Disparities in dry eye severity, access to dry eye care in racial and ethnic minorities

Cui

Reviewed by David Cui

Patients who are members of racial and ethnic minority groups present clinically with worse objective measures of dry eye than patients who do not belong to these groups, according to poster research presented at the annual meeting of the Association for Research in Vision and Ophthalmology.

“Dry eye is a condition that is very prevalent and very expensive to treat,” said David Cui, a medical student at the Pennsylvania State College of Medicine in Hershey, PA, one of the study’s investigators, and a research assistant at Johns Hopkins University School of Medicine, Baltimore, MD.

Cui noted that estimates of global prevalence for dry eye range from 5% to 50%, and the disease is a leading cause for patient visits to an eye care clinician.

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In the US, the estimated price tag associated with dry eye disease treatment is $3.8 billion annually, representing a substantial stress on the country’s healthcare system, said Cui.

Cui noted the need to look at the topic of race and if it influences access to dry eye care and if patients have greater dry eye severity, pointing out that no published literature on disparities regarding race and ethnicity and dry eye patients exists.

He added that existing literature on dry eye and racial minorities is limited to patients in Asia and that research demonstrates that these patients have a greater prevalence with potentially increased severity.

The retrospective investigation involved review of electronic health records of patients who were treated at a single center by a single ophthalmologist, Esen Karamursel Akpek, MD, the Bendann Professor of Ophthalmology and founder of the Ocular Surface Disease Clinic at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, noted Cui.

Investigators excluded patients whose dry eye was secondary to another ocular surface disease such as mucous membrane pemphigoid, Stevens-Johnson syndrome, atopic keratoconjunctivitis, or graft-versus-host disease.

Cui and fellow investigators divided patients into four categories: Asian, Black, Hispanic/Latino, and White.

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A total of 465 patients were included including 157 White, 157 Black, 85 Asian, and 66 Hispanic/Latino. The majority of patients (78%) were women, and the gender of patients were equivalent in all cohorts.

They used objective dry eye measures such as conjunctival staining, corneal staining, combined ocular surface staining, Schirmer’s test, and tear osmolarity at baseline and at a final visit.

Investigators found a larger amount of minority patients were without health insurance or were on Medicaid, and Black and Hispanic patients had a lower estimated median household income compared to White patients.

Another finding that emerged was that fewer minority patients previously received prescription treatments or procedures.

At their baseline visit, patients from minority groups had worse mean conjunctival and corneal staining scores.

There were, however, no statistically significant differences noted in objective dry eye measures at the final visit for patients with a minimum of 18 months of follow-up.

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Cui drew an analogy between the treatment of dry eye disease, often a chronic disease in which the chief symptom is ocular discomfort, and data on the treatment of chronic pain.

“There are a lot of publications in the US that show providers treat people with chronic pain differently based on their race and ethnicity,” said Cui. “Patients who are non-white typically will be prescribed less treatment for their pain. Moreover, clinicians are less likely to empathize with non-white patients or validate their pain and suffering.”

Because dry eye disease is not a condition that can lead to permanent vision loss if left untreated, clinicians may be routinely under-treating the condition despite it having an adverse impact on quality of life, noted Cui.

He and fellow investigators found fewer minority patients received prescription treatments or procedures (White 61.8% vs minority patients 30.6%-43.9%, all P ≤ .016).

“Medicaid patients are often of low-income status, making it difficult to access care and these insurances almost never cover dry eye treatments,” he said.

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Cui noted the study is limited by the fact that is it retrospective and by the fact that it was conducted at a single center.

“Because of that, it is hard to draw causation,” he said. “We can, however, draw correlation. We see that minorities do have barriers to care such as having lower household income, are more likely to be uninsured or are on Medicaid, and have less than full-time employment. We also see that these groups receive less care, and present with worse objective dry eye parameters but the differences disappear after adequate treatment and follow-up. We hope that this study brings awareness to clinicians that these disparities exist, and that future research examines the public health concerns of dry eye.”

Cui thanked his mentors for their guidance and noted that this study will serve as a foundation for their team for future studies regarding disparities associated with dry eye diagnosis and management.

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David Cui
E: davidcui@jhu.edu