Social Deprivation and the Risk of Screening Positive for Glaucoma in the MI-SIGHT Telemedicine-Based Glaucoma Detection Program

Screening of Glaucoma in High-Risk Minority Populations

PRECIS

This chapter reviews the current recommendations on screening for open angle glaucoma in Black and Hispanic populations. Strategies for increasing case-finding and decreasing cost, with emphasis on evolving technologies, are presented.

PURPOSE

To address the current recommendations on primary open angle glaucoma screening in high-risk minority populations and to discuss potential strategies to improve the screening of glaucoma in these populations.

METHODS

A literature review was performed by searching PubMed, EMBASE, and Google Scholar. All English-language papers that resulted from the search terms from January 1980 to October 2023 were reviewed.

RESULTS

In the next few decades, the societal burden of glaucoma will increase because of the demographic shift to an older and more diverse US population, including Black and Hispanic populations, which have been shown to have a higher prevalence of the disease. The current (2022) conclusion of the US Preventive Services Task Force is that the evidence to assess the balance of benefits and harms of screening for glaucoma in adults is insufficient to recommend widespread screening. The Preferred Practice Pattern guideline similarly states that screening for glaucoma in the general population is not cost-effective. However, the guidelines state that screening is more useful and cost-effective when it is targeted at populations at high risk for glaucoma, such as older adults, those with a family history of glaucoma, and Black and Hispanic individuals. Strategies for improving the effectiveness of glaucoma screening must increase case finding and decrease cost. New screening technologies, such as telemedicine and artificial intelligence, are expanding access for underserved populations.

CONCLUSIONS

There is still no clear consensus on the effectiveness of glaucoma screening for the general population. However, glaucoma screening may be useful and cost-effective when it is targeted at populations at high risk for glaucoma, particularly using emerging technologies that improve access and case-finding.

Influence of Social Determinants of Health on Presentation and Outcomes of Primary Congenital Glaucoma

PURPOSE

Assess the effect of social determinants of health on presentation and outcomes in primary congenital glaucoma (PCG).

DESIGN

Retrospective case series.

SUBJECTS

Patients with PCG presenting between 2011 and 2023 with > 3 months follow-up.

METHODS

The percentage of households with 0, 1-2, or > 3 community resilience estimates (CREs) risk factors and median income for the census tract of residence for each patient were collected. Initial details and final outcomes were correlated with race, ethnicity, insurance type, and census tract data.

MAIN OUTCOME MEASURES

Final best-corrected visual acuity (BCVA).

RESULTS

Of 59 patients (105 eyes, 68% male), the presenting average age was 294 ± 365 days. Black patients (n = 16) were younger (P < 0.001) than White (n = 31) or other race patients (n = 12). Although there was no racial or ethnic differences in initial intraocular pressure (IOP), IOP > 30 mmHg was associated with worse final BCVA. Patients with Medicaid (n = 31) required more glaucoma surgeries compared with those with commercial insurances (n = 28, P = 0.0305), respectively. Linear regression analysis demonstrated that census tracts with higher percentage of households with > 3 CRE risk factors correlated with worse visual acuity (ß = 0.02, P = 0.0028, R2 = 0.2). There were no racial, ethnic, insurance type, tract median income, or CRE risk factor differences in IOP, number of glaucoma medications, spherical equivalent, or cup-to-disc ratio at final follow-up.

CONCLUSIONS

Type of insurance and census data as markers for social determinants of health demonstrated increased risk factors can be associated with worse visual outcomes in PCG.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Social Vulnerability Associated With Frequency of Visual Field and Optical Coherence Tomography Testing in Glaucoma Patients

PRECIS

Higher Social Vulnerability Index scores, limited-English proficiency, and retirement/disability status were associated with lower odds of completing one visual field and optical coherence tomography/year in glaucoma patients.

PURPOSE

To assess the correlation between sociodemographic factors and the Social Vulnerability Index to the likelihood of not receiving 1 visual field test and 1 retinal nerve fiber layer optical coherence tomography test per year.

METHODS

Patient records with glaucoma living in Washington state from a single academic institution (2014-2021) were reviewed. Those with a single visit, an address with no Social Vulnerability Index score, or a diagnosis relating to pre-glaucoma, glaucoma-suspect, or ocular hypertension were excluded. Demographic data, Social Vulnerability Index scores, and the number of visual fields and optical coherence tomography were collected. Patients were classified as meeting testing criteria if they had at least one visual field and optical coherence tomography per year. Logistic regression was used to assess whether sociodemographic factors and Social Vulnerability Index scores were associated with not meeting testing criteria.

RESULTS

Three thousand nine hundred seventy-one patients were included: 1470 (37.0%), 1834 (46.2%), and 1413 (35.6%), had at least 1 visual field/year, at least 1 optical coherence tomography/year, and at least 1 visual field and 1 optical coherence tomography/year, respectively. On average 0.8±0.6 visual field/year and 0.9±0.6 optical coherence tomography/year were performed. Limited English proficiency ( P =0.009), being disabled/retired ( P =0.003), and higher Social Vulnerability Index scores ( P <0.001) were associated with higher odds of not meeting testing criteria.

CONCLUSIONS

Although higher Social Vulnerability Index scores were linked to reduced odds of glaucoma testing, specific sociodemographic factors-such as limited English proficiency and retirement/disability-further reduced the odds.

Inequities in glaucoma research: an analysis of Cochrane systematic reviews and randomized trials

OBJECTIVES

To understand the level of equity considerations within Cochrane systematic reviews (CSR) on glaucoma and their primary studies.

METHODS

A review of equity considerations in systematic reviews on glaucoma published in The Cochrane Library from inception (2003) to January 31, 2024 and a sample of recently published primary studies included in those reviews (n = 122). Extraction was performed by two independent reviewers using a prepiloted extraction form based on a validated, contemporary, structured equity framework. If consensus could not be reached, a third reviewer was involved.

RESULTS

A total of 40 CSRs on glaucoma were identified, all of which exclusively included randomized control trials (RCTs) or quasi-RCTs. Twenty-nine (72.5%) reviews acknowledged populations experiencing inequities in glaucoma care; none were able to perform subgroup analysis due to data unavailability in primary studies. Six (15.0%) reviews considered equity-relevant factors when discussing applicability or limitations of study findings to specific populations. Seventy-four (46.8%) review authors were women, while 84 (53.2%) were men. Most review authors were primarily affiliated with institutions in the European Region (85, 53.8%) or the Americas (55, 34.8%), while none were primarily affiliated with institutions in Africa or low-income countries. Most RCTs were conducted in the Americas (32.8%), European Region (27.9%), or in high-income countries (72.1%). While most RCTs reported gender or sex of participants (107, 87.7%), only half reported race or ethnicity (61, 50.0%). No RCTs reported place of residence, occupation, socioeconomic status (SES), or social capital of participants. Approximately half (51.7%) of the participants in these RCTs were female.

CONCLUSION

Equity considerations can be better addressed in research on glaucoma. Reporting of patient sociodemographic in RCTs, particularly race and ethnicity, as well as global representation were insufficient. This may limit the generalizability and applicability of intervention efficacy to populations experiencing inequities and people from low-income countries.

Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine Program: Impact on Vision, Follow-up, and Costs

PURPOSE

To evaluate the impact of the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine Program (MI-SIGHT) on visual acuity (VA), vision-related quality of life (VRQOL), satisfaction, follow-up visit attendance, and costs among medically underserved participants receiving primary care at community health centers.

DESIGN

Prospective cohort study with an embedded randomized controlled trial.

SUBJECTS

MI-SIGHT participants ≥18 years.

METHODS

MI-SIGHT participants underwent an eye disease screening exam with a trained ophthalmic technician, received assistance ordering low-cost glasses, and completed surveys. Participants could return for a repeat screening after 1 year. The prevalence of disease identified was compared to national rates using z-tests. VA and VRQOL were compared between initial and repeat visits with paired t-tests and Wilcoxon signed-rank tests. Satisfaction was summarized with descriptive statistics. Participants who screened positive for disease were assessed for attendance at recommended follow-up with a clinician, including those with glaucoma who were randomized to care navigation plus personalized education and health coaching (treatment) or care navigation plus written education (control). Attendance rates were calculated and compared between arms of the trial with Chi-Square tests.

MAIN OUTCOMES MEASURES

1) Eye disease prevalence; 2) Change in VA and VRQOL; 3) Program satisfaction; 4) Follow-up attendance; 5) Costs.

RESULTS

3714 participants were included; 11.5% were visually impaired, 9.3% had un- or undercorrected refractive error causing visual impairment; 22.4% had glaucoma/suspected glaucoma; 4.7% had diabetic retinopathy (rates higher than national averages at p<0.0001); 99% were satisfied or very satisfied, and 68% attended recommended follow-up. 943 participants completed repeat screening (mean of 1.2±0.3 years after initial screening). At repeat screening, worse eye presenting logMAR VA improved (mean±SD, 0.25±0.59 to 0.21±0.52, p=0.0012) as did VRQOL (NEI VFQ9 composite score 81.1±14.1 to 86.4±12.0, p<0.0001). Of the 490 participants who screened positive for glaucoma/suspected glaucoma and were randomized (n=247 treatment, n=243 control), follow up attendance did not differ (61% vs 59% p=0.7). The program cost $110.99/participant served, and $206.72/case of eye disease detected.

CONCLUSIONS

Expanding glaucoma and eye disease screening and treatment of refractive error to community health centers with care navigation support could improve vision and eye health outcomes.

Federally Qualified Health Centers as a Model to Improve Vision Health: A Systematic Review

Importance

Disparities in eye health are associated with lower-income and minoritized populations, many of whom seek care at federally qualified health centers (FQHCs).

Objective

To examine the literature addressing vision and eye health care provided at FQHCs, identify barriers to providing care at FQHCs, and highlight recommendations on how FQHCs can decrease disparities in eye health.

Evidence Review

A systematic review of Embase, SCOPUS, and PubMed was performed, and articles regarding eye and vision health at FQHCs within the US published between January 1, 1965, and July 14, 2023, were included. This review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Structured data and case studies were extracted and collated using an a priori method to reduce bias.

Findings

The systematic review yielded 423 unique articles, with 43 meeting inclusion criteria. Only 18.3% to 29% of FQHCs reported on-site vision services with the remainder relying on external referrals to vision specialists. Primary eye conditions evaluated included diabetic retinopathy (26 studies), general eye health (11 studies), and glaucoma (6 studies). Telehealth vision initiatives were an important method to expand access (18 studies). Other topics included economic analysis (5 studies) and policy suggestions (3 studies) to increase vision services at FQHCs. Systemic barriers to accessing care at FQHCs were the lack of eye clinicians available to provide services, the cost of resources, and limited reimbursement to implement screening programs. Patient barriers to accessing care included financial constraints for specialist care, limited awareness of the importance of eye examinations, and difficulty navigating the insurance system.

Conclusions and Relevance

Findings of this systematic review suggest that FQHCs are well positioned to increase vision services and thus improve vision health equity, serving populations who are at a higher risk for vision disorders. Results find systemic and patient-level barriers to vision health that may need to be addressed. Policy leaders could leverage existing gaps for purposeful advocacy, set standards and metrics for vision health at FQHCs, promote novel models of care, and encourage collaboration of eye clinicians with partnering FQHCs.

Impact of Physiological and Psychological Stress on Glaucoma Development and Progression: A Narrative Review

Glaucoma is a leading cause of irreversible blindness worldwide. Presently, elevated intraocular pressure (IOP) is the only approved modifiable risk factor. A consensus of the current literature suggests that both physiological and psychological stress may also impact the lifelong course of glaucoma. Specifically, stress is known to influence sympathetic nervous system activity. An increase in sympathetic nervous system activity may elevate a person's blood pressure (BP) and IOP, and both are strongly associated with glaucomatous disease. Anxiety and depression have more conflicting evidence in relation to glaucoma. Socioeconomic and environmental stress may worsen adherence to therapy and disease outcomes due to a lack of financial resources and related access to healthcare. Neighborhood quality and environmental conditions, particularly urban environments, have been associated with glaucoma risk factors, higher glaucoma prevalence, and delayed surgical interventions. Racial differences have also been identified, with Black patients being more stressed and likely to present with increased glaucoma severity and faster disease progression than White patients. Mindfulness, meditation, and other forms of psychological relaxation have been shown to reduce IOP and stress biomarkers and result in improved quality of life (QOL). Larger studies in more diverse populations are needed to clarify risk and identify the best therapeutic approaches to reduce stress as a method to improve clinical outcomes and QOL for glaucoma patients.

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

Purpose

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

Design

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

Participants

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

Methods

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

Main Outcome Measures

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

Results

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

Conclusions

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

Financial Disclosures

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

Association Between Greater Social Vulnerability and Delayed Glaucoma Surgery

PURPOSE

Timing of surgical intervention in glaucoma is crucial to preserving sight. While ocular characteristics that increase surgical risk are known, the impact of neighborhood-level social risk factors such as the Social Vulnerability Index (SVI) and Area Deprivation Index (ADI) on time to glaucoma surgery is unknown. The objective of this study was to evaluate the association between SVI or ADI scores and the timing of glaucoma surgical intervention.

DESIGN

Retrospective cohort study.

METHODS

Adult subjects with open-angle glaucoma were identified from the Bascom Palmer Glaucoma Repository using International Classification of Disease-10 codes. Subject demographics, ocular characteristics, and standard automated perimetry data were extracted. Geocoded data were obtained using subject residences and American Community Survey data. Univariable and multivariable time-to-event survival analyses using accelerated failure time models were completed to evaluate whether geocoded SVI and ADI scores accelerated or delayed time to glaucoma surgery from initial glaucoma diagnosis in the electronic health record.

RESULTS

A total of 10,553 eyes from 6934 subjects were evaluated, of which 637 eyes (6.0%) from 568 subjects (8.2%) underwent glaucoma surgery. Mean age was 68.3 ± 13.5 years, with 57.9% female, 21.5% Black, and 34.5% Hispanic subjects. Mean follow-up time was 5.0 ± 2.1 years, with time to surgery of 3.2 ± 1.9 years. Multivariable accelerated failure time models demonstrated that higher mean intraocular pressure (time ratio [TR] 0.27 per 5 mm Hg higher; 95% confidence interval [CI]: 0.23-0.31, P < .001), faster standard automated perimetry rate of progression (TR 0.74 per 0.5 dB/year faster; 95% CI: 0.69-0.78, P < .001), moderate (TR 0.69; 95% CI: 0.56-0.85, P < .001) or severe baseline severity (TR 0.39; 95% CI: 0.32-0.47, P < .001), and thinner central corneal thickness (TR 0.85 per 50 µm thinner; 95% CI: 0.77-0.95, P = .003) all accelerated time to surgery. In contrast, overall SVI delayed surgery (TR 1.11 per 25% increase; 95% CI: 1.03-1.20, P = .006). Specifically, SVI Themes 1 (TR 1.08; 95% CI: 1.01-1.17, P = .037) and 4 (TR 1.11; 95% CI: 1.03-1.19, P = .006) were significant. Patients from the most deprived neighborhoods (highest national ADI quartile) had a 68% increase in time to surgery compared to the least deprived quartile (TR 1.68; 95% CI: 1.20-2.36, P = .002).

CONCLUSIONS

Residence in areas with higher SVI or ADI scores was associated with delayed glaucoma surgery after controlling for demographic and ocular parameters. Awareness of such disparities can guide initiatives aimed at achieving parity in health outcomes.

A Screening Strategy to Mitigate Vision Impairment by Engaging Adults Who Underuse Eye Care Services

Importance

Underuse of eye care services leads to underdiagnosed and undertreated eye disease.

Objective

To assess the reasons for underuse of eye care and whether a novel, free eye disease screening program is engaging adults who are both at high risk of eye disease and were underusing eye care services.

Design, Setting, and Participants

In a population-based cross-sectional study, adult participants from the first year of the Michigan Screening and Intervention for Glaucoma and Eye Health Through Telemedicine (MI-SIGHT) Program were included. The participants were recruited from primary care clinics serving 2 low-income communities. Recruitment occurred between June 28, 2020 and June 27, 2021 at the free clinic, and between January 27, 2021 and January 26, 2022 at a federally qualified health clinic. Data were analyzed from December 7, 2022, to May 29, 2024. Participants received comprehensive eye disease screening and completed surveys assessing health and prior eye care use. Risk factors for eye disease included age 65 years and older, diabetes, personal or family history of eye disease, and self-identifying as Black or African American individuals who were aged 50 years or older. Underuse of eye care was defined as no eye examination in 2 or more years.

Main Outcomes and Measures

Percentage of participants who were at high risk of eye disease and underused eye care services before accessing this program.

Results

A total of 1171 MI-SIGHT participants were a mean (SD) age of 55 (14.5) years; 437 (38%) identified as male; 591 (54%) self-identified as Black or African American, 101 (10%) as Hispanic or Latino, and 371 (34%) as White; 492 (43%) had high school education or less, and 696 (70%) reported an annual household income of less than $30 000. Characteristics of participants reporting not having had an eye examination in 2 years or more included 23% (n = 151) of participants 65 years and over, 33% (n = 214) of participants who self-reported diabetes, 25% (n = 130) of participants reporting a family history of glaucoma, 3% (n = 14) of those with self-reported glaucoma; and 33% (n = 202) of Black or African-American participants aged 50 years and older. In participants who reported not having had an eye examination in 2 or more years, 21% (n = 137) screened positive for glaucoma, 20% (n = 129) for cataract, 6% (n = 38) for diabetic retinopathy, and 1% (n = 9) for age-related macular degeneration. Reported reasons for why participants had not had an eye examination included no insurance (175 of 627 [28%]), no reason to go (no problem) (135 of 627 [22%]), and cost of eye examination (101 of 627 [16%]).

Conclusions and Relevance

The findings of this study suggest that placing eye disease detection programs in primary care clinics in underserved areas may improve eye disease detection and treatment, possibly mitigating needless vision loss in the US.

Loneliness and social isolation are associated with an increased risk of glaucoma: a UK Biobank cohort study

BACKGROUND

Loneliness and social isolation have been found to be associated with various health-related outcomes. Our study aimed to evaluate the association of loneliness and social isolation with the risk of glaucoma.

METHODS

A total of 373,330 participants from the UK Biobank without glaucoma at recruitment were included in this study. Self-reported questionnaires were used to define loneliness and social isolation. Incident glaucoma events were identified by hospital inpatient admissions and self-reported data. COX proportional hazards models adjusted for sociodemographic, lifestyle, and health-related factors were used to estimate hazard ratios (HRs) and 95% CIs.

RESULTS

During a median follow-up of 13.1 (interquartile range: 12.3-13.9) years, 6,489 participants developed glaucoma. After adjusting for confounding factors, loneliness (yes vs. no: adjusted HR: 1.16; 95% CI: 1.04-1.30; P = 0.009) and social isolation (yes vs. no: adjusted HR: 1.08; 95% CI: 1.01-1.16; P = 0.033) were associated with an increased risk of glaucoma.

CONCLUSIONS

In this population-based prospective cohort study, loneliness and social isolation were associated with a higher risk of glaucoma.

Association Between Sociodemographic Factors and Self-reported Glaucoma in the National Health Interview Survey: A Population-Based Analysis

PURPOSE

To investigate the association between social determinants of health (SDH) in the domains of social and community context, education access, environmental context, economic stability, and healthcare access, with glaucoma prevalence.

DESIGN

Cross-sectional study.

METHODS

The study population consisted of adult participants who answered glaucoma-related questions on the 2017 National Health Interview Survey (NHIS), the most recent iteration that includes glaucoma-related questions. The main outcome measures included the relationships between SDH-related factors and self-reported glaucoma diagnosis as well as self-reported glaucomatous vision loss were examined using univariable and multivariable regression models.

RESULTS

In total, 26,696 of 26,742 (99.83%) NHIS respondents were included, of whom 880 (3.30%) reported a glaucoma diagnosis and 275 (1.03%) reported glaucomatous vision loss. Participants were predominantly middle-aged (50.95 ± 18.60 years), female (54.75%), and non-Hispanic White (70.49%). In age-adjusted multivariable regression (n = 25,456), non-Hispanic Black race (odds ratio [OR] = 1.87, 99% CI = [1.37, 2.55], P < .001, compared to non-Hispanic White race) and poor health status (OR = 1.54, 99% CI = [1.00, 2.37], P = .01, compared to good health status) were significant predictors of glaucoma diagnosis. For glaucomatous vision loss, having an income below the poverty threshold (OR = 2.41, 99% CI = [1.12, 5.20], P = .003, compared to income ≥5 times the poverty threshold) was the only significant predictor in univariable analyses. No SDH-related factors were significantly associated with glaucomatous vision loss in multivariable analysis (n = 848). Multicollinearity was minimal (variation inflation factor<1.6 for all independent variables).

CONCLUSIONS

Non-Hispanic Black race and poor health status were associated with self-reported glaucoma diagnosis. Physicians and policymakers may consider SDH when assessing clinical risk and designing public health interventions.

Socioeconomic Disparities in Glaucoma Severity at Initial Diagnosis: A Nationwide Electronic Health Record Cohort Analysis

PURPOSE

To assess disparities in initial disease severity among open-angle glaucoma (OAG) patients.

DESIGN

Cross-sectional study.

METHODS

In this analysis of Epic Cosmos, an aggregated electronic health record dataset encompassing >213 million patients, OAG patients examined in ophthalmology or optometry clinics between January 1, 2013, and June 1, 2023, were evaluated. OAG severity at presentation was classified as mild, moderate, or severe using International Classification of Disease-10 codes. Demographics, social vulnerability index (SVI) scores, and rural-urban commuting area codes were evaluated as predictors of disease stage using ordinal logistic regression. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

Of 245,669 patients, 38.1% had mild, 32.5% moderate, and 29.3% severe disease at presentation. In multivariable analyses, significant determinants of worse severity included older age (OR: 1.23 per decade, 95% CI: 1.22-1.23), male sex (OR: 1.37, 95% CI: 1.35-1.39), Black race (OR: 1.61, 95% CI: 1.58-1.65), Hispanic ethnicity (OR: 1.15, 95% CI: 1.11-1.18), non-commercial insurance or uninsured status (OR: 2.53, 95% CI: 2.33-2.74), secondary OAGs (eg, pseudoexfoliative glaucoma - OR: 1.65, 95% CI: 1.58-1.72), and higher socioeconomic SVI scores (OR: 1.25 for highest versus lowest quartile, 95% CI: 1.22-1.28). Black and Hispanic patients were diagnosed at younger ages compared to White patients (mean ages: 67.8 ± 12.3 and 68.1 ± 12.8 vs 73.3 ± 11.8 years respectively, P < .001).

CONCLUSIONS

Worse OAG at presentation was associated with older age, male sex, Black race, Hispanic ethnicity, non-commercial insurance or uninsured status, secondary OAGs, and greater socioeconomic vulnerability in this nationwide cohort. These findings can help tailor screening programs towards vulnerable populations.

The Impact of Social Vulnerability on Structural and Functional Glaucoma Severity, Worsening, and Variability

PURPOSE

To determine the associations between social vulnerability index (SVI) and baseline severity, worsening, and variability of glaucoma, as assessed by visual field (VF) and OCT.

DESIGN

Retrospective longitudinal cohort study.

PARTICIPANTS

Adults with glaucoma or glaucoma suspect status in 1 or both eyes. Visual fields were derived from 7897 eyes from 4482 patients, while OCTs were derived from 6271 eyes from 3976 patients. All eyes had a minimum of 5 tests over follow-up using either the Humphrey Field Analyzer or the Cirrus HD-OCT.

METHODS

Social vulnerability index, which measures neighborhood-level environmental factors, was linked to patients' addresses at the census tract level. Rates of change in mean deviation (MD) and retinal nerve fiber layer (RNFL) thickness were computed using linear regression. The slope of the regression line was used to assess worsening, while the standard deviation of residuals was used as a measure of variability. Multivariable linear mixed-effects models were used to investigate the impact of SVI on baseline, worsening, and variability in both MD and RNFL. We further explored the interaction effect of mean intraocular pressure (IOP) and SVI on worsening in MD and RNFL.

MAIN OUTCOME MEASURES

Glaucoma severity defined based on baseline MD and RNFL thickness. Worsening defined as MD and RNFL slope. Variability defined as the standard deviation of the residuals obtained from MD and RNFL slopes.

RESULTS

Increased (worse) SVI was significantly associated with worse baseline MD (β = -1.07 dB, 95% confidence interval [CI]: [-1.54, -0.60]), thicker baseline RNFL (β = 2.46 μm, 95% CI: [0.75, 4.17]), greater rates of RNFL loss (β = -0.12 μm, 95% CI: [-0.23, -0.02]), and greater VF variability (β = 0.16 dB, 95% CI: [0.07, 0.24]). Having worse SVI was associated with worse RNFL loss with increases in IOP (βinteraction = -0.07, 95% CI: [-0.12, -0.02]).

CONCLUSIONS

Increased SVI score is associated with worse functional (VF) loss at baseline, higher rates of structural (OCT) worsening over time, higher VF variability, and a greater effect of IOP on RNFL loss. Further studies are needed to enhance our understanding of these relationships and establish their cause.

FINANCIAL DISCLOSURE(S)

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

Place-Based Measures of Inequity and Vision Difficulty and Blindness

Importance

Known social risk factors associated with poor visual and systemic health in the US include segregation, income inequality, and persistent poverty.

Objective

To investigate the association of vision difficulty, including blindness, in neighborhoods with measures of inequity (Theil H index, Gini index, and persistent poverty).

Design, Setting, and Participants

This cross-sectional study used data from the 2012-2016 American Community Survey and 2010 US census tracts as well as Theil H index, Gini index, and persistent poverty measures from PolicyMap. Data analysis was completed in July 2023.

Main Outcomes and Measures

The main outcome was the number of census tract residents reporting vision difficulty and blindness (VDB) and the association with the Theil H index, Gini index, or persistent poverty, assessed using logistic regression.

Results

In total, 73 198 census tracts were analyzed. For every 0.1-unit increase in Theil H index and Gini index, there was an increased odds of VDB after controlling for census tract-level median age, the percentage of the population that identified as female sex, the percentage of the population that identified as a member of a racial or ethnic minority group, state, and population size (Theil H index: odds ratio [OR], 1.14 [95% CI, 1.14-1.14; P < .001]; Gini index: OR, 1.15 [95% CI, 1.15-1.15; P < .001]). Persistent poverty was associated with an increased odds of VDB after controlling for census tract-level median age, the percentage of the population that identified as female sex, the percentage of the population that identified as a member of a racial or ethnic minority group, state, and population size compared with nonpersistent poverty (OR, 1.36; 95% CI, 1.35-1.36; P < .001).

Conclusions and Relevance

In this cross-sectional study, residential measures of inequity through segregation, income inequality, or persistent poverty were associated with a greater number of residents living with VDB. It is essential to understand and address how neighborhood characteristics can impact rates of VDB.

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.

Spatial Vision Inequalities: A Literature Review of the Impact of Place on Vision and Eye Health Outcomes

"Neighborhood and built environment" is one of the five domains of social determinants of health that has been outlined by Healthy People 2030, and this domain impacts an individual's well-being, health, and quality of life. Social risk factors (SRFs) in the neighborhood and built environment domain include unstable or unsafe housing, poor access to transportation, lack of green spaces, pollution, safety concerns, and neighborhood measures of inequity. In this narrative literature review, we assess the relationship between neighborhood and built environment SRFs and eye health and vision outcomes. We explain how mapping neighborhood-level SRFs may be used to advance health equity in the field of eye health and vision care.

Identifying, Understanding, and Addressing Disparities in Glaucoma Care in the United States

Glaucoma is the leading cause of irreversible blindness worldwide, currently affecting around 80 million people. Glaucoma prevalence is rapidly rising in the United States due to an aging population. Despite recent advances in the diagnosis and treatment of glaucoma, significant disparities persist in disease detection, management, and outcomes among the diverse patient populations of the United States. Research on disparities is critical to identifying, understanding, and addressing societal and healthcare inequalities. Disparities research is especially important and impactful in the context of irreversible diseases such as glaucoma, where earlier detection and intervention are the primary approach to improving patient outcomes. In this article, we first review recent studies identifying disparities in glaucoma care that affect patient populations based on race, age, and gender. We then review studies elucidating and furthering our understanding of modifiable factors that contribute to these inequities, including socioeconomic status (particularly age and education), insurance product, and geographic region. Finally, we present work proposing potential strategies addressing disparities in glaucoma care, including teleophthalmology and artificial intelligence. We also discuss the presence of non-modifiable factors that contribute to differences in glaucoma burden and can confound the detection of glaucoma disparities.

Translational Relevance

By recognizing underlying causes and proposing potential solutions, healthcare providers, policymakers, and other stakeholders can work collaboratively to reduce the burden of glaucoma and improve visual health and clinical outcomes in vulnerable patient populations.