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The Intersection of Ophthalmology in Public Health

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14 min read

Discover how ophthalmology and public health can intersect to improve accessibility to eyecare and address eye health challenges in the US.

The Intersection of Ophthalmology in Public Health
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
  1. Preventive
  2. Curative
  3. 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.
  1. Enoch J, McDonald L, Jones L, et al. Evaluating Whether Sight Is the Most Valued Sense. JAMA Ophthalmol. 2019 Nov 1;137(11):1317-1320. doi: 10.1001/jamaophthalmol.2019.3537. PMID: 31580383; PMCID: PMC6777262.
  2. GBD 2019 Blindness and Vision Impairment Collaborators, Vision Loss Expert Group of the Global Burden of Disease Study. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: the Right to Sight: an analysis for the Global Burden of Disease Study. Lancet Glob Health. 2021 Feb;9(2):e144-e160. doi: 10.1016/S2214-109X(20)30489-7. Epub 2020 Dec 1. Erratum in: Lancet Glob Health. 2021 Apr;9(4):e408. PMID: 33275949; PMCID: PMC7820391.
  3. Forrest SL, Mercado CL, Engmann CM, et al. Does the Current Global Health Agenda Lack Vision? Glob Health Sci Pract. 2023 Feb 28;11(1):e2200091. doi: 10.9745/GHSP-D-22-00091. PMID: 36853641; PMCID: PMC9972379.
  4. Ackland P, Resnikoff S, Bourne R. World blindness and visual impairment: despite many successes, the problem is growing. Community Eye Health. 2017;30(100):71-73. PMID: 29483748; PMCID: PMC5820628.
  5. Li M, Xu L, Tan CS, et al. Systematic Review and Meta-Analysis on the Impact of COVID-19 Pandemic-Related Lifestyle on Myopia. Asia Pac J Ophthalmol (Phila). 2022 Sep 1;11(5):470-480. doi: 10.1097/APO.0000000000000559. PMID: 36179338.
  6. Wirz-Justice A, Skene DJ, Münch M. The relevance of daylight for humans. Biochem Pharmacol. 2021 Sep;191:114304. doi: 10.1016/j.bcp.2020.114304. Epub 2020 Oct 28. PMID: 33129807.
  7. Kupfer C. Public health ophthalmology. Br J Ophthalmol. 1987 Feb;71(2):116-7. doi: 10.1136/bjo.71.2.116. PMID: 3828264; PMCID: PMC1041101.
  8. Srinivasan S, Swaminathan G, Kulothungan V, et al. Prevalence and the risk factors for visual impairment in age-related macular degeneration. Eye (Lond). 2017 Jun;31(6):846-855. doi: 10.1038/eye.2017.72. Epub 2017 May 26. PMID: 28548646; PMCID: PMC5518841.
  9. Office of Disease Prevention and Health Promotion. Healthy People 2030. US Department of Health and Human Services.
  10. National Committee for Quality Assurance. 2024 Health Plan Ratings Required HEDIS, CAHPS, and HOS Measures. Updated July 31, 2023.
  11. Schempf T, Kalra G, Commiskey PW, et al. Accuracy Assessment of Outpatient Telemedicine Encounters at an Academic Ophthalmology Department. J Acad Ophthalmol (2017). 2022 Sep 2;14(2):e193-e200. doi: 10.1055/s-0042-1756200. PMID: 37388173; PMCID: PMC9927968.
  12. Crews JE, Chou CF, Zack MM, et al. The Association of Health-Related Quality of Life with Severity of Visual Impairment among People Aged 40-64 Years: Findings from the 2006-2010 Behavioral Risk Factor Surveillance System. Ophthalmic Epidemiol. 2016 Jun;23(3):145-53. doi: 10.3109/09286586.2016.1168851. Epub 2016 May 9. PMID: 27159347; PMCID: PMC4924343.
  13. Gulshan V, Peng L, Coram M, et al. Development and Validation of a Deep Learning Algorithm for Detection of Diabetic Retinopathy in Retinal Fundus Photographs. JAMA. 2016;316(22):2402–2410. doi:10.1001/jama.2016.17216
  14. Lee CS, Gibbons LE, Lee AY, et al. Association Between Cataract Extraction and Development of Dementia. JAMA Intern Med. 2022 Feb 1;182(2):134-141. doi: 10.1001/jamainternmed.2021.6990. PMID: 34870676; PMCID: PMC8649913.
  15. Clay OJ, Edwards JD, Ross LA, et al. Visual function and cognitive speed of processing mediate age-related decline in memory span and fluid intelligence. J Aging Health. 2009 Jun;21(4):547-66. doi: 10.1177/0898264309333326. PMID: 19436063; PMCID: PMC2828155.
  16. Elam AR, Tseng VL, Rodriguez TM, et al. Disparities in Vision Health and Eye Care. Ophthalmology. 2022 Oct;129(10):e89-e113. doi: 10.1016/j.ophtha.2022.07.010. Epub 2022 Sep 1. PMID: 36058735; PMCID: PMC10109525.
  17. Scott AW, Bressler NM, Ffolkes S, et al. Public Attitudes About Eye and Vision Health. JAMA Ophthalmol. 2016 Oct 1;134(10):1111-1118. doi: 10.1001/jamaophthalmol.2016.2627. PMID: 27490785.
  18. Ahmed H, Price M, Robbins W, Braich P. Practice Locations of Michigan Ophthalmologists as a Model to Compare Practice Patterns of DO and MD Surgical Subspecialists. J Osteopath Med. 2020;120(9):568-574. doi:
  19. American Medical Association. Another year of Medicare physician pay cuts unconscionable. Published September 14, 2023.
  20. American Medical Association. Medicare Updates Inflation Chart. Updated April 2023.
  21. H.R.2474 - 118th Congress (2023-2024): Strengthening Medicare for Patients and Providers Act. (2023, April 14).
  22. Health Resources and Services Administration. Teaching Health Center Graduate Medical Education. Last reviewed July 2023.
  23. Crews JE, Chou CF, Zack MM, et al. The Association of Health-Related Quality of Life with Severity of Visual Impairment among People Aged 40-64 Years: Findings from the 2006-2010 Behavioral Risk Factor Surveillance System. Ophthalmic Epidemiol. 2016 Jun;23(3):145-53. doi: 10.3109/09286586.2016.1168851. Epub 2016 May 9. PMID: 27159347; PMCID: PMC4924343.
  24. National Eye Institute. Current Funding Opportunities. National Eye Institute. Updated March 8, 2022.
  25. National Eye Institute. Budget and Congress. National Eye Institute. Updated 13, 2023.
  26. Jammal HM, Khader Y, Kanaan SF, et al. The Effect of Visual Impairment and Its Severity on Vision-Related and Health-Related Quality of Life in Jordan: A Comparative Cross-Sectional Study. J Multidiscip Healthc. 2023 Oct 18;16:3043-3056. doi:10.2147/JMDH.S431159. PMID: 37873536; PMCID: PMC10590562.
  27. Kandel H, Nguyen V, Piermarocchi S, et al. Quality of life impact of eye diseases: a Save Sight Registries study. Clin Exp Ophthalmol. 2022 May;50(4):386-397. doi: 10.1111/ceo.14050. Epub 2022 Feb 7. PMID: 35080803; PMCID: PMC9303885.
  28. Binder KW, Wrzesińska MA, Kocur J. Anxiety in persons with visual impairment. Psychiatr Pol. 2020 Apr 30;54(2):279-288. English, Polish. doi: 10.12740/PP/OnlineFirst/85408. Epub 2020 Apr 30. PMID: 32772060.
  29. Rein DB, Wittenborn JS, Zhang P, et al. The Economic Burden of Vision Loss and Blindness in the United States. Ophthalmology. 2022 Apr;129(4):369-378. doi: 10.1016/j.ophtha.2021.09.010. Epub 2021 Sep 21. PMID: 34560128.
  30. Rein DB, Zhang P, Wirth KE, et al. The economic burden of major adult visual disorders in the United States. Arch Ophthalmol. 2006 Dec;124(12):1754-60. doi: 10.1001/archopht.124.12.1754. Erratum in: Arch Ophthalmol. 2007 Sep;125(9):1304. PMID: 17159036.
Julia Moore, MS2
About Julia Moore, MS2

Julia Moore, a second year-medical student at Edward Via College of Osteopathic Medicine, actively engages in healthcare advocacy through membership in OPAC, SOMA, and OBI. She has a keen interest in preventative medicine, with a focus on how nutrition, community, lifestyle practices, and belief-systems impact human health.

Julia Moore, MS2
Elizabeth Turner, MS3
About Elizabeth Turner, MS3

Elizabeth Turner BS, is a third-year medical student attending Noorda College of Osteopathic Medicine in Provo, Utah. She is dedicated to making a positive impact in the realm of eye health and enjoys volunteering with the University of Utah's Moran Eye Center outreach program.

Before medical school, she gained hands-on experience as an ophthalmic technician, laying the groundwork for her understanding of eye care. A unique aspect of her professional journey is that her twin sister happens to be an optometrist with whom she hopes to become clinical partners.

Elizabeth Turner, MS3
Nikhita Yadlapalli, MS3
About Nikhita Yadlapalli, MS3

Nikhita Yadlapalli, BS, is a third-year medical student at FIU Herbert Wertheim College of Medicine in Miami, FL. She graduated in 2020 with a BS in Zoology from the University of Florida. Her interests include community health and increasing access to vision care.

Nikhita Yadlapalli, MS3
Hailey Ahmed, MPH, CHES
About Hailey Ahmed, MPH, CHES

Hailey Ahmed is a dedicated public health advocate, holding a Master's degree of Public Health from the University of Southern California. With a wealth of experience spanning USAID, CDPH/CDC Foundation, LADPH, and Kaiser Permanente, she brings a comprehensive understanding of health systems and policies. Hailey's passion lies in health education and promotion, focusing on diverse topics, including mental health, sexual health, substance use, infectious diseases, and global health and development. Through her work, she strives to empower communities with knowledge and resources for healthier lives.

Hailey Ahmed, MPH, CHES
Harris Ahmed DO, MPH
About Harris Ahmed DO, MPH

Harris Ahmed DO, MPH is a resident physician in ophthalmology at the Loma Linda University Eye Institute. He is a leader in health policy, serving in national leadership positions in multiple organizations including the AMA, AOCOOHNS, and AOA and has authored many publications and given lectures on public health advocacy and health policy, specializing in topics such as scope of practice, physician distribution, and medical education.

Harris Ahmed DO, MPH
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