The study found that lower income was most strongly correlated with higher likelihood of uncorrected refractive error in the African-American population, prompting the authors to argue for universal vision care coverage in the US. Photo: Jessica Felicio on Unsplash.

Simple refractive errors remain a significant cause of visual disability, not just in developing countries but here at home, too. Remedying this issue would reduce visual impairment and its associated morbidity, and also improve quality of life and productivity. To quantify the burden of uncorrected refractive error and its related visual impairment in African-American adults, researchers based out of the Southern California Eye Institute assessed the prevalence of any uncorrected refractive error and unmet refractive need in participants of the African American Eye Study, a population-based study of eye disease in African-American adults 40 years and older residing in Los Angeles. The team found a high burden of correctable refractive error in African-American adults, making it the leading cause of visual impairment in this population.¹

The analysis, which was published in JAMA Ophthalmology, included 6,337 participants (mean age, 61; 63% female) with complete refractive error data. Uncorrected refractive error was measured in all those with any level of presenting visual acuity (VA; including those with VA of 20/40 or better), whereas unmet refractive need was measured in those whose presenting VA is worse than 20/40 (i.e., visually impaired).

Refractive error–related correctable visual impairment was present in over two-thirds of participants with visual impairment (68.7%). The overall prevalence of any uncorrected refractive error was 14.6%, and the overall prevalence of any unmet refractive need was 5.4%

Compared with those 40 to 49 years old, the prevalence of any uncorrected refractive error was higher for those 50 to 69 (odds ratio: 1.31), 60 to 69 years (OR: 1.60), 70 to 79 years (OR: 1.49) and 80 years and older (OR: 1.61). Higher prevalence was also associated with those participants in the lowest category of annual household income (<$20,000, OR: 1.94), those who were current smokers (OR: 1.54), those who reported no history of having had an eye examination within the past 12 months (OR: 1.41) and those who reported that they did not have vision care insurance (OR: 1.31)

Risk indicators associated with a higher prevalence of unmet refractive need were those with low/intermediate category of annual household income, including income less than $20,000, income between $20,000 and $40,000 and those who did not have vision care insurance. Interestingly, prevalence was lower in participants who were overweight or obese.

“One explanation for this reduced burden is that, since this group likely had additional comorbidities such as diabetes, high blood pressure and joint disease, they would be more likely to access the health care system and obtain vision care and vision correction in addition to general medical care,” the researchers wrote in their paper.

“Given the relatively inexpensive and easy intervention of refraction and provision of refractive correction, it may be possible to reduce this leading cause of visual impairment in this vulnerable segment of the US population, assuming these individuals subsequently used the refractive correction habitually,” they concluded.¹

A commentary also published in JAMA Ophthalmology highlighted that, no matter which unmet refractive need outcome was evaluated, by far the cohort that most strongly associated with unmet refractive need was the cohort of participants who made less than $20,000 per year. Also, across all outcomes assessed, more than roughly 90% of patients with an unmet refractive need already had health insurance.

“Recognizing this percentage may not be representative of all vulnerable populations across the US, lobbying for a policy that would mandate vision care insurance within standard health insurance would seem to offer an easy policy path for addressing this issue,” the commentary author wrote.

He noted that specific social determinants of health such as lower education, food insecurity, health care coverage through Medicaid, difficulty paying medical bills and cost-related skipping doses of medications have each been associated with self-reported visual impairment.

“Simply granting everyone vision insurance is not going to remove all barriers to obtaining needed vision correction,” the author wrote. “Until these issues can be further explored and better elucidated, uncorrected refractive error is likely to remain a substantial cause of visual impairment.”²