Women and Vision: Eye Care Disparities in the USA

1. Women and Vision: Eye Care Disparities in the USA Lynn K Gordon, MD, PhD Professor , Ophthalmology Associate Dean, Diversity Affairs David Geffen School of Medicine at UCLA

2. Disclosure • The presenter has no financial interest in the topics discussed

3. British Columbia Centre for Epidemiologic& International Ophthalmology (BCEIO), 2000 • Two-thirds of all blind individuals in the world are female • Most are older than 50 years • 90% of blind people live in poverty • Gender bias is not limited to the developing world

4. Healthy People 2010: The Numbers Speak • US Department of Health and Human Services • 2000: vision objectives were initially included • >80 million people have potentially blinding diseases • >4 million individuals in the United States • low vision • legally blind • severe visual limitations • Economic impact: • >50 billion dollars in 2002 for health care for individuals with visual disorders (both direct and indirect costs) • Estimate: by 2030 the number of visually impaired and legally blind individuals may double http://www.healthypeople.gov/document/html/volume2/28vision.htm

5. Visual Loss is Associated With……. • Decreased quality of life • Changes in independent living • Increased injury and falls • Increased depression • Increased isolation • Untreated poor vision is associated with cognitive decline and onset of dementia • Rogers, MA, Langa KM. Untreated poor vision: a contributing factor to late-life dementia. Am. J. Epidemiol. 2010 171:728

6. Visual Impairment and Falls • Falls in older adults • Occur in 35-40% of individuals • Responsible for 90% of fractures in the elderly • Clinical risk factors include vision impairment, gait abnormality and muscle weakness • Fractures associated with • Poor visual acuity in older women • Poor contrast sensitivity • Decreased depth perception • Binocular visual field loss Coleman AL, el al. J Am Geriatr Soc. 2009; 57:1825. Patino CM el al. Ophthalmology. 2010; 117:199.

7. Common Eye Diseases in the United States Associated with Vision Loss • Treatable or preventable eye disease: the big 4 • Age-related macular degeneration • Diabetic retinopathy • Glaucoma • Cataract • Less common, important causes for vision loss in women • Trauma • Immune-related eye disease • Idiopathic Intracranial Hypertension (IIH)

8. British Columbia Centre for Epidemiologic& International Ophthalmology (BCEIO), 2000 • What about gender? • Female gender bias held true for many diseases • Cataract • Glaucoma • Trachoma • Age-Related Macular Degeneration (ARMD) • Age-adjusted risk is about equal for men and women • Percentage of women in the at-risk population is larger than the percentage of men

9. Women and Macular Degeneration • ARMD: leading cause of legal blindness in the USA • 9 million people have some form of ARMD • 1.6 million have advanced disease • Age is the greatest risk factor • 55-64: one percent are affected • 65-74: four percent are affected • >75: thirty percent are affected • Women tend to live longer than men, F:M lifetime risk 2:1 • 6% for females • 3% for males Women’s Eye Health.org

10. Women with Diabetes • Younger women and those of reproductive age are less likely than older women to receive eye examinations • Women > 75 years were twice as likely to have been examined as compared to women < 50 years • Barriers for preventive care • Low socioeconomic position • Lack of insurance • Low levels of education Owens, et al. Women with diagnosed diabetes across the life stages: Underuse of recommended preventive care services. 2008. Journal of Women’s Health. 17: 1415

11. Women and Glaucoma • Prevalence of glaucoma is higher in women than in men • Risk for angle closure glaucoma is higher in females • No gender bias in the incidence of open angle glaucoma • Burden of blindness due to glaucoma is larger for women • Rate of visual impairment is higher in women • Women are 24% less likely to be treated for glaucoma Vajaranant, TS, et. al. Gender and glaucoma: what we know and what we need to know. Curr. Opin. Ophthalmol. 2010. 21:91.

12. Women and Glaucoma • Vision loss from glaucoma can be slowed or prevented with adequate therapy • About 50% of individuals with glaucoma are not diagnosed: • Must identify affected individuals and provide adequate therapy • Health disparities in glaucoma require additional study and intervention

13. Women and Cataract • Cataract prevalence increases with increasing age • Surgery for cataract accounts for 60% of Medicare expenses for vision • Nuclear sclerosis is the most common form of cataract • Gender association: more common in women • Other associations: diabetes, low education, myopia, smoking, BMI >35

14. Women and cataract • Significant cataracts in the Los Angeles Latino Eye Study • Females 20% more likely than males • Prevalence of cataract: • 2.6% in the age range 60-69 • 17% in individuals > 80 • 1/3 of patients with cataract had an unmet need for surgery • Risk factors for unmet need • Lack of health insurance • Income <$20,000 per year • Self-reported barriers to care • Last eye exam > 5 years ago Richter, CM et al. Ophthalmology. 2009; 116:2327.

15. Women and Eye Trauma • Massachusetts Eye and Ear Hospital experience • 20% of open globe injuries are in patients > 65 years old • Average age in this group = 79.8 years • 65% of these are caused by falls • 76% of these occur at home, mid-day and night-time peaks • Women as a percentage of the total • 58% of the geriatric patients • 14% of the non-geriatric patients • Opportunities for counseling and home preventive care Andreoli, MT, and Andreoli, CM. Geriatric Traumatic Open Globe Injuries. Ophthalmology. 2010. in press

16. Women and Eye Disease • Inflammatory eye disease • Many autoimmune diseases are gender-associated • One million Sjögren’s patients in the USA, 90% are women • Idiopathic intracranial hypertension • Occurs primarily in women • Significant risk for visual loss

17. Women and Eye Disease: USA • Gender issues and eye disease: increased eye disease in American women • Increased incidence • Angle closure glaucoma, cataract, IIH, autoimmunity • Increased prevalence • Aging population: glaucoma, ARMD • Barriers to care • Access • Education • Cultural sensitivity

18. Opportunities for the Future • Increase research to understand disease pathophysiology • Enhance importance of prevention education • Improve access to care • Ensure treatment equality • Eliminate barriers and reduce co-morbidities!

19. Together we can effect change • Thank you for your attention