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The Future of Glaucoma
A clear vision for a better tomorrow: The Future of Glaucoma can be brighter
Ensuring access to glaucoma care is truly equitable
Poor people and members of ethnic minorities often receive worse glaucoma care. Fixing these inequities requires a tailored approach, finds Michael Marshall.
This article was commissioned and funded by Santen.
Edited by Mohammed Abu-Bakra & Catherine Park
“Middle-class middle-aged women are the ones who care about their health,” says Imran Masood at the Birmingham and Midland Eye Centre.
In contrast, poorer people and members of ethnic minorities tend to receive less care and are more likely to suffer severe vision loss.1 “We really need to get out to those harder-to-reach populations,” says Nishani Amerasinghe at University Hospital Southampton. “That’s a massive need in the glaucoma population.”
There is even a danger that these inequities will be repeated and entrenched by new technologies such as artificial intelligence (AI).2 Often, AI models are only trained on certain groups of people.2 “A lot of the best algorithms work best largely in people of European origin,” says Anthony Khawaja at Moorfields Eye Hospital in London.3
If we are to improve glaucoma outcomes, it is vital to improve access to glaucoma care for under-represented groups.1 The glaucoma care community has committed to doing so: in 2024, optometrists and ophthalmologists updated their joint care vision, which now calls for “the provision of timely eye care in an equitable, appropriate and accessible way.”4,5
The challenge is how to improve access, when the inequities affect so many disparate groups, from the poor and ethnic minorities to elderly people and those living in rural areas.6
This is a complex problem. But the good news is that it is fairly well-defined, because our understanding of health equity issues in glaucoma care has improved considerably.6
A review published in 2024 identified a host of disparities.6 For example, Black people tend to have fewer eye exams and fewer follow-up visits, while people with lower socioeconomic status, and especially lower income, tend to have more advanced disease at presentation.6 However, the study also found that the increased use of electronic health records has enabled better understanding of these inequities.6 The authors conclude that such datasets “highlight potential targets for interventions to combat these disparities and improve overall patient outcomes.”6
In short, we know what the problems are: the issue is how to fix them.
Ethnicity
People of colour and other ethnic groups often have less access to glaucoma care, compared to white British people.6 In particular, people of colour are often diagnosed late and have more advanced vision loss than whites.7
Multiple factors are at play.
There are persistent inequalities between migrants and non-migrants in healthcare access,8 meaning that in many cases glaucoma has been left untreated. “I regularly see young Black patients who need urgent surgery,” says Masood. But even people who have lived in the UK all their lives also have reduced access to care. This is partly a result of ‘social deprivation’, which is common among immigrant communities, says Masood.9
Many of these communities also have low levels of trust in the medical system.10 Masood describes patients from ethnic minorities origins, who remember older relatives losing their vision as a result of bad surgery. “They are less likely to want to engage with health care and actually frightened about having any operations,” he says.
Mohammed Abu-Bakra from King’s College Hospital NHS Foundation Trust says, “it is important to continue to reassure patients from ethnic minorities that they are treated the same as every other patient and not treated differently based on their conception of previous generational experience. This continuing dialogue of reassurance during care is important to instil and build trust, increase inclusion and work in partnership with our patients from ethnic minorities.”
Overcoming these barriers to care requires specialist outreach.11 For instance, some members of non-white ethnic groups speak limited English. Healthcare workers need to give these people information in their native languages.11 At present, the provision for this is spotty.12 Translation services do exist but are often substandard – and letters to patients are still typically sent in English only.13,14
It is also helpful to employ a diverse medical staff who can connect with specific groups, whether by speaking their language or exhibiting better cultural understanding. There is some evidence that diversity levels have improved.15 According to a 2022 study, the percentage of consultant ophthalmologists identifying as from ethnic minorities rose from 42% in 2013 to 52% in 2021, with 44.5% of optometrists identifying as from ethnic minorities in 2021.15,16
This growing pool of cultural knowledge needs to be harnessed to improve outreach to under-represented ethnic groups.
Poverty
Low socioeconomic status is a major barrier to accessing glaucoma care.17
“You can call it class, if you will, but it’s often about poverty,” says Gus Gazzard at Moorfields Eye Hospital in London. “Much inequality is about poverty.”
A 2023 study found that people with low socioeconomic status were over-represented among those who presented with advanced glaucoma – indicating poorer people were presenting later.18 People from deprived areas also tend to seek care later.19
However, another 2023 report found no association between poverty and accelerated visual field loss among people in the glaucoma care system.20 This suggests the inequities associated with poverty largely disappear once people are in the healthcare system. “Once you’re in the health service,” says Gazzard, “people seem to behave roughly similarly.”20
“The bigger problem is getting access in the first place,” concludes Gazzard.
Again, multiple factors contribute to this lack of access. A 2010 study found that deprived areas had fewer optometrists.21 Even where optometrists are available, international surveys indicate that affordability is an issue.21 While glaucoma checks are free, some people assume optometrists will try to sell them expensive glasses, and thus avoid going.22 “I think there’s still a perception that, if you go to an optometrist, there’s going to be some charge involved,” says Andrew Tatham at Princess Alexandra Eye Pavilion, Edinburgh.
There are also practical realities of life in poverty to consider. People who must work multiple jobs just to get by will struggle to find time for eye health appointments. “Sometimes it’s just people with busy lives, looking me in the eye and saying: ‘How can I possibly visit you six times in the next year for post-op appointments? I will lose my job, and I’m supporting four kids on my own’,” says Gazzard.
Similarly, Khawaja describes “We also essentially have a two-tier health system where some people can afford private healthcare and they may end up receiving better medical care than those who have to rely on the NHS. While the NHS delivers excellent care for most people, there are regions with huge backlogs and delays to assessment and treatment can result in worse outcomes.”
To overcome these barriers, clinics need to be run in a way that makes it easier for people living in poverty to attend. “You can see somebody even if they’re two hours late,” says Gazzard. “You can give them an appointment at five o’clock instead of one o’clock, which means that they can come after their shift.” Virtual clinics can also help because they eliminate the cost and time lost to travel.23 However, they are not always suitable – notably for populations with low digital literacy, where off-site satellite clinics could be an effective solution.23
The overall aim is to increase the flexibility of glaucoma clinics, reducing the barriers to attendance, and expand shared care with primary care optometrists for patients at lower risk.
Rural populations
Similar barriers to accessing glaucoma care affect people in rural communities. Eye healthcare coverage is often patchy, so people have to travel long distances to appointments.24 This is compounded by the significant rates of poverty among the rural population.25
“A lot of those people are certainly not well-off,” says Michael Smith at Exeter Eye. They may need to “sit on the bus for an hour and a half” to get to an appointment. “It’s difficult,” he says.
Virtual clinics may offer a solution. Alternatively, glaucoma services may go mobile in order to visit remote communities.
Elderly
The third and final under-represented group is the elderly. “Glaucoma becomes more common with older age,” says Khawaja, so the elderly are at the highest risk from the condition.26 But they struggle to access glaucoma care.27,28
Smith highlights “the increasing number of people who just can’t come into hospital at all, because they don’t leave the house.”29 Even those living in care homes, who are more closely monitored, often don’t get glaucoma care.30 “There are lots of patients in care homes who don’t get seen because they are frail, or the assumption is they’re frail, or they’ve got many other things going on,” says Smith. Staff may assume that “their eyes are the least of their worries,” but this lack of glaucoma care may lead to “hundreds and thousands of people sat in care homes going blind.”
For elderly people who really cannot travel, the solution is to offer visual testing where they live – whether that’s a private residence or a care home. The challenge is that such mobile services are time-consuming and expensive.31 However, care home staff can play a key role: for instance, they can be trained to help patients put in drops, says Sancy Low at St. Thomas’ Hospital in London.
Tailored solutions
These examples show that there is no one-size-fits-all solution for dealing with inequities in access to glaucoma care. The challenges vary from region to region, depending on the mix of groups living there and the socioeconomic conditions. A region with many elderly people may need clinicians who can visit people in care homes, while a region with a large immigrant population may require healthcare workers who can speak languages other than English. Furthermore, the sources of inequality intersect: notably, people of colour are more likely to be living in poverty.32
Instead of a top-down programme, improving access to glaucoma care can only be achieved by local and regional programmes tailored to communities’ needs. In each city or region, ophthalmologists, optometrists and their colleagues need to work together to design systems that suit their populations. These programmes need to be flexibly designed, so that they can change course as the demographics of the region shift.
Only by responding to the changing needs of their communities can glaucoma care specialists reduce the barriers to access.
What matters to patients
Our patient research revealed some key themes that contribute to unequitable access to eye health care, particularly in accessing eye services at the right time. For those in lower socio-economic groups, behaviour can be strongly driven by cost and the perceived cost of going to the optometrist for an eye health check or the pressure to buy glasses.21
This combined with the fact that some communities may not readily talk about health issues or may mistrust the health system or doctors can contribute to late presentation, which in an irreversible eye condition like glaucoma adds to the challenges.21
A lack of patient education and accessible information – language being one of the main barriers – was highlighted in the research. Also, that signposting to services is not always specific to them or their needs (appropriate medical professionals, understanding why they are on a specific pathway).21
Many attitudes are entrenched and patients from ethnic minorities or lower socio-economic groups are less likely to self-advocate when testing or monitoring is stretched out. This can add to a more likelihood to be lost to the system or presenting late.21
Mohammed Abu-Bakra is a Consultant Ophthalmologist and a Glaucoma Surgeon at King’s College Hospital NHS Foundation Trust.
Catherine Park is a Specialist Optometrist at University of Manchester University NHS Foundation Trust.
References
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Read The Articles Here
Article 1: Introduction
A clear look at a better future for glaucoma care. Glaucoma is one of the most common causes of vision loss and blindness. More than 3% of people over 40 have glaucoma, and perhaps 10% of over-75s.
Article 2: Setting the Scene
A shared vision of the future of glaucoma care. Glaucoma patients and healthcare professionals have different perspectives on glaucoma care, but they share many of the same priorities.
Article 3: Artificial Intellegence
AI could help the highest-risk patients get glaucoma care . While artificial intelligence has many possible uses in glaucoma, its greatest potential is in identifying those at greatest risk.
Article 4: Sustainable Service Delivery
Ensuring the right patient is seen by the right person at the right time. How can the healthcare system ensure that every glaucoma patient is seen, while also maintaining empathic health professional - patient relationships.
Article 5: Innovative Treatments
The new cornucopia of treatments for glaucoma. From new types of pharmaceuticals to novel surgical approaches, there are now many more treatments available for glaucoma.
Article 6: Health Equality
Ensuring access to glaucoma care is truly equitable. Poor people and members of ethnic minorities often receive worse glaucoma care. Fixing these inequities requires a tailored approach.
Article 7: Patient Education and Engagement
People with glaucoma need clarity about their condition. Patients with glaucoma who are educated about their diagnosis are more likely to actively engage in their care and often have better outcomes.
Article 8: Conclusions and Recommendations
What if we got it right? The Future of Glaucoma Care in the UK. Shaping the future of glaucoma care at every level will not only improve patients’ lives but deliver lasting benefits for society.
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