Across communities worldwide, there are people who have inequitable access to healthcare, including eye care. At least 2.2 billion people around the globe have a vision impairment or blindness that could have been prevented or has not yet been addressed in at least 1 billion people.¹ At the practitioner level, ophthalmologists can take tangible steps to improve access to healthcare and overall health at their eye clinics and volunteer activities in their communities.

1. Assess the COVID-19 Vaccination Status of Every Patient

The COVID-19 pandemic continues to persist, resulting in significant excess mortality both directly and indirectly that disproportionately affect Black and Afro-Latino communities.² As a result, it is critical to determine each patient’s COVID-19 vaccination status and, if not fully vaccinated with a booster, start a conversation that encourages patients to consider a vaccine.³ Using your medical expertise, you can make yourself available to answer any questions they may have. While misinformation persists across social media, we can play a role in providing accurate information.

2. Advocate for Healthy Dietary Choices

“Food deserts,” where access to healthy options are scarce, can be found across the US, but predominantly in neighborhoods with a high proportion of residents who are in a racial minority.⁴ As diet and exercising are important parts of ocular health, it is incumbent upon the ophthalmologists in these areas to offer lifestyle guidance. Discuss the effect these changes may have on your patients vision and reducing vision loss associated with common conditions such as diabetic retinopathy and other retinal vascular diseases. Vitamins, especially vitamin A, and amino acids, especially tryptophan, are essential for maintaining quality vision.⁵

For patients with a poor appetite, consider writing a multivitamin prescription, which reminds patients that an investment in healthy food and exercise can reduce disease, improve health, and reduce out of pocket healthcare costs. I have seen many patients have regression of their diabetes and retinopathy upon receiving this information.

3. Embrace Comanagement and Technology for Patient Education

To reinforce patient education efforts, practitioner offices should hire additional support staff who you train to conduct patient work ups, assist with medical record documentation, take histories, and discuss systemic health recommendations. Comanaging with a local or in-house optometrist can also help give patients access to primary eye care.

4. Offer Early Glaucoma Intervention

Medical therapy remains the first-line approach for managing primary open-angle glaucoma. But early surgical interventions for glaucoma, such as minimally invasive glaucoma surgeries (MIGS) performed at the time of cataract removal, can effectively lower intraocular pressure (IOP) with less diurnal variation and reduce the need for potentially cost-restrictive IOP-lowering medication which also improves adherence.^6-8 While this approach is appropriate for any patient, research shows that Americans who are Black or Latino are at greater risk for developing glaucoma.⁹ Advocating for earlier cataract removal in these patients may help stave off glaucoma, especially as research shows they are less likely to undergo cataract surgery than White patients.¹⁰

5. Provide Medicaid Eligibility Information

Depending on the Medicaid insurance sub-type, patients with Medicaid insurance are less able to obtain appointments with eye care providers compared with patients who have private insurance.¹¹ For patients who qualify, some Medicaid managed care plans provide reimbursements compatible with competitive Medicare rates which can help more patients readily access eye care providers. Ophthalmology practices should carefully consider which Medicaid managed care plans they are willing to take. Don’t be afraid to negotiate Medicare rates.

6. Volunteer With EyeCare America or Other Free Clinic

The American Academy of Ophthalmology’s EyeCare America program provides access to eye care for high-risk, low-access populations, including seniors without a medical eye exam in the past 3 or more years and patients with glaucoma risk factors. Another opportunity in some communities is to volunteer as faculty for a student-run eye clinic affiliated with many medical schools and their ophthalmology departments. The exact quantity of student-run free eye clinics nationwide is unknown, but many medical schools have student-run free medical clinics which may offer eye care.¹² If they don’t offer eye care, it may be appropriate to propose developing such a service. Many existing free eye clinics are understaffed and would benefit from additional volunteer practitioners, particularly those with specialty expertise.

7. Mentor Minority Students in Your Practice

Black, Latino, and Native American populations are underrepresented in ophthalmology. If you run into talented individuals interested in medicine, provide an opportunity for them to shadow you in your ophthalmology practice or ambulatory surgical center and encourage them to pursue medicine and ophthalmology. Shadowing remains a common and important tool for students to learn about patient care, medicine and careers.¹³ During the COVID-19 pandemic, there have been limitations in clinical experiences, including the cancellation of clerkships at many medical institutions. These experiences are essential for both skill acquisition as well as for relationship building. To rectify the gaps in clinical experience, providing shadowing opportunities through your practice can give underrepresented students an opportunity to be exposed to ophthalmology and consider this as a career choice by sharing your passion and expertise. You can also refer students to and financially support the Student National Medical Association and the National Medical Association’s Ophthalmology Rabb-Venable Program for additional mentoring opportunities to augment your initial efforts.

Saving Vision Saves Lives

Vision impairment results in significant costs, both direct and indirect, and has the potential to negatively affect almost every aspect of a person’s life, not just their vision.^14,15 Loss of vision has been linked with depression, anxiety, and the development of cognitive dysfunctions.^15,16 Vision loss complicates chronic disease management by limiting transportation to and from doctor’s appointments, and the ability to properly administer medicine. Combined, these negative effects on eye health and overall health more generally have been compounded by the COVID-19 pandemic.

By taking action, in your ophthalmology practice, and through volunteering in your community, you can help make a global impact on addressing the healthcare disparities and the associated costs to society.

Daniel Laroche, MD, is clinical assistant professor of ophthalmology at Mount Sinai, and the president of Advanced Eyecare of New York. Melanie Scheiveis a student at the Indiana University School of Medicine, Indianapolis, IN.

References

1. World Health Organization. World report on vision. https://www.who.int/publications/i/item/9789241516570. Updated October 8, 2019. Accessed December 27, 2021.

2. Shiels MS, Haque AT, Haozous EA, et al. Racial and ethnic disparities in excess deaths during the COVID-19 pandemic, March to December 2020. Ann Intern Med. 2021;174(12):1693-1699. doi:10.7326/M21-2134

3. Zheng H, Jiang S, Wu Q. Factors influencing COVID-19 vaccination intention: The roles of vaccine knowledge, vaccine risk perception, and doctor-patient communication. Patient Educ Couns. 2021;S0738-3991(21)00632-7. doi:10.1016/j.pec.2021.09.023.

4. Walker R, Keanea CR, Burkea JG. Disparities and access to healthy food in the United States: A review of food deserts literature. Health & Place. 2010;16(5):876-884.

5. Blaner WS, Nau H, Agadir A. Retinoids: the Biochemical and Molecular Basis of Vitamin A and Retinoid Action. Berlin: Springer-Verlag; 1999. https://doi-org.ezproxy.med.cornell.edu/10.1007/978-3-642-58483-1. Accessed January 4, 2021.

6. Konstas AG, Quaranta L, Mikropoulos DG, et al. Peak intraocular pressure and glaucomatous progression in primary open-angle glaucoma. J Ocul Pharmacol Ther. 2012;28(1):26-32. doi:10.1089/jop.2011.0081.

7. Ahmed IK. 5 year follow up from the HORIZON trial. American Glaucoma Society Virtual Annual Meeting. 2021.

8. Lindstrom R, Sarkisian SR, Lewis R, Hovanesian J, Voskanyan L. Four-year outcomes of two second-generation trabecular micro-bypass stents in patients with open-angle glaucoma on one medication. Clin Ophthalmol. 2020;14:71-80. doi:10.2147/OPTH.S235293.

9. Laroche D, Nkrumah G, Ng C. Clear lensectomy and the hydrus stent lower IOP and medication use in Black and Afro-Latino patients with glaucoma. American Society of Cataract and Refractive Surgery. 2021.

10. Schein OD, Cassard SD, Tielsch JM, Gower EW. Cataract surgery among Medicare beneficiaries. Ophthalmic epidemiology. 2012;19(5):257-264. doi:10.3109/09286586.2012.698692

11. Lee YH, Chen AX, Varadaraj V, et al. Comparison of access to eye care appointments between patients with medicaid and those with private health care insurance. JAMA Ophthalmol. 2018;136(6):622-629. doi:10.1001/jamaophthalmol.2018.0813

12. Smith S, Thomas R, Cruz M, Griggs R, Moscato B, Ferrara A. Presence and characteristics of student-run free clinics in medical schools. JAMA. 2014;312(22):2407-2410. doi:10.1001/jama.2014.16066

13. Langenau E, Frank SB, Calardo SJ, Roberts MB. Survey of osteopathic medical students regarding physician shadowing experiences before and during medical school training. J Med Educ Curric Dev. Published online May 30, 2019. doi:10.1177/2382120519852046.

14. Pezzullo L, Streatfeild J, Simkiss P, Shickle D. The economic impact of sight loss and blindness in the UK adult population. BMC health services research. 2018;18(1):1-13. doi:10.1186/s12913-018-2836-0

15. Dayal A, Sodimalla KVK, Chelerkar V, et al. Prevalence of anxiety and depression in patients with primary glaucoma in western India. J Glaucoma. Published online January 1, 2022. doi:10.1097/ijg.0000000000001935

16. Lee CS, Gibbons LE, Lee AY, et al. Association between cataract extraction and development of dementia. JAMA Intern Med. Published online December 6, 2021. doi:10.1001/jamainternmed.2021.6990

Seven Steps to Combat Disparities in Eye Care