Equitable access to refractive surgery: Bridging gaps in vision care
Resolving eye care disparities can yield positive results for patients of all backgrounds.
Image credit: AdobeStock/inimalGraphic
As an optometrist, I have witnessed firsthand the transformative impact that refractive surgery can have on patients’ lives. Refractive surgery, such as LASIK, small incision lenticule extraction, and photorefractive keratectomy (PRK), offers a long-term solution to vision problems like myopia, hyperopia, and astigmatism. Despite its benefits, equitable access to these services remains a significant challenge, with numerous barriers preventing certain populations from receiving the vision care they need. This article explores the intersection of refractive surgery and public health, emphasizing the importance of ensuring equal access to vision correction services for all patients.
Barriers to access
Socioeconomic, geographical, and systemic barriers significantly impede access to refractive surgery. The out-of-pocket cost of these procedures is often prohibitive for many individuals, particularly those who are already without adequate insurance coverage. Even for patients who do have insurance, most plans do not cover elective surgeries such as LASIK or PRK, leaving patients to bear the full financial burden. This financial strain is exacerbated for those in low-income brackets or living in poverty.1 Even though refractive surgery can be less expensive in the long term compared with the continuous costs of glasses or contact lenses, the up-front cost remains a significant barrier.
Geographical barriers further complicate access. Refractive surgery services are typically concentrated in urban areas, making it difficult for individuals in rural or underserved regions to access these procedures.2 Limited availability of specialized eye care services in these areas means that even basic eye health needs often go unmet, let alone elective surgical options.2
Systemic barriers, including health care access disparities, also keep patients from accessing these services. Marginalized communities, including racial and ethnic minority groups, often face systemic discrimination within the health care system.3 These populations may have lower rates of health care utilization due to mistrust, lack of overall cultural awareness, and language barriers—all of which can hinder access to refractive surgery and other vision care services.3
Burden of uncorrected refractive error
Although we are discussing refractive surgery, it is important to also consider the general public health implications of uncorrected refractive error. Vision impairment can significantly affect a patient’s quality of life, educational attainment, employment opportunities, and overall mental health. As optometrists, we are well aware that uncorrected vision problems can negatively affect academic and social development for children. As adults, this may lead to decreased productivity at work and a higher risk of accidents and injuries.
Marginalized communities and vulnerable populations experience a disproportionate burden of uncorrected refractive error, leading to higher prevalence rates of vision problems due to limited access to preventive and corrective eye care services.4 These uncorrected vision impairments exacerbate the existing social and economic inequalities, perpetuating a cycle of disadvantage.4
Long-term cost-effectiveness
The initial cost of refractive surgery may seem high, but it is important to also consider the long-term financial benefits. The average cost of LASIK surgery in the United States ranges from $1500 to $5000 per eye, according to Market Scope’s most recent survey on US ophthalmologists.5 Over a lifetime, the cumulative cost of purchasing glasses or contact lenses, along with regular eye exams and lens care products, can far exceed the 1-time cost of refractive surgery. For individuals with significant refractive errors, the financial and practical benefits of refractive surgery become even more apparent.
Furthermore, refractive surgery can offer intangible benefits such as improved quality of life and convenience. Patients no longer need to worry about broken glasses or lost contact lenses, and they can engage in activities such as camping, skiing, and other sports without visual aids. These improvements can lead to enhanced productivity and well-being, contributing to the overall cost-effectiveness of the procedure.
Addressing disparities
Some initiatives and strategies have been developed to address disparities in access to vision care, but very few to refractive surgery. Most of these are community-based or state-run outreach programs bringing eye care services directly to underserved communities. Staffed by volunteer eye care providers, they often provide screenings, education, and sometimes materials including glasses and referrals for further care. Programs such as Remote Area Medical couple these ocular services with other specialties like dental and primary care, making a huge impact on many patients’ lives. Regarding post-evaluation care at the pop-up clinics and programs, some ophthalmologists do donate their services, including refractive surgery, but it is not consistent or in large volume. Therefore, these donated services are limited in how many patients they can help.
Telemedicine is continually evolving—booming with growth in 2020 amid the COVID-19 pandemic—and is emerging as a valuable tool in health care. As technology improves, virtual consultations with optometrists and ophthalmologists are starting to help bridge the gap for individuals in remote areas, providing them with professional advice and recommendations without the need for travel. Telemedicine can also facilitate follow-up care and monitoring for patients who have undergone refractive surgery, ensuring continuity of care.
Subsidized or low-cost surgical options are critical in making refractive surgery more accessible. Programs that offer sliding scale fees based on income or provide financial assistance for those in need can help alleviate the cost barrier. Partnerships between health care providers, nonprofits, and government agencies can further expand access by pooling resources and coordinating efforts to reach underserved populations.
It takes a village
The reality of what it takes to make these types of changes are no less than daunting. Public health policies and advocacy efforts play a vital role in promoting equitable access to health care. Future legislative measures would be needed that mandate insurance coverage for refractive surgery, leading to significant reduction in financial barriers for patients. For example, policies that require insurance companies to cover a portion or the entire cost associated with vision correction surgeries can provide more affordable procedures to reach more patients in need.
Another essential step would include funding initiatives aimed at supporting underserved communities. Government grants and subsidies could help establish and sustain eye care programs in rural and low-income areas. Additionally, policies that incentivize surgeons to work in underserved regions would be needed to help address geographical disparities in access.
Getting the patient on board
Public health campaigns are crucial in raising awareness about refractive surgery as a safe and effective option for vision correction. Educating the public about the benefits of these procedures helps encourage patients to consider them as viable alternatives to glasses or contact lenses. It is important to debunk myths and misconceptions surrounding refractive surgery, such as concerns about safety and long-term effectiveness.
Encouraging individuals to seek comprehensive eye exams and consultations with qualified eye care physicians is another key aspect of promoting awareness. As optometrists, we know that regular eye exams can detect refractive errors and other ocular/systemic health issues early, allowing for timely intervention. A good public health campaign could help to highlight the importance of eye health, driving patients to our offices for comprehensive care. Then we can discuss availability of refractive surgery in appropriate cases.
Future directions
Looking ahead, there are several potential directions for addressing disparities in access to refractive surgery and vision care. Leveraging technology and innovation can play a significant role in expanding access. Advances in surgical techniques and equipment can make refractive surgery more efficient and cost-effective, potentially lowering the overall cost of these procedures.
Strengthening collaborations between eye care providers and community organizations is another important strategy. By working together, these entities can coordinate efforts to reach underserved populations and provide, at the very least, comprehensive eye care services. Community optometrists and local leaders can act as liaisons, helping to build trust and facilitate access to care.
Advocating for policies that prioritize vision health as a public health priority is essential. Vision care should be integrated into broader health initiatives and recognized as a critical component of overall health and well-being. Optometry as a legislative profession is no stranger to the efforts that are needed when it comes to developing and implementing policies. For any changes to occur, there must be continued education of policymakers about the public health implications of uncorrected refractive error and the benefits of ensuring equitable access to vision correction services.
Addressing the intersection of refractive surgery and public health through the lens of equitable access is crucial for ensuring that all individuals are provided the opportunity to benefit from vision correction services. By understanding and addressing the barriers to access, promoting awareness and education, and advocating for supportive policies, we can bridge gaps in vision care as a whole and improve the quality of life for individuals across all socioeconomic backgrounds. As an optometrist, I am committed to working toward a future where general vision care is accessible to all. We have an opportunity to improve access to refractive surgery for appropriate patients, regardless of their socioeconomic status or background.
References:
Resnikoff S, Pascolini D, Mariotti SP, Pokharel GP. Global magnitude of visual impairment caused by uncorrected refractive errors in 2004. Bull World Health Organ. 2008;86(1):63-70. doi:10.2471/blt.07.041210
World report on vision. World Health Organization. October 8, 2019. Accessed June 1, 2024. https://www.who.int/publications/i/item/world-report-on-vision
Vision and eye health. CDC. Accessed June 1, 2024. https://www.cdc.gov/visionhealth/index.htm
Cao H, Cao X, Cao Z, Zhang L, Han Y, Guo C. The prevalence and causes of pediatric uncorrected refractive error: pooled data from population studies for Global Burden of Disease (GBD) sub-regions. PloS One. 2022;17(7):e0268800. doi:10.1371/journal.pone.0268800
2024 Annual US Cataract Surgeon Survey Report, May, 2024. Market Scope. Accessed August 13, 2024. https://www.market-scope.com/pages/reports/449/2024-annual-us-cataract-surgeon-survey-report-may-2024#reports
