Eye Care Disparities: Mend the Social Gaps First

By: Olivia Qin, Biological Sciences 2027

“One better or two better?” An all-too-familiar question at an annual eye examination. You answer, “Two.” The doctor scribbles down some numbers. A week later, you pick up a new pair of glasses and your vision is as good as new. The process is straightforward. Regardless of your race, sexual orientation, and socioeconomic status, blurry vision is blurry vision and a prescription is a prescription. But as you age, diagnostic complications arise with increasing risks for complex diseases.

When discussing biomedical and clinical research, the rapid advancement of screening technology and surgical techniques may be the first thought that comes to mind. However, this curtain of progress veils layers of cost concerns, accessibility barriers, and inaccurate diagnoses. Although there has been an abundance of research on several scientific aspects of healthcare, the  need for awareness toward the social determinants of health remains unfulfilled. Researchers and medical practitioners have overlooked epidemiology factors such as racial distribution, population density, wealth gaps, education quality, and health literacy in clinical practice, leading to false medical labeling, unnecessary testing, disregarded risk factors, and poor health maintenance. In the field of ophthalmology, this unintended negligence has significantly reduced the reliability of eye care services. 

Demographic analysis of the populations most affected by cases of cataracts, the clouding of the natural intraocular crystalline lens in the eye, demonstrates the consequences of this negligence. As the leading cause of blindness worldwide, the elderly population experiences this condition to a notable extent. According to population studies, the prevalence of cataracts is disproportionately elevated in minority populations including those of African, Hispanic, and Chinese Americans. Cataract removal surgery, first invented by French surgeon Jacques Daviel in the eighteenth century, is also more complex for these minorities in comparison to Caucasians. For example, postoperative patients of African descent experience worse outcomes of visual acuity and a greater frequency of complications, such as anterior uveitis1 [1]. The artificial intraocular lens that surgeons transplant into the eye is tailored to the preferences and prescription of each individual and the anatomical measurements of their eyes. However, the surgical procedure is nearly identical for every patient regardless of race or ethnicity. Yet, the variance in postoperative complications demonstrates that the current method produces the most desirable results for Caucasian patients. This finding reveals the likelihood that researchers tested the effectiveness of cataract surgery and optimized the procedure for a historically privileged population.

Diabetic retinopathy2 cases serve as another indicator of eye care disparities due to social determinants. As the prevalence of diabetes mellitus increases, African and Hispanic Americans continue to experience a greater severity in disease burden yet receive lower rates of recommended screenings and eye examinations [1]. Severe cases often occur from inattention toward risk factors for these demographic groups. In addition, diabetic retinopathy has become more common in rural communities than in urban environments, even following accessibility adjustments. Patients in rural regions have reported cost hurdles, lack of insurance, and transportation barriers [1]. These obstacles prevent patients from keeping up with follow-up appointments and annual examinations, which become increasingly important with age. Furthermore, greater prevalence of retinopathies among patients with lower income and educational attainment is attributable to a lack of knowledge of preventative measures and limited access to eye care services due to the amplified wealth gap between affluent and under-resourced individuals. Low health literacy is another contributing factor to deficient knowledge of ophthalmic diseases. For instance, although a large percentage of the population is aware of common eye diseases and disorders, most are unaware that the onset of these diseases may come without early warning signs [2]. Thus, the contrast between a wide distribution of eye care services and inadequate medical awareness also limits the ability of different demographic groups to maintain their ocular health.

The epitome of eye care disparities resides in cases of glaucoma3, the leading cause of irreversible blindness. The cup-to-disc ratio is a measurement taken from the optic nerve at the back of the eye and reflects a major risk of developing glaucoma. Patients with a cup-to-disc ratio of 0.6 or greater are flagged as glaucoma suspects, subjecting them to frequent appointments [3]. It is not a coincidence that Asians and Africans, who have naturally larger cup-to-disc ratios than Caucasians, are over-labeled as glaucoma suspects. After all, the accepted normal range for cup-to-disc ratios of 0.2-0.3 derives from statistical data of ophthalmic features in Caucasian males [4]. This standardization must adjust to acknowledge differences in ocular anatomy between different races and genders. Furthermore, similar to cataract surgery cases, patients of African descent experience higher rates of surgical failure for glaucoma than Caucasians [5]. The lack of research regarding different surgical procedures for optimal results in each racial and ethnic category explains this observation. Recent studies reveal that minor modifications in minimally invasive surgeries yield better outcomes for African and African-American patients, further demonstrating the value of researching variations for standard surgical procedures and their potential to offer greater benefits to different populations. 

In the face of exciting innovations, it is easy to neglect the multifaceted social determinants of eye care and overlook or mislabel signs of risk. While it is important to continue expanding the horizons of medical knowledge, it is even more fundamental that clinicians, researchers, and health policy-makers merge their expertise to provide holistic and individualized eye care services and treatments for everyone.

References

1. Elam, A. R., Tseng, V. L., Rodriguez, T. M., Mike, E. V., Warren, A. K., Coleman, A. L., ... & Zebardast, N. (2022). Disparities in vision health and eye care. Ophthalmology, 129(10), e89-e113.

2. Katibeh, M., Ziaei, H., Panah, E., Moein, H. R., Hosseini, S., Kalantarion, M., ... & Yaseri, M. (2014). Knowledge and awareness of age related eye diseases: a population-based survey. Journal of ophthalmic & vision research, 9(2), 223.

3. Soares, R. R., Mokhashi, N., Sharpe, J., Zhang, Q., Hinkle, J., Patel, S. N., ... & Hsu, J. (2023). Patient Accessibility to Eye Care in the United States. Ophthalmology, 130(4), 354-360.Barquet-Pizá, V., & Siegfried, C. J. (2024). Understanding racial disparities of glaucoma. Current Opinion in Ophthalmology, 35(2), 97-103.

4. Belamkar, A., Harris, A., Oddone, F., Verticchio Vercellin, A., Fabczak-Kubicka, A., & Siesky, B. (2022). Asian Race and Primary Open-Angle Glaucoma: Where Do We Stand? Journal of Clinical Medicine, 11(9), 2486.

Tseng, V. L., Kitayama, K., Yu, F., & Coleman, A. L. (2023). Disparities in glaucoma surgery: a review of current evidence and future directions for improvement. Translational Vision Science & Technology, 12(9), 2-2.