Glaucoma Disparities in the Hispanic Population

ABSTRACT

The Hispanic population is the United States’ largest minority and one of the fastest growing as well. In the next 30 to 40 years, the proportion of open-angle glaucoma patients represented by Hispanics is expected to dramatically rise. Here we examine the unique considerations and challenges of glaucoma care in this population, from demographics to risk factors to treatments and outcomes. Currently, access to care and the under-diagnosis of glaucoma in this population are significant issues that look only to grow in significance as the glaucoma burden continues to grow. Additionally, utilization of medical and surgical therapy remains lower in Hispanics than in many other ethnic groups. Understanding and proactively addressing the unique challenges in the screening and treatment of Hispanics will be of utmost importance to providing effective care to this population.     

Disparities in Adherence to Screening Guidelines for Diabetic Retinopathy in the United States: A Comprehensive Review and Guide for Future Directions

ABSTRACT

Diabetic retinopathy (DR) is the leading cause of new-onset blindness in American adults aged 20–74 years old. The number of diabetics living with diagnosed DR increased by 89%, from 4.06 million to 7.69 million, between 2000 and 2010. Projected numbers from the Vision Health Initiative by the CDC predict that the rate of DR will triple by 2050, from 5.5 million people living with DR to 16 million. Screening guidelines aim to detect cases early because the treatments for DR can reduce severe vision loss by up to 94%. However, adherence to these guidelines is quite low. It is estimated that more than half of patients with diabetes may fail to receive necessary screening. Risk factors for non-screening discussed in this study include low health literacy, lack of access to care, pregnancy, physician adherence to guidelines, unique factors present in different minority populations, gender and age disparities, and living in rural regions. This paper also aims to address potential interventions that may improve adherence rates.     

Geographic Disparities in the Etiology of Bacterial and Fungal Keratitis in the United States of America

ABSTRACT

Infectious keratitis is a serious cause of vision loss. Proper treatment of infectious keratitis requires antimicrobials that target the organism responsible for a patient’s ulcer. The frequency of infection by a given organism varies by location. We examined the literature to determine geographic disparities in the etiology of bacterial and fungal keratitis in the United States of America. Bacterial keratitis makes up a greater proportion of cases in northern locations, and fungal keratitis increases in prevalence in southern locations. Gram-negative organisms make up a greater proportion of bacterial keratitis in southern locations when compared to northern locations.     

Cataracts in India: Current Situation,Access, and Barriers to Services Over Time

Background: Blindness, especially related to cataracts, poses a major challenge all over the developing world. India, as one of the biggest developing countries, has a large number of blind requiring sight-restoring cataract surgery. Despite the increase in service availability and heightened outreach screening efforts, blindness has not decreased and uptake of offered cataract surgery services is suboptimal. Methods: Barriers to access cataract surgery services in India have been investigated in several studies, which were reviewed after having been identified through a Medline and Pubmed search and summarized by using a model of health care utilization. Results: Numerous barriers, such as financial reasons, distance, fear, lack of service awareness, lack of support, or other obligations, could be identified but have not been put into the wider context of health care utilization behavior. Financial barriers continue to be a major reason not to take up offered cataract surgery services. Discussion: More in-depth research of underlying factors is needed to increase self-motivated uptake of offered cataract surgery services. This would free resources currently invested into patient recruitment such as outreach screening. Freed resources could then be invested into treatment and further interventions such as health literacy promotion.     

Diagnosed cataracts in patients with cystic fibrosis in a United States administrative database

Background: We estimated the incidence and prevalence of diagnosed cataracts among patients with cystic fibrosis (CF) versus the general population (GP).

Methods: Using a large US health insurance claims database, we identified a CF cohort and a GP cohort matched with respect to age, gender, and calendar year. The prevalence and incidence of diagnosed cataract (primary outcome) for both cohorts were calculated, as well as the incidence rate ratios (IRRs).

Results: The prevalence of diagnosed cataracts among patients with CF alive and enrolled in the health plan on August 31, 2012 was 4.8% versus 2.8% in the GP. The incidence in the CF cohort was higher than in the GP and increased with age in both cohorts. The adjusted IRR comparing the CF and GP cohorts was 1.5 (95% CI: 1.2–1.8).

Conclusions: The study suggests that the risk of developing cataract was higher among patients with CF than among the GP.     

High-Risk Populations for Vision Loss and Eye Care Underutilization: A Review of the Literature and Ideas on Moving Forward

Much work has been done to highlight and understand the significant disparities in the use of eye care services, but they continue to exist. We review the existing literature on utilization in high-risk populations to provide a context for understanding what “high-risk” means, to understand the utilization patterns among high-risk populations, and to highlight barriers to appropriate eye care utilization. We also discuss potential approaches to reduce these disparities.     

Outcomes of a Vision Screening Program for Underserved Populations in the United States

ABSTRACT

Purpose: To evaluate which components of a vision screening process are most effective in identifying individuals who need eye care services.

Methods: Subjects visiting a free health clinic were screened using visual acuity and a questionnaire. Persons who failed screening were referred for a professional eye examination.

Results: A total of 1380 of 3004 screened persons (46%) screened positive on question(s) or distance visual acuity; 81% of screened positives were referred for an eye exam, <50% of the positives attended the examination, and one-third had ≥1 problem requiring intervention or monitoring. The most common problem was distance refractive error that, once corrected, improved vision by two or more lines, followed by glaucoma or glaucoma suspect (8.9%), visually significant cataract (7.2%), and diabetic retinopathy (2.5%). Ninety-four subjects who screened negative (“normal”) were examined; nearly half of these had 2+ lines of visual acuity improvement with refraction (from 20/40 or 20/32 to 20/20). Sensitivity for detecting specific eye conditions varied substantially, ranging from 0–83% for individual screening questions. Time since last exam and distance acuity <20/50 were the most sensitive questions for visually significant cataract; however, their specificity was low. No combination of questions and acuity testing had both high sensitivity and specificity.

Conclusions: Vision problems requiring intervention were common among this relatively young population, but no combination of screening questions and vision testing proved effective for screening. More than half of those who screened positive never showed for an examination, indicating that on-site eye exams might be more effective.     

Poor Vision and Self-Reported Functional Difficulties among Recently Hospitalized Individuals in the United States

Purpose: Many hospitalized adults may have limited vision and as a result be at increased risk of worse functional outcomes. Here, we determine the prevalence of poor vision among recently hospitalized United States adults. Additionally, we evaluate the impact of objective vision defects on reading difficulty and external mobility outcomes (difficulty with falls and going down steps).

Methods: Our cross-sectional study included 1,347 adult Americans aged 50 years and older, all recently hospitalized, participating in the 2001–2008 National Health and Nutrition Examination Survey (NHANES). Self-reported difficulty with reading and going down steps/stairs/curbs data were collected for all participants, while data on self-reported falling difficulty were only available for the 2001–2004 NHANES (n=631). Presenting near and distance visual acuity (VA) were measured, with poor vision defined as VA worse than 20/40.

Results: Poor near and distance vision were present in 17.4% and 9.8% of individuals, respectively. Multivariable analyses showed that the odds of reading difficulty were greater with worse VA (odds ratio, OR, 1.9 per 0.3 logMAR increment in near VA, 95% confidence interval, CI, 1.6–2.4, P<0.01), as were the odds of difficulty going down steps/stairs/curbs (OR 2.4 per 0.3 logMAR increment in distance VA, 95% CI 1.9–3.1, P<0.01) and odds of falling difficulty (OR 1.6 per 0.3 logMAR increment in distance VA, 95% CI 1.1–2.4, P=0.04).

Conclusion: About 1 in 10 and 1 in 6 recently hospitalized older Americans had poor distance and near vision, respectively. Many of these individuals may experience trouble reading hospital documents and ambulating, and may be at increased risk of falls.     

Measurement and analysis of visual acuity in multicenter randomized clinical trials in the United States: Findings from a survey

Purpose To describe visual acuity (VA) testing and scoring methods used in multicenter randomized clinical trials in ophthalmology in the United States (USA) sponsored by the National Eye Institute (NEI). Methods A survey was conducted among multicenter studies in the US that included one or more randomized clinical trials and were sponsored by the NEI, National Institutes of Health. To be included in the survey, a study had to have VA reported in one or more publications or patient eligibility based on VA, a majority of study subjects 13 years of age or older, and a patient population primarily or exclusively from the US. A standard survey form was completed for each study based on information presented in the study manual of procedures and publications. Findings were summarized and displayed with frequency distributions. Results The survey included 24 studies, each with enrollment initiated in the period 1972 to 1999.VA was one of the study eligibility criteria for 19 (79%) studies, and VA or change in VA was the primary outcome in 12 (50%) studies. ETDRS charts have been employed in 16 of 19 studies initiated after the charts were published in 1982. All studies but one specified in the documents reviewed that VA testing was performed at multiple VA test distances. For studies that used ETDRS charts, methods of converting VA scores obtained at different test distances to a common scale fell into two categories: 11 studies used a method similar in nature to that first reported in the Macular Photocoagulation Study, and 7 studies used a method similar in nature to that first reported in the Krypton-Argon Regression of Neovascularization Study. Conclusion The development of the ETDRS charts and a custom light box has led to more uniformity in VA test charts and chart illumination. However, details of VA measurement protocols vary widely from study to study. To assure comparable data across studies and ocular conditions, it would be useful to have a standard VA testing and scoring protocol with provisions for testing different levels of visual acuity that recommends a single method for converting scores from different test distances to a common scale and standard conversion of “off the chart”VA levels for calculation of means and changes in VA.     

The Local Availability of Eye Care Providers and the Vision Health of Adults in the United States

Purpose: To examine whether the local availabilities of ophthalmologists and optometrists were associated with outcomes related to the prevention and timely treatment of vision conditions.

Methods: Data on adults from the 2008 National Health Interview Survey were linked to county-level information on the numbers of ophthalmologists and optometrists per capita from the Area Health Resources File. Multivariate logistic regression models were estimated for whether individuals likely to perceive themselves as being at lower risk of vision conditions had undergone a dilated eye exam in the previous 2 years, whether individuals with diabetes had a dilated eye exam in the previous year, and whether individuals with an age-related eye disease (ARED) had lost vision due to the condition. The models included measures of local eye care provider availability and additional explanatory variables.

Results: The county-level availabilities of ophthalmologists and optometrists were positively and significantly related to the likelihood that perceived lower-risk individuals had undergone a dilated eye exam in the previous 2 years. Local eye care provider availability was not significantly related to whether individuals with diabetes had a dilated eye exam in the previous year. Greater county-level availability of ophthalmologists, but not optometrists, was associated with a significantly lower likelihood that individuals with an ARED had lost vision due to the condition.

Conclusion: Public health interventions may be needed in order to increase access to preventive eye care in areas with limited overall eye care provider availability and to improve the treatment of vision conditions in areas with limited ophthalmologist availability.     

视网膜计对白内障术后视力预测可靠性评价及相关影响因素分析

目的为了客观评价视网膜计对白内障患者潜视力预测的准确率、找出影响准确率的相关因素和指导其临床应用。方法对拟手术患者600例白内障患者在手术前用视网膜计对患者的潜在视力(手术后可能达到的视力)进行预测,手术后对其视力复查。并以第2周时做验光矫正后所达到的最佳视力为准。结果判定标准:相符:手术后2周所达视力与手术前预测一致或相差一行对数视力者;基本相符:手术后视力与手术前预测相差2行者;不符:手术后视力与手术前预测相差2行以上者。结果600眼中其中手术前预测与手术后实际最佳矫正视力相符者85眼占14.17%,基本相符者339眼占56.50%,不符合者176眼,占29.33%,总体符合率为70.67%。其中107眼超度高近视眼中符合与基本符合相加所占比例高达93.46%。结论视网膜计具有预测方法简便,检查时间短,结果符合率较高,有较高的参考价值,可以作为白内障手术前常规检查项目。影响其准确率的因素主要有:成熟期、IV级以上硬度核白内障因光栅的透过性差而直接影响患者的分辨能力和测试准确度。高龄、弱智、不合作者也是相关因素。     

Outcomes Disparities between Black and White Populations in the Surgical Management of Glaucoma

ABSTRACT

African descent is a well-documented risk factor for glaucoma development, progression, and medical and surgical failure. We reviewed the literature for evidence of outcomes disparities between Black and White populations after trabeculectomy, Ex-PRESS shunt, viscocanalostomy, canaloplasy, tube shunt, laser trabeculoplasty, and cyclophotocoagulation. There are reports of decreased surgical success in Black patients after trabeculectomy, Ex-PRESS shunt, tube-shunt, and canaloplasty. At this time, there is no strong evidence that any procedure is more effective for intraocular pressure control than standard trabeculectomy for Black patients. Furthermore, there is insufficient evidence to recommend any particular secondary intervention over another, despite differences in inflammation and bleb-dependence. There is a need for randomized, controlled trials to assess race as a risk factor for failure after non-penetrating filtration surgery (NPFS). There is also a need for data on the efficacy of minimally invasive glaucoma surgery (MIGS) in Black populations.