Race, Gender, and Ethnicity Differences in Ocular Disease

Ocular diseases such as diabetic retinopathy (DR), age-related macular degeneration (AMD), and glaucoma affect people of different races, genders, and ethnicities in various ways. Some population groups are more likely to develop certain ocular diseases for physiological reasons. However, access to care and other disparities can also affect the quality of healthcare many people receive, which, in turn, can affect disease prevalence and outcomes.¹ Here are several examples of how certain ocular diseases, including retina-related ones, affect people of different races, genders, and ethnicities:

Those who are Black or Latinx are more likely to develop open-angle glaucoma (OAG) than those who are White.²
The rate of OAG is double among Blacks compared to Whites in the United States (US).²
In a study focusing on anti-vascular endothelial growth factor therapy for diabetic macular edema, White and non-Hispanic patients presented with a higher baseline visual acuity than Blacks and Hispanics. Having Medicare or private insurance also contributed to a higher visual acuity.³
Non-Hispanic Whites have a higher prevalence of AMD compared with non-Hispanic Blacks.⁴
In an analysis of annual eye exams recommended for Medicare beneficiaries with diabetes, researchers found that 55.6% of non-Hispanic Whites completed their annual exam compared with only 48.9% among Blacks and 48.2% among Hispanics.⁵
Women are at an overall greater risk for vision loss compared with men.⁶
When comparing men and women with central retinal vein occlusion (CRVO), visual outcomes and treatment burden were similar; however, gender differences were present in perfusion status, subfoveal choroidal thickness, central subfield thickness, and prevalence of foveal avascular zone enlargement.⁷
Transgender patients may face unique challenges such as increased vulnerability to certain eye diseases, including central serous retinopathy and ophthalmic conditions mediated by inflammation, due to the use of sex hormones.^8,9 Additionally, HIV infection among transgender women is 49 times higher than that of other groups, yet transgender women are underserved in HIV care due to stigmatization and fear of potential treatment interactions with hormone therapy.⁹

Other Factors That Can Contribute to Eye Disease

As mentioned previously, other factors beyond physiological reasons can contribute to the prevalence of eye disease in certain population groups. Many of these factors fall under the umbrella of social determinants of health, defined by the US Department of Health and Human Services as “conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”¹⁰

Social determinants of health are grouped under five categories: Economic Stability, Education Access and Quality, Healthcare Access and Quality, Neighborhood and Built Environment, and Social and Community Context. Within eyecare, several prominent social determinants of health can contribute to the prevalence of eye disease including:

Finding Solutions to Improve Ocular Disease Prevention and Outcomes

Recognizing a greater need to assist population groups that are more vulnerable to certain ocular diseases, the field of ophthalmology as a whole is making efforts toward improvement. Below is a sampling of some of the changes underway on the organizational, practice, and individual levels:

Differences in ocular disease prevalence and outcomes vary widely and encompass a large number of factors. Efforts to make improvements can and should eliminate barriers, ideally improving care for all patients.

References

Office of Disease Prevention and Health Promotion, US Department of Health and Human Services. Access to health services. https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Access-to-Health-Services
Ou Y. Racial disparities in glaucoma. BrightFocus Foundation. https://www.brightfocus.org/ glaucoma/article/health-disparities-glaucoma
Malhotra NA, Greenlee TE, Iyer AI, et al. Racial, ethnic, and insurance-based disparities upon initiation of anti-vascular endothelial growth factor therapy for diabetic macular edema in the US. Ophthalmology. 2021;128:1438-1447. https://www.sciencedirect.com/science/article/abs/pii/ S0161642021001962
Zhang X, Cotch MF, Ryskulova A, et al. Vision health disparities in the United States by race/ethnicity, education, and economic status: findings from two nationally representative surveys. Am J Ophthalmol. 2012;154:S53-S62.e1. https://pubmed.ncbi.nlm.nih.gov/23158224/
Lundeen EA, Wittenborn J, Benoit SR, Saaddine J. Disparities in receipt of eye exams among Medicare Part B fee-for-service beneficiaries with diabetes — United States, 2017. MMWR. 2019;68:1020-1023. https://www.cdc.gov/mmwr/volumes/68/wr/mm6845a3.htm
Zambelli-Weiner A, Crews JE, Friedman DS. Disparities in adult vision health in the United States. Am J Ophthalmol. 2012;154:S23-S30.e1. https://www.sciencedirect.com/science/article/abs/pii/ S0002939412002097
Mirzania D, Thomas AS, Stinnett SS, Fekrat S. Gender differences in presentation, treatment patterns, and clinical outcomes in central retinal vein occlusion. Invest Ophthalmol Vis Sci. 2019;60:3943. https://iovs.arvojournals.org/article.aspx?articleid=2743641
Nuzzi R, Scalabrin S, Becco A, Panzica G. Gonadal hormones and retinal disorders: a review. Front Endocrinol (Lausanne). 2018;9(66):1-15. doi: 3389/fendo.2018.00066
Hollar MW, Zhang MM, Mawn LA. Ophthalmic disparities in transgender patients. Semin Ophthalmol. 2016;31:426-431. https://pubmed.ncbi.nlm.nih.gov/27128494/
US Department of Health and Human Services. Social determinants of health. https://health.gov/healthypeople/objectives-and-data/social-determinants-health
Capó H. The importance of health literacy in addressing eye health and eye care disparities. Presented at the American Academy of Ophthalmology 2021 annual meeting, New Orleans, Louisiana.
Soares R, Parikh D, Shields CN, et al. Geographic access disparities to clinical trials in diabetic eye disease in the United States. Ophthalmology Retina. 2021;5:879-887. https://www.sciencedirect.com/science/article/abs/pii/S2468653020304875
Cai CX, Li Y, Zeger SL, McCarthy ML. Social determinants of health impacting adherence to diabetic retinopathy examinations. BMJ Open Diabetes Research & Care. 2021;9:e002374. https://drc.bmj.com/content/9/1/e002374
Lu Y, Serpas L, Genter P, Mehranbod C, Campa D, Ipp E. Disparities in diabetic retinopathy screening rates within minority populations: differences in reported screening rates among African American and Hispanic patients. Diabetes Care2016;39:e31-e32. https://diabetesjournals.org/care/article/39/3/e31/37157/Disparities-in-Diabetic-Retinopathy-Screening
American Academy of Ophthalmology. Diversity, equity, and inclusion. https://www.aao.org/diversity-equity-and-inclusion
Smith GL, Dixon WA, Phillips M. Expanding health care access and equity through telehealth. October 22, 2021.https://www.kevinmd.com/blog/2021/10/expanding-health-care-access-and-equity-through-telehealth.html
Younossi A, Sanhai W, Shah S, Chang C. Enhancing clinical trial diversity. November 2021. https://www2.deloitte.com/us/en/insights/industry/life-sciences/lack-of-diversity-clinical-trials.html
Shoge RY. Improving access to eye care. Presented at the American Academy of Ophthalmology 2021 annual meeting, New Orleans, Louisiana.