Area deprivation, individual socioeconomic status and low vision in the EPIC-Norfolk Eye Study

The Risk of Cardiovascular Disease Risk Among Adults with Vision Impairment from Low-, Middle- and High-Income Countries

PURPOSE

The limited evidence for cardiovascular disease (CVD) among adults with vision impairment (VI) has often been from developed countries using self-reported VI. This study evaluated the association of objectively-determined VI with the risk of CVD among adults from low-, middle-, and high-income countries.

METHODS

Data were from 32,268 adults aged 30-74 years without CVD or blindness from China, Ghana, India, Mexico, Russian Federation, South Africa, and the United States during 2007-2010. VI and severe VI was defined as presenting visual acuity worse than 6/18, and 6/60, respectively. The Framingham risk algorithm was used to estimate the risk for incident CVD. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals.

RESULTS

The mean age of participants was 46.4 years, with half of them being women (49.3%). The age-adjusted prevalence of VI ranged from 1.1% (United States) to 14.2% (South Africa) while severe VI ranged from 0.4% (United States) to 4.5% (Ghana). In models adjusting for country, sociodemographic factors, waist girth, healthcare use, activities of daily living and other health-related factors, VI was associated with CVD risk ≥ 10% (OR = 1.69, 95% CI: 1.22-2.36). This observed association was largely consistent across countries (p = 0.119). The observed CVD risk was similar among adults with moderate or severe VI (OR = 0.95, 95% CI: 0.50-1.83). CVD risk was higher among adults with VI who were <65 years old (OR = 1.89, 95% CI: 1.36-2.63) or were employed (OR = 2.24, 95% CI: 1.58-3.16).

CONLUSIONS

This cross-national study shows that individuals with VI are at high risk for future CVD.

Exercise to Prevent Accelerated Vascular Aging in People Living With HIV

Given advances in antiretroviral therapy, the mortality rate for HIV infection has dropped considerably over recent decades. However, people living with HIV (PLWH) experience longer life spans coupled with persistent immune activation despite viral suppression and potential toxicity from long-term antiretroviral therapy use. Consequently, PLWH face a cardiovascular disease (CVD) risk more than twice that of the general population, making it the leading cause of death among this group. Here, we briefly review the epidemiology of CVD in PLWH highlighting disparities at the intersections of sex and gender, age, race/ethnicity, and the contributions of social determinants of health and psychosocial stress to increased CVD risk among individuals with marginalized identities. We then overview the pathophysiology of HIV and discuss the primary factors implicated as contributors to CVD risk among PLWH on antiretroviral therapy. Subsequently, we highlight the functional evidence of premature vascular dysfunction as an early pathophysiological determinant of CVD risk among PLWH, discuss several mechanisms underlying premature vascular dysfunction in PLWH, and synthesize current research on the pathophysiological mechanisms underlying accelerated vascular aging in PLWH, focusing on immune activation, chronic inflammation, and oxidative stress. We consider understudied aspects such as HIV-related changes to the gut microbiome and psychosocial stress, which may serve as mechanisms through which exercise can abrogate accelerated vascular aging. Emphasizing the significance of exercise, we review various modalities and their impacts on vascular health, proposing a holistic approach to managing CVD risks in PLWH. The discussion extends to critical future study areas related to vascular aging, CVD, and the efficacy of exercise interventions, with a call for more inclusive research that considers the diversity of the PLWH population.

The BLV App Arcade: a new curated repository and evaluation rubric for mobile applications supporting blindness and low vision

PURPOSE

Visual impairment-related disabilities have become increasingly pervasive. Current reports estimate a total of 36 million persons with blindness and 217 million persons with moderate to severe visual impairment worldwide. Assistive technologies (AT), including text-to-speech software, navigational/spatial guides, and object recognition tools have the capacity to improve the lives of people with blindness and low vision. However, access to such AT is constrained by high costs and implementation barriers. More recently, expansive growth in mobile computing has enabled many technologies to be translated into mobile applications. As a result, a marketplace of accessibility apps has become available, yet no framework exists to facilitate navigation of this voluminous space.

MATERIALS AND METHODS

We developed the BLV (Blind and Low Vision) App Arcade: a fun, engaging, and searchable curated repository of app AT broken down into 11 categories spanning a wide variety of themes from entertainment to navigation. Additionally, a standardized evaluation metric was formalized to assess each app in five key dimensions: reputability, privacy, data sharing, effectiveness, and ease of use/accessibility. In this paper, we describe the methodological approaches, considerations, and metrics used to find, store and score mobile applications.

CONCLUSION

The development of a comprehensive and standardized database of apps with a scoring rubric has the potential to increase access to reputable tools for the visually impaired community, especially for those in low- and middle-income demographics, who may have access to mobile devices but otherwise have limited access to more expensive technologies or services.

An Examination of Visually Impaired Individuals' Uncertainty Management

Being visually impaired or legally blind (having vision that is uncorrectable or cannot be corrected to a legally acceptable level) is inherently uncertain. Although uncertainty can result in positive, negative, or neutral consequences, little is known about how uncertainty is experienced and negotiated in this understudied population. Thus, through in-depth, semi-structured interviews of 24 individuals with a visual impairment, we apply uncertainty management theory (UMT) to examine the communication strategies visually impaired individuals used to manage the personal, vision-related, and social uncertainty they experienced. Many participants appraised the uncertainty negatively and consequently aimed to reduce it by seeking social support and information, using instrumental strategies, and proactively disclosing their visual impairment. Interviewees who preferred to remain uncertain maintained it by avoiding thinking about their visual impairment or worsening vision and/or by concealing their low vision and passing as sighted. Last, some participants, particularly those who were born with low vision or had been visually impaired longer, learned to adapt to the uncertainty through reframing and accepting, self-care, and by turning to God. The study also uncovered that some participants' uncertainty management was limited by ableist constraints, such as inadequate support systems, systemic barriers, and stigma. The study also underscores the universal and fluid nature of uncertainty and uncovers tangible ways individuals with visual impairment can navigate uncertainty within a pervasive cultural biomedical model of disability.

Social Risk Factor Associations With Presenting Visual Acuity in Patients With Microbial Keratitis

Importance

Neighborhood-level social risk factors may contribute to health disparities in microbial keratitis (MK) disease presentation. Understanding neighborhood-level factors may identify areas for revised health policies to address inequities that impact eye health.

Objective

To investigate if social risk factors were associated with presenting best-corrected visual acuity (BCVA) for patients with MK.

Design, Setting, and Participants

This was a cross-sectional study of patients with a diagnosis of MK. Patients presenting to the University of Michigan with a diagnosis of MK between August 1, 2012, and February 28, 2021, were included in the study. Patient data were obtained from the University of Michigan electronic health record.

Main Outcomes and Measures

Individual-level characteristics (age, self-reported sex, self-reported race and ethnicity), presenting log of the minimum angle of resolution (logMAR) BCVA, and neighborhood-level factors, including measures on deprivation, inequity, housing burden, and transportation at the census block group, were obtained. Univariate associations of presenting BCVA (< 20/40 vs ≥20/40) with individual-level characteristics were assessed with 2-sample t, Wilcoxon, and χ2 tests. Logistic regression was used to test associations of neighborhood-level characteristics with the probability of presenting BCVA worse than 20/40 after adjustment for patient demographics.

Results

A total of 2990 patients with MK were identified and included in the study. Patients had a mean (SD) age of 48.6 (21.3) years, and 1723 were female (57.6%). Patients self-identified with the following race and ethnicity categories: 132 Asian (4.5%), 228 Black (7.8%), 99 Hispanic (3.5%), 2763 non-Hispanic (96.5%), 2463 White (84.4%), and 95 other (3.3%; included any race not previously listed). Presenting BCVA had a median (IQR) value of 0.40 (0.10-1.48) logMAR units (Snellen equivalent, 20/50 [20/25-20/600]), and 1508 of 2798 patients (53.9%) presented with BCVA worse than 20/40. Patients presenting with logMAR BCVA less than 20/40 were older than those who presented with 20/40 or higher (mean difference, 14.7 years; 95% CI, 13.3-16.1; P < .001). Furthermore, a larger percentage of male vs female sex patients presented with logMAR BCVA less than 20/40 (difference, 5.2%; 95% CI, 1.5-8.9; P = .04), as well as Black race (difference, 25.7%; 95% CI, 15.0%-36.5%;P < .001) and White race (difference, 22.6%; 95% CI, 13.9%-31.3%; P < .001) vs Asian race, and non-Hispanic vs Hispanic ethnicity (difference, 14.6%; 95% CI, 4.5%-24.8%; P = .04). After adjusting for age, self-reported sex, and self-reported race and ethnicity, worse Area Deprivation Index (odds ratio [OR], 1.30 per 10-unit increase; 95% CI, 1.25-1.35; P < .001), increased segregation (OR, 1.44 per 0.1-unit increase in Theil H index; 95% CI, 1.30-1.61; P < .001), higher percentage of households with no car (OR, 1.25 per 1 percentage point increase; 95% CI, 1.12-1.40; P = .001), and lower average number of cars per household (OR, 1.56 per 1 less car; 95% CI, 1.21-2.02; P = .003) were associated with increased odds of presenting BCVA worse than 20/40.

Conclusion and Relevance

Findings of this cross-sectional study suggest that in a sample of patients with MK, patient characteristics and where they live were associated with disease severity at presentation. These findings may inform future research on social risk factors and patients with MK.

Association Between Social Determinants of Health and Examination-Based Vision Loss vs Self-reported Vision Measures

Importance

Recent evidence suggests that social determinants of health (SDOH) affect vision loss, but it is unclear whether estimated associations differ between clinically evaluated and self-reported vision loss.

Objective

To identify associations between SDOH and evaluated vision impairment and to assess whether these associations hold when examining self-reported vision loss.

Design, Setting, and Participants

This population-based cross-sectional comparison included participants 12 years and older in the 2005 to 2008 National Health and Nutrition Examination Survey (NHANES), participants of all ages (infants and older) in the 2019 American Community Survey (ACS), and adults 18 years and older in the 2019 Behavioral Risk Factor Surveillance System (BRFSS).

Exposures

Five domains of SDOH that are based on Healthy People 2030: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context.

Main Outcomes and Measures

Presenting vision impairment of 20/40 or worse in the better-seeing eye (NHANES) and self-reported blindness or serious difficulty seeing, even with glasses (ACS and BRFSS).

Results

Of 3 649 085 included participants, 1 873 893 were female (51.1%) and 2 504 206 were White (64.4%). SDOH across domains of economic stability, educational attainment, health care access and quality, neighborhood and built environment, and social context were significant predictors of poor vision. For example, higher income (poverty to income ratio [NHANES]: OR, 0.91; 95% CI, 0.85-0.98; [ACS]: OR, 0.93; 95% CI, 0.93-0.94; categorical income [BRFSS:<$15 000 reference]: $15 000-$24 999; OR, 0.91; 95% CI, 0.91-0.91; $25 000-$34 999: OR, 0.80; 95% CI, 0.80-0.80; $35 000-$49 999: OR, 0.71; 95% CI, 0.71-0.72; ≥$50 000: OR, 0.49; 95% CI, 0.49-0.49), employment (BRFSS: OR, 0.66; 95% CI, 0.66-0.66; ACS: OR, 0.55; 95% CI, 0.54-0.55), and owning a home (NHANES: OR, 0.85; 95% CI, 0.73-1.00; BRFSS: OR, 0.82; 95% CI, 0.82-0.82; ACS: OR, 0.79; 95% CI, 0.79-0.79) were associated with lower odds of vision loss. The study team identified no differences in the general direction of the associations when using either clinically evaluated or self-reported vision measures.

Conclusions and Relevance

The study team found evidence that associations between SDOH and vision impairment track together when using either clinically evaluated or self-reported vision loss. These findings support the use of self-reported vision data in a surveillance system to track trends in SDOH and vision health outcomes within subnational geographies.

Prevalence of pediatric eye disease in the optumlabs data warehouse

PURPOSE

To define the prevalence of medical eye disease diagnoses among children enrolled in commercial insurance plans in the United States and to evaluate differences among groups based on the US census region, race/ethnicity, and familial net worth.

METHODS

: Retrospective study of de-identified claims data from the OptumLab® Data Warehouse (OLDW) between 2007 and 2018. All children (<19 years) in the OLDW with coverage were studied and those with a claim for a significant eye disease (strabismus, amblyopia, nystagmus or structural eye disorders) with minimum 6-months follow-up were studied. Baseline characteristics were extracted for the calculation of eye disease prevalence, including age, sex, race/ethnicity, region of residence, and family net worth. The prevalence of each type of eye disease was calculated among all children and by baseline characteristics.

RESULTS

: 10,759,066 children met the study criteria. The presence of any significant eye diagnosis was 6.7%. Disease was diagnosed more often in whites (6.9%) than blacks (5.6%) and Hispanics (5.9%). The most common eye disease diagnosed was strabismus (3.2%) followed by amblyopia (1.5%). In the North-East region, there was a 10.6% prevalence of any significant eye disease diagnosis, whereas in the Mid-West, it was 7.4% followed by the South and West (5.9% and 5.3%, respectively) (p < .001). There was an increase in eye disease diagnoses with increasing income (5.5% in<$25,000 and 9.4% in >$500,000 household net worth groups, p > .001).

CONCLUSION

: Diagnosis of significant eye diseases is relatively common in American children. The most common medical eye disease diagnosis is strabismus. Prevalence of eye disease diagnosis from claims data varies between geographical regions and different income groups. This may reflect differences in healthcare utilization rather than true disease prevalence.

Health-related quality of life among adult patients with visual impairments in Yazd, Iran

BACKGROUND

Visual impairment (VI) is one of the major public health problems that cause suffering, disability, loss of productivity, and reduced quality of life (QoL). This study aimed to evaluate the health-related QoL (HRQoL) among adults with visual problems in 2021.

MATERIALS AND METHODS

This analytical cross-sectional study was conducted on 300 patients with VIs referring to ophthalmology centers in Yazd, Iran. Data were collected through face-to-face interviews using EQ-5D, visual analog scale (VAS), and demographic information questionnaires. The results were analyzed using independent sample t-test, one-way analysis of variance, Pearson correlation coefficient, and adjusted limited dependent variable mixture model (ALDVMM) model by STATA, and SPSS.

RESULTS

The mean and standard deviation of EQ-5D-5 L index and EQ-VAS score in the studied patients were 0.68 ± 0.25 and 72.46 ± 19.36, respectively. Most problems at unable/extreme level were related to the mobility dimension (12%) and the usual activities dimension (9%). Factors related to HRQoL scores using ALDVMM model showed that divorced or widow marital status, age over 50, having strabismus, and acuter visual problems had significant negative effects on EQ-5D-5 L index values (P < 0.05).

CONCLUSIONS

The results showed that HRQoL was moderate in patients with VIs and reduced in patients with high disease severity, old age, lack of a spouse, retirement, and nonuniversity education. As a result, socioeconomic and demographic characteristics were required to be considered in visual health policies.

Waiting Times for Cataract Surgery in Scotland since 2002 and the Effect of Austerity: An Interrupted Time Series Analysis

PURPOSE

In Scotland, in 2002, the National Waiting Times Unit was launched to reduce NHS waiting times. This was accompanied by a series of waiting time targets across the NHS in Scotland. The purpose of this study is to analyse changes in equality of access to treatment by socioeconomic deprivation associated with this initiative.

METHODS

Trends in annual cataract rates were calculated using secondary care admissions' Scottish Morbidity Record (SMR01) data on NHS funded elective cataract procedures for patients treated in Scotland from 01 April 1997 to 31 March 2019. An interrupted time series model was used to analyse socioeconomic differences in waiting times by deprivation quintile over three time periods; pre and post waiting time initiative, and post austerity.

RESULTS

Cataract Surgical Rates more than doubled from 3,723 per million population in 1997/1998 to 7,896 per million population in 2018/2019. Mean waiting time fell from 129.5 days in 1997/1998 to 87.7 days in 2018/2019. Inequality in mean waiting time between most and least deprived cataract patients increased by 1.34 days per quarter between 01 April 1997 and 30 June 2002 and following the waiting time initiative fell by 0.41 days per quarter through to 31 March 2010; and then decreased by 0.002 days per quarter between 01 April 2010 and 31 March 2019.

CONCLUSION

The waiting time initiative had a major impact on reducing inequality in waiting times between socioeconomic groups. The onset of austerity in 2010 was associated with a very small and insignificant increase in inequality.

The Impact of COVID-19 and Pandemic Mitigation Measures on Persons With Sensory Impairment

PURPOSE

To assess the impact of the COVID-19 pandemic and associated mitigation measures on persons with sensory impairments (SI), including visual impairments (VI) and hearing impairments (HI).

DESIGN

Cross-sectional survey.

METHODS

Adults with VI (best-corrected visual acuity <20/60 in the better-seeing eye), HI (International Classification of Diseases, Tenth Revision, codes), and age- and sex-matched controls (n = 375) were recruited from the University of Michigan. The 34-item Coronavirus Disability Survey was administered. Both χ² tests and logistic regression were used to compare survey responses between groups.

RESULTS

All groups reported high levels of disruption of daily life, with 80% reporting "a fair amount" or "a lot" of disruption (VI: 76%, HI: 83%, CT: 82%, P = .33). Participants with VI had greater difficulty with day-to-day activities and were more likely to cite the following reasons: caregiver was worried about COVID-19 (odds ratio [OR]_VI = 7.2, 95% CI = 3.5-14.4, P < .001) and decreased availability of public transportation (OR_VI = 5.0, 95% CI = 1.5-15.6, P = .006). Participants with VI, but not HI, showed a trend toward increased difficulty accessing medical care (OR_VI = 2.0, 95% CI = 0.99-4.0, P = .052) and began relying more on others for day-to-day assistance (OR_VI = 3.1, 95% CI = 1.6-5.7, P < .001). Overall, 30% reported difficulty obtaining trusted information about the pandemic. Those with VI reported more difficulty seeing or hearing trusted information (OR_VI = 6.1, 95% CI = 1.6-22.1, P = .006). Employed participants with HI were more likely to report a reduction in wages (OR_HI = 2.5, 95% CI = 1.2-5.3, P = .02).

CONCLUSIONS

Individuals with VI have experienced increased disruption and challenges in daily activities related to the pandemic. People with SI may benefit from targeted policy approaches to the current pandemic and future stressors. Minimal differences in some survey measures may be due to the large impact of the pandemic on the population as a whole. The SARS-CoV-2 (COVID-19) pandemic and public health mitigation measures have had an exceedingly large impact around the globe. As of the time of writing, more than 114 million global cases (28 million US) had been diagnosed, and there had been more than 2.5 million fatalities attributed to COVID-19 (517,000 US).^1,2.

Vision impairment and differential access to eye health services in Aotearoa New Zealand: protocol for a scoping review

INTRODUCTION

In Aotearoa New Zealand, Māori and Pacific people experience worse health outcomes compared with other New Zealanders. No population-based eye health survey has been conducted, and eye health services do not generate routine monitoring reports, so the extent of eye health inequality is unknown. This information is required to plan equitable eye health services. Here we outline the protocol for a scoping review to report the nature and extent of the evidence reporting vision impairment, and the use of eye health services by ethnicity in New Zealand.

METHODS AND ANALYSIS

An information specialist will conduct searches on MEDLINE and Embase, with no limit on publication dates or language. We will search the grey literature via websites of relevant government and service provider agencies. Reference lists of included articles will be screened. Observational studies will be included if they report the prevalence of vision impairment, or any of the main causes (cataract, uncorrected refractive error, macular degeneration, glaucoma or diabetic retinopathy) or report the use of eye health services in New Zealand among people of any age. Two authors will independently review titles, abstracts and full-text articles, and complete data extraction. Overall findings will be summarised using descriptive statistics and thematic analysis, with an emphasis on disaggregation by ethnicity where this information is available.

ETHICS AND DISSEMINATION

Ethical approval has not been sought as our review will only include published and publicly accessible data. We will publish the review in an open access peer-reviewed journal. We anticipate the findings will be useful to organisations and providers in New Zealand responsible to plan and deliver eye care services, as well as stakeholders in other countries with differential access to eye care.

REGISTRATION DETAILS

The protocol has been registered with Open Science Framework (https://osf.io/yw7xb).

Self-reported visual difficulties in Europe and related factors: a European population-based cross-sectional survey

PURPOSE

There is a relative paucity of self-reported vision problems data in European countries.

METHODS

In this context, we investigated self-reported vision problems through European Health Interview Survey 2, a cross-sectional European population survey based on a standardized questionnaire including 147 medical, demographic and socioeconomic variables applied to non-institutionalized individuals aged 15 years or more in 28 European countries, in addition to Iceland and Norway.

RESULTS

The survey included 311 386 individuals (54.18% women), with overall crude prevalence of self-reported vision problems of 2.07% [95% CI; 2.01-2.14]. Among them, 1.70 % [1.61-1.78] of men, 2.41% [2.31-2.51] of women and 4.71% [4.53-4.89] of individuals aged 60 or more reported to have a lot of vision problems or to be not able to see. The frequency of self-reported vision problems was the highest in Eastern European countries with values of 2.43% [2.30-2.56]. In multivariate analyses, limiting long-standing illness, depression, daily smoking, lack of physical activity, lower educational level and social isolation were associated with self-reported vision problems with ORs of 2.66 [2.42-2.92], 2.16 [2.01-2.32], 1.11 [1.01-1.23], 1.31 [1.21-1.42], 1.29 [1.19-1.40] and 1.45 [1.26-1.67], respectively, while higher income was associated with less self-reported vision problems with OR of 0.80 [0.73-0.86].

CONCLUSIONS

This study demonstrated inequalities in terms of prevalence of self-reported vision problems in Europe, with higher prevalence in Eastern European countries and among women and older individuals.

Teleophthalmology Screening for Early Detection of Ocular Diseases in Underserved Populations in Israel

Background: The purpose of this study was to investigate the feasibility and effectiveness of an innovative telemedicine community-based intervention to increase detection of previously undiagnosed ocular diseases in high-risk populations in Israel. Methods: A team comprising an ocular technician, a project manager, and a driver was sent to underserved areas in Israel. Patient demographics, ocular, and medical information were recorded. Visual acuity (VA), intraocular pressure and fundus photographs were obtained. The data were transferred to the Ophthalmology Reading Center in Tel-Aviv Medical Center, where it was interpreted by an ophthalmologist. A letter was sent to the patients indicating examination results. It instructed them to return for a follow-up examination if indicated. Results: A total of 124 individuals underwent telemedicine remote screening examinations in 10 locations. The mean age was 79.9 ± 7.2 years, with female predominance of 67%. The major pathologies detected were (1) reduction in VA >6/12 in at least one eye (n = 48, 38.7%); (2) glaucoma suspicion in the optic disk (n = 18, 14.5%); (3) ocular hypertension >21 mmHg (n = 15, 12.1%); (4) age-related macular degeneration (AMD; n = 15, 12.1%); (5) diabetic retinopathy (n = 6, 4.8%); (6) visually significant cataract (n = 6, 4.8%); and (7) other pathologies (n = 11, 8.9%); 97.7% of the patients reported high satisfaction rates (they were satisfied or very satisfied from the project model). Conclusions: Our pilot telemedicine screening project effectively detected ocular diseases in underserved areas in Israel and helped improve access to eye care. This project has the potential of reaching a national level, allow for early diagnosis, and prevent vision loss and blindness in underserved areas.

Incidence, individual, and macro level risk factors of severe binocular visual impairment and blindness in persons aged 50 and older

OBJECTIVE

This study aims to estimate the incidence of severe binocular vision impairment and blindness (SVI/B) and to identify eye diseases and regional risk factors of persons with SVI/B at ages 50 years and older.

METHODS

We designed an observational cohort study based on longitudinal, multifactorial, and administrative information of a random sample of 250,000 persons at ages 50+. All individuals were included in the process-produced health claims register of the Allgemeine Ortskrankenkasse in 2004, and were followed until 2015. We analyzed ten selected eye diseases and regional characteristics as risk factors for SVI/B using Cox models, adjusting for demographic characteristics and multi-morbidity.

RESULTS

The age-standardized incidence was 79 new diagnoses of SVI/B per 100,000 person-years (95%-CI: 76-82); 77 for males (72-82) and 81 for females (77-85). By adjusting for multiple factors, the model revealed and confirmed that individuals who were very old (Hazard ratio90+: 6.67; 3.59-12.71), male (1.18; 1.01-1.38), had multi-morbidities (three+ diseases: 3.36; 2.51-4.49), or had diabetes (1.26; 1.07-1.49) had an increased risk of SVI/B. Compared to persons without the particular eye disease (all p<0.001), persons diagnosed with secondary glaucoma had a multiple-adjusted 4.66 times (3.17-6.85) higher risk, those with retinal vascular occlusion had a 4.51 times (3.27-6.23) higher risk, and those with angle-closure glaucoma had a 4.22 times (2.60-6.85) higher risk. Population density was not a risk factor, while persons living in wealthier regions had 0.75 times (p=0.003) to 0.70 times (p<0.001) the risk of SVI/B than persons in the least wealthy regions of Germany.

CONCLUSION

The study revealed and confirmed some profound risk factors of SVI/B at both the individual and the macro level. The sizes of the effects of the characteristics of the living context were smaller than those of the individual characteristics, especially for some severe eye diseases. While urbanity and access to health services had no effect, regional economic wealth was a risk factor for SVI/B. Future health care measures and advice by physicians should take these dimensions of inequalities in SVI/B into account.

Association between sensory impairment and suicidal ideation and attempt: a cross-sectional analysis of nationally representative English household data

OBJECTIVES

Sensory impairments are associated with worse mental health and poorer quality of life, but few studies have investigated whether sensory impairment is associated with suicidal behaviour in a population sample. We investigated whether visual and hearing impairments were associated with suicidal ideation and attempt.

DESIGN

National cross-sectional study.

SETTING

Households in England.

PARTICIPANTS

We analysed data for 7546 household residents in England, aged 16 and over from the 2014 Adult Psychiatric Morbidity Survey.

EXPOSURES

Sensory impairment (either visual or hearing), Dual sensory impairment (visual and hearing), visual impairment, hearing impairment.

PRIMARY OUTCOME

Suicidal ideation and suicide attempt in the past year.

RESULTS

People with visual or hearing sensory impairments had twice the odds of past-year suicidal ideation (OR 2.06; 95% CI 1.17 to 2.73; p<0.001), and over three times the odds of reporting past-year suicide attempt (OR 3.12; 95% CI 1.57 to 6.20; p=0.001) compared with people without these impairments. Similar results were found for hearing and visual impairments separately and co-occurring.

CONCLUSIONS

We found evidence that individuals with sensory impairments are more likely to have thought about or attempted suicide in the past year than individuals without.

Visual Impairment and Mental Health: Unmet Needs and Treatment Options

Purpose

An estimated 2.2 billion people are visually impaired worldwide. Given that age-related vision loss is a primary cause of vision impairment, this number is projected to rise with increases in average lifespan. Vision loss often results in significant disability and is associated with a substantial economic burden, reduced quality-of-life, concurrent medical issues, and mental health problems. In this review, the mental health needs of people with vision impairment are examined.

Patients and methods

A review of recent literature on mental health outcomes and current treatments in people with visual impairment was conducted.

Results

Considerable data indicate that rates of depression and anxiety are elevated among people with visual impairments. Moreover, individuals of lower socioeconomic status may be at increased risk for vision impairment and subsequent mental health problems. Existing psychosocial interventions for improving mental health in people with visual impairment show some promise, but are limited by low adherence and lack generalizability.

Conclusion

In order to improve outcomes, a better understanding of the mechanisms linking visual impairment and poor mental health is needed. It will also be essential to develop more effective interventions and expand access to services to improve the detection and treatment of mental health problems in this population.

Visual function assessment of diagnostic radiography students

INTRODUCTION

Deterioration of visual acuity (VA) and visual impairment has been linked to age-related subtle changes, gender, and a correlation to socioeconomic status. This study aimed to assess first-year diagnostic radiography students' visual functional abilities by applying the International Classification of Impairments, Disabilities and Handicaps (ICIDH) recommendations of functional VA screening and health-related quality of life questionnaire (HRQOL).

METHODS

The design followed the World Health Organisation (WHO) electronic VA testing of monocular sight using LogMAR charts and binocular vision using Snellen charts, and an HRQOL questionnaire assessing for reduced ability of visual-based tasks in activities of daily living (ADL). The data was evaluated in correlation to the participant's visual correction, age, gender, and socioeconomic background.

RESULTS

Seventy students were recruited, all meeting the WHO standard level for visual ability, with 100% (n = 70/70) met or achieved above normal binocular vision, correlating to expected normal population results from published studies for age. The monocular vision demonstrated 74% (n = 52/70) for the right eye, and 80% (n = 56/70) for the left eye for normal vision levels. The results did not differ significantly between each eye (p = 0.21), gender variations between the left eye (p = 0.27) and the right eye (p = 0.10) results were affected by sample ratio of females (80%; n = 56/70) to males (20%; n = 14/70), the visual correction did not impair binocular VA. The HRQOL assessment indicated no significant functional VA issues in the study sample. The study demonstrated no association between the participant's socioeconomic background that may influence their VA ability.

CONCLUSION

The results provided normative binocular and monocular data on visual function in a sample of student radiographers and indicated that their thresholds align to normal (or near-normal) VA standards.

IMPLICATIONS FOR PRACTICE

The visual health data was reviewed for subgroup comparison and trend analysis, and did not identify risk factors within this sample group that their VA and visual functioning would impact upon radiography clinical placement tasks and activities. The sample is not generalisable to the wider population; further studies are recommended.

Geographical inequalities in uptake of NHS funded eye examinations: Poisson modelling of small-area data for Essex, UK

Background

Small-area analysis of National Health Service (NHS)-funded sight test uptake in Leeds showed significant inequalities in access among people aged <16 or ≥60.

Methods

Data were extracted from 604 126 valid General Ophthalmic Services (GOS)1 claim forms for eye examinations for Essex residents between October 2013 and July 2015. Expected GOS1 uptake for each lower super output area was based on England annual uptake. Poisson regression modelling explored associations in GOS1 uptake ratio with deprivation.

Results

People aged ≥60 or <16 living in the least deprived quintile were 15% and 26%, respectively, more likely to have an NHS funded eye examination than the most deprived quintile, although all are equally entitled. GOS1 uptake is higher in the more deprived quintiles among 16-59-year old, as means tested social benefits are the main eligibility criteria in this age-group. Inequalities were also observed at local authority level.

Conclusions

Inequalities in access among people ≥60 years were not as large as those reported in Leeds, although inequalities in <16-year old were similar. However, demonstrable inequalities in this data set over a longer time period and a larger and more diverse area than Leeds, reinforce the argument that interventions are needed to address eye examination uptake inequalities.

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.

Twenty-year outcomes in patients with newly diagnosed glaucoma: mortality and visual function

Background/aims

To determine the mortality within 20 years of diagnosis of chronic open-angle glaucoma (COAG) and visual acuity and visual field progression of a cohort followed for 20 years.

Methods

Twenty years following the diagnosis of COAG in 68 of 436 (16%) patients seen in a glaucoma case-finding clinic, visual and mortality outcomes were audited from medical records. Causes of death were obtained from general practitioner records and death certificates. Probability of death was calculated using a Kaplan-Meier survival curve. The visual field of each eye of survivors was graded using a nine-stage severity scale. Visual outcome was analysed at the 20-year follow-up visit.

Results

From 68, 14 (21%) were lost to follow-up. In the remaining 54, 20 (37%) were alive 20 years after diagnosis. Of 63% who died, mean age of death was 84 years, most commonly due to vascular disease. Mean age at presentation of those who died was 73.7 years versus 63.2 years for survivors (P=0.001). The median time to death was 16 years. On visual field analysis, nearly half (48.9%) of eyes did not deteriorate, but 28.3% eyes deteriorated by more than two stages. Those who died had worse final visual acuity than survivors (P<0.001). Three who died were registered severely visually impaired mainly from macular disease, but no survivors were registered (P<0.001).

Conclusion

In this cohort, approximately two-thirds of patients with glaucoma died within 20 years of diagnosis. In most older patients with glaucoma, the overall goal of preventing visual handicap and blindness is achievable 20 years after diagnosis.

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.

Health Inequalities Associated with Post-Stroke Visual Impairment in the United Kingdom and Ireland: A Systematic Review

The aim of this study was to report on the health inequalities facing stroke survivors with visual impairments as described in the current literature. A systemic review of the literature was conducted to investigate the potential health inequalities facing stroke survivors with subsequent visual impairments. A quality-of-evidence and risk-of-bias assessment was conducted for each of the included articles using the appropriate tool dependent on the type of article. Only four articles discussed health inequalities affecting stroke survivors with visual impairment specifically. A further 23 articles identified health inequalities after stroke, and 38 reported on health inequalities within the visually impaired UK or Irish population. Stroke survivors with visual impairment face inconsistency in eye care provision nationally, along with variability in the assessment and management of visual disorders. The subgroups identified as most at risk were females; black ethnicity; lower socioeconomic status; older age; and those with lower education attainment. The issue of inconsistent service provision for this population must be addressed in future research. Further research must be conducted in order to firmly establish whether or not stroke survivors are at risk of the aforementioned sociodemographic and economic inequalities.

Socioeconomic Disparities in Cataract Prevalence, Characteristics, and Management

PURPOSE

To review the current literature on socioeconomic disparities relationship with cataract prevalence, characteristics, and management.

SUMMARY

Cataracts are an important cause of preventable visual impairment in both the developing and industrialized world. Cataract surgery is a highly effective operation with an excellent risk profile. Furthermore, cataract surgery has been shown to have significant positive functional, social, and economic implications for patients. Several medical conditions have been shown to have correlation with socioeconomic factors and cataract is among several forms of visual impairment that demonstrate this relationship. Disparities in prevalence, clinical characteristics, and management are documented in the ophthalmic literature. A better understanding of these socioeconomic factors and their clinical relevance is critical to alleviating the burden of cataract-related visual impairment in an aging population.

Neighborhood Deprivation and Risk of Age-Related Eye Diseases: A Follow-up Study in Sweden

PURPOSE

To examine whether there is an association between neighborhood deprivation and age-related eye diseases, particularly macular degeneration, cataract, diabetes-related eye complications, and glaucoma.

METHODS

The study population comprised a nationwide sample of 2,060,887 men and 2,250,851 women aged 40 years or older living in Sweden who were followed from 1 January 2000 until the first hospitalization/outpatient registration for age-related eye disease during the study period, death, emigration, or the end of the study period on 31 December 2010. Multilevel logistic regression was used to estimate the association between neighborhood deprivation and age-related eye diseases.

RESULTS

In men, the odds ratio (OR) for age-related eye diseases for those living in high-deprivation neighborhoods compared to those living in low-deprivation neighborhoods remained significant after adjustment for potential confounding factors (macular degeneration, OR 1.08, 95% confidence interval [CI] 1.03-1.12; cataract, OR 1.31, 95% CI 1.26-1.35; diabetes-related eye complications, OR 1.36, 95% CI 1.30-1.43; glaucoma, OR 1.11, 95% CI 1.06-1.15). In women, similar patterns were observed (macular degeneration, OR 1.11, 95% CI 1.07-1.15; cataract, OR 1.36, 95% CI 1.31-1.40; diabetes-related eye complications, OR 1.50, 95% CI 1.42-1.59; glaucoma, OR 1.12, 95% CI 1.08-1.17).

CONCLUSION

Our results suggest that neighborhood deprivation is associated with age-related eye diseases in both men and women. These results implicate that individual- as well as neighborhood-level factors are important for preventing age-related eye diseases.

Composite Measures of Individual and Area-Level Socio-Economic Status Are Associated with Visual Impairment in Singapore

Purpose

To investigate the independent relationship of individual- and area-level socio-economic status (SES) with the presence and severity of visual impairment (VI) in an Asian population.

Methods

Cross-sectional data from 9993 Chinese, Malay and Indian adults aged 40–80 years who participated in the Singapore Epidemiology of eye Diseases (2004–2011) in Singapore. Based on the presenting visual acuity (PVA) in the better-seeing eye, VI was categorized into normal vision (logMAR≤0.30), low vision (logMAR>0.30<1.00), and blindness (logMAR≥1.00). Any VI was defined as low vision/blindness in the PVA of better-seeing eye. Individual-level low-SES was defined as a composite of primary-level education, monthly income<2000 SGD and residing in 1 or 2-room public apartment. An area-level SES was assessed using a socio-economic disadvantage index (SEDI), created using 12 variables from the 2010 Singapore census. A high SEDI score indicates a relatively poor SES. Associations between SES measures and presence and severity of VI were examined using multi-level, mixed-effects logistic and multinomial regression models.

Results

The age-adjusted prevalence of any VI was 19.62% (low vision = 19%, blindness = 0.62%). Both individual- and area-level SES were positively associated with any VI and low vision after adjusting for confounders. The odds ratio (95% confidence interval) of any VI was 2.11(1.88–2.37) for low-SES and 1.07(1.02–1.13) per 1 standard deviation increase in SEDI. When stratified by unilateral/bilateral categories, while low SES showed significant associations with all categories, SEDI showed a significant association with bilateral low vision only. The association between low SES and any VI remained significant among all age, gender and ethnic sub-groups. Although a consistent positive association was observed between area-level SEDI and any VI, the associations were significant among participants aged 40–65 years and male.

Conclusion

In this community-based sample of Asian adults, both individual- and area-level SES were independently associated with the presence and severity of VI.

Area deprivation and age related macular degeneration in the EPIC-Norfolk Eye Study

Objectives

To investigate the relationship between area deprivation, individual socio-economic status (SES) and age related macular degeneration (AMD).

Study design

Cross sectional study nested within a longitudinal cohort study.

Methods

Data were collected in the EPIC-Norfolk Eye Study by trained nurses, using standardized protocols and lifestyle questionnaires. The English Index of multiple deprivation 2010 (IMD) was derived from participants' postcodes. AMD was identified from standardized grading of fundus photographs. Logistic regression was used to examine associations between IMD, SES and AMD.

Results

5344 pairs (62.0% of total 8623) of fundus photographs were of sufficient quality for grading of AMD. Of 5182 participants with complete data, AMD was identified in 653 participants (12.60%, 95%CI = 11.7–13.5%). Multivariable logistic regression showed that people living in the most affluent 5% of areas had nearly half the odds of AMD compared to those living in comparatively more deprived areas (OR = 0.56, 95% CI = 0.36–0.89, P = 0.02), after adjusting for age, sex, education, social class and smoking.

Conclusions

The authors found that living in the most affluent areas exerted a protective effect on AMD, independently of education and social class. Further investigation into underlying mechanisms will inform potential interventions to reduce health inequalities relating to AMD.

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The relationship between area deprivation and AMD diagnosed from fundus photographs was examined.

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Data from 5182 participants from the EPIC-Norfolk Eye study were analyzed.

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Predominantly early AMD was identified in 653 participants (12.6%).

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People living in more affluent areas had nearly half the risk of AMD.

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Results require interpretation with caution due to the healthy population studied.