Making Eyecare Accessible: In-Office Strategies You Can Start Today

Significant gaps in healthcare provision persist across the United States. Regrettably, the healthcare system, including vision care services, offers inadequate support to those at highest risk of vision-threatening diseases.

Despite 93 million American adults (18 and older) at risk of severe vision loss, only 55.8 million of them reportedly had an eye exam in the past year.¹

This article will outline how optometrists can take action to tackle these discrepancies, promote health equity, and improve visual outcomes for more patients.

Overview of the disparities in eyecare accessibility

Unaddressed eyecare accessibility continues to be one of the most pressing healthcare needs in the United States,² and is a rising public health concern. Underutilized vision services directly impact an individual's ability to identify and manage sight-threatening diseases. Early detection, timely diagnosis, and treatment through preventative care are essential to preserve vision and produce positive visual outcomes.

However, race, ethnicity, income, insurance coverage, geographic region, and education level remain significant predictors of visual impairment (routinely defined as best-corrected visual acuity [BCVA] ≤20/70 in the better eye, although BCVA ≤20/40 was utilized in certain studies) and barriers to vision care utilization.^2,3

Race/Ethnicity

Race and ethnicity play a major role in inequitable distribution of eyecare services. According to 2019 data from the Centers for Disease Control and Prevention (CDC), white (non-Hispanic) and Asian adults accessed the eyecare system substantially more than their North American, Black (non-Hispanic), and Hispanic (any race) counterparts, even though the North American, Black (non-Hispanic) and Hispanic (any race) populations experience higher rates of visual impairment (VI).

Figure 1 illustrates the comparison of eyecare services utilized to the prevalence of VI in key racial/ethnic population groups.

^{Figure 1: Data adapted from CDC/Vision and Eye Health Surveillance System (VEHSS).}

Socioeconomic status (SES)

Inadequate or no insurance coverage, inability to pay for vision care and treatment costs (eyeglasses, vision aids, etc.), and limited transportation options contribute to the challenges patients from low SES face in accessing eyecare.

Routine vision care is not considered essential primary care for most medical insurance plans, leaving as many as 63% of Americans without vision insurance.³ This results in many patients not seeking care until they experience significant visual problems far too often when permanent vision loss has already occurred.²

Among people with VI, 45% and 73% of costs associated with optometry visits and glasses and contact lenses, respectively, were out-of-pocket by the patient.⁴ For individuals lacking sufficient funds, obtaining routine vision care and achieving optimal vision becomes challenging.

Transportation is another important factor associated with low SES that highly impacts eyecare accessibility,² with an estimated 5.8 million Americans delaying medical care in 2017 due to transportation issues.⁵

Figures 2 and 3 illustrate the reported payers for optometrist visit costs associated with VI.

Geographic location

A 2015 analysis of eyecare provider geographic distribution across the US revealed that 60.7% of US counties had limited availability of both ophthalmologists and optometrists.⁶

Additionally, 24% lacked any eyecare provider (ophthalmologist or optometrist), while another 24% had sufficient optometrist coverage but limited availability of ophthalmologists.

Inadequate number of providers in counties across the United States is a significant factor that negatively impacts eyecare accessibility in rural and low-income communities.

Education

The level of education has been established as a predictor of eyecare usage. More than 80% of college graduates with VI and/or eye disease reported receiving eye exams; however, only 62% and 52%, respectively, of those who graduated from high school and those who did not report access to eyecare.⁷

Primary causes of visual impairment

The six most common ocular conditions that can cause VI in the US are cataracts, age-related macular degeneration (AMD), diabetic retinopathy, uncorrected refractive error (URE), and glaucoma.

Cataracts

Cataracts disproportionately affect older individuals from Black, Hispanic, and Chinese race/ethnicity, lower income brackets, low educational attainment, and the female gender.²

Additionally, lower rates of cataract surgery have been associated with many of the same groups of people: Black and Hispanic race/ethnicity, lower income brackets, and lower educational attainment as well as rural residence.²

Discrepancies in cataract surgical outcomes have also been noted, with Hispanic, Black, and Asian American patients, often requiring more complex procedures.²

Additionally, Black patients and those with intellectual disabilities are more likely to experience post-surgical anterior uveitis, and male Black and Native American individuals face post-surgical endophthalmitis more frequently than other groups.²

Age-related macular degeneration

AMD is commonly linked to female individuals aged 65+ of white ethnicity. Modifiable risk factors like smoking, waist circumference, waist-hip ratio, and cardiovascular issues (such as serum cholesterol levels and hypertension) can escalate disease progression to advanced or exudative AMD.²

Diabetes, lower educational attainment, and specific anti-inflammatory medications also heighten the risk.²While white ethnicity is a significant risk factor, patients from racial or ethnic minorities often exhibit significantly reduced visual acuity at the time of diagnosis.²

Diabetic retinopathy

Diabetic retinopathy (DR) is the leading cause of legal blindness among individuals aged 20 to 74,¹¹ yet 90% of DR-induced blindness is avoidable.⁹ Although any person with diabetes can develop DR, factors such as elevated hemoglobin A1c (HbA1c), insulin dependence, prolonged disease duration, hypertension, and elevated blood glucose increase the risk.²

Moreover, Black and Hispanic Americans typically bear a greater and more severe disease burden, yet they undergo recommended screening and eye exams less frequently, resulting in more severe DR at anti-vascular endothelial growth factor (VEGF) treatment initiation.² Malhotra et al. also identified lack of insurance as a factor in delay of care and treatment.¹⁵

Uncorrected refractive error (URE)

While race/ethnicity disparities are more pronounced in patients with low annual household income, low education attainment, and lack of health insurance coverage, they persist in patients with higher income, higher education, and health insurance.¹⁰

Moreover, many individuals struggle to regularly update prescriptions, leading to undercorrected refractive errors.¹⁰

Glaucoma

Glaucoma prevalence rises with age and is associated with lower SES. Glaucoma prevalence among various racial and ethnic groups is complex, and differences in ocular anatomy may contribute to glaucoma risk (central corneal thickness, etc.).² Despite similar rates of glaucoma-related blindness, Black patients undergo fewer surgeries when compared to their white counterparts.²

Glaucoma management requires additional testing, continuous monitoring, and treatment, which is challenging due to its chronic nature and absence of early symptoms. Ancillary glaucoma testing is less common with Hispanic patients, patients with Medicaid, and in certain geographic regions.²

Factors like race/ethnicity, limited understanding of the condition, other health conditions, and distance to healthcare providers, among others, often lead to patients discontinuing follow-up care.²

The most notable risk factors of vision loss

The primary known factors that elevate the risk of eye disease and vision loss include advanced age, racial/ethnic minority groups, low SES, and diabetes mellitus.²

Furthermore, language barriers, culturally-based perceptions and norms, and a lack of knowledge about vision-threatening conditions increase the risk of VI and blindness among poor, rural, and minority populations.³

Blindness: A growing public health concern

The 2015 prevalence of VI and blindness is expected to double by 2050, with an estimated 2 million people with blindness since 2015.¹² In addition, there are 7 million people with VI (3 million in 2015), and 16 million with VI due to URE (8 million in 2015).

As a result, the economic burden of VI is expected to reach $373 billion by 2050 due to population growth and the rising prevalence of systemic disease. The demographic landscape is changing. By 2050, Hispanic Americans are expected to surpass African Americans as the group with the highest occurrence of VI and blindness.

Frequently reported barriers to eyecare accessibility¹⁴

Cost/coverage
Clinic accessibility
Trust/doctor-patient relationship
Lack of awareness
Poor communication

In addition to the well-established socioeconomic challenges associated with cost, insurance coverage, and clinic accessibility, a significant barrier frequently reported in focus group discussions, in association with Duke University, was the lack of trust and positive patient-doctor relationship.¹⁴

Moreover, there is a general lack of awareness of eye health and ocular diseases. A Harris Poll survey revealed that while 81% of adults believe they are well-informed about vision and eye health, only 19% know the primary causes of blindness, and less than 11% understand that there are no early symptoms of glaucoma or DR.¹³

7 steps to reduce eyecare barriers in your optometry practice

Address cost and insurance issues.
1. Incorporate payment plans and carry frames from all price points.
2. Refer patients to specific local health centers as needed.
Personalize individual patient education plans.
1. Personalize education with the patient’s retinal photos.
2. Include family members and caretakers in education and treatment plans.
  1. The National Eye Institute's NEI-VR: See What I See app can be a great tool to demonstrate vision with different ocular diseases to patients, their families, and/or caretakers.
3. Distribute written material or direct patients to reliable information sources.
  1. You can find pamphlets on the American Optometric Association (AOA) or American Academy of Ophthalmology (AAO) websites.
4. Follow-up a few days later to clarify and/or answer questions.
Incorporate technology to improve care and patient adherence.
1. Use telehealth to complement in-office exams (video/messaging/call).
  1. Ensure patients are able to get newly prescribed medications.
  2. Confirm understanding of condition, treatment, and medication use.
2. Use telehealth/mobile services for follow-up/monitoring appointments if possible.
  1. The Alleye app allows patients to self-test while the eyecare practitioner monitors them virtually.
Foster multi-disciplinary collaboration.
1. Build relationships with other healthcare providers to coordinate the care of shared patients.
2. Maintain consistent written communication after any encounter with shared patients.
Maintain community outreach and ocular health education efforts.
1. Expand school/community screening services.
2. Partner with community-based clinics to provide services.
3. Commit to office participation in various community activities.
4. Begin eye health educational initiatives to enhance community awareness.
  1. This could include presentations covering relevant eye health/safety issues in schools, businesses, churches, community centers, etc.
5. Support or participate in the InfantSEE program.
  1. Offer free exams to children aged 6 to 12 months.
6. Support community programs such as Driving Real Improvement in Value and Equity (DRIVE) and Racial and Ethnic Approaches to Community Health (REACH).
Improve accessibility to eyecare services.
1. Offer telehealth/mobile services to increase accessibility.
2. The Peek Vision app may be valuable for remote screenings/exams.
Prioritize diversity within your office.
1. Diversity helps overcome cultural and/or language barriers to help improve patient trust and patient satisfaction.

Final thoughts

Maintaining good eye health relies on overcoming obstacles to achieve equal access to eyecare. The main factors influencing outcomes are not biological in nature, but the social determinants of health.

With the growing prevalence of visual impairment and blindness, particularly among vulnerable groups, it’s essential for the eyecare sector to enhance clinic accessibility, raise eye health awareness, and extend services to underserved communities.

We must take action now to prepare for the challenges of tomorrow.