Can More be Done to Reduce Global Disparities in Vision Loss?

As the global population continues to age, the ensuing increase in visual acuity loss rates may lead to detrimental effects on population health and have lasting impacts on the healthcare industry.

Recently, there has been particular interest regarding disparities in vision care for patients who may suffer from an increased burden of visual impairment, such as older adults and those from underrepresented populations. Dilsher Dhoot, MD, of the California Retina Consultants, recently told HCPLive that in general, research into the socioeconomic factors of and access to health care has been on the climb.

“There is a disparity and unfortunately that does result in vision left on the table," Dhoot said. "Having access to care and timely treatments, with the necessary medications, becomes vital.”

The rates of visual acuity loss are often staggering, as an analysis published in JAMA Ophthalmology last year suggested. The research team found that approximately 7 million people in the US were living with uncorrectable visual acuity loss based on 2017 data—a nearly doubled rate to the previously estimated 4.2 million.

The data additionally suggest 1.08 million Americans were living with blindness, indicating a larger burden on the healthcare system than was previously reported.

Moreover, a global report from The Lancet Global Health suggested that by 2050, an estimated 1.8 billion people will have untreated vision loss, compared to estimates of 1.1 billion patients with distance vision impairment or uncorrected presbyopia in 2020.

Seeking Targeted Solutions

The Commision on Global Eye Health hypothesized the majority of those patients will live in low- or middle-income countries, while women, ethnic minorities, and patients in rural areas will be those disproportionately affected by these rates.

As a result, the report suggested action such as cost-effective treatment measures, including access to eyeglasses or lower costs for procedures such as cataract surgery. The report additionally highlighted the need to include eye health as an integral part of healthcare, from the planning and resource stages to the actual provision of the care.

However, a recent county-level analysis in the United States reported a positive correlation between poverty and visual acuity loss or blindness prevalence. Data show that nonmetropolitan counties had a lower density of ophthalmologists (2.19 per 100,000 persons), in comparison to metropolitan countries (8.29 per 100,000 persons).

Further, experts suggest that disparities may continue in various retina diseases due to the high cost of anti-VEGF therapy as well as its burdensome regimens, requiring frequent treatment consultation and good insurance to keep costs low.

“Some of that is driven by healthcare disparities with regards to economics, some of it is driven by racial and socio- and ethnic biases toward health care providers, and not understanding what the value is of this,” said Rishi Singh, MD, Cleveland Clinic Florida. “We have the opportunity to improve this.”

Data published in JAMA Ophthalmology suggest visual acuity improvement associated with anti-VEGF treatment generated $5.1 billion to $8.2 billion in patient benefits and $0.9 billion to $3.0 billion in societal value across 3 years. New innovations in the field may have even added further economic benefit.

However, a significant way to tackle disparities may be the inclusion of more underrepresented groups within clinical trials. These disparities often occur in a subset of populations based on previously discussed factors, including insurance status, race and ethnicity, and their region within the country or globe.

Experts have discussed the now conscious effort to initiate clinical trials and enroll patients representative of the population at large who are dealing with these diseases.

“There’s a lot of interest looking at the clinical trials to make sure that we enroll the patients that we see in our clinics, and have all the different patient populations represented,” said Aleksandra Rachitskaya, MD, Cleveland Clinic Cole Eye Institute. “There is a lot of effort to enroll the population that represents the folks that we see day in and day out. I think having a variety of options when it comes to patient care is extremely important.”

Some trials are attempting to level out that representative imbalance between real-world practice and clinical trials, including the phase 4 Elevatum trial looking at the efficacy of faricimab in underrepresented patients with diabetic macular edema.

“We are generating data for faricimab in underrepresented minorities, so I think the outcomes could be different,” said Arshad Khanani, MD, Sierra Eye Associates. “I think we all need to do a better job to enroll a broader population in clinical trials. Of course, access to care may lead to under-representation in clinical trials also.”

A Booming Issue

Yet, the potential solutions to disparate visual acuity loss are varied and often unclear as to their effectiveness. A 2022 recommendation statement from the US Preventive Services Task Force on screening for vision loss in older adults reported that the evidence was insufficient to address the balance of benefit and harms of screening for impaired visual acuity.

This statement highlighted the need for more research to formally test potential benefits of impaired visual acuity screening among this older, asymptomatic population.

Future studies will need to focus on a robust collection of data to determine the worth of screening. The population of adults aged 65 years and older is expected to increase to 22% of the population by 2048 and 6.6 million people aged 60 years and older are projected to have vision impairment or blindness in 2050. These increases will have far-reaching consequences for patients, their caretakers, and policy-makers worldwide.

Barriers will additionally need to be overcome to ensure coverage is provided to those who need it, particularly marginalized groups including women and Black and Hispanic individuals who may be affected the most.

“There truly is, first and foremost, a need to get out more education toward these populations and put it in the language of the individuals who we are trying to educate,” Singh said. “But, we additionally need to talk to healthcare providers about these gaps and the fact that these patients may have preconceived notions about what the treatments encounter and what the outcomes are. We can do a better job counseling those patients through this process.”

The larger impact of better access may ultimately be maximized when forward-thinking healthcare policy matches vision screening research in order to reduce the overwhelming vision loss disparities that are seen today in the US and worldwide.

“You can target care to a patient,” Rachitskaya said. “We are obviously treating ocular conditions, but ultimately, we're treating people and I think it's important to keep that in mind as we take care of the patients.”