 1966 to 2021

Importance

Workforce diversity is integral to optimal function within health care teams.

Objective

To analyze gender, race, and ethnicity trends in rank and leadership among US full-time academic ophthalmology faculty and department chairs between 1966 and 2021.

Design, Setting, and Participants

This cohort study included full-time US academic ophthalmology faculty and department chairs registered in the Association of American Medical Colleges. Study data were analyzed in September 2023.

Exposure

Identifying with an underrepresented in medicine (URiM) group.

Main Outcomes and Measures

The main outcome measures were demographic (ie, gender, race, and ethnicity) changes among academic faculty and department chairs, assessed in 5-year intervals. The term minoritized race refers to any racial group other than White race.

Results

There were 221 academic physicians in 1966 (27 women [12.2%]; 38 minoritized race [17.2%]; 8 Hispanic, Latino, or Spanish [3.6%]) and 3158 academic faculty by 2021 (1320 women [41.8%]; 1298 minoritized race [41.1%]; 147 Hispanic, Latino, or Spanish ethnicity [4.7%]). The annual proportional change for women, minoritized race, and Hispanic, Latino, or Spanish ethnicity was +0.63% per year (95% CI, 0.53%-0.72%), +0.54% per year (95% CI, 0.72%-0.36%), and -0.01% (95% CI, -0.03% to 0%), respectively. Women were underrepresented across academic ranks and increasingly so at higher echelons, ranging from nonprofessor/instructor roles (period-averaged mean difference [PA-MD], 19.88%; 95% CI, 16.82%-22.94%) to professor (PA-MD, 81.33%; 95% CI, 78.80%-83.86%). The corpus of department chairs grew from 77 in 1977 (0 women; 7 minoritized race [9.09%]; 2 Hispanic, Latino, or Spanish ethnicity [2.60%]) to 104 by 2021 (17 women [16.35%]; 22 minoritized race [21.15%]; 4 Hispanic, Latino, or Spanish ethnicity [3.85%]). For department chairs, the annual rate of change in the proportion of women, minoritized race, and Hispanic, Latino, or Spanish ethnicity was +0.32% per year (95% CI, 0.20%-0.44%), +0.34% per year (95% CI, 0.19%-0.49%), and +0.05% per year (95% CI, 0.02%-0.08%), respectively. In both faculty and department chairs, the proportion of URiM groups (American Indian or Alaska Native, Black or African American, Hispanic, and Native Hawaiian or Other Pacific Islander) grew the least. Intersectionality analysis suggested that men and non-URiM status were associated with greater representation across ophthalmology faculty and department chairs. However, among ophthalmology faculty, URiM women and men did not significantly differ across strata of academic ranks, whereas for department chairs, no difference was observed in representation between URiM men and non-URiM women.

Conclusion & Relevance

Results of this cohort study revealed that since 1966, workforce diversity progressed slowly and was limited to lower academic ranks and leadership positions. Intersectionality of URiM status and gender persisted in representation trends. These findings suggest further advocacy and intervention are needed to increase workforce diversity.

Social Determinants of Health and Glaucoma Screening and Detection in the SIGHT Studies

PRCIS

Targeted glaucoma screenings in populations with high levels of poverty and high proportions of people who identify as African American or Hispanic/Latino identified a 27% rate of glaucoma and suspected glaucoma, which is 3 times the national average.

PURPOSE

To describe the neighborhood-level social risk factors across the 3 SIGHT Study sites and assess potential characteristics of these populations to help other researchers effectively design and implement targeted glaucoma community-based screening and follow-up programs in high-risk groups.

METHODS/RESULTS

In 2019, Columbia University, the University of Michigan, and the University of Alabama at Birmingham each received 5 years of CDC funding to test a wide spectrum of targeted telehealth delivery methods to detect glaucoma in community-based health delivery settings among high-risk populations. This collaborative initiative supported innovative strategies to better engage populations most at risk and least likely to have access to eye care to detect and manage glaucoma and other eye diseases in community-based settings. Among the initial 2379 participants enrolled in all 3 SIGHT Studies; 27% screened positive for glaucoma/glaucoma suspect. Of all SIGHT Study participants, 91% were 40 years of age and older, 64% identified as female, 60% identified as African-American, 32% identified as White, 19% identified as Hispanic/Latino, 53% had a high school education or less, 15% had no health insurance, and 38% had Medicaid insurance. Targeted glaucoma screenings in populations with high levels of poverty and high proportions of people who identify as African American or Hispanic/Latino identified a 27% rate of glaucoma and suspected glaucoma, three times the national average.

CONCLUSION

These findings were consistent across each of the SIGHT Studies, which are located in 3 geographically distinct US locations in rural Alabama, small urban locations in Michigan, and urban New York City.

Establishment and review of educational programs to train optometrists in laser procedures and injections

Current scope of practice for optometrists in many countries include topical and oral medication with injectable and lasers being added more recently to scope in the United States (US), Canada, the United Kingdom (UK) and New Zealand (NZ). This expanded scope of optometric practice improves access to eyecare and is critical since an ageing population with a higher prevalence of vision disorders and higher healthcare costs looms. Expanded scope has been shown alongside strong safety records. This review paper aims to investigate the expansion of optometric scope of practice regarding lasers and injectables in the US, UK, Canada, Australia and NZ. The design and delivery of post-graduation educational programs, curriculum frameworks for advanced skills and the metrics of laser procedures performed by optometrists will be discussed. The State of Oklahoma in the US was first to authorise optometrists to use lasers and injectables in 1988. As of 2024, qualified optometrists in the UK, in twelve states in the US, and specialist optometrists in NZ perform laser procedures. However, lasers and injectables are not within the current scope of optometric practice in Australia and Canada. Training courses such as Northeastern State University Oklahoma College of Optometry Advanced Procedures Course and Laser Procedures Course have been successfully designed and implemented in the US to train graduate optometrists. The outcomes of over 146,403 laser procedures performed by optometrists across the US have shown only two negative outcomes, equating to 0.001%. These metrics outline the effectiveness of these procedures performed by optometrists and show strong support for future optometric scope expansion. Eye health professionals, relevant educational institutions, advocacy groups, and policymakers are called upon to work collaboratively to expand the optometric scope of practice globally.

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.

Illuminating Perspectives: Navigating Eye Care Access in Sub-Saharan Africa Through the Social Determinants of Health

Ensuring access to proper eye health services is not only a fundamental human right but also crucial for preserving an individual's quality of life, preventing blindness, and promoting overall well-being. This is especially true in low-income countries like Sub-Saharan Africa (SSA) where recognizing the intricate relationship between access to healthcare and social determinants of health (SDOH ) is crucial to addressing health disparities. The goal of this study was to elucidate and highlight not only the barriers millions face in obtaining eye care but also pave the way for interventions and policies aimed at creating equitable access across diverse populations. To do this, a scoping review was conducted across the Cumulated Index to Nursing and Allied Health Literature (CINAHL), Embase, and PubMed databases for studies meeting the search terms and inclusion criteria. The results show that intervention strategies that increase vision care must extend beyond the healthcare sector to address the multifaceted challenges. Collaborating with stakeholders involved in addressing broader livelihood issues, such as food security, education, and SDOH, becomes imperative to ensure comprehensive and sustainable improvements in vision care accessibility in SSA.

Place, Race, and Lapses in Diabetic Retinopathy Care

This cohort study investigates the association of neighborhood-level social determinants of health with lapses in diabetic retinopathy care by race and ethnicity.

Social Determinants of Dry Eye in the United States: A Systematic Review

PURPOSE

To conduct a systematic review to summarize current evidence on associations between social determinants of health (SDOH) indicators and dry eye in the United States.

DESIGN

Systematic review.

METHODS

We followed a protocol registered on Open Science Framework to include studies that examined associations between SDOH indicators and dry eye. We mapped SDOH indicators to 1 of the 5 domains following the Healthy People 2030 framework and categorized dry eye measures into "dry eye diagnosis and care," "dry eye symptoms," or "ocular surface parameters." We summarized the direction of association between SDOH indicators and dry eye as worsening, beneficial, or null. We used items from the Newcastle Ottawa Scale to assess risk of bias.

RESULTS

Eighteen studies reporting 51 SDOH indicators, mostly mapped to the neighborhood and built environment domain, were included. Thirteen studies were judged at high risk of bias. Fifteen of 19 (79%) associations revealed an increase in the diagnosis of dry eye or delayed specialty care for it. Thirty-four of 56 (61%) associations unveiled exacerbated dry eye symptoms. Fifteen of 23 (65%) found null associations with corneal fluorescein staining. Ten of 22 (45%) associations revealed an increased tear break up time (45%) whereas another 10 (45%) showed null associations.

CONCLUSIONS

Most SDOH indicators studied were associated with unfavorable dry eye measures, such as a higher disease burden, worse symptoms, or delayed referral, in the United States. Future investigations between SDOH and dry eye should use standardized instruments and address the domains in which there is an evidence gap.

Manhattan Vision Screening and Follow-Up Study (NYC-SIGHT): optometric exam improves access and utilization of eye care services

PURPOSE

To describe the benefits of optometric evaluation for detection of vision-affecting conditions in the context of community-based eye health screenings and identify factors associated with having a recent dilated eye exam.

METHODS

Enrolled participants were age 40 and older, living independently in affordable housing developments in New York City. Eye health screening failure and criteria for seeing the on-site study optometrist were defined as visual acuity 20/40 or worse in either eye, intraocular pressure 23-29 mmHg, or an unreadable fundus image. The optometrist conducted a manifest refraction using loose lenses and used a portable slit lamp and ophthalmoscope to perform a non-dilated anterior and posterior segment ocular health evaluation. Demographics, social determinants of health, eye health screening results, and rates of suspected ophthalmic conditions were recorded. To determine factors associated with having a recent dilated eye exam, which was the main outcome for this statistical analysis, a stepwise multivariate logistic regression was performed.

RESULTS

A total of 708 participants were screened, 308 attended the optometric exam; mean age 70.7 ± 11.7 [standard deviation (SD)] years. Among this subgroup, 70.1% identified as female, 54.9% self-identified as African American, 39% as Hispanic/Latino, and 26.6% Dominican ethnicity; 78.2% (241/308) had not undergone a dilated eye exam within the last year, 71.4% reported they did not have an eye care provider. Stepwise multivariate logistic regression analysis indicated that participants who self-reported having cataracts (odds ratio (OR) 2.15; 95% confidence interval (CI) 1.03-4.47; p = 0.041), self-reported having glaucoma/glaucoma suspect (OR 5.60; 95% CI 2.02-15.43; p = 0.001), or spoke Spanish as their primary language (OR 3.25; 95% CI 1.48-7.11; p = 0.003) had higher odds of having a recent dilated eye exam.

CONCLUSIONS

This community-based screening initiative demonstrated the effectiveness of optometric exams in detecting vision-affecting conditions and identified factors associated with having a recent dilated eye exam. Optometrists play a vital role in increasing access to eye care for high-risk, underserved populations.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04271709).

Association of Sociodemographic Characteristics with Pediatric Vision Screening and Eye Care: An Analysis of the 2021 National Survey of Children's Health

PURPOSE

Vision screening and regular eye care can help detect and treat potentially irreversible vision impairment. This study aims to investigate the associations between sociodemographic and health characteristics and the receipt of eye care among children aged 17 years and younger in the United States.

DESIGN

This cross-sectional study used data from the National Survey of Children's Health (NSCH), a nationally representative and population-based survey of randomly sampled households.

PARTICIPANTS

Participants were children aged 0 to 17 years, residing in all 50 states and the District of Columbia, whose caregivers or parents answered an address-based survey by mail or online.

METHODS

Weighted prevalence calculations were applied to analyze the data, and logistic regression was performed to explore associations between reported eye care and demographic, health, and parent-related variables.

MAIN OUTCOME MEASURES

Caregiver-reported vision screenings, referral to an eye doctor after vision screening, eye doctor visits, and prescription of corrective lenses.

RESULTS

Caregivers reported that 53.2% of children had a vision screening at least once (if child ≤ 5 years) or within the past 2 years (if child > 5 years). Of those screened, 26.9% were referred to an eye doctor. Overall, 38.6% of all children had a previous eye doctor visit, and among them, 55.4% were prescribed corrective lenses during the visit. Factors associated with decreased odds of vision screening included younger age, lack of health care visits, no insurance coverage, parent education high school or less, and lower household income. Non-White ethnicities, households with a non-English primary language, and lower incomes were more likely to be referred to an eye doctor after vision screening. Lower rates of eye doctor visits were associated with younger age, lack of insurance coverage, and primary household languages other than English.

CONCLUSIONS

Children from disadvantaged backgrounds are less likely to receive vision screening and eye care. Targeted strategies are needed to increase vision screening and access to eye care services in these vulnerable groups.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Novel Methods of Identifying Individual and Neighborhood Risk Factors for Loss to Follow-Up After Ophthalmic Screening

PRCIS

Residence in a middle-class neighborhood correlated with lower follow-up compared with residence in more affluent neighborhoods. The most common explanations for not following up were the process of making an appointment and lack of symptoms.

PURPOSE

To explore which individual-level and neighborhood-level factors influence follow-up as recommended after positive ophthalmic and primary care screening in a vulnerable population using novel methodologies.

PARTICIPANTS AND METHODS

From 2017 to 2018, 957 participants were screened for ophthalmic disease and cardiovascular risk factors as part of the Real-Time Mobile Teleophthalmology study. Individuals who screened positive for either ophthalmic or cardiovascular risk factors were contacted to determine whether or not they followed up with a health care provider. Data from the Social Vulnerability Index, a novel virtual auditing system, and personal demographics were collected for each participant. A multivariate logistic regression was performed to determine which factors significantly differed between participants who followed up and those who did not.

RESULTS

As a whole, the study population was more socioeconomically vulnerable than the national average (mean summary Social Vulnerability Index score=0.81). Participants whose neighborhoods fell in the middle of the national per capita income distribution had a lower likelihood of follow-up compared with those who resided in the most affluent neighborhoods (relative risk ratio=0.21, P -value<0.01). Participants cited the complicated process of making an eye care appointment and lack of symptoms as the most common reasons for not following up as instructed within 4 months.

CONCLUSIONS

Residence in a middle-class neighborhood, difficulty accessing eye care appointments, and low health literacy may influence follow-up among vulnerable populations.

Older adults' perceptions of navigating eye health care in Denmark: a qualitative study

BACKGROUND

Vision impairment can have an impact on cognition, health, and social function. Vision loss may be avoided if detected early and treated promptly. Eye health is a minor topic in general practice, but the ongoing relationship between doctor and patient has the potential to assist the patient in navigating the healthcare system and guaranteeing timely healthcare service delivery.

AIM

To explore the attitudes of older members of the public (aged ≥60 years) towards navigating primary sector eye health care in Denmark, with a focus on optometrists, practising ophthalmologists (POs), and GPs.

DESIGN & SETTING

Qualitative study in Copenhagen, Denmark.

METHOD

Focus group interviews were performed in the spring of 2022 with 21 older members of the public.

RESULTS

Older members of the public perceived optometrists and POs to be the most relevant health professionals to consult about eye health. Opportunities were identified for enhancing the function of general practice including detecting early signs of visual impairment, being in charge of further referrals, and managing issues affecting quality of life such as dry eyes.

CONCLUSION

Older members of the public sought help from health professionals who are directly qualified to treat symptoms of vision impairment that patients are experiencing or expect to face in the near future. Participants identified a potential for GPs to address vision impairment. This included focusing on the patient's general health and function, as well as potential comorbidities influencing treatment trajectories. The current denigration of general practice risks missing out on the potential benefits of robust engagement from general practice in eye health.

Infectious Keratitis After Keratoplasty in the United States: Analysis of a National Medicare Claims Data Set

PURPOSE

The aim of this study was to assess the incidence, trends, and risk factors of infectious keratitis (IK) and subsequent repeat keratoplasty after penetrating keratoplasty (PK) and endothelial keratoplasty (EK).

METHODS

Using a retrospective cohort study design, IK cases within 6 months of keratoplasty were identified using billing codes among 100% Medicare beneficiaries aged 65 years and older who underwent either PK or EK between 2011 and 2020. Multivariable logistic regression models were used to evaluate factors associated with postkeratoplasty IK.

RESULTS

We identified 115,588 keratoplasties, of which 20.0% (n = 23,144) were PK and 80.0% (n = 92,444) were EK. IK developed within 6 months with a rate of 3.32% (n = 769) post-PK and 0.72% (n = 666) post-EK. Overall rates of IK decreased from 16.05 to 9.61 per 1000 keratoplasties between 2011 and 2020 ( P < 0.001). The median interval between keratoplasty and diagnosis of IK was 73 days (interquartile range: 29-114 days) for PK and 74 days (interquartile range: 38-116 days) for EK. After IK, 22.9% (n = 176) and 23.8% (n = 159) eyes underwent repeat keratoplasty within 1 year for PK and EK, respectively. The occurrence of IK after PK was associated with age 85 years and older [odds ratio (OR): 1.38; 95% confidence interval (CI): 1.13-1.68] relative to patients aged 65 to 74 years. The occurrence of IK after EK was also associated with age 85 years and older (OR: 1.44; 95% CI: 1.14-1.82) relative to patients aged 65 to 74 years.

CONCLUSIONS

IK was 4 times more common after PK than EK and the complication was associated with older age. Our findings may help corneal surgeons in counseling patients at higher risk and guiding their postoperative care.

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.

Vision Need Profiles for the City of Richmond, Virginia: A Pilot Application of Calibration Methods to Vision Surveillance

Purpose

People with vision problems (VPs) have different needs based on their age, economic resources, housing type, neighborhood, and other disabilities. We used calibration methods to create synthetic data to estimate census tract-level community need profiles (CNPs) for the city of Richmond, Virginia.

Design

Cross-sectional secondary data analysis.

Subjects

Anonymized respondents to the 2015 to 2019 American Community Survey (ACS).

Methods

We used calibration methods to transform the ACS 5-year tabular (2015-2019) and Public Use Microdata estimates into a synthetic data set of person-level records in each census tract, and subset the data to persons who answered yes to the question "Are you blind or do you have serious difficulty seeing even when wearing glasses?" To identify individual need profiles (INPs), we applied divisive clustering to 17 variables measuring individual demographics, nonvision disability status, socioeconomic status (SES), housing, and access and independence. We labeled tracts with CNP names based on their predominant INPs and performed sensitivity analyses. We mapped the CNPs and overlayed information on the number of people with VP, the National Walkability Index, and an uncertainty measure based on our sensitivity analysis.

Main Outcome Measures

Individual need profiles and CNPs.

Results

Compared with people without VP, people with VP exhibited higher rates of disabilities, having low incomes, living alone, and lacking access to the internet or private home vehicles. Among people with VP, we identified 7 INP clusters which we mapped into 6 CNPs: (1) seniors (≥ age 65); (2) low SES younger; (3) low SES older; (4) mixed SES; (5) higher SES; and (6) adults and children in group quarters. Three CNPs had lower-than-average walkability. Community need profile assignments were somewhat sensitive to calibration variables, with 18 tracts changing assignments in 1 sensitivity analysis, and 4 tracts changing assignments in ≥ 2 sensitivity analyses.

Conclusions

This pilot project illustrates the feasibility of using ACS data to better understand the support and service needs of people with VP at the census tract level. However, a subset of categorical CNP assignments were sensitive to variable selection leading to uncertainty in CNP assignment in certain tracts.

Financial Disclosures

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Amblyopia Care Trends Following Widespread Photoscreener Adoption

Importance

Amblyopia can result in permanent vision loss if not properly treated before age 7 years. In 2017, the US Preventive Services Task Force recommended that vision screening should occur at least once in all children aged 3 to 5 years to detect amblyopia.

Objective

To understand trends and factors associated with screening, referral, or diagnosis of amblyopia before and after photoscreening expansion across a relatively large health care system in late 2017.

Design, Setting, and Participants

This is a retrospective cohort study of electronic health record data from patients with a well child care visit at approximately age 3 years (ages 2.75-3.25 years) in a relatively large, multispecialty group practice in Northern California and linked census data between 2015 and 2022. Data were extracted and analyzed from October 2022 through August 2023.

Exposures

Patient sex, race and ethnicity, immunization records, previous well child care visits, and census-level median household income.

Main Outcomes and Measures

Vision screening, pediatric ophthalmology referral, or amblyopia diagnosis, compared using adjusted odds ratios (AORs).

Results

The study included 2015-2017 data from 23 246 patients aged 3 years with at least 1 well child care visit (11 206 [48.2%] female) compared with 2018-2022 postexpansion data from 34 281 patients (16 517 [48.2%] female). The screening rate increased from 5.7% (424 of 7505) in 2015 to 72.1% (4578 of 6354) in 2022. The referral rate increased from 17.0% (1279 of 7505) in 2015 to 23.6% (1836 of 7792) in 2018. The diagnosis rate was 2.7% (200 of 7505) in 2015, peaked at 3.4% (263 of 7792) in 2018, and decreased to 1.4% (88 of 6354) in 2022. Compared with White patients, patients who were Asian, Black, or Hispanic were less likely to be screened (Asian: AOR, 0.80; 95% CI, 0.72-0.88; Black: AOR, 0.71; 95% CI, 0.53-0.96; Hispanic: AOR, 0.88; 95% CI, 0.80-0.97). Compared with White patients, patients who were Asian or Hispanic were more likely to be referred (Asian: AOR, 1.49; 95% CI, 1.36-1.62; Hispanic: AOR, 1.32; 95% CI, 1.18-1.48) and were more likely to be diagnosed (Asian: AOR, 1.29; 95% CI, 1.07-1.56; Hispanic: AOR, 1.67; 95% CI, 1.33-2.11).

Conclusions and Relevance

In this study, increased availability of photoscreeners was associated with an increase in overall rates of vision screening for children aged 3 years in a relatively large health care system. Given that US rates of visual impairment are predicted to increase, additional targeted interventions would be needed to address remaining disparities in amblyopia care along patient- and clinician-level factors.