MAKING EYE HEALTH
A POPULATION
HEALTH IMPERATIVE

VISION FOR TOMORROW

Steven M. Teutsch, Margaret A. McCoy, R. Brian Woodbury,
and Annalyn Welp, Editors

Committee on Public Health Approaches to Reduce Vision Impairment
and Promote Eye Health

Board on Population Health and Public Health Practice

Health and Medicine Division

A Report of

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was supported by American Academy of Ophthalmology; American Academy of Optometry; American Optometric Association; Association for Research in Vision and Ophthalmology; National Alliance for Eye and Vision Research; National Center for Children’s Vision and Eye Health; Prevent Blindness; Research to Prevent Blindness; Contract No. 200-2011-38807, TO#32 with the U.S. Department of Health and Human Services [Centers for Disease Control and Prevention]; and Contract No. HHSN2632012000741, TO#61 with the U.S. Department of Health and Human Services [National Institutes of Health]. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-43998-5
International Standard Book Number-10: 0-309-43998-1
Digital Object Identifier: 10.17226/23471
Library of Congress Control Number: 2016956972

Additional copies of this publication are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.

Copyright 2016 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2016. Making Eye Health a Population Health Imperative: Vision for Tomorrow. Washington, DC: The National Academies Press. doi: 10.17226/23471.

COMMITTEE ON PUBLIC HEALTH APPROACHES TO REDUCE VISION IMPAIRMENT AND PROMOTE EYE HEALTH

STEVEN M. TEUTSCH (Chair), Adjunct Professor, University of California, Los Angeles, Fielding School of Public Health; Senior Fellow, Public Health Institute; Senior Fellow, Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California

SANDRA S. BLOCK, Professor, Illinois College of Optometry, Medical Director, School-based Vision Clinics, Global Clinical Advisor Special Olympics Lions Clubs International Opening Eyes

ANNE L. COLEMAN, Professor of Ophthalmology and Epidemiology, Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles

KEVIN FRICK, Professor and Vice Dean for Education, Carey Business School, Johns Hopkins University

KAREN GLANZ, George A. Weiss University Professor, Director, University of Pennsylvania Prevention Research Center

LORI GROVER, Senior Vice President for Health Policy, King-Devick Technologies, Inc.

EVE HIGGINBOTHAM, Vice Dean, Perelman School of Medicine, University of Pennsylvania

PETER D. JACOBSON, Professor of Health Law and Policy, School of Public Health, University of Michigan

EDWIN C. MARSHALL, Professor Emeritus of Optometry and Public Health, Indiana University

CHRISTOPHER MAYLAHN, Program Research Specialist, Office of Public Health Practice, New York State Department of Health

JOYAL MULHERON, Managing Director, Sagacity Group, LLC

SHARON TERRY, President and CEO, Genetic Alliance

CHERYL ULMER, Retired, Institute of Medicine

ROHIT VARMA, Grace and Emery Beardsley Professor and Chair, University of Southern California (USC) Department of Ophthalmology; Director, USC Eye Institute; Associate Dean for Strategic Planning and Network Development, Keck School of Medicine of USC

HEATHER E. WHITSON, Associate Professor of Medicine (Geriatrics) and Ophthalmology, Duke University Medical Center and Durham Veterans Affairs Medical Center

Study Staff

MARGARET A. McCOY, Study Director

ASHNA KIBRIA, Associate Program Officer (until August 2015)

R. BRIAN WOODBURY, Research Associate

ANNALYN WELP, Research Assistant

BETTINA RITTER, Research Assistant (until November 2015)

MARJORIE PICHON, Senior Program Assistant

ROSE MARIE MARTINEZ, Senior Director, Board on Population Health and Public Health Practice

Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by BOBBIE BERKOWITZ, Columbia University School of Nursing and Columbia University Medical Center, and BRADFORD H. GRAY, Urban Institute. They were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Contents

ACRONYMS AND ABBREVIATIONS

PREFACE

SUMMARY

1 INTRODUCTION

Statement of Task and Scope of Study

Core Principles

Definition of Key Terms in Eye and Vision Health

A Population Health Approach to Improve Eye and Vision Health and Reduce Vision Impairment

Conclusion

References

2 UNDERSTANDING THE EPIDEMIOLOGY OF VISION LOSS AND IMPAIRMENT IN THE UNITED STATES

Anatomy of the Eye and Function of the Visual System

The Epidemiology of Vision Impairment in the United States

Understanding the Etiology of Vision Impairment in the United States

Characterizing Vision Impairment for Population Health

Estimating the Preventable Burden from Refractive Error and Cataracts

Key Knowledge and Research Gaps

Conclusion

References

3 THE IMPACT OF VISION LOSS

Consequences of Vision Impairment

Multiple Comorbid Conditions

Overview of Expenditures

Conclusion

References

4 SURVEILLANCE AND RESEARCH

Surveillance

Research

Opportunities

Conclusion

References

5 THE ROLE OF PUBLIC HEALTH AND PARTNERSHIPS TO PROMOTE EYE AND VISION HEALTH IN COMMUNITIES

Overview of the Governmental Public Health System

Building Capacity and Strategies to Promote Eye and Vision Health

Opportunities to Incorporate Eye and Vision Health: The Public Health Agenda

Expanding Access to Community-Based Vision Screening Services and Follow-Up Care

Encouraging Environments That Support Eye Health and Visual Function: Policy Development and Enforcement

Enhancing Accountability

Conclusion

References

6 ACCESS TO CLINICAL VISION SERVICES: WORKFORCE AND COVERAGE

The Clinical Eye and Vision Care Workforce

Coverage for Eye and Vision Care Services

Cost-Effectiveness Research

Conclusion

References

7 TOWARD A HIGH-QUALITY CLINICAL EYE AND VISION SERVICE DELIVERY SYSTEM

The Need for Evidence-Based Guidelines: Establishing the Baseline

Assessing Quality and Improvement Initiatives

Promoting Diagnosis and Follow-Up Care Transitions Through Integration

Workforce Training and Education to Promote Eye and Vision Health

Conclusion

References

8 MEETING THE CHALLENGE OF VISION LOSS IN THE UNITED STATES: IMPROVING DIAGNOSIS, REHABILITATION, AND ACCESSIBILITY

Vision Rehabilitation Interventions and Models

Barriers and Opportunities in Vision Rehabilitation

Novel Technologies, New Therapies, and Promising Research

Conclusion

References

9 EYE AND VISION HEALTH: RECOMMENDATIONS AND A PATH TO ACTION

Translating a Conceptual Framework into Action: Recommendations

Facilitate Public Awareness Through Timely Access to Accurate and Locally Relevant Information

Generate Evidence to Guide Policy Decisions and Evidence-Based Actions

Expand Access to Appropriate Clinical Care

Enhance Public Health Capacities to Support Vision-Related Activities

Promote Community Actions That Encourage Eye- and Vision-Healthy Environments

Recommendations in Action: Examples for Implementation

Conclusion

References

Addendum

APPENDIXES

A Committee Biographies

B Committee Meeting Agendas

C Glossary

D Examples of Federal Entities Involved in Advancing Eye Health and Safety

E Examples of Recommended Eye Protection for Recreational Sports

F Eye and Vision Care Professionals and Education

G Medicaid Vision Coverage by State

Acronyms and Abbreviations

Preface

Losing one’s eyesight, at any age, is frightening. That fear has merit: compared to their peers, people with vision loss have reduced independence and quality of life, lower performance in school, lower wages and job attainment, and higher health costs. Fortunately, two of the most common causes of vision loss among adults (i.e., refractive errors and cataracts) can be readily treated with proper access to, and utilization of, currently available care. This report estimates that undiagnosed or untreated refractive error alone affects between 8.2 and 15.9 million people in the United States. Uncorrectable vision impairment affects another 6.4 million people. The toll of correctable vision loss among children who do not received adequate detection, follow-up, and treatment is troubling. Ensuring that people receive proper visual acuity screenings and preventive eye care services and adhere to effective eye protection practices would eliminate thousands of preventable or correctable cases of vision impairment that result each year from amblyopia and eye injuries. Success in simply applying current knowledge would reduce significant health care disparities, because avoidable vision loss disproportionately affects minorities and the poor. Failure of the United States to address these sources of preventable suffering and disparity is simply not acceptable.

But the population health imperative for eye health does not end with eliminating avoidable vision loss. Even if all vision impairment due to refractive errors, cataracts, or avoidable conditions vanished, millions of people would still be visually impaired. Although recent advances in eye care are impressive and have reduced the vision loss that results from genetic conditions and common, age-related eye diseases (e.g., age-related

macular degeneration, glaucoma, diabetic retinopathy), there remains no cure. Due to the aging of our population and the strongly age-related incidence of many eye diseases, we project a near doubling, by 2050, in the prevalence of “chronic vision impairment.” The good news for people living with vision impairment and blindness is that vision impairment is a surmountable obstacle. With proper training, equipment, and accommodations, people with vision impairment can lead independent, productive, joyful lives. The problem is that many individuals today do not receive the full complement of resources they need to overcome vision-related disability.

An important and immediate population health need is to bolster our ability as a nation to manage the rising challenge of chronic vision impairment. Despite enormous potential costs for individuals, caregivers, and society, chronic vision impairment receives little emphasis in most national and public health agendas focused on chronic conditions. Chronic vision impairment frequently co-occurs with, and may be a risk factor for, many comorbid conditions including other sensory impairments, depression, anxiety, and cognitive impairment. Comorbidities add to the challenge of living with and accommodating vision loss, and in turn, vision impairment complicates one’s ability to manage other health conditions. Due to its prevalence and potential interference with other health domains, chronic vision impairment must not only receive greater attention as a chronic condition in its own right, but also be a part of all dialogues and action plans geared toward maximizing health and well-being in an aging society.

The primary goal of this Committee was to outline population health strategies to promote eye health and reduce vision impairment and its consequences in the United States. The ultimate objective is straight-forward: (1) no person should live with vision impairment that could have been avoided or could be treated and (2) every person with chronic vision impairment should have access to community and health services that minimize the impact of vision loss on overall health and life. Making this objective a reality will be complicated. It will require action from national, state, and local stakeholders. It will require practical changes to policies and systems as well as cultural changes that involve shifts in paradigms and ways of thinking.

This report represents the collective conclusions and recommendations of a diverse group of experts, each of whom brought their expertise and perspectives. The Committee recognizes and salutes the many devoted people across the nation already working tirelessly to promote eye and vision health and lessen the burden of vision impairment. This report emphasizes the need to address the underlying social and environmental conditions that contribute to unacceptable health disparities as well as to make quality clinical eye care and support services available to everyone. To accomplish this will take the concerted action of eye professionals, payers,

clinical care systems, public health, and community organizations. We can eliminate preventable vision loss and ensure that each person with chronic vision impairment has every opportunity to live a full and productive life. We need to do so.

Steven M. Teutsch, Chair

Committee on Public Health Approaches to Reduce Vision Impairment and Promote Eye Health

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