Studies show eyesight, the primary sense for navigating three-dimensional space, is often considered the most valued sense by the public.1 Worldwide, millions of adults aged 50 years and older are affected by blindness due to cataracts, and even more suffer from moderate to severe visual impairment caused by under-corrected refractive errors.2
With visual impairment ranked third in the leading causes of global disability,3 public health ophthalmology will continue to serve as a crucial component in addressing the challenges to eye health.
The global population is projected to reach 9.7 billion by 2050, with 2.1 billion of those individuals over the age of 60. The combined growing and aging population is projected to increase the global prevalence of blindness, moderate to severe vision impairment (MSVI), diabetic retinopathy, and high myopia.4
Additionally, myopia diagnosis is rapidly increasing in younger generations and is associated with increased screen time and decreased daylight exposure.5,6
The goal of public health ophthalmology
Public health ophthalmology is committed to addressing the various eye health challenges through three core community-based measures:7
- Preventive
- Curative
- Promotive
Studies on preventive measures in public health ophthalmology
Preventive measures in public health ophthalmology are often research-driven to gain insights into various vision pathologies. An illustrative example is a South Indian cross-sectional study, which identified an association between increasing age and female gender with vision impairment in patients reporting age-related macular degeneration (AMD).8
Preventive eye health measures aid in understanding various vision conditions and serve as a critical metric for assessing public health outcomes. For example, Healthy People 2030, a United States public health initiative led by the US Department of Health and Human Services, includes a vision workgroup that tracks established vision-related objectives throughout the decade leading up to 2030.9
Additionally, the 2024 Health Plan Ratings Required Healthcare Effectiveness Data and Information Set (HEDIS) Measures, created by the National Committee for Quality Assurance (NCQA), includes eye examination as a measure for diabetes evaluation. This criterion highlights vision health as a critical indicator in managing this chronic disease.10
However, the Global Burden of Disease study found that contrary to the World Health Organization’s (WHO) goal of reducing visual impairment from 2010 to 2019 by 25%, the prevalence of avoidable vision impairment increased from 3.92% in 2010 to 4.34% in 2020.3 These findings argue for including vision impairment in additional public health metrics to monitor ongoing trends.
Increasing eyecare accessibility through telemedicine
Recognizing the need for eyecare, university-based medical centers have shown interest in providing telemedicine services that may help address demands in their communities.
Recent literature highlights an academic ophthalmology practice’s success in achieving strong diagnostic and management consensus for vision visits and subsequent follow-up encounters. This is particularly evident in nonurgent chief complaints, post-operative patient evaluations, and individuals at significant distances from clinic sites.11
A US population-based survey supported by the Centers for Disease Control and Prevention (CDC) found that compared to individuals with no visual impairment, people with MSVI reported more concerns for healthcare costs, less health insurance coverage, and less access to regular healthcare providers.12
Thus, increased utilization of teleophthalmology may provide a nuanced medium to reach patients who cannot physically visit the office, allowing for an additional avenue for preventative and maintenance eye evaluations.
AI’s influence on public health ophthalmology
Another promising approach for delivering preventative eye care involves leveraging artificial intelligence (AI). Companies like Google utilize AI to leverage retina and fundus photos as an entry point into healthcare.
The use of these high-resolution images offers a level of intimate detail about one’s health. Many systemic conditions, such as diabetes, hypertension, and atherosclerotic disease, are reflected in the eye's blood vessels. Machine learning algorithms are now employed to analyze and detect these diseases in the images.
For example, Google's introduction of Automated Retinal Disease Assessment, or ARDA, uses AI to help detect diabetic retinopathy. A study using over 100,000 images with this model was published in JAMA, reporting its accuracy in interpreting retinal scans. This offers an opportunity for increased access to care using cost-effective solutions and an early intervention for patients.13
Understanding curative measures in eyecare
Curative measures are another pillar of public health ophthalmology, as specific ophthalmic surgical interventions have been linked to enhanced overall health outcomes.
A 2021 cohort study comprised of 3,038 adults 65 or older with cataracts showed that participants who underwent cataract extraction had a reduced risk of developing dementia when compared to those who did not undergo such surgery.14
The sensory deprivation hypothesis is one proposed explanation for this association; it states that a prolonged lack of adequate sensory input (i.e., vision) will cause neuronal atrophy.15 Further exploring the interplay between eye health and overall well-being may reveal new avenues for public health interventions.
The interconnectedness of curative interventions, such as cataract surgery, with preventive and promotive measures is fundamental to public health ophthalmology. Access to education and expertise is also pivotal for the success of this field’s mission. Lack of access to vision care prevails for much of the United States population.
Predictors of outpatient vision care participation
Outpatient vision care participation predictors include ethnicity, income, race, insurance coverage, geographic region, and educational status. In the US, non-Hispanic white patients have reported increased use of outpatient ophthalmologic visits compared to Hispanic and Black patients.
Additionally, individuals lacking insurance coverage and those with lower economic and educational attainment tend to have fewer visits to ophthalmic clinic visits.16 Furthermore, findings from a nationwide poll surveying 2,044 non-Hispanic, African American, Asian, and Hispanic adults found that many Americans were unaware of behavioral or familial risk factors for certain eye diseases.
This study identified diabetic retinopathy as the pathology with the lowest awareness across all groups.17 These results suggest that prioritizing educational measures for eye health and increasing access to ophthalmologists may improve national health outcomes.
In 2018, among 643 ophthalmologists practicing in Michigan, 244 were practicing in communities of 49,999 or less. Notably, a higher proportion of DO than MD ophthalmologists worked in these smaller population sizes.
This pattern suggests that the recent discontinuation of numerous American Osteopathic Association (AOA) ophthalmology residency programs may exacerbate the shortage of eye healthcare access in less-populated communities.18
Meeting the need for more eyecare practitioners
Lack of adequate compensation may contribute to the sparsity of practitioners in such areas. Data compiled by the American Medical Association (AMA) shows that after adjustment for inflation in practice costs, Medicare payments to physicians declined 26% from 2001 to 2023.19,20
Fortunately, a current bill under consideration by the House Subcommittee on Health, the Strengthening Medicare for Patients and Providers Act, intends to tie Medicare physician reimbursement to inflation. This would help physicians in rural communities continue to care for low-income patients.21
While this proposed legislation has the potential to aid in increasing access to healthcare services, adjustments in the treatment of physician reimbursement may be necessary to ensure primary vision care is provided to all in need.
Programs such as Teaching Health Center Graduate Medical Education (THCGME) also recognize the need for increased care in rural and underserved communities, offering valuable support to public health ophthalmologists. Throughout 2023 to 2024, the THCGME program is poised to fund training for more than 1,096 residents in 81 community-based residency programs.22
This initiative aims to significantly enhance the primary care workforce, which is crucial in managing chronic diseases—a factor often associated with developing or exacerbating vision impairment. In adults 40 to 64 years of age, self-reported moderate/severe visual impairment compared to no visual impairment was associated with a greater prevalence of co-morbid chronic conditions.23
The role of research in public health ophthalmology
Moreover, as part of the National Institute of Health (NIH), the National Eye Institute (NEI) plays a crucial role in conducting and supporting research on vision and eye health.24 The NEI’s mission is to “eliminate vision loss and improve quality of life through vision research.”
As part of the NIH, the NEI is crucial in conducting and supporting vision and eye health research. Funding from these organizations ultimately leads to an improved understanding of eye diseases, better treatments and technologies used in eyecare, and overall better vision for patients struggling with eye morbidities.
According to the NEI’s 2024 congressional justification, their research budget is projected to be $896.1 million. They intend to allocate these funds to vision research in various areas of eye health, including retina, cornea, cataract, glaucoma, sensorimotor disorders, visual processing, and rehabilitation.25
The NIH and NEI’s continued dedication to sponsoring these research endeavors likely stems from the direct and significant impact of better vision on individuals' social output and economic productivity. Eye diseases such as AMD, diabetic retinopathy, cataracts, and glaucoma—some of the most prevalent among them—afflict millions of Americans, threatening numerous aspects of their lives.
The impact of vision challenges on quality of life
It impacts their mobility, independence, career opportunities, sense of enjoyment, mental health, and overall quality of life.26,27 Findings from Binder et al. revealed that the combined impact of stigmatization, social isolation, and reduced opportunities significantly heightens the likelihood of developing anxiety disorders in people suffering from vision challenges.28
Modern technology, computers, and devices are inevitably becoming an increasingly integral part of many occupations. As such, clear vision and the ability to interpret and perceive information at various distances are personal conveniences and fundamental requirements for effectively contributing to the current professional landscape.
In 2021, the American Academy of Ophthalmology estimated that the economic burden of vision loss and blindness would potentially cost the United States $134.2 billion, directly from medical costs and indirectly via productivity losses (i.e., people who could not work who would have worked if fully sighted).29,30
Final thoughts
In conclusion, decreasing domestic and global vision health necessitates implementing multifaceted measures, including prevention, cure, and promotion. Public health ophthalmology is crucial in developing national and international vision health initiatives.
Emerging preventive measures, such as increased utilization of teleophthalmology and artificial intelligence, offer pathways to deliver routine care for patients facing challenges to in-person eye evaluations. Curative measures, exemplified by cataract surgical intervention, have improved vision and delayed cognitive impairment.
Additionally, promotive measures, including federal initiative TCHGME, sustained support from the NIH and NEI, and legislation aimed to improve healthcare access, will contribute to advancing the goals of public health ophthalmology.
