Pediatric Ophthalmologists Need Apply: Why The Subspeciality is Facing a Shortage

Pediatric ophthalmologists are specially trained, not just to work with often uncooperative pediatric patients, but to offer specialized knowledge and skills that cater to the problems of developing young eyes. Its existence offers both unique care for children and relief to general ophthalmologists focused on routine adult care and surgery. So, why are America’s pediatric ophthalmologists disappearing? 

According to a JAMA Ophthalmology study, nearly 1 in 3 of the 1056 identified pediatric ophthalmologists in March 2022 were located in just 4 US states: California, New York, Florida, and Texas. Ninety percent of US counties appear to have no pediatric ophthalmologist at all, and 45% of the remaining counties had only 1 such subspecialist. 

Entire states — New Mexico, North Dakota, South Dakota, Vermont — are without even a single pediatric ophthalmologist.¹ However, nearly 7% of children across the US have a significant eye disease diagnosis that requires intervention (and, presumably, even more go undiagnosed).² 

With stagnant reimbursements and antiquated technology, the subspecialty’s dwindling workforce may not be a surprise. But are those reasons really enough to explain why 90% of US counties have no pediatric ophthalmologists? 

Those in the field maintain that, while incentives and industry investments are needed to keep it afloat, the opportunity to thrive persists, and educational outreach just might turn some of these declining numbers around.

Regional Disparities 

Where there is higher socioeconomic status, there is better access to pediatric ophthalmologists, according to research. And that relationship may go both ways.

The JAMA Ophthalmology cross-sectional study relied on databases of the American Academy of Ophthalmology and the American Association for Pediatric Ophthalmology and Strabismus. It found a rate of 12.7 pediatric ophthalmologists for each 1 million American younger than 19 years of age. However, this breakdown shifts significantly when you only consider the parts of the United States that already have a pediatric ophthalmologist. Those regions have an available 32.2 subspecialists per million persons younger than 19 years of age.¹ Pediatric ophthalmologists appear to be clustering in coastal metropolitan countries, while large swarths of Central and Northern US states go unserved altogether.¹ 

The study also shows that counties with access to pediatric ophthalmology have higher rates of health insurance, more internet and vehicle access, and advanced education, as well as greater median family income and mean household spending on vision care.¹ In other words, pediatric ophthalmology is less available to areas with greater socioeconomic inequities. In fact, the dearth of pediatric ophthalmologists may be more than a symptom of socioeconomic disparity, it may be a contributing factor.   

“Vision and eye health represent an important health barrier to learning in children,” explains Julius Oatts, MD, an assistant professor and associate residency program director at the Department of Ophthalmology, University of California, San Francisco, who responded to the study in a JAMA Ophthalmology published commentary. “Lack of access to pediatric vision screening and care also contributes to the academic achievement gap and educational disparities. Attention to this matter is urgent and requires direct and innovative approaches to fill an unmet need that ultimately perpetuates an inequitable system.”³

Some evidence suggests this potential link to education perpetuates generationally, as Americans who earn a bachelor’s degree tend to live in areas with close access to more pediatric ophthalmologists than Americans without a college degree.¹

In addition to socioeconomic status, the counties lacking access to a pediatric ophthalmologist share another common factor; they have, on average, more children. The result is an underserved population. 

“However, while the authors suggest a notion of incentivizing the redistribution of the existing pool of pediatric ophthalmologists to more underserved areas, the more significant problem appears to be the astonishing scarcity of total pediatric ophthalmologists,” Dr Oatts’ commentary adds. “There are greater than 3000 counties in the United States, so even if each of the existing 1056 pediatric ophthalmologists are assigned to a separate county, two-thirds of them would remain unfilled.”³

In another study, researchers analyzed data from the National Survey of Children’s Health. They found that the proportion of children who underwent eye screening from a specialist dropped from 55.6% in 2016 to 50.4% in 2020.⁴ A nonsignificant decrease in reported unmet access for vision care became an 85.7% relative increase after the pandemic began in early 2020.⁴

The medical community must seek to recruit more eye care professionals and increase availability of other options for eye and vision care for pediatric patients, the commentary writers explain.³

However, that is easier said than done, a recent survey indicates.

Perceptions and Reimbursements

Approximately 38% of US-based pediatric ophthalmologists would not recommend a resident pursue a pediatric ophthalmology fellowship, according to a 2022 survey that was distributed in social media forums and an association discussion board.

Karen Lee, MD, MS, a Bradway Research Fellow in pediatric ophthalmology at the Wills Eye Hospital, worked on that survey, which polled 243 doctors. She said the shortage in pediatric ophthalmologists is affecting access to pediatric care and largely stems from a Medicaid dilemma.

Due to Medicaid reimbursement cuts, approximately 1 in 10 ophthalmologists stopped operating, and nearly 30% of the doctors limited how many patients they took who had Medicaid or publicly funded insurance.⁵

“Because Medicaid reimbursements are so low, many providers are choosing not to accept those patients anymore,” Dr Lee explained. “But if they don’t accept them, patients may have to travel to academic eye centers or children’s hospitals, where Medicaid is accepted.”

Academic centers and children’s hospitals typically are often either far away from where patients live, or are inundated with a high volume of patients, causing longer wait times for patients who need to make an appointment or undergo surgery. Those wait times can drag on for, sometimes, 6 months.^3,5

In Dr Lee’s survey, 107 doctors said their surgical revenue decreased by between 10% and 25% between January 2021 and July 2022, 117 said their clinical revenue decreased less than 10%, and 127 said overhead costs increased by between 10% and 25%.⁴ Close to 1 in 3 respondents said they had side jobs to increase their income.⁵

The economic challenges were particularly grave among doctors in private practice. They were more likely to have greater decreases in income and increases in overhead costs, and they more frequently said they took side work, stopped operating, or limited Medicaid patients.⁵

According to Paul Phillips, MD, professor and chairman of the Department of ophthalmology and director of the Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, while Medicaid reimbursements are lower in pediatric ophthalmology, that is not the only concern of doctors who steer away from the field. While many areas of ophthalmology involve quick examinations, with ample technological advances and gratifying results, pediatric ophthalmology tends to require more challenging exams and surgeries on uncooperative children. For example, doctors addressing vertical strabismus have to decide whether 1 of the eyes is too high, or if the other is too low, and which eye muscle should undergo operation. Assessing those factors in a 5-year-old patient would prove still more challenging. The painstaking analysis involved in treating strabismus attracted him to the specialty, but challenging exams in pediatric patients might deter other physicians, he acknowledged.

If the shortage continues, pediatric ophthalmologists will likely have to specialize more in taking care of the patients who need tertiary care, leaving general ophthalmologists to do more of the primary care. 

Limited technological advancements are also a challenge noted by Dr Lee, who added that the issue may contribute to a sense that pediatric ophthalmology is not as prestigious as other specialties. But technology, applied appropriately, could also help overcome some of the regional disparities, according to Dr Phillips, as telemedicine and screening could eventually play a role in the future of pediatric care.

Pediatric Patients in General Ophthalmology

While it can be a challenge for general ophthalmologists to simultaneously provide a welcoming atmosphere for young pediatric patients and serve adults, they may have to get more comfortable doing so, Dr Phillips suggested. Pediatric ophthalmologists might be able to provide some guidance and foster partnerships.

In Dr Oatts’s experience, surgical conversion rates are lower for pediatric patients compared with adults, he said. Pediatric patients tend to be less cooperative and take longer to examine compared with adults. They’re less likely to need surgery. While a high-volume cataract practice might see a 50% to 70% conversion rate to surgery of patients presenting for cataracts, pediatric ophthalmologists may simply be seeing patients who failed their pediatrician’s vision screening exam. Even many types of strabismus do not require surgery.

Orthoptists, who are experts in sensory motor examination, may also be able to help stem the tide, by increasing the number of patients an ophthalmologist is able to see in a day, explained Dr Oatts.

It is also possible telemedicine screening will play a bigger role, in the future.

Solutions for the Shortage

Exposure is key to encouraging doctors to pursue pediatric ophthalmology, according to Dr Oatts. Currently, it is not a given that an ophthalmology residency includes a pediatric ophthalmologist, and residents who don’t have exposure to pediatric ophthalmology might not realize they like it.

It may be helpful to propose that pediatric residents consider ophthalmology in addition to encouraging ophthalmologists to consider pediatrics, Dr Oatts said. However, a pediatrics residency is not surgical, so the resident would not have the same type of surgical training that other ophthalmology residents would.

There is also a push for switching to time-based billing coding to bolster pediatric ophthalmologists’ income, according to Dr Oatts.

In his commentary piece, Dr Oatts and others said mentorship programs that can draw trainees from underserved communities and provide economic incentives for doctors who are willing to remain in their underserved area could prove useful too.³ 

In pediatric ophthalmology, neither supply nor incentives to increase the supply of subspecialists appear to be keeping pace with demand. But those in the practice have a noble view of their field. As Dr Oatts puts it, pediatric ophthalmologists have the opportunity to treat a child with a potentially blinding illness, and that care can lead to a lifetime of preserved vision. A confluence of updated educational approaches, growing technologies, and incentivization programs may be what’s needed to preserve this subspecialty.