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

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 :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: 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
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 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 :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 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
Women’s Eye Health

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

20. 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
Owens, et al. Women with diagnosed diabetes across the life stages: Underuse of recommended preventive care services Journal of Women’s Health. 17: 1415

21. 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 Journal of Women’s Health. 17: 1415

22. 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: % 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 Journal of Women’s Health. 17: 1415