The role of social deprivation in severe neovascular age-related macular degeneration

Do Socioeconomic Inequalities Exist Within Ophthalmology and Orthoptics in the UK?: A Scoping Review

Introduction

It is well documented that socioeconomic disadvantage adversely affects general health and ocular health worldwide. Within orthoptics, while clinicians recognise a relationship between socioeconomic situation and treatment outcome, no previous literature review was found to address this issue. Neither was a UK-specific literature review found to address the same issue for ophthalmology as a whole.

Aim

This literature review evaluates evidence for an association between socioeconomic situation and ophthalmic/orthoptic conditions and their treatment outcomes, specifically within the UK.

Methods

Keyword searches were conducted on Google Scholar and the University of Liverpool library catalogue. Results for the main analyses were limited to full papers, specific to the UK, written in English. Literature was only included from pre-2000 if more recent evidence was insufficient.

Results

There is evidence of socioeconomic disadvantage being associated with the following: reduced visual acuity; reduced attendance at diabetic retinopathy screening appointments; and delayed presentation of glaucoma, cataracts, and diabetic retinopathy. However, evidence linking socioeconomic disadvantage to AMD is mixed. There is limited evidence of the increased prevalence of amblyopia and subsequent barriers to its treatment for socioeconomically underserved children. There is also evidence of a reduction in quality of life for socioeconomically underserved adults with strabismus.

Conclusions

Health inequalities within ophthalmology and orthoptics are reported, but with confounding results for some conditions. Further research should explore the reasons behind the inequalities that are found and identify methods of reducing them.

Barriers to care in neovascular age-related macular degeneration: Current understanding, developments, and future directions

Neovascular age-related macular degeneration is the advanced and irreversible stage of age-related macular degeneration, the leading cause of severe vision loss in older adults. While anti-vascular endothelial growth factor injections have been shown to preserve or improve vision quality in eyes with neovascular age-related macular degeneration, the treatment regimen can be demanding of patients and caregivers, leading to lower rates of adherence. Therefore, it is crucial that disparities and obstacles in neovascular age-related macular degeneration care are identified to improve access to treatment. Review of the current literature revealed 7 major categories of barriers: travel burden, psychological barriers, financial burden and socioeconomic status, treatment regimen, other comorbidities, provider-level barriers, and system-level barriers. We provide an overview of the major barriers to neovascular age-related macular degeneration care that have been reported, as well as gaps in research that need to be investigated further.

The Impact of Social Determinants of Health on Presentation, Treatment, and Outcomes in Branch Retinal Vein Occlusion With Cystoid Macular Edema

BACKGROUND AND OBJECTIVE

To investigate the impact of social determinants of health on the presentation, treatment, and outcomes of branch retinal vein occlusion (BRVO) with cystoid macular edema (CME).

PATIENTS AND METHODS

A retrospective chart review was conducted of patients with BRVO and CME treated with anti-vascular endothelial growth factor (anti-VEGF) injections at Atrium Health Wake Forest Baptist from 2013 to 2021. Patients' baseline characteristics including visual acuity (VA), age, sex, race, Area Deprivation Index (ADI), insurance status, baseline central macular thickness (CMT), treatment details, final VA, and final CMT were recorded. The primary outcome measure was final VA comparing more and less deprived groups, and White and non-White groups.

RESULTS

Two hundred forty-four eyes of 240 patients were included. Patients with higher socioeconomic deprivation scores had thicker final CMT (P = 0.05). Non-White patients had worse presenting (P = 0.01) and final VA (P = 0.02).

CONCLUSION

This study demonstrated disparities in presentation and outcomes based on socioeconomic status and race in patients with BRVO and CME treated with anti-VEGF therapy. [Ophthalmic Surg Lasers Imaging Retina 2023;54:xx-xx.].

The impact of the first United Kingdom COVID-19 lockdown on environmental air pollution, digital display device use and ocular surface disease symptomatology amongst shielding patients

Worldwide lockdown reduced air pollution during the first phase of the COVID-19 pandemic. The relationship between exposure to ambient air pollution, digital display device use and dry eye symptoms amongst patients with severe ocular surface disease (OSD) were considered. Symptoms and air pollutant concentrations for three different time periods (pre, during and post COVID-19 lockdown) were analysed in 35 OSD patients who achieved an immunosuppression risk-stratification score > 3 fulfilling the UK Government criteria for 12-week shielding. OSDI symptoms questionnaire, residential postcode air pollution data obtained from the Defra Automated Urban and Rural monitoring network for concentrations of nitrogen dioxide (NO₂), nitrogen oxides (NOx), particulate matter (PM) with diameters below 10 µm and 2.5 µm, and English Indices of Deprivation were analysed. Significant reductions in NO₂ and NOx concentrations were observed between pre- and during-lockdown periods, followed by a reversal in the post-lockdown period. Changes were linked to the Living Environment outdoor decile. A 12% increase (p = 0.381) in symptomatology during-lockdown was observed that reversed post-lockdown by 19% (p = 0.144). OSDI scores were significantly correlated with hours spent on digital devices (r² = 0.243) but not with air pollutant concentrations. Lockdown measures reduced ambient air pollutants whilst OSD symptomatology persisted. Environmental factors such as increased time indoors and use of bluescreen digital devices may have partly played a role.

Socio-economic differences in accessing NHS spectacles amongst children with differing refractive errors living in Scotland

BACKGROUND/OBJECTIVES

Adults living in more deprived areas are less likely to attend an eye examination, resulting in greater visual impairment from undiagnosed eye disease and a widening of health inequalities. It is unknown if the introduction of free NHS eye examinations and help with spectacle costs has benefited children in Scotland. This study aimed to explore factors associated with accessing NHS spectacles including level of deprivation, refractive error, urbanity and age.

SUBJECTS/METHODS

NHS-financed General Ophthalmic Services (GOS) 3 supplement the cost of spectacles for children under 16 years. Administrative data on the spectacle refraction dispensed were obtained from Information Services Division (ISD) for mainland Scotland, 2018, and categorised by: Emmetropes/low hyperopes (reference group), myopes and moderate/high hyperopes. Data were linked to the Scottish Index of Multiple Deprivation (SIMD) quintile.

RESULTS

Data included 108, 043 GOS 3 claims. Greater deprivation was associated with greater GOS 3 claims p = 0.041. This was most evident in emmetropic/low hyperopic children and in moderate/high hyperopic children. GOS 3 claims in the myopes group increased with age across all SIMD and decreased with age in the moderate/high hyperope group (all p < 0.001). GOS 3 claims were not associated with urbanity for all Health Boards (p = 0.13).

CONCLUSIONS

Children in areas of greater deprivation and in more rural areas are not disadvantaged in accessing NHS spectacles. This did not vary by refractive error group. This suggests that health policy in Scotland is accessible to those from all deprivation levels and refractive errors.

Socioeconomic deprivation and development of diabetic retinopathy in patients with type 1 diabetes mellitus

INTRODUCTION

Very little is known about the influence of socioeconomic status on type 1 diabetes mellitus (T1DM) complications. Our aim was to determine whether socioeconomic level is a risk factor for the development of diabetic retinopathy (DR) in patients with T1DM.

RESEARCH DESIGN AND METHODS

A cohort of 150 patients with T1DM were studied prospectively over 9 years. Socioeconomic status was assessed using a neighborhood-level measure based on an index of deprivation. The contribution of other variables such as hypertension, dyslipidemia, diabetic nephropathy and smoking habit was evaluated. Cox proportional hazards models were used to quantify the associations.

RESULTS

The incidence of DR was 21.6 cases per 1000 patient-years. Multivariable analyses showed that for each percentage point increase in glycated hemoglobin (HbA1c), the risk of developing DR increased by 58% (HR 1.58, 95% CI 1.19 to 2.10).Patients with T1DM onset >18 years of age and resident in areas of lower socioeconomic levels presented with almost triple the risk of developing DR (HR 2.95, 95% CI 1.08 to 8.00) compared with those with onset <18 years of age and resident in less deprived areas. We did not find significant relationships with other variables studied such as hypertension, dyslipidemia, diabetic nephropathy and smoking habit.

CONCLUSIONS

Low socioeconomic level is a risk factor, independent of glycemic control, in the development of DR in patients with T1DM when the onset of diabetes is in adulthood. This finding indicates that socioeconomic status and age of onset need to be considered in population screening for DR in patients with T1DM.

Quantitative Analysis of OCT for Neovascular Age-Related Macular Degeneration Using Deep Learning

PURPOSE

To apply a deep learning algorithm for automated, objective, and comprehensive quantification of OCT scans to a large real-world dataset of eyes with neovascular age-related macular degeneration (AMD) and make the raw segmentation output data openly available for further research.

DESIGN

Retrospective analysis of OCT images from the Moorfields Eye Hospital AMD Database.

PARTICIPANTS

A total of 2473 first-treated eyes and 493 second-treated eyes that commenced therapy for neovascular AMD between June 2012 and June 2017.

METHODS

A deep learning algorithm was used to segment all baseline OCT scans. Volumes were calculated for segmented features such as neurosensory retina (NSR), drusen, intraretinal fluid (IRF), subretinal fluid (SRF), subretinal hyperreflective material (SHRM), retinal pigment epithelium (RPE), hyperreflective foci (HRF), fibrovascular pigment epithelium detachment (fvPED), and serous PED (sPED). Analyses included comparisons between first- and second-treated eyes by visual acuity (VA) and race/ethnicity and correlations between volumes.

MAIN OUTCOME MEASURES

Volumes of segmented features (mm³) and central subfield thickness (CST) (μm).

RESULTS

In first-treated eyes, the majority had both IRF and SRF (54.7%). First-treated eyes had greater volumes for all segmented tissues, with the exception of drusen, which was greater in second-treated eyes. In first-treated eyes, older age was associated with lower volumes for RPE, SRF, NSR, and sPED; in second-treated eyes, older age was associated with lower volumes of NSR, RPE, sPED, fvPED, and SRF. Eyes from Black individuals had higher SRF, RPE, and serous PED volumes compared with other ethnic groups. Greater volumes of the majority of features were associated with worse VA.

CONCLUSIONS

We report the results of large-scale automated quantification of a novel range of baseline features in neovascular AMD. Major differences between first- and second-treated eyes, with increasing age, and between ethnicities are highlighted. In the coming years, enhanced, automated OCT segmentation may assist personalization of real-world care and the detection of novel structure-function correlations. These data will be made publicly available for replication and future investigation by the AMD research community.

A qualitative exploration of Australian eyecare professional perspectives on Age-Related Macular Degeneration (AMD) care

Despite the existence of evidence-based recommendations to decrease risk and progression of Age-Related Macular Degeneration (AMD) for some time, self-reported practices suggest that eyecare professionals' advice and people with AMD's adherence to these recommendations can be very poor. This study uses qualitative methods to explore Australian eyecare professionals' perspective on barriers to effective AMD care. Seven focus groups involving 65 optometrists were conducted by an experienced facilitator. A nominal group technique was used to identify, prioritize and semi-quantify barriers and enablers to AMD care. Participants individually ranked their perceived top five barriers and enablers with the most important granted a score of 5 and the least important a score of 1. For each barrier or enabler, the number of votes it received and its total score were recorded. Barriers and enablers selected by at least one participant in their top 5 were then qualitatively analysed, grouped using thematic analysis and total score calculated for each consolidated barrier or enabler. In-depth individual interviews were conducted with 10 ophthalmologists and 2 optometrists. Contributions were audio-recorded, transcribed verbatim and analysed with NVivo software. One hundred and sixty-nine barriers and 51 enablers to AMD care were identified in the focus groups. Of these, 102 barriers and 42 enablers were selected as one of their top 5 by at least one participant and further consolidated into 16 barriers and 10 enablers after thematic analysis. Factors impacting AMD care identified through analysis of the transcripts were coded to three categories of influence: patient-centered, practitioner-centered, and structural factors. Eyecare professionals considered poor care pathways, people with AMD's poor disease understanding / denial, and cost of care / lack of funding, as the most significant barriers to AMD care; they considered shared care model, access, and communication as the most significant enablers to good AMD care. These findings suggest that Australian eyecare professionals perceive that there is a need for improved patient support systems and appropriately funded, clearer care pathway to benefit people with AMD.

[Reasons for delayed and discontinued therapy in age-related macular degeneration]

BACKGROUND

Critical prerequisites for successful therapy of neovascular age-related macular degeneration (nvAMD) are an early initiation and continuous monitoring; however, delays in starting therapy and non-medically indicated discontinuation of therapy are frequent, which limits therapy efficacy and, thus, visual outcomes.

OBJECTIVE

To identify the reasons for delay in therapy and non-medically indicated termination of therapy.

MATERIAL AND METHODS

Patients who had started a new therapy (starters) and those who independently terminated therapy (dropouts) were interviewed by telephone with a specific, standardized questionnaire. Results were summarized descriptively.

RESULTS

A total of 100 starters and 55 dropouts were interviewed. The mean therapy delay was 22 (±28 SD) days. This was mainly due to the time until the decision to see an ophthalmologist was made. Main reasons for dropping out were: transportation issues (27%), poor general health (25%) and the assumption that there is no benefit from therapy (11%). Of the patients who dropped out 63% would have liked to continue therapy.

CONCLUSION

There is potential for improvement in nvAMD management regarding therapy start as well as therapy maintenance. Sensitizing for initial nvAMD symptoms is important as is reduction of barriers to therapy maintenance, since most therapy dropouts would like to continue the therapy.

United Kingdom Diabetic Retinopathy Electronic Medical Record (UK DR EMR) Users Group: report 4, real-world data on the impact of deprivation on the presentation of diabetic eye disease at hospital services

AIM

To assess the impact of deprivation on diabetic retinopathy presentation and related treatment interventions, as observed within the UK hospital eye service.

METHODS

This is a multicentre, national diabetic retinopathy database study with anonymised data extraction across 22 centres from an electronic medical record system. The following were the inclusion criteria: all patients with diabetes and a recorded, structured diabetic retinopathy grade. The minimum data set included, for baseline, age and Index of Multiple Deprivation, based on residential postcode; and for all time points, visual acuity, ETDRS grading of retinopathy and maculopathy, and interventions (laser, intravitreal therapies and surgery). The main  outcome measures were (1) visual acuity and binocular visual state, and (2) presence of sight-threatening complications and need for early treatment.

RESULTS

79 775 patients met the inclusion criteria. Deprivation was associated with later presentation in patients with diabetic eye disease: the OR of being sight-impaired at entry into the hospital eye service (defined as 6/18 to better than 3/60 in the better seeing eye) was 1.29 (95% CI 1.20 to 1.39) for the most deprived decile vs 0.77 (95% CI 0.70 to 0.86) for the least deprived decile; the OR for being severely sight-impaired (3/60 or worse in the better seeing eye) was 1.17 (95% CI 0.90 to 1.55) for the most deprived decile vs 0.88 (95% CI 0.61 to 1.27) for the least deprived decile (reference=fifth decile in all cases). There is also variation in sight-threatening complications at presentation and treatment undertaken: the least deprived deciles had lower chance of having a tractional retinal detachment (OR=0.48 and 0.58 for deciles 9 and 10, 95% CI 0.24 to 0.90 and 0.29 to 1.09, respectively); in terms of accessing treatment, the rate of having a vitrectomy was lowest in the most deprived cohort (OR=0.34, 95% CI 0.19 to 0.58).

CONCLUSIONS

This large real-world study suggests that first presentation at a hospital eye clinic with visual loss or sight-threatening diabetic eye disease is associated with deprivation. These initial hospital visits represent the first opportunities to receive treatment and to formally engage with support services. Such patients are more likely to be sight-impaired or severely sight-impaired at presentation, and may need additional resources to engage with the hospital eye services over complex treatment schedules.

Socio-economic status and outcomes for patients with age-related macular degeneration

OBJECTIVES

To explore disparities in severity of baseline disease, treatment completion, and treatment outcomes among patients with wet age-related macular degeneration (AMD) receiving anti-vascular endothelial growth factor therapy by socio-economic status (SES) and distance from home to hospital.

STUDY DESIGN

Retrospective cohort study.

METHODS

Data from clinic records of 756 wet AMD patients receiving treatment for wet AMD with aflibercept between May 2013 and Jan 2017 were obtained. Area SES (using Index of Multiple Deprivation (IMD) 2015) and distance from hospital (dichotomized > = 10 vs. <10 km) were derived from anonymized postcodes. Univariate and multivariable logistic regression models were used to identify associations of area deprivation and distance from hospital at baseline-with visual acuity (VA) at baseline-treatment completion, and treatment outcome.

RESULTS

Living in the most deprived compared with less deprived areas was associated with a significantly higher risk of presenting with severe reduction in VA (OR = 3.59; 95% CI = 1.39-9.27; P = .01). This association was maintained after adjustment for age, gender, and distance from hospital. On univariate analysis, delayed treatment completion was more likely in those living in most deprived areas (OR = 2.80; 95% CI = 1.21-6.47; P = .04), though this association was attenuated after adjustment for age, gender, and distance from hospital. No association was observed between SES and treatment outcomes or between distance from hospital and baseline VA, treatment completion or treatment outcome.

CONCLUSION

This study found poorer baseline VA among people with wet AMD from more deprived areas. This work suggests a need for earlier identification of AMD among more deprived populations.

Multiple deprivation, vision loss, and ophthalmic disease in adults: global perspectives

The association between socioeconomic position and morbidity and mortality has long been recognized. We evaluate the evidence for an association between multiple aspects of deprivation and ocular health in a global context. This is a systematic review of studies that evaluated deprivation in the adult population in the context of the major acquired causes of visual loss such as cataract, diabetic eye disease, glaucoma, age-related macular degeneration, and ocular trauma. The search strategy identified relevant studies reported between 1946 and August 2016, with randomized control trials, case-control, cohort, and cross-sectional study designs being selected for inclusion. The studies identified in this review from across the world demonstrate the extent to which the common themes such as low educational attainment and low income may be associated with increased incidence of various sight-threatening conditions and may adversely affect access to specialist assessment and delivery of treatment. Health inequality may always persist, but an increased recognition of the importance of the various impacts of deprivation may empower policy makers to target limited resources to the most vulnerable groups in order to deliver the greatest benefit.

Clinical and social characteristics associated with reduced visual acuity at presentation in Australian patients with neovascular age-related macular degeneration: a prospective study from a long-term observational data set. The Fight Retinal Blindness! Project

IMPORTANCE

Identifying variables that influence presenting visual acuity (VA) in patients with neovascular age-related macular degeneration (nAMD) is important because it is a strong predictor of long-term outcomes.

BACKGROUND

To assess the clinical and social characteristics associated with low presenting VA in nAMD patients.

DESIGN

The present study is a cross-sectional analysis from a prospective, observational database.

PARTICIPANTS

We identified 3242 treatment-naïve patients from 54 Australian practices in the Fight Retinal Blindness! registry.

METHODS

Age, gender, ethnicity and VA were recorded at the baseline visit. Socio-economic status was determined using the Australian Bureau of Statistics socio-economic indexes for areas.

MAIN OUTCOME MEASURES

Association between clinical and socio-economic characteristics with presenting VA was identified.

RESULTS

Poor VA (≤35 letters) in the presenting eye was associated with older age (adjusted odds ratio [AOR]: 1.33 for patients aged ≥80 years vs. <80 years [95% confidence interval, CI: 1.04, 1.71]), treatment at a public practice (AOR: 1.91 for public vs. private practices [95% CI: 1.46, 2.50]) and intermediate (36-69 letters) VA in the fellow eye (AOR: 0.67 [95% CI: 0.47, 0.95] and 0.64 [95% CI: 0.48, 0.85] for poor [≤35 letters] and good [≥70 letters] VA vs. intermediate VA in the fellow eye). Gender, ethnicity and socio-economic status were not independently associated with VA at presentation.

CONCLUSIONS AND RELEVANCE

Poor presenting vision is detrimental to the long-term outcomes of nAMD. Poor presentation of nAMD in Australia may not be related to socio-economic circumstances, but due to systems of care. Further research is warranted to determine why patients at public practices present with worse vision compared with private practices in Australia.

Social deprivation as a risk factor for late presentation of proliferative diabetic retinopathy

Purpose

The aim of this study was to determine whether social deprivation is a risk factor for late presentation of patients with proliferative diabetic retinopathy and whether it affects their access to urgent laser treatment.

Methods

Using a 2:1 case: control design, 102 patients referred to a UK teaching hospital as part of the UK Diabetic Retinopathy National Screening Programme were identified for the period between 1 June 2010 to 1 June 2013. Social deprivation was scored using the Index of Multiple Deprivation 2010. Additional variables considered included age, duration of disease, ethnicity, and HbA_1c at time of referral.

Results

The cases comprised 34 patients referred with proliferative (grade R3) retinopathy with a control group of 68 patients with lower retinopathy grades; two control patients were excluded due to incomplete data. On univariate analysis, R3 retinopathy was associated with higher social deprivation (P<0.001, Mann–Whitney U-test), and with higher HbA_1c (11.5% vs 8.4%; P<0.001, Mann–Whitney U-test). Forward stepwise multivariable analysis showed that the association of R3 retinopathy with deprivation was significant even after adjusting for HbA_1c (P=0.016). On univariate analysis South Asian ethnicity was also identified as being a risk factor for presentation with R3 retinopathy, but this was no longer significant when HbA_1c was adjusted for in a forward stepwise logistic regression analysis.

Conclusion

In our cohort social deprivation appears to be associated with late presentation of proliferative diabetic retinopathy. Our study supports the need to target these groups to reduce preventable blindness and to identify strategies which overcome barriers to care.