Street Medicine Ophthalmology Needs Assessment:
Lauren DeLamielleure, Lisa Gonzalez, Lauren Hucko, Taha Rasul
Despite new developments and technologies to enhance eye health, the vicious cycle that exists between poverty and sight loss remains. Poor eye health and vision issues are multifactorial in nature, with sight affecting every aspect of health and quality of life. According to the Centers for Disease Control and Prevention (CDC), 80 million Americans are estimated to be living with potentially blinding diseases, many of which can be avoided with early detection and treatment . Despite this, most health insurance plans do not provide coverage for necessary annual eye exams or eyewear for adults.
People experiencing homelessness (PEH) suffer from a lack of access to care and have a disproportionate disease burden compared to the general population,,. As a result, they are at high risk of ocular pathology and untreated visual impairment, yet there is limited data regarding the prevalence and burden of eye-related issues among this at-risk population ,.
In this assessment we aim to do the following:
Utilize a street medicine model to determine the extent of eye and vision needs among PEH in the Miami-Dade community.
Highlight the trends and risk factors that impact ocular health, specifically comorbidities including hypertension and diabetes.
Demonstrate how street medicine models can be implemented as a solution for reducing preventable sight loss and narrowing eye health inequities among this vulnerable population.
For street medicine clinicians, it is crucial to understand how the social determinants of health can worsen existing eye disease and contribute to the onset of new conditions in PEH. The most notable risks to our patient population are multifactorial and are highlighted in the following section.
Ultraviolet (UV) exposure:
Miami’s tropical climate introduces a high volume of cumulative sun exposure, coupled with a high UV index. With a lack of access to proper shelter and eye protection, PEH in Miami are chronically exposed to the sun. The degeneration of eye structures and the development of fleshy tissues on the eye (pterygium) is a very noticeable consequence of UV radiation exposure that demonstrates a dose-response relationship, with increased risk of pterygium development associated with greater UV radiation exposure . Additionally, cataracts, macular degeneration, pediatric retinal damage, impaired vision and blindness, and photokeratitis are byproducts of chronic UV exposure and can be debilitating to the physical and mental health of patients who lack the means for adequate treatment ,.
Ethnicity: Minority groups such as African American and Hispanic Americans are more likely to develop glaucoma, hypertensive retinopathy, and diabetic retinopathy in comparison to their Caucasian counterparts, which is associated with the increased incidence of hypertension and diabetes in such populations , ,. According to the figure below, 78.1% of our patients are of African American (46.2%) and/or Hispanic (31.9%) descent. Unfortunately, homelessness in Miami-Dade County disproportionately affects communities of color, which can worsen their already precipitous ocular health, resulting in detrimental visual outcomes.
Age: Mean age: 51.2, 308 Patients
Diabetes, Blood Pressure, and Hypertension: For PEH, chronic illnesses such as hypertension and diabetes are often inadequately managed or remain undiagnosed for long periods of time ,. High blood glucose and blood pressure can lead to retinopathy, permanent vision damage, and blindness ,. Therefore, preemptive management of hypertension and diabetes for PEH is paramount. This can be challenging for PEH due to the lack of access to antihypertensive medications and insulin supplies ,. Preliminary UM street medicine data shows that the average blood pressure of patients encountered in a street setting is 140/87 mmHg, significantly higher than that of the general population (120/72 mmHg, p<0.0001) per the National Health and Nutrition Examination Survey. Moreover, many street medicine patients suffer from poorly-managed diabetes. Among patients whose blood glucose has been measured, the mean is 205.7 mg/dL+/- 119.0 (n=68), which is more than double the healthy range of 70-100 mg/dL.
Lifestyle: Up to 80% of homeless adults smoke tobacco, which interferes with the blood flow to the retina and accelerates the development of age-related macular degeneration (AMD),. Smoking can also contribute to inflammation in the eye (uveitis) as well as cataracts, glaucoma, and complications from retinal detachment surgery ,.
Utilizing Miami Street Medicine (MSM) outreach to identify PEH's most pressing eye and vision needs
Figure 1 displays the eye-related concerns reported by MSM patients (N=42)
Beginning January 1, 2022, our street team documented patients’ chief complaints in our secure, electronic REDCap database. 42 patients reported eye-related concerns, which are summarized in Figure 1. Under physician guidance, eye conditions such as pterygium and bacterial conjunctivitis were promptly identified. Additionally, a majority of patients (38.10%) reported some form of vision impairment related to a lack of corrective eyewear. Vision-threatening diseases including glaucoma and cataracts were reported by approximately 26.19% of patients. Symptoms of burning, redness, itching, and dry eyes were also reported among patients. The multifactorial nature of these symptoms suggests they warrant further evaluation by an ophthalmologist.
There are many barriers to accessing healthcare, stable housing, employment, and consistent food resources for PEH, but when such barriers are confounded by vision impairment or blindness, these challenges are amplified. Vision impairment greatly impacts one’s health, relationships, and well-being . For those living at or below the poverty line, the negative impacts of vision loss are exacerbated . The diagram below outlines the impact of vision impairment or loss on PEH.
Figure 2: The Cascading Effects of Vision Difficulties
Figure 2 details the confounding effects of vision impairment on PEH.
MSM Initiative to reduce the gap in access to eye and vision care
The literature reveals that there is a clear healthcare gap between the ocular disease burden on PEH and the resources allocated toward addressing these needs . During weekly rounds, MSM can directly identify patients' needs and subsequently coordinate future treatment through our team of medically-trained case coordinators. For many patients who reside full-time on the street, limitations in access to care can be due to a lack of knowledge of care resources, transportation barriers, and financial barriers, among others. Figure 3 below identifies the most common treatments provided to our patients since January 2022 through efforts to close this gap in care.
In September, we partnered with America’s Best to offer free examinations and eyewear for over twenty patients. The deal consists of MSM purchasing a $49.99 America’s Best Gift Certificate, which is given to our patients to obtain a free eye exam and two pairs of glasses. This is distinct from the discount for the general public, which is $79.99 for a free eye exam and two pairs of glasses. The discounted glasses are a limited selection, but there is still a wide array of glasses, and the inventory is continuously updated. As of January 13, 2023, America’s Best competitive prices have gone up, but our MSM discount remains the same.
Addressing our patients’ vision needs has the potential to significantly improve their quality of life. With effective screening and treatment, we can intervene in the cycle that exists between poverty and vision loss. A person with a treatable issue will no longer progress into a disability that will require more extensive care and needs down the road.
The vignette below outlines an example of how ophthalmic care interventions can impact MSM patients’ quality of life and ocular health:
A Colombian refugee: successful cataract surgeries as an undocumented immigrant. The patient, a 65-year-old male escaped political persecution in Colombia and was seeking political asylum in the United States. In pursuit of a safer environment, the patient traveled to various islands and countries, working as a welder to survive before arriving at the U.S. border. The patient expressed frustration at how everything was expensive, the government did not provide aid, and healthcare access was challenging. Notably, he suffered from cataracts but needed to regain sight to continue working.
The individual came to the U.S. with no documentation other than a passport which was held at Immigration and Customs Enforcement (ICE)—a branch of United States Citizenship and Immigration Services (USCIS)—when he was detained in an Immigration Processing Center. The patient did not have a Florida ID or any other government-issued ID except the one provided in the processing center; therefore, he was ineligible for most government assistance programs and other services or benefits.
The MSM team met the patient in May 2022. The first step in connecting him with necessary ophthalmic care was assisting him with obtaining a Jackson Card (J-11), which would allow him to receive free healthcare at Jackson Memorial Hospital and Bascom Palmer Eye Institute at the University of Miami). Obtaining the J-11 card was straightforward and took less than three weeks. Our patient was compliant with all primary care and ophthalmology appointments and procedures and would always ask if he did not understand anything. We saw the patient every Saturday on our outreach street runs, and he maintained close contact with his MSM Case Manager a few times a week.
On June 30th, 2022, our patient finally received cataract surgery for the right eye, and by July 2nd, surgery was completed in the left eye. July 10th, 2022, was the last time we saw the patient. Tearful and delighted, our patient expressed overwhelming gratitude for our efforts. When we spoke to the patient for the last time, the plan was to move to Canada because of strict USCIS regulations. Nevertheless, the patient has crystal-clear vision and can now continue his welding job duties wherever he pleases. He is also able to adequately complete his activities of daily living such as bathing and cleaning, which were previously impaired.
In just two months, we assisted with organizing a life-altering procedure that this patient had struggled to obtain in many places, including his hometown. It is an example of a truly heartening success story made possible through our comprehensive case management approach that prioritizes a holistic view of the individual. Additionally, being the Case Manager's second patient ever, this was someone that she would never forget.
Closing Thoughts and Future Direction:
Eyes are responsible for more than one’s ability to perceive the world around us—they can also reveal information about an individual’s current state of health and status of chronic disease management. Considering the eyes can indirectly act as a warning system for other more serious diseases and complications, it is crucial that ophthalmic assessments and vision examinations are regularly administered. Our current agenda to incorporate a more comprehensive method of eye and vision care for our patients is outlined below:
Expanding partnerships with ophthalmic and optometric providers.
Ensuring patients requiring corrective eyewear can have access within 2-3 weeks of initial evaluation.
Collecting more systematic data on vision health parameters.
Applying for vision health grants to better support our ongoing efforts.
Screening for vision difficulties in new patients encountered, as well as in established patients.
In October 2022, our team implemented head-to-toe evaluations that included screening questions about vision health as part of standard patient care provided to PEH. A majority of the patients triaged from October-December of 2022 expressed that they were concerned about their eyesight and felt their lack of vision interfered with their daily activities.
Figure 4 outlines patients’ attitudes regarding their vision and if vision impairment impacts their activities.
Beginning in January 2023, patients with eye-related concerns will be triaged. See below a flowchart of the protocol MSM will be using:
Vision loss: a public health problem | cdc. Published December 9, 2022. Accessed January 12, 2023. https://www.cdc.gov/visionhealth/basic_information/vision_loss.htm
Bensken WP, Krieger NI, Berg KA, Einstadter D, Dalton JE, Perzynski AT. Health Status and Chronic Disease Burden of the Homeless Population: An Analysis of Two Decades of Multi-Institutional Electronic Medical Records. J Health Care Poor Underserved. 2021;32(3):1619-34.
Wadhera RK, Choi E, Shen C, Yeh RW, Joynt Maddox KE. Trends, causes, and outcomes of hospitalizations for homeless individuals: a retrospective cohort study. Medical Care. 2019;57(1):21-27. doi:10.1097/MLR.0000000000001015
Noel CW, Fung H, Srivastava R, Lebovic G, Hwang SW, Berger A, et al. Visual impairment and unmet eye care needs among homeless adults in a Canadian city. JAMA Ophthalmol. 2015;133(4):455-60.
Henstenburg J, Thau A, Markovitz M, Plumb J, Markovitz B. Visual Impairment and Ocular Pathology Among the Urban American Homeless. J Health Care Poor Underserved. 2019;30(3):940-50.
Jiang S, Mikhail M, Slomovic J, Pereira A, Lebovic G, Noel C, et al. Prevalence and impact of eye disease in an urban homeless and marginally housed population. Can J Ophthalmol. 2020;55(1):76-81.
Threlfall TJ, English DR. Sun exposure and pterygium of the eye: a dose-response curve. American Journal of Ophthalmology. 1999;128(3):280-287. doi:10.1016/S0002-9394(99)00161-0
Roberts JE. Ultraviolet radiation as a risk factor for cataract and macular degeneration. Eye Contact Lens. 2011;37(4):246-9.
Varma R, Wu J, Chong K, Azen SP, Hays RD. Impact of severity and bilaterality of visual impairment on health-related quality of life. Ophthalmology. 2006;113(10):1846-1853. doi:10.1016/j.ophtha.2006.04.028
Nannini D, Torres M, Chen Y-DI, Taylor KD, Rotter JI, Varma R, et al. African Ancestry Is Associated with Higher Intraocular Pressure in Latinos. Ophthalmology. 2016;123(1):102-8.
Wong TY, Klein R, Duncan BB, et al. Racial differences in the prevalence of hypertensive retinopathy. Hypertension. 2003;41(5):1086-1091. doi:10.1161/01.HYP.0000064181.63546.53
Asgary R, Beideck E, Naderi R. Diabetes care and its predictors among persons experiencing homelessness compared with domiciled adults with diabetes in New York City; An observational study. eClinicalMedicine. 2022;48. doi:10.1016/j.eclinm.2022.101418
Asgary R, Sckell B, Alcabes A, Naderi R, Schoenthaler A, Ogedegbe G. Rates and predictors of uncontrolled hypertension among hypertensive homeless adults using new york city shelter-based clinics. Ann Fam Med. 2016;14(1):41-46. doi:10.1370/afm.1882
Bhargava M, Ikram MK, Wong TY. How does hypertension affect your eyes? J Hum Hypertens. 2012;26(2):71-83.
Davidson JA, Ciulla TA, McGill JB, Kles KA, Anderson PW. How the diabetic eye loses vision. Endocrine. 2007;32(1):107-16.
Baggett TP, Lebrun-Harris LA, Rigotti NA. Homelessness, cigarette smoking and desire to quit: results from a US national study. Addiction. 2013;108(11):2009-18.
Smoking and eye disease. American Academy of Ophthalmology. Published December 2, 2022. Accessed January 14, 2023. https://www.aao.org/eye-health/tips-prevention/smokers
Xu K, Chin EK, Bennett SR, et al. Predictive factors for proliferative vitreoretinopathy formation after uncomplicated primary retinal detachment repair. Retina. 2019;39(8):1488-1495. doi:10.1097/IAE.0000000000002184
Vision loss and Mental Health | CDC. Published September 27, 2022. Accessed January 17, 2023. https://www.cdc.gov/visionhealth/resources/features/vision-loss-mental-health.html
Riazi A, Riazi F, Yoosfi R, Bahmeei F. Outdoor difficulties experienced by a group of visually impaired Iranian people. J Curr Ophthalmol. 2016;28(2):85-90. Published 2016 May 2. doi:10.1016/j.joco.2016.04.002
Patino CM, McKean-Cowdin R, Azen SP, et al. Central and peripheral visual impairment and the risk of falls and falls with injury. Ophthalmology. 2010;117(2):199-206.e1. doi:10.1016/j.ophtha.2009.06.063
Smith M, Bailey T. Identifying solutions to medication adherence in the visually impaired elderly. Consult Pharm. 2014;29(2):131-134. doi:10.4140/TCP.n.2014.131
Harrabi H, Aubin MJ, Zunzunegui MV, Haddad S, Freeman EE. Visual difficulty and employment status in the world. PLoS One. 2014;9(2):e88306. Published 2014 Feb 7. doi:10.1371/journal.pone.0088306
National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Public Health Approaches to Reduce Vision Impairment and Promote Eye Health; Welp A, Woodbury RB, McCoy MA, et al., editors. Making Eye Health a Population Health Imperative: Vision for Tomorrow. Washington (DC): National Academies Press (US); 2016 Sep 15. 3, The Impact of Vision Loss. Available from: https://www.ncbi.nlm.nih.gov/books/NBK402367/