High-risk populations for vision loss and eye care underutilization: a review of the literature and ideas on moving forward

Visual impairment and associated factors in adults from three suburban communities in Nampula, Mozambique

CLINICAL RELEVANCE

Scientific evidence on the burden of visual impairment, its causes, and associated factors are essential to monitor progress in eye health, identify priorities and develop strategies and policies that meet the needs of the population, towards the eradication of preventable blindness.

BACKGROUND

The aim of this study was to determine the prevalence of visual impairment, its causes and associated factors in adults living in suburban communities in Nampula.

METHODS

This is a cross-sectional study conducted from November 2019 to February 2020. Eye examinations were performed on adults aged ≥18 years covered by the Lúrio University program, 'one student, one family'. The odds ratio (OR) and adjusted odds ratio (aOR) were calculated to study the association between the dependent variable (presenting visual impairment) and independent variables (gender, age, school level, residence, family income and systemic diseases), with a 95% confidence interval.

RESULTS

Distance and near presenting visual impairment had a prevalence of 16.3% and 21.1%, respectively, and were statistically associated with the age groups between 45-65 (OR:4.9) and >65 years (OR: 29.1), illiterate (OR:13.8), primary (OR:4.8) and secondary (aOR:37.5) school level, farmer (OR:32.8) and retired (OR:14.3) occupation, and presence of systemic diseases (OR :3.3). The main causes of presenting visual impairment were uncorrected refractive error and cataract.

CONCLUSION

The prevalence of presenting visual impairment is relatively high, given the enormous effort undertaken within the framework of VISION 2020: The Right to Sight global initiative. There is a need to develop intervention plans targeted at the highest risk groups, with a view to achieving the 'one student, one family' program goals with respect to eye health.

Practice Patterns and Sociodemographic Disparities in the Clinical Care of Anatomical Narrow Angles in the United States

PURPOSE

To assess treatment and visit patterns among patients with newly diagnosed anatomical narrow angle (ANA) and identify sociodemographic factors associated with disparities in care.

DESIGN

Retrospective practice pattern evaluation study.

METHODS

A total of 263,422 patients diagnosed with ANA between 2007 and 2019 were identified in the Optum Clinformatics Data Mart. Inclusion was limited to newly diagnosed ANA, defined as (1) continuous enrollment during a 2-year lookback period and 1-year study period from first diagnosis; (2) diagnosis by an ophthalmologist or optometrist; and (3) no history of pseudophakia, ANA treatments, or prior primary angle closure glaucoma diagnosis. Outcome measures were treatment with laser peripheral iridotomy (LPI), cataract surgery, or intraocular pressure-lowering medications and number of eye care visits. Logistic and Poisson regression were performed to assess factors associated with treatment and eye care visits, respectively.

RESULTS

Among 52,405 eligible cases, 27.7% received LPI, 13.9% received drops, and 15.1% received cataract surgery. Odds of LPI were higher in Asians and Hispanics (odds ratio [OR] ≥ 1.16, P < .001). Non-Whites had higher odds of drops (OR ≥ 1.19, P < .001), but Hispanics had lower odds of cataract surgery (OR = 0.79, P < .001). The mean number of eye care visits was 2.6±2.1 including the day of diagnosis. Older age and treatment were associated with higher rates of eye care visits (rate ratio > 1.15, P < .001).

CONCLUSION

More than a quarter of patients with newly diagnosed ANA receive treatment with LPI. Racial minorities are more likely to receive ANA-specific treatments but less likely to receive cataract surgery. These differences may reflect racial differences in disease severity and the need for clearer practice guidelines in ANA care.

Barriers in older adults' decision-making process to use routine eye examinations in Hong Kong

CLINICAL RELEVANCE

The decision to have a routine eye examination involves individual- and service-level judgement. A deeper understanding of patient access barriers and expectations could facilitate the design of better-aligned service models in optometric practice, improving the utilisation rate of an important facet of primary healthcare services.

BACKGROUND

Routine eye examinations achieve several health objectives, including mitigation of sight-threatening risk factors. However, there are barriers to service uptake. Through the qualitative approach, a deeper understanding of these barriers can be realised and enhanced strategies designed to improve the uptake of the routine eye examination. A qualitative study was conducted to identify the factors influencing the decision-making process of older adults to use the routine eye examination service.

METHODS

This study was guided by the grounded theory approach. Participants were purposively recruited from six community elderly centres. Semi-structured interviews were conducted with 25 community-dwelling adults aged 65 years or above in Hong Kong. Data were transcribed and constant comparison techniques were used for data analysis.

RESULTS

Difficulty in prioritising and including the routine eye examination in the existing health service utilisation was the central theme associated with its lower use. Four sub-themes were identified to explain this phenomenon: (1) previous health care service utilisation as a reference for judging primary eye care; (2) low perceived primary eye care service needs; (3) low perceived self-efficacy on routine eye care utilisation; (4) service expectations.

CONCLUSION

Multiple modifiable factors influence decision-making by older adults, suggesting that their routine eye care seeking behaviour might be altered through behaviour change intervention. The context in which services are delivered requires further study, with a focus on exploring the factors influencing service experience and its subsequent impact on regular eye care seeking behaviour.

Manhattan Vision Screening and Follow-Up Study: (NYC-SIGHT)Tele-Retinal Image Findings and Importance of Photography

Purpose: To describe tele-retinal abnormality image findings from the Manhattan Vision Screening and Follow-up Study (NYC-SIGHT), which aims to investigate whether community-based eye health outreach strategies using telemedicine can improve visual outcomes among at-risk populations in Upper Manhattan. Methods: A 5-year prospective, cluster-randomized clinical trial was conducted. Eligible individuals aged 40 years and older were recruited from affordable housing developments and senior centers in New York City. Participants underwent on-site eye health screening (best-corrected visual acuity, intraocular pressure [IOP] measurements, and fundus photography). Fundus images were graded via telemedicine by a retina specialist. Multivariate logistic regression modeling was used to assess the factors associated with abnormal retinal findings requiring referral to ophthalmology. Results: Participants with a retinal abnormality on fundus photography (n = 157) were predominantly older adults, with a mean age of 68.4 ± 11.1 years, female (63.7%), African American (50.3%), and Hispanic (43.3%). A total of 32 participants in our study passed the vision and IOP screening but had an abnormal retinal image and ocular pathology that would have been missed without fundus photography. Individuals who self-identified as having preexisting glaucoma (odds ratio [OR] = 3.749, 95% confidence interval [CI] = 1.741-8.074, p = 0.0001) and had severe vision impairment (OR = 4.1034, 95% CI = 2.0740-8.1186, p = 0.000) at the screening had significantly higher odds of having an abnormal retinal image. Conclusion: This community-based study targeted populations at-risk for eye disease, improved access to eye care, detected a significant number of retinal image abnormalities requiring follow-up by using telemedicine, and provided evidence of the importance of fundus photography during eye health screenings. CTR number: NCT04271709.

Evaluating the Relationship between Neighborhood-Level Social Vulnerability and Patient Adherence to Ophthalmology Appointments

PURPOSE

To examine the association between neighborhood-level social vulnerability and adherence to scheduled ophthalmology appointments.

METHODS

In this retrospective cohort study, records of all patients ≥18 years scheduled for an ophthalmology appointment between September 12, 2020, and February 8, 2021, were reviewed. Primary exposure is neighborhood-level Social Vulnerability Index (SVI) based on the patient's residential location. SVI is a rank score of 15 social factors into four themes (socioeconomic status, household composition/disability, minority status/language, and housing type/transportation), ranging from 0 to 1.0, with higher ranks indicating greater social vulnerability. The overall SVI score and each theme were analyzed separately as the primary exposure of interest in multivariable logistic regression models that controlled for age, sex, appointment status (new or established), race, and distance from clinic. The primary outcome, non-adherence, was defined as missing more than 25% of scheduled appointments.

RESULTS

Of 8,322 patients (41% non-Hispanic Black, 24% Hispanic, 22% non-Hispanic White) with scheduled appointments, 28% were non-adherent. Non-adherence was associated with greater social vulnerability (adjusted odds ratio [aOR] per 0.01 increase in overall SVI = 2.46 [95% confidence interval, 1.99, 3.06]) and each SVI theme (socioeconomic status: aOR = 2.38 [1.94, 2.91]; household composition/disability: aOR = = 1.51 [1.26, 1.81]; minority status/language: aOR = 2.03 [1.55, 2.68]; housing type/transportation: aOR = 1.41 [1.16, 1.73]).

CONCLUSION

Neighborhood-level social vulnerability is associated with greater risk of non-adherence to scheduled ophthalmology appointments, controlling for individual characteristics. Multi-level intervention strategies that incorporate neighborhood-level vulnerabilities are needed to reduce disparities in access to ophthalmology care.

Disparities in Retinal Vein Occlusion Presentation and Initiation of Anti-VEGF Therapy: An Academy IRIS® Registry Analysis

OBJECTIVE

Investigate disparities in retinal vein occlusion (RVO) presentation and initiation of anti-VEGF treatment.

DESIGN

Retrospective cohort study.

SUBJECTS

Patients in the American Academy of Ophthalmology IRIS® (Intelligent Research in Sight) Registry database (2015-2021) with branch or central RVO and macular edema (ME).

METHODS

The association of demographic characteristics and presenting visual acuity (VA) with anti-VEGF treatment initiation were quantified using multivariable logistic regression.

MAIN OUTCOME MEASURES

Treatment with ≥ 1 anti-VEGF injection within 12 months after RVO diagnosis.

RESULTS

A total of 304 558 eligible patients with RVO and ME were identified. Age at presentation varied by race, ethnicity, sex, and RVO type (all P values < 0.001). Within the first year after RVO presentation, 192 602 (63.2%) patients received ≥ 1 anti-VEGF injection. In a multivariable regression model adjusting for relevant covariates, female (vs. male) patients had lower odds of receiving injections (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.93-0.96; P < 0.0001) as did Black/African American (vs. White) patients (OR, 0.90; 95% CI, 0.88-0.92; P < 0.0001) and Asian (vs. White) patients (OR, 0.95; 95% CI, 0.91-0.99; P = 0.02), whereas older patients (vs. patients aged < 51 years) had higher odds (61-70 years: OR, 1.20; 95% CI, 1.16-1.24; 71-80 years: OR, 1.20; 95% CI, 1.16-1.24; > 80 years: OR, 1.15; 95% CI, 1.11-1.18; all P values < 0.0001). Hispanic (vs. non-Hispanic) patients had a small increased odds of treatment initiation (OR, 1.08; 95% CI, 1.04-1.11; P < 0.0001). Results were similar in the subset of 226 143 patients with VA data. In this subset, patients with presenting VA < 20/40 to 20/200 were most frequently treated in the first year after diagnosis (∼ 70%) and patients with light perception/no light perception (LP-NLP) vision or VA of 20/20 or better were treated least frequently (36.9% and 41.9%, respectively).

CONCLUSIONS

In this large national clinical registry, 37% of RVO patients with ME had no anti-VEGF treatment documented in the first year after diagnosis. Black/African American, Asian, and female patients and patients with VA of LP-NLP were least likely to receive treatment. Awareness of this undertreatment and these disparities highlight the need for initiatives to ensure all RVO patients receive timely anti-VEGF injections for optimized visual outcomes.

FINANCIAL DISCLOSURES

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

Barriers and Facilitators to Ophthalmology Visit Adherence in an Urban Hospital Setting

Purpose

To explore barriers and facilitators to completing scheduled outpatient appointments at an urban academic hospital-based ophthalmology department.

Methods

Potential participants were stratified by neighborhood Social Vulnerability Index (SVI) (range, 0-1.0, higher scores indicate greater vulnerability), and semistructured interviews were conducted with individuals 18 years and older with an SVI of greater than 0.61 (n = 17) and providers delivering care in the General Eye Clinic of the University of Illinois Chicago (n = 8). Qualitative analysis informed by human-centered design methods was conducted to classify barriers and facilitators into three domains of the Consolidated Framework for Implementation Research: outer setting, inner setting, and characteristics of individuals.

Results

There were four main themes-transportation, time burden, social support, and economic situation-all of which were within the outer setting of the Consolidated Framework for Implementation Research; transportation was most salient. Although providers perceived health literacy as a barrier affecting motivation, patients expressed a high motivation to attend visits and felt well-educated about their condition.

Conclusions

A lack of resources outside of the health system presents significant barriers for patients from neighborhoods with high SVI. Future efforts to improve adherence should focus on resource-related interventions in the outer setting. Improving access to eye care will require community-level interventions, particularly transportation.

Translational Relevance

Understanding the barriers and facilitators within the Consolidated Framework for Implementation Research provides useful guidance for future interventions, specifically to focus future efforts to improve adherence on resource-related interventions.

Disparities in Eye Care Access and Utilization: A Narrative Review

This narrative review summarizes the literature on factors related to eye care access and utilization in the United States. Using the Healthy People 2030 framework, this review investigates social determinants of health associated with general and follow-up engagement, screenings, diagnostic visits, treatment, technology, and teleophthalmology. We provide hypotheses for these documented eye care disparities, featuring qualitative, patient-centered research. Lastly, we provide recommendations in the hopes of appropriately eliminating these disparities and reimagining eye care.

Barriers and enablers of utilization of low-vision rehabilitation services among people 50 years or older in East and Southeast Asia: a scoping review protocol

OBJECTIVES

This scoping review aims to explore and describe the barriers and enablers of low-vision rehabilitation service utilization among people 50 years or older in East and Southeast Asia.

INTRODUCTION

Vision impairment is strongly associated with aging. East and Southeast Asia are experiencing a rapidly growing aging population and the associated eye-related health burdens. Despite the benefits of low-vision rehabilitation services, they are underutilized in these regions. Identifying the barriers and enablers of service utilization could be a crucial first step in making the services more accessible and, ultimately, easing the burden of this health issue.

INCLUSION CRITERIA

This review will include published quantitative, qualitative, or mixed methods studies and reviews that examine the barriers and/or enablers of low-vision rehabilitation service utilization among people aged 50 years or older living in East and Southeast Asia. Low-vision rehabilitation services are defined as any kind of intervention that aims to mitigate the impact of disability induced by eye-related health conditions.

METHODS

A literature search of 4 databases (MEDLINE, Web of Science, Academic Search Ultimate, and Ichushi-Web), as well as a manual search of the reference lists of included articles, will be conducted to identify eligible articles. Two independent reviewers will assess the articles for inclusion. Data extraction will focus on general information of the study, demographic or descriptive information about the study population, the eye condition being studied, means of low-vision rehabilitation, and the barriers and/or enablers of service utilization. The information will be tabulated to depict the categories of barriers and enablers that influence access to services.

REVIEW REGISTRATION

Open Science Framework https://osf.io/8y2wp.

Planning an artificial intelligence diabetic retinopathy screening program: a human-centered design approach

Diabetic retinopathy (DR) is a leading cause of vision loss in the United States and throughout the world. With early detection and treatment, sight-threatening sequelae from DR can be prevented. Although artificial intelligence (AI) based DR screening programs have been proven to be effective in identifying patients at high risk of vision loss, adoption of AI in clinical practice has been slow. We adapted the United Kingdom Design Council's Double-Diamond model to design a strategy for care delivery which integrates an AI-based screening program for DR into a primary care setting. Methods from human-centered design were used to develop a strategy for implementation informed by context-specific barriers and facilitators. The purpose of this community case study is to present findings from this work in progress, including a system of protocols, educational documents and workflows created using key stakeholder input.

Barriers in Ophthalmology Residency Applications for Students Identifying as Underrepresented in Medicine: A San Francisco Match Analysis

OBJECTIVE

There is a significant lack of ophthalmologists who self-identify as underrepresented in medicine (URiM) in the physician workforce. Prior literature has revealed bias in traditional metrics for selection relied on by resident programs such as United States Medical Licensing Examination (USMLE) scores, letters of recommendation (LOR), and induction into medical honors societies such as Alpha Omega Alpha (AOA). The purpose of this study was to elucidate race-based differences in word usage within ophthalmology residency letters of recommendation that may disproportionately affect URiM applicants.

DESIGN

This was a retrospective, cohort study.

SETTING

This was a multicenter study across the Wilmer Eye Institute at Johns Hopkins, the University of California San Francisco, and the University of North Carolina at Chapel Hill.

PARTICIPANTS

San Francisco (SF) Match applications submitted to three ophthalmology residency programs between 2018 and 2020 were reviewed. URiM status, USMLE Step 1 score, and AOA membership were recorded. Letters of recommendation were analyzed using text analysis software. T-tests and chi-squared or Fisher's exact tests were used to compare continuous and categorical variables, respectively. Frequency of word/summary term usage in letters of recommendation were the main outcome measures.

RESULTS

Relative to non-URiM applicants, URiM applicants had lower USMLE Step 1 scores (mean difference=7.0; p<0.001). Non-URiM letters of recommendation were more likely to describe applicants as "dependable" (p=0.009) and highlight "research" (p=0.046). URiM letters were more likely to describe applicants as "warm" (p=0.02) and "caring" (p=0.02).

CONCLUSIONS

This study identified potential barriers for URiM ophthalmology residency applicants which can help guide future interventions to increase workforce diversity.

Urgent unmet needs in the care of bacterial keratitis: An evidence-based synthesis

Bacterial corneal infections, or bacterial keratitis (BK), are ophthalmic emergencies that frequently lead to irreversible visual impairment. Though increasingly recognized as a major cause of global blindness, modern paradigms of evidence-based care in BK have remained at a diagnostic and therapeutic impasse for over half a century. Current standards of management - based on the collection of corneal cultures and the application of broad-spectrum topical antibiotics - are beset by important yet widely underrecognized limitations, including approximately 30% of all patients who will develop moderate to severe vision loss in the affected eye. Though recent advances have involved a more clearly defined role for adjunctive topical corticosteroids, and novel therapies such as corneal crosslinking, overall progress to improve patient and population-based outcomes remains incommensurate to the chronic morbidity caused by this disease. Recognizing that the care of BK is guided by the clinical axiom, "time equals vision", this chapter offers an evidence-based synthesis for the clinical management of these infections, underscoring critical unmet needs in disease prevention, diagnosis, and treatment.

Topical Review: Teaching Serious News Delivery in Eye Care

SIGNIFICANCE

Eye doctors regularly convey serious illness news to their patients. There is an evolving understanding of how medical educators can effectively teach this vital communication skill during real-time patient care. This article proposes teaching strategies to improve clinical optometric education related to serious illness conversations.Effectively conveying serious illness news is an essential skill in optometry practice. Established protocols can help optometrists navigate these nuanced, emotional, and complex conversations with patients, yet protocols for teaching this skill in eye care settings have not been described. Clinical educators need discrete strategies for making such pivotal communication skills learnable in an environment where patient care, teaching priorities, and limited resources are regularly juggled. Despite the importance of this competency, limited study has focused on teaching optometry learners to deliver serious eye news. In this article, we explore the importance of optometry talk, serious news delivery tools, and considerations for optometric educators teaching serious news delivery. We then adapt specific strategies from medical education to help optometry educators teach serious news delivery in clinical settings.

Ang Ating Mata: Disparities in Eye Health Knowledge, Attitudes and Practices among Older Adult Filipino-Americans in the San Francisco Bay Area Counties

Filipino-Americans are the third largest Asian-American population, with a median age of 44. However, there is limited literature focusing on the group's ophthalmic care engagement. Timely eye examinations and outreach are necessary to reduce visual impairment in this older community. To assess eye care knowledge, attitudes, and practices, we conducted a cross-sectional study surveying Filipino-Americans within the nine San Francisco Bay Area counties. Associations between primary outcomes and sociodemographic factors were analyzed using chi-squared analysis and student's T-test. In our convenience sample of 256 surveys, a majority of participants are receiving appropriate eye care; those that lacked health and eye insurance, immigrated and are lower income did not receive optimal eye care. Study participants also demonstrated a lack of awareness of eye diseases and risk factors. Our results suggest that culturally sensitive eye health education materials are lacking and should be made accessible for this large and rapidly growing population.

Socioeconomic Correlates of Keratoconus Severity and Progression

PURPOSE

The purpose of this study was to investigate the social determinants of health for keratoconus.

METHODS

In this retrospective cohort study of patients with keratoconus, the electronic health record was reviewed for keratometry, treatments received, clinical comorbidities, and social characteristics. Outcomes included severe keratoconus at presentation (steep keratometry ≥52 diopters), disease progression (≥0.75 diopters increase from the first to the most recent clinical visit), and corneal transplantation. Logistic regression was used to evaluate factors associated with severity at presentation and corneal transplantation. Cox proportional hazards modeling was used to evaluate progression.

RESULTS

A total of 1038 patients with keratoconus were identified, 725 (70%) of whom had baseline imaging. Compared with commercially insured patients, Medicaid recipients were more likely to have severe keratoconus, independent of social and clinical confounders [odds ratio (OR) 1.94, 95% confidence interval (CI), 1.12-3.35, P = 0.017]. Male sex was independently associated with progression (hazard ratio = 1.38, 95% CI, 1.03-1.84, P = 0.030). Medicare and Medicaid recipients were more likely to require transplantation compared with commercially insured patients (OR 2.71, 95% CI, 1.65-4.46, P < 0.001 and OR 1.74, 95% CI, 1.08-2.80, P = 0.022, respectively). Other social determinants of health, including non-White race/ethnicity, limited English proficiency, and unemployment, were associated with the outcomes only in univariate analysis. Obstructive sleep apnea, atopy, body mass index, and tobacco use were not associated with any outcome.

CONCLUSIONS

Socioeconomic factors were more consistent predictors of keratoconus severity and corneal transplantation compared with clinical factors that have received relatively greater attention in the keratoconus literature.

Adherence to Urgent Eye Visits during the COVID-19 Pandemic: A Population Characteristics Study

PURPOSE

To explore individual and community factors associated with adherence to physician recommended urgent eye visits via a tele-triage system during the COVID-19 pandemic.

METHOD

We retrospectively reviewed acute visit requests and medical exam data between April 6, 2020 and June 6, 2020. Patient demographics and adherence to visit were examined. Census tract level community characteristics from the U.S. Census Bureau and zip code level COVID-19 related death data from the Cook County Medical Examiner's Office were appended to each geocoded patient address. Descriptive statistics, t-tests, and logistic regression analyses were performed to explore the effects of individual and community variables on adherence to visit.

RESULTS

Of 229 patients recommended an urgent visit, 216 had matching criteria on chart review, and 192 (88.9%) adhered to their visit. No difference in adherence was found based on individual characteristics including: age (p = .24), gender (p = .94), race (p = .56), insurance (p = .28), nor new versus established patient status (p = .20). However, individuals who did not adhere were more likely to reside in neighborhoods with a greater proportion of Blacks (59.4% vs. 33.4%; p = .03), greater unemployment rates (17.5% vs. 10.7%; p < .01), and greater cumulative deaths from COVID-19 (56 vs. 31; p = .01). Unemployment rate continued to be statistically significant after controlling for race and cumulative deaths from COVID-19 (p = .04).

CONCLUSION

We found that as community unemployment rate increases, adherence to urgent eye visits decreases, after controlling for relevant neighborhood characteristics. Unemployment rates were highest in predominantly Black neighborhoods early in the pandemic, which may have contributed to existing racial disparities in eye care.

Disparities in Vision Health and Eye Care

Significant disparities in vision health and eye care exist. To achieve health equity, we must understand the root causes and drivers of health disparities and inequities, including social determinants of health and systemic racism.

The Vision Detroit Project: Integrated Screening and Community Eye-Health Education Interventions Improve Eyecare Awareness

PURPOSE

Poor eye-health knowledge and health literacy are pervasive, contributing to worse outcomes. This study aims to examine short- and long-term eye-health knowledge retention following eye-health education interventions in adults.

METHODS

Vision Detroit was an outreach vision screening program that integrated a 5-Point Teaching Intervention (5PTI), at a Southwest Community Center (SW-CC) from 2015-2017. The 5PTI consists of eye-health learning points developed to verbally educate patients. During vision screenings, eye-health knowledge tests were administered before and after 5PTI (Test 1 and Test 2, respectively). In 2016, Community Eye-Health Education Interventions (CHEI) were initiated at the SW-CC. During CHEI, bilingual healthcare students taught voluntary SW-CC members the 5PTI learning points, regardless of participant interest to attend future screenings. CHEI sessions occurred on separate dates prior to vision screening events. Test 1 and Test 2 scores were compared for all participants. Test 1 scores were compared for those who underwent CHEI prior to vision screening (CHEI positive) versus those who did not (CHEI negative).

RESULTS

Two-hundred-seventeen adult patients met inclusion criteria, with 75.8% women, 82.6% Hispanic, mean age 50.4 ± 16.2 years, 74.6% had high school or less education, and 49.2% had health insurance. Test 1 to Test 2 scores improved after 5PTI (71.2 ± 26.4% vs. 97.2 ± 9.9%, p < .00001). Forty-eight participants attended CHEI and subsequent vision screening. Test 1 scores were higher among those CHEI positive versus CHEI negative (81.1 ± 2.1% vs. 68.3 ± 3.4%, p = .0027).

CONCLUSION

Simple eye-health education interventions, delivered during vision screenings and via community-based education, can improve eye-health knowledge.

Long-term persistence with aflibercept therapy among treatment-naïve patients with exudative age-related macular degeneration in a universal health care system: a retrospective study

Background

This study  aimed to analyse the persistence rates of treatment-naïve patients with neovascular age-related macular degeneration (nAMD) who received intravitreal aflibercept therapy in a universal health care system.

Methods

In this single-centre retrospective cohort study, we audited data of 918 treatment-naïve patients who received exclusively intravitreal aflibercept therapy for nAMD between September 2015 and May 2021. The primary outcome measures were the rates of treatment nonpersistence (gap in ophthalmological care > 6 months) and long-term nonpersistence (> 12 months).

Results

The rates of nonpersistence and long-term nonpersistence were 12.3% and 3.4% after one year; 22.4% and 9.5% after two years; and 38.3% and 19.3% after five years, respectively. Logistic regression analysis revealed that older age (p = 0.045), male sex (p = 0.039), requirement for caretakers or ambulance (p = 0.001), and low visual acuity of the study eye (p = 0.010) or fellow eye (p = 0.029) were independent risk factors for long-term nonpersistence. Patients aged > 80 and > 85 years (p = 0.013 and p = 0.022, respectively) had more than twice the risk for being nonpersistent to therapy within two years of follow-up compared with younger patients. Male patients (p = 0.033), patients requiring a caretaker (p = 0.038), and patients living > 60 km from the clinic (p = 0.029) had a 2 × higher risk of being persistently nonpersistent to therapy.

Conclusions

Patients with nAMD who were treated with aflibercept had lower nonpersistence rates than those reported in current literature. Multiple independent risk factors were correlated with long-term nonpersistence, early nonpersistence, or complete loss to follow-up. Considering the possible consequences of reduced compliance, further strategies are urgently needed for patients at risk of nonpersistence to therapy.

Characteristics and Outcomes of Patients with Scleritis in the IRIS® Registry (Intelligent Research in Sight) Database

PURPOSE

To report patient characteristics and factors associated with poor visual acuity and abnormal intraocular pressure (IOP) in patients with scleritis in the American Academy of Ophthalmology's IRIS® Registry (Intelligent Research in Sight).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients in the IRIS Registry with at least 3 office visits associated with an International Classification of Diseases scleritis code from 2013 through 2019.

METHODS

We evaluated demographic and clinical characteristics in scleritis and scleritis subtype cohorts. We conducted Cox proportional hazards and multiple logistic regression analyses to assess associations with poor best-corrected visual acuity (BCVA), vision loss, and IOP abnormalities.

MAIN OUTCOME MEASURES

Patient characteristics, BCVA of 0.6 logarithm of the minimum angle of resolution (logMAR) or more, BCVA worsened by more than 3 logMAR units 6 months after presentation, IOP of 30 mmHg or more, and IOP of 5 mmHg or less.

RESULTS

In this cohort of 111 314 patients with scleritis, the mean ± standard deviation age was 58.5 ± 16.6 years, 66% were women, and 30% had bilateral scleritis. Patients with scleromalacia perforans were older and more likely to have bilateral disease. Multiple logistic regression analysis identified factors with increased odds for poor presenting BCVA (older age, male sex, Black race, Hispanic ethnicity, smoking, and scleritis subtypes) and at least 3 lines of vision loss 6 months after initial scleritis diagnosis (older age, smoking, and anterior scleritis). Cox proportional hazards regression modeling of BCVA of 0.6 logMAR or more showed older age (adjusted hazard ratio [aHR] per 10-year unit, 1.11), Black race (aHR, 1.19), Hispanic ethnicity (aHR, 1.22), active smoking (aHR, 1.39), former smoking (aHR, 1.26), and certain scleritis subtypes increase the risk of poor visual acuity development (P < 0.001 for all). Older age, male sex, Black race, Hispanic ethnicity, smoking, and scleritis subtypes increased the odds of IOP abnormality.

CONCLUSIONS

Older age, Black or Hispanic ancestry, smoking, and specific scleritis subtypes are risk factors for worse visual and IOP outcomes in patients with scleritis in the IRIS Registry. Closer follow-up may be appropriate for older, Black, or Hispanic patients with scleritis; smokers should receive smoking cessation assistance.

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.

Parental Keratoconus Literacy: A Socioeconomic Perspective

Purpose

To assess the impact of parental socioeconomic status and keratoconus literacy on pediatric eye rubbing and keratoconus severity.

Methods

In this mixed-methods study, pediatric keratoconus patients (age ≤ 18 years) were retrospectively identified. Sociodemographic and clinical characteristics were extracted from the electronic medical record (EMR). Telephone surveys were subsequently conducted to assess parental keratoconus literacy, receipt of counseling on keratoconus prevention, eye rubbing, and household socioeconomic factors not available in the EMR. Parents reporting poor keratoconus literacy were probed via semi-structured interview to explore barriers to their understanding.

Results

Forty-eight patients met inclusion criteria, 22 (46%) of whom were reached by telephone. Most patients were insured by Medicaid (73%) and current eye rubbers (82%). Few parents reported good or excellent keratoconus literacy now (32%) or at the time of diagnosis (18%). Parents with a high-school education, limited English proficiency, lower income level, and Medicaid insurance tended to have lower keratoconus literacy, though this was not statistically significant. Parental keratoconus literacy was not correlated with disease severity. High-school education, limited English proficiency, lower income level, and Medicaid insurance were correlated with steeper keratometry readings, which was statistically significant for high-school education. In-depth interviews revealed parents felt unconfident with eye health in general and perceived a personal responsibility for learning more.

Conclusion

This is the first study exploring keratoconus literacy from a socioeconomic perspective, demonstrating lower literacy among socioeconomically marginalized parents and a tendency toward more severe disease in their children.

Addressing Social Determinants of Vision Health

Social determinants of health encompass the quality of an individual’s social and physical environment and its effect on health outcomes. Disparities in these social and environmental factors have a significant role in vision health disparities and inequity in eye care. In this review, we discuss how disparities in visual impairment and eye care utilization are affected by each of the five core domains of social determinants of health, namely economic stability (income, employment, and food security), education (education level and health literacy), health care access (insurance and medical costs), neighborhood environment (housing conditions, home ownership, pollution, and crime), and social context (race and racism). Moreover, we describe a framework by which ophthalmologists can take action to address social determinants of vision health. These actionable strategies are guided by recommendations from the National Academies of Sciences, Engineering, and Medicine and have five complementary components to address social needs: awareness (screening for social needs), assistance (connecting patients with social care resources), adjustment (altering clinical care in recognition of social needs), alignment (understanding social assets and collaborating with community organizations), and advocacy (promoting policies to address social needs). Addressing social determinants of health is complex but achievable through collaborative strategies. Ophthalmologists have an important leadership role in addressing eye care disparities by taking action on underlying social determinants of vision health.

Disparities in Eye Care Utilization During the COVID-19 Pandemic

PURPOSE

To assess the relationship between telemedicine utilization and sociodemographic factors among patients seeking eye care.

DESIGN

Comparative utilization analysis.

METHODS

We reviewed the eye care utilization patterns of a stratified random sample of 1720 patients who were seen at the University of Michigan Kellogg Eye Center during the height of the COVID-19 pandemic (April 30 to May 25, 2020) and their odds of having a video, phone, or in-person visit compared with having a deferred visit. Associations between independent variables and visit type were determined using a multinomial logistic regression model.

RESULTS

Older patients had lower odds of having a video visit (P = .007) and higher odds of having an in-person visit (P = .023) compared with being deferred, and in the nonretina clinic sample, older patients still had lower odds of a video visit (P = .02). Non-White patients had lower odds of having an in-person visit (P < .02) in the overall sample compared with being deferred, with a similar trend seen in the retina clinic. The mean neighborhood median household income was $76,200 (±$33,500) and varied significantly (P < .0001) by race with Blacks having the lowest estimated mean income.

CONCLUSION

Disparities exist in how patients accessed eye care during the COVID-19 pandemic with older patients-those for whom COVID-19 posed a higher risk of mortality-being more likely to be seen for in-person care. In our affluent participant sample, there was a trend toward non-White patients being less likely to access care. Reimbursing telemedicine solely through broadband internet connection may further exacerbate disparities in eye care.

A seven-year analysis of the role and impact of a free community eye clinic

BACKGROUND

The Indiana University Student Outreach Clinic (IUSOC) Eye Clinic is a monthly student-run eye clinic that provides free visual screening to the Near East Side community of Indianapolis, IN, USA. Screening includes assessments of visual acuity, intraocular pressure, peripheral visual fields, refraction, and non-mydriatic fundus photography.

METHODS

This is a retrospective chart review of 875 patients seen at the IUSOC Eye Clinic from October 2013 to February 2020. Data on demographics, insurance coverage, ocular history, physical examination, suspected diagnosis, referral status, and glasses provided were collected and analyzed.

RESULTS

875 patients were seen at the IUSOC Eye Clinic from October 2013 to February 2020. 39.2% of the patients seen at the clinic reported being uninsured. 61.4% of patients were found to have visual acuity of 20/40 or worse, while 51.3% of patients were found to have a near visual acuity of 20/40 or worse. 20.3% of patients were referred to the local county hospital for further evaluation by an ophthalmologist, 14.4% of patients received free glasses prescriptions, and 27.9% of patients received free reading glasses. Common reasons for referral for further ophthalmology evaluation included glaucoma, decreased visual acuity, and diabetic retinopathy. An estimated value of services provided over the seven years of the clinic was 1271 relative value units.

CONCLUSION

The IUSOC Eye Clinic fills an important role in advancing ocular health and preventing irreversible blindness in an underserved Indianapolis community. Additionally, the clinic demonstrates an educational model for involving medical student volunteers.

Awareness of Diabetic Retinopathy: Insight From the National Health and Nutrition Examination Survey

INTRODUCTION

This study determines the prevalence and associated correlates of people unaware of their diabetic retinopathy diagnosis in the U.S.

METHODS

Participants unaware of diabetic retinopathy from the National Health and Nutrition Examination Survey from 2005 to 2008 were identified. The prevalence of those unaware of their diabetic retinopathy diagnosis was determined. Descriptive statistics and logistic regression were used to determine correlates associated with being unaware of one's diabetic retinopathy diagnosis (completed in 2018‒2020).

RESULTS

Among 5,563 participants aged ≥40 years who underwent fundus photography, the prevalence of those unaware of their diabetic retinopathy diagnosis was 10.6% (9.8 million). This included 23.1% of those with self-reported diabetes (2.9 million) and 6.8% of those who reported not having diabetes (6.9 million). Among participants reporting diabetes with photographic evidence of retinopathy, 70.1% were unaware. Among individuals with self-reported diabetes, correlates of being unaware of one's diabetic retinopathy diagnosis included diabetes diaganosis for ≥10 years (OR=3.15, 95% CI=1.78, 5.56), HbA1c ≥6.5% (OR=2.92, 95% CI=1.65, 5.18), and treatment with insulin only (OR=4.04, 95% CI=1.43, 11.39). Self-reported hypertension was associated with decreased odds of undiagnosed diabetic retinopathy (OR=0.48, 95% CI=0.28, 0.82). Among those without self-reported diabetes, correlates of being unaware of diabetic retinopathy included older age (OR=1.02, 95% CI=1.01, 1.04), male sex (OR=1.83, 95% CI=1.31, 2.56), Black race (OR=1.81, 95% CI=1.12, 2.92), Hispanic race/ethnicity (OR=1.60, 95% CI=1.14, 2.25), elevated blood pressure (OR=1.54, 95% CI=1.23, 1.93), current smoking (OR=1.74, 95% CI=1.21, 2.51), and history of stroke (OR=2.20, 95% CI=1.06, 4.58).

CONCLUSIONS

A substantial proportion of individuals with diabetic retinopathy are unaware of the diagnosis. These data provide a path toward refining efforts to diagnose and treat diabetic retinopathy to decrease the burden of preventable blindness.

Prevalence of Visual Acuity Loss or Blindness in the US: A Bayesian Meta-analysis

Importance

Globally, more than 250 million people live with visual acuity loss or blindness, and people in the US fear losing vision more than memory, hearing, or speech. But it appears there are no recent empirical estimates of visual acuity loss or blindness for the US.

Objective

To produce estimates of visual acuity loss and blindness by age, sex, race/ethnicity, and US state.

Data Sources

Data from the American Community Survey (2017), National Health and Nutrition Examination Survey (1999-2008), and National Survey of Children's Health (2017), as well as population-based studies (2000-2013), were included.

Study Selection

All relevant data from the US Centers for Disease Control and Prevention's Vision and Eye Health Surveillance System were included.

Data Extraction and Synthesis

The prevalence of visual acuity loss or blindness was estimated, stratified when possible by factors including US state, age group, sex, race/ethnicity, and community-dwelling or group-quarters status. Data analysis occurred from March 2018 to March 2020.

Main Outcomes or Measures

The prevalence of visual acuity loss (defined as a best-corrected visual acuity greater than or equal to 0.3 logMAR) and blindness (defined as a logMAR of 1.0 or greater) in the better-seeing eye.

Results

For 2017, this meta-analysis generated an estimated US prevalence of 7.08 (95% uncertainty interval, 6.32-7.89) million people living with visual acuity loss, of whom 1.08 (95% uncertainty interval, 0.82-1.30) million people were living with blindness. Of this, 1.62 (95% uncertainty interval, 1.32-1.92) million persons with visual acuity loss are younger than 40 years, and 141 000 (95% uncertainty interval, 95 000-187 000) persons with blindness are younger than 40 years.

Conclusions and Relevance

This analysis of all available data with modern methods produced estimates substantially higher than those previously published.

Manhattan Vision Screening and Follow-Up Study in Vulnerable Populations: 1-Month Feasibility Results

Purpose/Aim: In the United States, high rates of vision impairment and eye disease disproportionately impact those who lack access to eye care, specifically vulnerable populations. The objective of our study was to test instruments, implement protocols, and collect preliminary data for a larger 5-year study, which aims to improve detection of eye diseases and follow-up eye care in vulnerable populations using community health workers (CHW) and patient navigators. In the study, trained CHWs conducted vision screening and patient navigators scheduled on-site eye exams and arranged appointments for those referred to ophthalmology to improve adherence to follow-up eye care.Materials and Methods: Eligible individuals age 40-and-older were recruited from the Riverstone Senior Center in Upper Manhattan, New York City. Participants underwent on-site vision screening (visual acuity with correction, intraocular pressure measurements, and fundus photography). Individuals who failed the vision screening were scheduled with an on-site optometrist for an eye exam; those with ocular pathologies were referred to an ophthalmologist. Participants were also administered the National Eye Institute Visual Function Questionnaire-8 (NEI-VFQ-8) and Stopping Elderly Accidents, Deaths, and Injuries (STEADI) test by community health workers.Results:Participants (n = 42) were predominantly older adults, with a mean age of 70.0 ± 9.8, female (61.9%), and Hispanic (78.6%). Most individuals (78.6%, n = 33) failed vision screening. Of those who failed, 84.8% (n = 28) attended the on-site eye exam with the optometrist. Ocular diagnoses: refractive error 13/28 (46.4%), glaucoma/glaucoma suspect 9/28 (32.1%), cataract 7/28 (25.0%), retina abnormalities 6/28 (21.4%); 13 people required eyeglasses.Conclusion: This study demonstrates the feasibility of using CHWs and patient navigators for reducing barriers to vision screening and optometrist-based eye exams in vulnerable populations, ultimately improving early detection of eye disease and linking individuals to additional eye care appointments. The full five-year study aims to further examine these outcomes.

The Effect of Transitioning from SITA Standard to SITA Faster on Visual Field Performance

PURPOSE

To determine the effect of transitioning from Swedish Interactive Thresholding Algorithm (SITA) Standard to SITA Faster on visual field (VF) performance in glaucomatous eyes with a broad spectrum of disease severity undergoing longitudinal VF testing in a real-world clinical setting.

DESIGN

Retrospective, longitudinal study.

PARTICIPANTS

A total of 421 patients (766 eyes) with manifest or suspect glaucoma followed at a single institution.

METHODS

Each included eye received the following sequence of VF examinations during routine clinical care: (1) SITA Standard, (2) SITA Standard, and (3) SITA Faster (mean time between tests = 13.9 months). Intra-eye comparisons were made between the first 2 VFs (Standard-Standard sequence) and the last 2 VFs (Standard-Faster sequence). The primary dependent variable was the difference in mean deviation (MD) between the second and first VF of the sequence (ΔMD, calculated as MD_VF2 - MD_VF1). The primary independent variable was the VF sequence (Standard-Standard or Standard-Faster). Linear mixed-effects models were used to study the effect of testing sequence on ΔMD, adjusting for confounders including time between VFs and change in false-positive (FP) errors. Results were stratified to understand the effect of glaucoma severity on the relationship between testing sequence and ΔMD.

MAIN OUTCOME MEASURES

The difference in ΔMD between Standard-Standard and Standard-Faster sequence by mild, moderate, and advanced disease severity.

RESULTS

In eyes with mild or suspect glaucoma, there was no significant difference in ΔMD between Standard-Faster and Standard-Standard sequences (-0.23 decibels [dB]; 95% confidence interval [CI], -0.60 to 0.15 dB). However, the Standard-Faster sequence was associated with a 0.87 dB (95% CI, 0.18-1.57 dB) improvement in ΔMD compared with the Standard-Standard sequence in eyes with moderate glaucoma and a 1.49 dB (95% CI, 0.79-2.19 dB) improvement in ΔMD in eyes with advanced glaucoma.

CONCLUSIONS

Converting to SITA Faster in eyes that were previously followed with SITA Standard led to similar VF performance in mild glaucoma but resulted in higher MD values in moderate and advanced glaucoma. For patients with moderate or severe glaucoma, this may conceal disease progression when transitioning testing strategies.

Healthcare disparities contribute to missed follow-up visits after cataract surgery in the USA: results from the perioperative care for intraocular lens study

OBJECTIVE

To identify factors that contribute to missed cataract surgery follow-up visits, with an emphasis on socioeconomic and demographic factors.

METHODS

In this retrospective cohort study, patients who underwent cataract extraction by phacoemulsification at Massachusetts Eye and Ear between 1 January and 31 December 2014 were reviewed. Second eye cases, remote and international patients, patients with foreign insurance and combined cataract cases were excluded.

RESULTS

A total of 1931 cases were reviewed and 1089 cases, corresponding to 3267 scheduled postoperative visits, were included. Of these visits, 157 (4.8%) were missed. Three (0.3%) postoperative day 1, 40 (3.7%) postoperative week 1 and 114 (10.5%) postoperative month 1 visits were missed. Age<30 years (adjusted OR (aOR)=8.2, 95% CI 1.9 to 35.2) and ≥90 years (aOR=5.7, 95% CI 2.0 to 15.6) compared with patients aged 70-79 years, estimated travel time of >2 hours (aOR=3.2, 95% CI 1.4 to 7.4), smokers (aOR=2.7, 95% CI 1.6 to 4.8) and complications identified up to the postoperative visit (aOR=1.4, 95% CI 1.0 to 2.1) predicted a higher rate of missed visits. Ocular comorbidities (aOR=0.7, 95% CI 0.5 to 1.0) and previous visit best-corrected visual acuity (BCVA) of 20/50-20/80 (aOR=0.4, 95% CI 0.3 to 0.7) and 20/90-20/200 (aOR=0.4, 95% CI 0.2 to 0.9), compared with BCVA at the previous visit of 20/40 or better, predicted a lower rate of missed visits. Gender, race/ethnicity, language, education, income, insurance, alcohol use and season of the year were not associated with missed visits.

CONCLUSIONS

Medical factors and demographic characteristics, including patient age and distance from the hospital, are associated with missed follow-up visits in cataract surgery. Additional studies are needed to identify disparities in cataract postoperative care that are population-specific. This information can contribute to the implementation of policies and interventions for addressing them.

Implementing Telemedicine Visits in an Underserved Ophthalmology Clinic in the COVID-19 Era

Introduction:

Many of the potential barriers to providing telehealth services already disproportionately impact vulnerable populations. The purpose of this study was to assess the incorporation of synchronous ophthalmology telemedicine visits in a tertiary university-based ophthalmology clinic for low-income and uninsured patients in the COVID-19 era.

Methods:

The records of 18 patients who were due for an in-person visit in the medically underserved patient clinic at our institute were reviewed. Patients considered high risk of ocular morbidity progression were approved to proceed with an in-person visit. Patients with non-urgent visit indications were attempted to be contacted by telephone to be offered a telemedicine telephone visit as an alternative to a postponed in-person office visit.

Results:

Clinical triage by an attending ophthalmologist determined that 17 patients (94.4%, n = 18) had visit indications appropriate for evaluation by telemedicine. Six patients (35.3%, n = 17) were successfully contacted and offered a telemedicine visit as an alternative to a postponed in-person office visit. All 6 patients accepted, scheduled, and completed a telemedicine visit. Eleven patients (64.7%, n = 17) were not able to be successfully contacted to offer and schedule either a telemedicine visit or a postponed in-person office visit. Patients who were not able to be successfully contacted were on average younger in age and more likely to be female, Hispanic/Latino, from Latin America, with a preferred language of Spanish.

Conclusions:

Synchronous ophthalmology telemedicine visits can be successfully incorporated in a tertiary university-based setting for low-income and uninsured patients. The primary barrier to providing telemedicine visits in this population was the ability to successfully contact patients to offer and schedule these visits.

Ophthalmology Departments Remain Among the Least Diverse Clinical Departments at United States Medical Schools

PURPOSE

The current demographics of the ophthalmology workforce do not reflect the diverse United States population, which has implications for addressing health disparities. The demographics of ophthalmology department faculty may influence the recruitment of underrepresented students into the field. This study sought to determine how the racial and ethnic demographics of ophthalmology department faculty compare with those of other clinical departments at United States medical schools.

DESIGN

Secondary data analysis of medical school faculty demographic data from the 2019 American Association of Medical Colleges (AAMC) Faculty Roster.

PARTICIPANTS

Clinical faculty and department chairs at United States medical schools.

METHODS

We analyzed the racial and ethnic demographics of clinical department faculty and department chairpersons using data from the 2019 AAMC Faculty Roster. We calculated the proportion of underrepresented minority (URM) faculty in ophthalmology and in 17 other clinical departments. We analyzed these data for statistically significant differences between ophthalmology and other clinical departments. In addition, we compared the percentage of URM ophthalmology faculty with the proportion of URM persons among graduating United States medical students and in the United States population using data from the Medical School Graduation Questionnaire and the United States census, respectively.

MAIN OUTCOME MEASURES

The proportion of URM persons, defined as Black, Hispanic or Latino, Native American, or Native Hawaiian or Pacific Islander among clinical faculty and department chairs.

RESULTS

Ophthalmology faculty are less racially and ethnically diverse than graduating medical students and the general United States population. When compared with 17 other clinical departments, ophthalmology has the third-lowest proportion of URM faculty, with only radiology and orthopedic surgery having a smaller proportion of URM faculty. These differences were statistically significant in most departments (12 of 18). No statistically significant difference was found in the proportion of URM department chairs in ophthalmology compared with most other clinical departments, although the absolute number of URM chairs in ophthalmology is low at only 8 chairpersons.

CONCLUSIONS

More work must be done to increase the recruitment of URM physicians into ophthalmology faculty positions to obtain parity with other clinical departments and with the diverse patient populations that physicians serve.

Eye Care Utilization in A Community-oriented Mobile Screening Programme for Improving Eye Health in Iran: A Cluster Randomized Trial

PURPOSE

To evaluate the effect of a mobile-based screening programme on eye care utilization in Iran.

METHOD

In this cluster randomized community trial, a representative sample of residents aged≥50 years from urban and rural areas in four districts in Tehran province were enrolled. The clusters were randomly assigned to one of the three parallel arms; the mHealth arm with digital data collection, vision screening test and retina evaluation using an integrated mobile application, the conventional arm with manual data collection and screening tests using Snellen chart and Fundus photography at the local primary healthcare facility, and the control arm with manual data collection without screening tests. The main outcome measure was eye care utilization which was defined as at least one visit to an optometrist or ophthalmologist.

RESULTS

Of 3312 eligible individuals, 2520 (76.1%) participated. In the first 3 months after the screening programme, eye care utilization was higher among those who were referred by the mHealth method (35.6% 95%CI: 31.1-40.4%) compared to those referred by the conventional method (32.7%, 95%CI: 27.5-38.2%) and to those observed in the control arm (4.5%, 95%CI: 3.2-6.0). Eye care utilization improved (OR = 1.5, 95%CI: 1.2-1.9) among the referred people after the screening programme compared to the utilization before this programme; however, this improvement was significantly higher in the mHealth method (OR: 1.7, 95%CI: 1.2-2.4) compared to the conventional method (OR: 1.2, 95%CI: 0.8-1.8).

CONCLUSION AND RELEVANCE

The mobile-based screening programme can significantly improve eye care utilization at the community level.

Barriers to and Facilitators of Diabetic Retinopathy Screening Utilization in a High-Risk Population

BACKGROUND

Diabetic retinopathy (DR) is among the leading causes of vision loss in the USA, yet an estimated 50% of patients with diabetes do not receive recommended annual screening eye exams. Patients with diabetes and low socioeconomic status or who are racial/ethnic minorities are at increased risk for vision loss.

METHODS

Qualitative interviews were conducted with 24 patients with diabetes at a federally qualified community health center in an urban area regarding factors influencing their use of screening. The interviews were recorded, transcribed, and analyzed line by line to identify themes. The themes were organized in a theoretical framework of factors influencing receipt of screening.

RESULTS

The median age of participants was 57.5 (range 44-73). Ten participants identified as female and 14 as male. Participants identified as Black (14), White (4), Hispanic (3), and other/no answer (3). Twenty-three had health insurance. Twenty-three had received an eye exam within in the past year, and 17 reported that they receive eye exams at least yearly. Four hundred fifteen comments were analyzed, and 22 concepts were identified under 7 broader themes and two overarching categories of individual and structural factors. Themes included vision status, competing concerns, emotional context, resource availability, in-clinic experience, cues to action, and knowledge about diabetes.

CONCLUSIONS

The factors that influence diabetic retinopathy screening utilization are complex. Visual symptoms and the need for glasses are important facilitators of screening. Many patients lack knowledge about diabetic retinopathy and the utility of preventative eye care. New strategies for engaging high-risk populations are necessary.

Treatment compliance and adherence among patients with diabetic retinopathy and age-related macular degeneration treated by anti-vascular endothelial growth factor under universal health coverage

PURPOSE

To analyze and compare loss to follow-up (LTFU) rates between patients with diabetic retinopathy (DR) and those with neovascular age-related macular degeneration (nAMD) in patients, receiving treatment with anti-vascular endothelial growth factor (VEGF), under universal health coverage.

METHODS

We retrospectively analyzed the relevant data of 1264 patients receiving anti-VEGF therapy, in this cohort study. The observation period ranged from September 01, 2015 to December 31, 2018. Intervals between each procedure and the subsequent follow-up examination were measured. Demographic data, visual acuity (VA), the type of transport for treatment access, and distance between the residence and clinic were evaluated as risk factors for LTFU.

RESULTS

We collected data for 841 patients with nAMD (age, 81.0 (± 8.1 years)) and 423 patients with DR (age, 67.7 (± 12.1 years)). The rate of LTFU, for at least 6 months, was 28.8% and 2.9% for patients with DR and nAMD, respectively (p < 0.001). In the DR group, 18.9% patients were lost to follow-up exceeding > 12 months. Multivariate regression analysis showed that advanced age, lack of mobility, and need for assisted transport, poor final VA despite treatment, and decrease in vision during the observational period were independent risk factors for LTFU exceeding 12 months (p < 0.05).

CONCLUSIONS

We found a high long-term LTFU rate for patients with DR, despite treatment under universal health coverage. Considering the risk of disease progression, particularly in patients with chronic DR, strategies for better compliance and adherence to therapy should be considered for optimized patient care.

Improved Outcomes in Patients with Retinal Detachment after Implementation of a Silicone Oil Registry and Phone Call Reminder System

PURPOSE

This retrospective study was performed to assess the clinical impact in reducing silicone oil (SO)-related complications such as keratopathy of a registry and appointment reminder system for patients with complicated retinal detachment (RD) who underwent pars plana vitrectomy (PPV) with SO tamponade.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 87 eyes of 87 patients who received SO tamponade were included.

METHODS

The study was carried out at Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG). Patients were divided into those who received SO before (control group, n = 48) or after (treatment group, n = 39) implementation of an SO registry and patient reminder system in 2014. Patient records were reviewed to identify clinical characteristics and outcomes.

MAIN OUTCOME MEASURES

The primary outcome measure was the difference in the rate of loss to follow-up before versus after the implementation of the registry and reminder system. Secondary outcomes were the duration of SO tamponade, keratopathy rate, and intraocular pressure (IOP) at the last visit before SO removal.

RESULTS

Forty-eight patients were included in the control group, and 39 patients were included in the treatment group. The number of patients lost to follow-up was 23 (47.9%) in the control group versus 6 (15.4%) in the treatment group (P = 0.0015). The mean duration before SO removal was 79.6±91.7 weeks in the control group and 36.3±31.5 weeks in the treatment group (mean±standard deviation [SD]) (P = 0.015). Keratopathy developed in 33.3% of patients in the control group and 12.8% of patients in the treatment group (P = 0.0425). Mean IOP at the last visit before SO removal was 13.0±5.2 mmHg (mean±SD) in the control group and 13.3±7 mmHg (mean±SD) in the treatment group (P > 0.05).

CONCLUSIONS

A phone call appointment reminder system for patients with complicated RD who underwent PPV and SO tamponade reduced the rate of loss to follow-up and the duration of SO tamponade, correlating with a reduction in the rate of keratopathy.

Blindness and Visual Impairment in the Medicare Population: Disparities and Association with Hip Fracture and Neuropsychiatric Outcomes

Purpose: Vision loss has been associated with negative health outcomes, but population-level data on vision loss are lacking, and there are limited data on low vision-associated outcomes among women, minorities, and older age groups. The objective of this study was to determine the prevalence of vision loss in a nationally representative sample of older US adults and examine its association with hip fracture, depression, anxiety, and dementia. Methods: Cross-sectional analysis of Medicare claims data from 2014. Blindness and low vision, hip fracture, depression, anxiety, and dementia were identified using Chronic Condition Warehouse indicator variables based on ICD-9 and CPT codes. Multivariable logistic regression models were built to examine whether sociodemographic factors were associated with vision loss and to determine the relationships between vision loss and hip fracture and neuropsychiatric outcomes. Results: The prevalence of low vision in the Medicare population was 994/100,000 and increased significantly with age, Black (1,854/100,000) or Hispanic (2,862/100,000) race/ethnicity, female gender (1,181/100,000), and Medicaid eligibility (2,975/100,000). After adjusting for relevant comorbidities, low vision was significantly associated with hip fracture (adjusted odds ratio [AOR] 2.54, 95% CI: 2.52-2.57), depression (AOR 3.99, 95% CI: 3.97-4.01), anxiety (AOR 2.93, 95% CI: 2.91-2.95), and dementia (AOR 3.91, 95% CI: 3.88-3.93). Conclusion: Blindness and low vision are common in older Americans, especially among racial and ethnic minorities and lower income individuals, and associated with hip fracture, depression, anxiety, and dementia. The prevention and treatment of vision loss may reduce health disparities and negative health outcomes in the aging population.

Systematic review on barriers and enablers for access to diabetic retinopathy screening services in different income settings

BACKGROUND

Diabetic retinopathy (DR) can lead to visual impairment and blindness if not detected and treated in time. Knowing the barriers/enablers in advance in contrasting different country income settings may accelerate development of a successful DR screening (DRS) program. This would be especially applicable in the low-income settings with the rising prevalence of DR.

OBJECTIVES

The aim of this systematic review is to identify and contrast the barriers/enablers to DRS for different contexts using both consumers i.e., people with diabetes (PwDM) and provider perspectives and system level factors in different country income settings.

METHODS

We searched MEDLINE, Embase, CENTRAL in the Cochrane Library from the databases start date to December 2018. We included the studies reported on barriers and enablers to access DRS services based at health care facilities. We categorised and synthesized themes related to the consumers (individuals), providers and the health systems (environment) as main dimensions according to the constructs of social cognitive theory, supported by the quantitative measures i.e., odds ratios as reported by each of the study authors.

MAIN RESULTS

We included 77 studies primarily describing the barriers and enablers. Most of the studies were from high income settings (72.7%, 56/77) and cross sectional in design (76.6%, 59/77). From the perspectives of consumers, lack of knowledge, attitude, awareness and motivation were identified as major barriers. The enablers were fear of blindness, proximity of screening facility, experiences of vision loss and being concerned of eye complications. In providers' perspectives, lack of skilled human resources, training programs, infrastructure of retinal imaging and cost of services were the main barriers. Higher odds of uptake of DRS services was observed when PwDM were provided health education (odds ratio (OR) 4.3) and having knowledge on DR (OR range 1.3-19.7).

CONCLUSION

Knowing the barriers to access DRS is a pre-requisite in development of a successful screening program. The awareness, knowledge and attitude of the consumers, availability of skilled human resources and infrastructure emerged as the major barriers to access to DRS in any income setting.

Socio-economic status, visual impairment and the mediating role of lifestyles in developed rural areas of China

PURPOSE

To examine the impacts of socio-economic status (SES) on visual impairment (VI), and the mediating role of lifestyles in developed rural areas of China.

METHODS

A cross-sectional study was conducted among people living in rural districts of Tianjin, a developed municipality in China. An interviewer-administered survey along with free eye screenings was conducted with participants. The questionnaire included questions about demographic characteristics, SES, medical histories and lifestyles. Presenting visual acuity (PVA) and main causes of VI were identified by ophthalmologists. χ2 test was undertaken to determine whether significant differences (p<0.05) exist between VI and demographic, SES, medical history and lifestyle factors. A stepwise regression method was conducted to investigate whether lifestyles play mediating roles between SES and VI. Multivariable logistic and ordinal logistic regression were used contingent on different types of dependent variables in each regression, and adjusted odds ratio (OR) values were estimated.

RESULTS

Of the 12,233 participants, 6,233 were male (50.59%); the mean age was 34.61 years; 310 (2.54%) had VI. Hypertension, diabetes and cardiopathy were main medical histories, with 1,640 had hypertension (13.41%), 854 had diabetes (6.98%) and 483 had cardiopathy (3.95%). About SES factors, higher education level (Adjusted OR, 0.84; 95% CI, 0.75-0.95) and higher income level (Adjusted OR, 0.54; 95% CI, 0.39-0.76), were significantly associated with VI in a gradient across severity of VI. Lifestyles including smoking (Adjusted OR, 1.55; 95% CI, 1.31-1.83) and drinking (Adjusted OR, 1.36; 95% CI, 1.06-1.74) played mediating roles between SES and VI when considering the full sample. Besides smoking and drinking, reading every week (Adjusted OR, 2.07; 95% CI, 1.53-2.82) and exercising more than 2h every day (Adjusted OR, 0.39; 95% CI, 0.15-1.00) also played mediating roles between SES and VI when considering the subsample (age≥16).

CONCLUSION

This study revealed the crucial impacts of SES factors on VI, and the mediating role played by several lifestyles. Targeted public health interventions for reducing VI should thus be proposed in developed rural areas of China.

A tailored intervention to promote uptake of retinal screening among young adults with type 2 diabetes - an intervention mapping approach

BACKGROUND

Young adults (18-39 years) with type 2 diabetes are at risk of early development and rapid progression of diabetic retinopathy, a leading cause of vision loss and blindness in working-age adults. Retinal screening is key to the early detection of diabetic retinopathy, with risk of vision loss significantly reduced by timely treatment thereafter. Despite this, retinal screening rates are low among this at-risk group. The objective of this study was to develop a theoretically-grounded, evidence-based retinal screening promotion leaflet, tailored to young adults with type 2 diabetes.

METHODS

Utilising the six steps of Intervention Mapping, our multidisciplinary planning team conducted a mixed-methods needs assessment (Step 1); identified modifiable behavioural determinants of screening behaviour and constructed a matrix of change objectives (Step 2); designed, reviewed and debriefed leaflet content with stakeholders (Steps 3 and 4); and developed program implementation and evaluation plans (Steps 5 and 6).

RESULTS

Step 1 included in-depth qualitative interviews (N = 10) and an online survey that recruited a nationally-representative sample (N = 227), both informed by literature review. The needs assessment highlighted the crucial roles of knowledge (about diabetic retinopathy and screening), perception of personal risk, awareness of the approval of significant others and engagement with healthcare team, on retinal screening intentions and uptake. In Step 2, we selected five modifiable behavioural determinants to be targeted: knowledge, attitudes, normative beliefs, intention, and behavioural skills. In Steps 3 and 4, the "Who is looking after your eyes?" leaflet was developed, containing persuasive messages targeting each determinant and utilising engaging, cohort-appropriate imagery. In Steps 5 and 6, we planned Statewide implementation and designed a randomised controlled trial to evaluate the leaflet.

CONCLUSIONS

This research provides an example of a systematic, evidence-based approach to the development of a simple health intervention designed to promote uptake of screening in accordance with national guidelines. The methods and findings illustrate how Intervention Mapping can be employed to develop tailored retinal screening promotion materials for specific priority populations. This paper has implications for future program planners and is intended to assist those wishing to use Intervention Mapping to create similar theoretically-driven, tailored resources.

Clinical and Psychosocial Factors Influencing Retinal Screening Uptake Among Young Adults with Type 2 Diabetes

PURPOSE OF REVIEW

Young adults with type 2 diabetes (T2D, 18-39 years) experience early-onset and rapid progression of diabetic retinopathy (DR), the leading cause of vision loss for working age adults. Despite this, uptake of retinal screening, the crucial first step in preventing vision loss from DR, is low. The aim of this review is to summarize the clinical and psychosocial factors affecting uptake of retinal screening.

RECENT FINDINGS

Barriers include lack of diabetes-related symptoms, low personal DR risk perception, high rates of depression and diabetes-related distress, fatalism about inevitability of complications, time and financial constraints, disengagement with existing diabetes self-management services, and perceived stigma due to having a condition associated with older adults. Young adults with T2D are an under-researched population who face an accumulation of barriers to retinal screening. Tailored interventions that address the needs, characteristics, and priorities of young adults with T2D are warranted.

Inequities in visual health and health services use in a rural region in Spain

OBJECTIVE

To analyse perceived visual health and health services use in a rural population in relation to socioeconomic characteristics and compared with the general population in Spain.

METHOD

Cross-sectional study in a rural population using a structured questionnaire including questions comparable to the Spanish National Health Survey (2012). A descriptive analysis was carried out through the calculation of frequencies and prevalence, the χ² test for independent variables, contrasts of proportions and logistic regression to obtain associations between the rural and general populations and socioeconomic variables.

RESULTS

For the rural population studied, the prevalence of poor perceptions of visual health is 40.8% in men and 39.4% in women, and is strongly associated with age, employment situation, income and presence of chronic diseases (p ˂0.001). Compared with the general population, the rural population has a higher risk of presenting with serious difficulties related to farsightedness (OR: 2.56; 95% CI: 1.32-4.95) and make less use of optical correction (OR: 0.57; 95%CI: 0.44-0.74). The use of health services is not sufficient for adequate prevention, particularly in diabetics. For those affected by poor vision, the distance to travel to receive an eye exam, the belief that eyesight problems come with age and the cost of glasses are the principal reasons used to explain why eyesight problems are not resolved.

CONCLUSIONS

The rural population presents worse visual health that is influenced by social and economic factors. Improving accessibility and reducing barriers is essential to tackle avoidable visual disability and reduce health inequities.

Etiology of optic atrophy: a prospective observational study from Saudi Arabia

BACKGROUND

Optic atrophy (OA) represents permanent retinal ganglion cell loss warranting study to establish etiology.

OBJECTIVES

To describe neurogenic causes of OA.

DESIGN

Prospective, observational.

SETTING

Tertiary care center, Riyadh, Saudi Arabia.

PATIENTS AND METHODS

We included consecutive patients of all ages with OA caused by lesions affecting the visual pathways who were referred over a 9-month period (November 2013 to July 2014). Diagnosis was based on visual acuity, ophthalmoscopic features and ancillary tests. Patient demographics, results of a clinical examination, test data and etiology were recorded. For each cause of OA, both gender and age group were analyzed as potential risk factors using simple univariate logistic regression. OA associated with glaucoma and retinal diseases was excluded.

MAIN OUTCOME MEASURE

Description of causes of OA.

RESULTS

Two hundred and four patients and 353 eyes met inclusion criteria. The median age was 27 years (range 3 months-77 years; interquartile range, 27 years) among 111(54.4%) females and 93(45.6%) males, with no statistically significant difference in age of presentation between the genders. The majority of lesions were bilateral (n=151, 74%). Tumors were the most common cause, accounting for 127 (62.2%) cases. These occurred mostly in adults (72.4%) compared to the pediatric group (OR=3.3, 95% CI: 1.79-6.03; P < .001). Hereditary neoplasia (OR=5.55; 95% CI: 1.67-18.42; P=.005) and metabolic diseases (OR=17.57; 95% CI: 2.15-143.62; P=.007) were more common causes in the pediatric group. There were no significant associations between gender or visual acuity and etiology of OA. In developed nations, OA is frequently the result of ischemia and neuritis. We found many other causes, especially orbital and intracranial tumors.

CONCLUSIONS

The frequency of tumors as the cause of OA may represent a higher incidence of aggressive tumors coupled with poor recognition/acknowledgement of symptoms and limited access, resulting in late presentations.

LIMITATIONS

These findings may reflect bias from selective referrals to a tertiary center and may not represent all of Saudi Arabia.

Comparison of Peristat Online Perimetry with the Humphrey Perimetry in a Clinic-Based Setting

Purpose

We determined the receiver operating characteristic (ROC) curves for Peristat online perimetry at detecting varying degrees of glaucoma and the correlation between Peristat online perimetry and Humphrey visual field.

Methods

A prospective, comparative study of Peristat online perimetry (an achromatic static computer threshold testing program) and Humphrey visual field (HVF) 24-2 SITA standard testing was performed by 63 glaucoma patients and 30 healthy controls in random order. The number of total adjacent abnormal test points were identified for each test, and compared with Spearman correlation. Receive operating characteristic curves were generated for Peristat online perimetry detection of mild and moderate-severe glaucoma patients using contrast sensitivity thresholds of −16.7, −21.7, and −26.7 dB.

Results

The area under the ROC curve for glaucoma detection ranged from 0.77 to 0.81 for mild disease (mean deviation [MD], >−6 dB on HVF) and 0.85 to 0.87 for moderate to severe disease (MD, <−6 dB on HVF) depending on contrast threshold. Peristat online perimetry and Humphrey visual field abnormal points were highly correlated with Spearman rank correlations ranging from 0.55 to 0.77 (all P < 0.001).

Conclusions

Peristat online perimetry exhibits a reasonable ROC curve without specialized equipment and exhibited significant correlation with the conventional 24° Humphrey visual field test.

Translational Relevance

Low cost widely available internet-based visual fields may complement traditional office-based visual field testing.