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

Disclosure The presenter has no financial interest in the topics discussed

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

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

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

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.

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)

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

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 Women’s Eye Health.org

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

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.

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

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

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.

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

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 Women’s Eye Health

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

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!

Together we can effect change Thank you for your attention

Women with Diabetes 2007 data: 24 million affected in the USA, half women Total cost $174 billion, 2/3 to direct medical expenses Cost of disease increases with increasing age Centers for Disease Control and Prevention (CDC) and the Agency of Healthcare Research and Quality AHRQ developed a report: Women and Diabetes: Quality of Health Care Report prepared in 2004-5 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

Women with Diabetes Women with diagnosed diabetes as compared to women without diabetes More likely to be older and non-white More likely to be socioeconomically disadvantaged 40% poor or near-poor Less likely to have completed high school 28-37% Accumulation of disadvantage 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

Women with Diabetes Data obtained for women > 18 years of age from three national surveys Self-reported dilated eye exam 67% of all women with diabetes 47.4% of women <45 years of age Hemoglobin A1C Blood test provides evidence for degree of metabolic control Good control: 50.9% of all women, 37.4% <45 years of age Poor control: 14.0% of all women, 19.3% <45 years of age 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