Glaucoma Disparities in the Hispanic Population

Missed Opportunities in Screening for Glaucoma

PURPOSE

To create a holistic and realistic view regarding current knowledge, understanding, and challenges of screening in general and in glaucoma.

METHODS/RESULTS

Based upon available literature, all systems suffer from the same challenges: huge variability of care practices (despite guidelines), simultaneous under care and over care, as well as the unsustainable increase of costs. While the magnitude of these challenges differs immoderately between well-off and developing countries, the Western world has already demonstrated that simply doing more than what we currently do is not the solution. System outcomes also matter in screening, that is, its benefits should outweigh any harms (over-care, false positives/negatives, uncertain findings, etc.) and be cost-effective. However, even when the evidence does not support screening (as is currently the case in glaucoma), it may feel justified as "at least we are doing something." Strong commercial interests, lobbying and politics star as well and will influence the control arm even in high-quality randomized screening trials (RCT).

CONCLUSIONS

As resources will never be sufficient for all health care activities that providers wish to deliver and what people wish to receive, we need to ask big questions and adopt a public health perspective in glaucoma and eye care. How can we create and maintain a sustainable balance between finding and treating underserved high-risk patients without burdening the broader patient population and societies with over-diagnostics and treatments? Considering numerous biases related to screening, including the variability in care practices, a high-quality RCT for the screening of glaucoma would be very challenging to organize and evaluate its universal usefulness.

Impact of Demographics on Regional Visual Field Loss and Deterioration in Glaucoma

Purpose

To elucidate the impact of demographics, including gender, race, ethnicity, and preferred language, on regional visual field (VF) loss and progression in glaucoma.

Methods

Multivariable linear mixed regressions were performed to determine the impact of race, ethnicity, and preferred language on regional VF loss with adjustment for age and gender. Regional VF loss was defined by pointwise total deviation values and VF loss patterns quantified by an unsupervised machine learning method termed archetypal analysis. All cross-sectional and longitudinal analyses were performed both without and with adjustment for VF mean deviation, which represented overall VF loss severity. P values were corrected for multiple comparisons.

Results

All results mentioned had corrected P values less than 0.05. Asian and Black patients showed worse pointwise VF loss than White patients with superior hemifield more affected. Patients with a preferred language other than English demonstrated worse pointwise VF loss than patients with English as their preferred language. Longitudinal analyses revealed Black patients showed worse VF loss/year compared to White patients. Patients with a preferred language other than English demonstrated worse VF loss/year compared to patients preferring English.

Conclusions

Blacks and non-English speakers have more severe VF loss, with superior hemifield being more affected and faster VF worsening.

Translational Relevance

This study furthered our understanding of racial, ethnic, and socioeconomic disparities in glaucoma outcomes. Understanding the VF loss burden in different racial, ethnic, and socioeconomic groups may guide more effective glaucoma screening and community outreach efforts. This research could help reduce vision loss and improve quality of life in disproportionately affected populations by guiding public health efforts to promote glaucoma awareness and access to care.

Social determinants of health and health disparities in glaucoma: A review

Social determinants of health and barriers to care can significantly impact patients' access to glaucoma care and treatment, resulting in disparities within disease presentation, progression, management, and treatment outcomes. The widespread adoption of electronic health record systems has allowed researchers and clinicians to further explore these relationships, identifying factors such as race, ethnicity, and socioeconomic status to be risk factors for more severe disease and lower treatment adherence. These disparities highlight potential targets for interventions to combat these disparities and improve overall patient outcomes. This article provides a summary of the available data on health disparities within glaucoma disease presentation, progression, management, treatment, and outcomes and discusses interventions to improve care delivery and outcomes among patients with glaucoma.

Demographic and socioeconomic disparities in receipt of ophthalmology consultation for facial trauma

OBJECTIVE

Functional outcomes following facial and ocular trauma are time-sensitive and require prompt evaluation to minimise long-term vision loss, yet few studies have systematically evaluated disparities in the management of these cases. This study investigates whether a patient's race/ethnicity, primary language, insurance status, gender or age affects receipt of ophthalmology consultation for facial trauma.

METHODS AND ANALYSIS

This study was a retrospective cohort analysis of patients from the Elmhurst City Hospital Trauma Registry in Queens, New York who were seen for facial trauma including open globe injuries and orbital fractures between January 2014 and May 2016.

RESULTS

Of the 264 patients included, 43% reported as Hispanic, 23% white, 11% Asian, 8% black and 15% other/unknown. After controlling for confounding variables by multivariable logistic regression, neither race/ethnicity, gender, nor primary language were significantly associated with the likelihood of receiving an ophthalmology consult. However, patients with private insurance had 2.57 times greater odds of receiving an ophthalmology consultation than those with Medicaid or state corrections insurance (95% CI 1.37 to 4.95). As age increased, the likelihood of receiving an ophthalmology consultation decreased (p=0.009); patients 60 years of age and older had one-third the odds of ophthalmology consultation as younger patients (OR 0.33; 95% CI 0.16 to 0.68).

CONCLUSIONS

This study highlights that lack of ophthalmology consultation in patients with facial trauma is linked to age and underinsurance. Extra attention must be paid during primary assessments to ensure elderly patients and those with public insurance have equitable access to timely and appropriate care for facial trauma.

Longitudinal Analysis of Social Isolation and Cognitive Functioning among Hispanic Older Adults with Sensory Impairments

OBJECTIVES

Understanding the intersection of age, ethnicity, and disability will become increasingly important as the global population ages and becomes more diverse. By 2060, Hispanics will comprise 28% of the U.S.

POPULATION

This study examines critical associations between sensory impairment, social isolation, and cognitive functioning among Hispanic older adults.

METHODS

Our sample consisted of 557 Hispanic older adults that participated in Rounds 1-3 or Rounds 5-7 of the National Health and Aging Trends Study. Longitudinal mediation models across a three-year span were estimated using Mplus, with vision, hearing, and dual sensory impairments predicting cognitive functioning directly and indirectly through social isolation.

RESULTS

Findings indicated that cognitive functioning was concurrently and, in certain cases, longitudinally predicted by vision and dual sensory impairments and by social isolation. Contrary to expectations, vision and hearing impairments were not predictive of social isolation. Dual sensory impairment was associated with social isolation, yet no significant indirect associations were found for sensory impairments predicting cognitive functioning through social isolation.

DISCUSSION

The finding that social isolation did not mediate the relationship between sensory impairment and cognitive decline among Hispanic older adults in the U.S. is contrary to findings from other studies that were not specifically focused on this population. This finding may be evidence that culturally motivated family support and intergenerational living buffer the impact of sensory impairments in later life. Findings suggest that Hispanic older adults experiencing dual sensory impairments may benefit from interventions that foster social support and include family members.

Inequities and Research Gaps in Ophthalmology: A Scoping Review

Importance

Deficient ophthalmologic care is costly to patients, making the identification of groups not receiving adequate care of vital importance. The current landscape of equity in ophthalmic care has yet to be thoroughly investigated and is important to ensure inclusivity and patient-centered care.

Objective

To perform a scoping review of the literature pertaining to health care inequities in the field of ophthalmology.

Evidence Review

A comprehensive database search using MEDLINE (via PubMed) and Ovid Embase was done in July 2022. English-language articles published from 2016 to 2021 were included and encompassed all article types except commentaries or correspondence. The search modeled the National Institutes of Health list of designated US health inequity populations, which includes income, education level, occupational status, rural and underresourced area, sex and gender, lesbian, gay, bisexual, transgender, and queer (LGBTQ) identity, and race and ethnicity. A total of 8170 abstracts and titles were screened by 2 independent investigators, and 189 studies were assessed in full text for eligibility. For inclusion, articles needed to be an ophthalmic study discussing health inequities. In a masked, duplicate fashion, 2 independent investigators screened 75 full-text studies for data extraction using a pilot-tested form. Data extraction included general publication characteristics and health inequity data based on the National Institutes of Health's defined inequity groups.

Findings

A total of 75 publications were included. Notable inequities were found among Black and Hispanic patients associated with negative ophthalmic outcomes and mixed associations regarding sex or gender. Overall, lower-income patients were more likely to have vision impairment, use eye care services less, and have lower adherence to eye examinations. No articles within our sample examined LGBTQ inequities among ophthalmology patients since the 2016 National Institutes of Health classification of sexual and gender minority populations. Substantial research gaps were observed within the ophthalmic literature pertaining to the LGBTQ community, race and ethnicity, and rural and underresourced areas.

Conclusions and Relevance

This scoping review found substantial findings associated with the LGBTQ community, race and ethnicity, and the role of telemedicine in rural and underresourced areas. Because of the importance of ophthalmic care in overall patient health, it is vital to understand the various inequities present and strive to improve the current gaps in the literature. Future studies should (1) examine barriers to clinical study and medical trainee recruitment as well as patient values and preference studies and (2) investigate the implementation of telemedicine in underresourced areas.

Trends in Retinopathy of Prematurity Care in the US 2009-2018: A Nationwide Analysis using National Inpatient Sample

PURPOSE

Retinopathy of prematurity (ROP) represents a leading cause of childhood blindness. The purpose of our study was to evaluate incidence, trends in cost and length of hospital stay, and risk factors for ROP using a publicly available population-based dataset, the National Inpatient Sample.

DESIGN

This cross-sectional study analyzed data from 2009 to 2018 using the National Inpatient Sample.

PARTICIPANTS

Premature neonates (n = 717 277) who met the screening criteria for ROP with gestational age of ≤ 30 weeks or birthweight (BW) of ≤ 1500 g were identified.

METHODS

Database analysis.

MAIN OUTCOME MEASURES

Incidence, demographics, risk factors for ROP development, trends in cost, and length of stay were evaluated.

RESULTS

In total, incidence of ROP increased from 11% in 2009 to 15% in 2018 (P < 0.001). Multivariate logistic regression model of ROP development showed its associations with female sex (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.10-1.17), Hispanic (OR, 1.10; 95% CI, 1.03-1.18), and Black (OR, 0.91; 95% CI 0.86-0.96) ethnicity. Neonates with lower BWs, particularly those in the 500- to 999-g subgroup (OR, 2.64; 95% CI, 2.44-2.85) and younger gestational ages, particularly those born between 25 and 28 weeks gestational age (OR, 2.41; 95% CI, 2.25-2.58), had increased risk of developing ROP. Comorbidities associated with the development of ROP were perinatal jaundice (OR, 1.84; 95% CI, 1.74-1.94), patent ducts arteriosus (OR, 1.67; 95% CI, 1.60-1.75), intraventricular hemorrhage (OR, 1.41; 95% CI, 1.35-1.48), perinatal infection (OR, 1.84; 95% CI, 1.74-1.94), and respiratory distress syndrome (OR, 1.05; 95% CI, 1.01-1.10).

CONCLUSIONS

Retinopathy of prematurity develops in about 1 of 10 premature infants and incidence has been shown to be increasing. Significant risk factors were female sex, Hispanic ethnicity, lower BW, younger gestational age, and systemic comorbidities, including perinatal jaundice, patent ductus arteriosus, intraventricular hemorrhage, perinatal sepsis, and respiratory distress syndrome.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Deep learning and optical coherence tomography in glaucoma: Bridging the diagnostic gap on structural imaging

Glaucoma is a leading cause of progressive blindness and visual impairment worldwide. Microstructural evidence of glaucomatous damage to the optic nerve head and associated tissues can be visualized using optical coherence tomography (OCT). In recent years, development of novel deep learning (DL) algorithms has led to innovative advances and improvements in automated detection of glaucomatous damage and progression on OCT imaging. DL algorithms have also been trained utilizing OCT data to improve detection of glaucomatous damage on fundus photography, thus improving the potential utility of color photos which can be more easily collected in a wider range of clinical and screening settings. This review highlights ten years of contributions to glaucoma detection through advances in deep learning models trained utilizing OCT structural data and posits future directions for translation of these discoveries into the field of aging and the basic sciences.

Factors associated with vision loss in Black or Hispanic patients 1 year after standalone or combined Ahmed glaucoma valve surgery

PURPOSE

To determine factors associated with vision loss 1 year after Ahmed glaucoma valve (AGV) surgery in Black or Hispanic patients, who bear disproportionate glaucoma burdens yet have been underrepresented in pivotal trials.

METHODS

This retrospective study included Black or Hispanic patients who received AGVs standalone or combined with phacoemulsification and/or cyclodestructive lasers. Univariate and multivariate generalized estimating equations evaluated the effects of baseline, surgical, and postoperative factors on vision loss of two Snellen lines or more at the 1-year follow-up visit. The primary term was the hypertensive phase (HP), which signified an intraocular pressure (IOP) reading > 21 mmHg within the first 3 postoperative months after reduction below 22 in the first week, without other tube malfunction.

RESULTS

Of 241 eyes from 186 patients, vision loss of ≥ 2 lines at the 1-year follow-up visit occurred in 21.6% (N = 52). Vision loss of ≥ 2 lines occurred in 52.5% of eyes at week 1, 36.9% of eyes at month 1, and 27.0% of eyes at month 3. Between 6 months and 1 year, vision loss frequencies stabilized. In the multivariate model, HP (OR = 4.71 (2.14, 10.38)), total quadrants with split fixation (1.47 (1.20, 1.81)), follow-up non-glaucomatous eye pathology (2.89 (1.44, 5.80)), and concurrent cataract surgery (0.42 (0.22, 0.82)) each met significance (p < 0.05).

CONCLUSION

Post-AGV vision loss in the early follow-up period among Black or Hispanic patients was often transient. Hypertensive phase and split fixation each increased the odds of vision loss at 1 year, while concurrent cataract surgery decreased the odds.

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

PURPOSE

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

CLINICAL RELEVANCE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

How to Stop People from Going Blind from Glaucoma Using Early Cataract Surgery/Refractive Lensectomy and Microinvasive Glaucoma Surgery

Glaucoma continues to be a leading cause of blindness worldwide for the same reasons as in the past several decades, including the lack of early detection, improper treatment, and non-adherence to therapy. Medical therapy continues to be the first-line therapy even as surgical techniques are improving in their safety and efficacy. To turn the tide in preventing blindness from glaucoma, attention must be focused on targeted patient education, screening, effective treatment, and addressing health disparities. To achieve this, early safer cataract surgery and microinvasive glaucoma surgery must be considered as a first-line therapy in addition to medical therapy to best lower both intraocular pressure and the medication burden.

Three-dimensional telesurgery and remote proctoring over a 5G network

Purpose

To present 2 cases of vitreoretinal surgery performed on a three-dimensional (3D) heads-up display surgical platform with real-time transfer of 3D video over a fifth-generation (5G) cellular network.

Methods

An epiretinal membrane peel and tractional retinal detachment repair performed at Massachusetts Eye and Ear in April 2019 were broadcast live to the Verizon 5G Lab in Cambridge, MA.

Results

Both surgeries were successful. The heads-up digital surgery platform, combined with a 5G network, allowed telesurgical transfer of high-quality 3D vitreoretinal surgery with minimal degradation. Average end-to-end latency was 250 ms, and average round-trip latency was 16 ms. Fine surgical details were observed remotely by a proctoring surgeon and trainee, with real-time communication via mobile phone.

Conclusions

This pilot study represents the first successful demonstration of vitreoretinal surgery transmitted over a 5G network. Telesurgery has the potential to enhance surgical education, provide intraoperative consultation and guidance from expert proctors, and improve patient outcomes, especially in remote and low-resource areas.

Racial Differences in Anti-VEGF Intravitreal Injections Among Commercially Insured Beneficiaries

BACKGROUND AND OBJECTIVE

This study assessed racial and ethnic differences in receiving anti-vascular endothelial growth factor (VEGF) intravitreal injections among commercially insured patients.

PATIENTS AND METHODS

A retrospective cohort study of 104,430 patients diagnosed with wet age-related macular degeneration (AMD), diabetic retinopathy, central retinal vein occlusion (CRVO), and branch retinal vein occlusion (BRVO) in the Optum Research Database between 2011 and 2016. Main outcomes included receiving an intravitreal anti-VEGF treatment; the first type of treatment received, if any; and subsequent treatment with ranibizumab or aflibercept among patients who were first treated with bevacizumab.

RESULTS

In a logistic regression model in all 104,430 patients, Asian patients were significantly less likely to receive an anti-VEGF treatment compared to white patients (odds ratio [OR] = 0.725; 95% confidence interval [CI], 0.667-0.789; P < .001), but Black and Hispanic patients were not. Overall, 19.9% (n = 20,753) of all included patients received treatment with intravitreal injections of anti-VEGF or steroids. In multinomial logistic models of treatment type among all patients who received intravitreal injections, Hispanic patients were less likely than white patients to initially be treated with ranibizumab (relative risk ratio [RRR] = 0.776; 95% CI, 0.647-0.929; P = .006) or aflibercept (RRR = 0.794; 95% CI, 0.654-0.964; P = .020). Black and Asian patients were not significantly more or less likely to receive different types of first-line injections compared to white patients. Among 17,092 patients who received bevacizumab as first-line therapy, Hispanic patients were less likely to subsequently transition to aflibercept than their white counterparts (RRR = 0.756; 95% CI, 0.634-0.903; P = .002).

CONCLUSIONS

The authors found minimal racial and ethnic differences in receiving anti-VEGF treatment among commercially insured patients with wet AMD, diabetic retinopathy, CRVO, and BRVO. These results are limited by the fact that all of the patients included were commercially insured, and there are limited data on the socioeconomic status of the patients in their sample. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:208-217.].

A Geodemographic Service Coverage Analysis of Travel Time to Glaucoma Specialists in Florida

PRECIS

Approximately 1 in 9 Florida residents over the age of 65 years (438,642 people) live more than an hour away from a glaucoma specialist, which represents a significant barrier to care.

PURPOSE

To describe access to glaucoma care for Florida's elderly population using travel time to American Glaucoma Society (AGS) member offices.

METHODS

For this cross-sectional service coverage analysis, a list of AGS member locations was extracted from the AGS website, and addresses were geocoded using ArcGIS Online. Driving time regions were created using the service area tool in ArcGIS Pro 2.4 and overlaid with 2010 United States Census and 2016 American Community Survey data for all Florida residents age 65 or older.

RESULTS

Fifty-eight AGS member providers with 65 locations were identified and geocoded. There were 3,797,625 individuals aged over 65 years in Florida, of which 1,153,320 (30.4%) lived within 15 minutes of driving time from an AGS provider's office, 2,586,825 (68.1%) within 30 minutes, 3,358,983 (88.4%) within 60 minutes, and 3,491,815 (91.9%) within 120 minutes. The areas with the lowest access include rural areas near Lake Okeechobee and the Florida Panhandle. The population living beyond a 60-minute drive was more likely to be White, non-Hispanic and older, but less likely to be living below the federal poverty level or receiving public assistance than the population living within a 60-minute drive.

CONCLUSIONS

There is a significant travel burden for the elderly community of Florida to reach AGS providers. Additional studies could help identify other social barriers to accessing glaucoma providers in Florida and beyond in an effort to improve patient compliance and, ultimately, vision outcomes.

Smoking Is Associated with Higher Intraocular Pressure Regardless of Glaucoma: A Retrospective Study of 12.5 Million Patients Using the Intelligent Research in Sight (IRIS®) Registry

PURPOSE

To compare the average intraocular pressure (IOP) among smokers, past smokers, and never smokers using the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry.

DESIGN

Retrospective database study of the IRIS® Registry data.

PARTICIPANTS

Intelligent Research in Sight Registry patients who were seen by an eye care provider during 2017.

METHODS

Patients were divided into current smoker, past smoker, and never smoker categories. The IOP was based on an average measurement, and separate analyses were performed in patients with and without a glaucoma diagnosis based on International Classification of Diseases (Ninth Edition and Tenth Edition) codes. Stratified, descriptive statistics by glaucoma status were determined, and the relationship between smoking and IOP was assessed with a multivariate linear regression model.

MAIN OUTCOME MEASURES

Mean IOP.

RESULTS

A total of 12 535 013 patients were included. Compared with never smokers, current and past smokers showed a statistically significantly higher IOP by 0.92 mmHg (95% confidence interval [CI], 0.88-0.95 mmHg) and 0.77 mmHg (95% CI, 0.75-0.79 mmHg), respectively, after adjusting for age, gender, glaucoma, age-related macular degeneration, diabetic retinopathy, cataract, glaucoma surgery, cataract surgery, and first-order interactions. In addition, the difference in IOP between current and never smokers was the highest in the fourth decade, regardless of the glaucoma status (glaucoma group, 1.14 mmHg [95% CI, 1.00-1.29 mmHg]; without glaucoma group, 0.68 mmHg [95% CI, 0.65-0.71 mmHg]).

CONCLUSIONS

Current smokers and past smokers have higher IOP than patients who never smoked. This difference is higher in patients with an underlying glaucoma diagnosis.