Looking at Vision-related Data: Research Gaps and Eye Care Guidelines

by Kay Miller Temple, MD

Back to: Eye Health Needs: Preserving the Eyesight of Rural and Underserved Populations

Public health experts said addressing rural issues starts with analyzing prevalence data. But, unlike other public health issues with data from multiple angles and multiple organizations, experts said that vision data are either outdated or nonexistent.

Convening in 2014 with its final report published in September 2016, a National Academies’ Health and Medicine Division (HMD) committee gathered to review the country’s eye health issues. Their report, Making Eye Health a Population Health Imperative: Vision for Tomorrow, said there were “no national, peer-reviewed estimates of how much vision impairment could be eliminated or improved through changes in various policies and practices.” The committee had to commission an analysis to get information about the most common eye problems. One finding was that “uncorrected refractive error and cataracts account for the vast majority of preventable and correctable vision impairment within the United States.”

The committee’s final report preface said, “This report estimates that undiagnosed or untreated refractive error alone affects between 8.2 and 15.9 million people in the United States. Uncorrectable vision impairment affects another 6.4 million people. The toll of correctable vision loss among children who do not [receive] adequate detection, follow-up, and treatment is troubling. Ensuring that people receive proper visual acuity screenings and preventive eye care services and adhere to effective eye protection practices would eliminate thousands of preventable or correctable cases of vision impairment that result each year from amblyopia and eye injuries. Success in simply applying current knowledge would reduce significant health care disparities, because avoidable vision loss disproportionately affects minorities and the poor. Failure of the United States to address these sources of preventable suffering and disparity is simply not acceptable.”

An additional concern raised by this committee was regarding age-related eye problems.

“Due to the aging of our population and the strongly age-related incidence of many eye diseases, we project a near doubling, by 2050, in the prevalence of ‘chronic vision impairment,’” the report noted.

The committee also recognized that “for many underserved and low-income communities, federally funded community and rural health centers may be the only source of eye and vision care services.” The June 2018 Community Health Center Chartbook noted that, in 2016, 330 of 1,367 health centers had onsite vision services. Of the total care team staff equivalents, 0.5% were dedicated to vision. The HMD report noted the 2009 National Rural Health Association and the American Public Health Association recommendations for strategies around improving vision care, including optometry being added to the National Public Health Service.

Summarizing their work, the HMD committee outlined 9 recommendations. Several impact rural and underserved populations. The first recommendation included a call to achieving “eye and vision equity by improving care in underserved populations.” Another included a call for population health research to reduce eye and vision health disparities. Also addressed was a need to “identify and eliminate barriers” to eye care within healthcare organizations and public health systems. A final suggestion was to develop community/public health partnerships to translate a vision health agenda into action.

The Centers for Disease Control and Prevention’s Vision and Eye Health Surveillance System

Since the HMD report, eye health experts and researchers have been working to increase vision health information and data availability. In an April 2018 Ophthalmology editorial, the University of Chicago’s NORC researchers introduced their cooperative agreement with the Centers for Disease Control and Prevention (CDC) to develop the Vision and Eye Health Surveillance System, “a comprehensive data and dissemination system intended to collect and centralize prevalence and use estimates from traditional and novel visual health data sources, and conduct analyses to summarize these different data sources into a set of national prevalence and service use estimates.” Strategic for rural populations, the NORC team said they are hoping to expand the system to produce county-level data.

VEHSS Goals

  • Provide national- and local-level prevalence data on vision loss and eye disorders.
  • Identify visual health and access to care disparities.
  • Monitor trends in prevalence, use, and practice patterns and evaluate the impact of interventions.
  • Information dissemination to the public, researchers, and federal, state, and local-level decision makers.

Source: CDC Vision and Eye Health Surveillance System

Collecting Rural Vision Data: A Link with Traumatic Brain Injuries (TBI)

As NORC researchers and their collaborators work on the VEHSS, other rural organizations see potential for rural vision-specific data collection in another CDC project, the Traumatic Brain Injury Disparities in Rural Areas project. Central to this CDC project is a 2-year data collection period to include information around the “challenges that rural healthcare providers face in diagnosing, treating, and managing TBI of all severities and develop a knowledge base upon which we can begin to address gaps in services to improve clinical care and TBI outcomes in rural communities.”

Researchers note that more than 50% of the brain’s surface is involved with visual processing, making brain injury another cause of vision impairment. Responding to the CDC’s public comment period, the American Optometric Association (AOA) emphasized the strategic link between brain injury and vision health. They provided the reminder that “even minor injuries to the brain can have significant impact on vision. In fact, 90 percent of people suffering from a traumatic brain injury (TBI), stroke, or concussion will have one or more visual effects.”

A plain-language discussion about how the eye works can be found at KidsHealth®.

Additionally, the organization’s letter highlighted the need to include optometrists in the project, stating, “As vision occurs in the brain, and the location of the visual cortex is at the rear of the brain, optic radiations traversing from the eyes cover a substantial portion of the brain; such that vision changes serve as the ‘canary in the coalmine.’ …To this end, it is critical that the CDC understand doctors of optometry role in TBI care, especially in rural areas.”

The National Rural Health Association also provided a comment, urging that optometrists be included in the project, as well as physical and occupational therapists.

Vision screening guidelines vary. The United States Preventive Task Force (USPTF) provides screening recommendations for several age groups, in addition to providing comments on research needs and data gaps. The American Optometric Association provides screening guidelines from birth to age 65 and older.

USPTF Screening Recommendations

All children aged 3 to 5 years

  • Screening at least once (type of screening test may vary)
  • Screening interval: unable to be determined
  • Research needs and data gaps:
    • Effects of no screening versus screening
    • Screening interval
    • Most favorable primary care screening tests
    • Benefits/harms of screening children less than 3 years
    • Long-term benefits/harms of preschool screening on health outcomes

Source: Vision Screening in Children Aged 6 Months to 5 Years: US Preventive Services Task Force Recommendation Statement, JAMA, 318(9), 836-844. Other professional groups’ screening recommendations are noted in this article.

Adults 65 years or older

  • Insufficient current evidence to assess screening benefits and harms
  • Research needs and data gaps:
    • Primary care setting screening methods for early identification of disorders that lead to vision loss
    • Evaluate whether screening benefits can be linked to improved function, independence, and quality of life
    • Evaluation of any association of corrective lenses with risk of falls, including prescription lens changes and use of multifocal glasses

Sources: Impaired Visual Acuity in Older Adults: Screening, USPTF; Screening for Impaired Visual Acuity in Older Adults: US Preventive Services Task Force Recommendation Statement, JAMA, 315(9), 908-914. Other professional groups’ screening recommendations are noted in this article.

American Optometric Association Eye and Vision Examination Recommendations

Birth to 24 months:

  • No symptoms/No risks: At 6 months
  • With risks: As recommended or at 6 months

2 to 5 years:

  • No symptoms/No risks: At 3 years
  • With risks: As recommended or at 3 years

6 to 18 years:

  • No symptoms/No risks: Before 1st grade, followed by exams every 2 years
  • With risks: As recommended or annually

18 to 60 years:

  • No symptoms/No risks: Every 2 years
  • With risks: As recommended or every 1 to 2 years

61 or older:

  • No symptoms/No risks: Annually
  • With risks: As recommended or annually