Guest Editorial Vision Loss: A Public Health Problem? A recent report from Prevent Blindness America and the National Eye Institute (NEI) draws attention to what may hitherto have been a large blind-spot for improving the quality of people’s lives.1 Based on a compilation of data, the report estimates that more than 3.4 million (3%) Americans aged 40 years and older are either blind (having visual acuity [VA] of 20/200 or less or a visual field of less than 20 degrees) or visually impaired (having VA of 20/40 or less). The major causes of vision loss in Americans in this age group are cataract, age-related macular degeneration (AMD), diabetic retinopathy, and glaucoma. One million six hundred thousands Americans aged 50 years or older have AMD, 5.3 million (about 2.5% of all people) aged 18 years or older have diabetic retinopathy. Among Americans aged 40 years or older, 20.5 million have cataracts, and 2.2 million have glaucoma (about 16% and 2% respectively). Is it not time to recognize vision loss as a serious public health problem and respond to it as if it were? Five criteria can assist us in evaluating whether a condition or disease is a public health problem.2 (1) Does it affect a lot of people? Yes, based on data in this report.1 (2) Does it contribute a large burden in terms of morbidity, quality of life, and cost? Absolutely. Vision loss imposes a large burden on individuals and society. Good vision is important to good quality of life, and loss of vision leads to disability, morbidity, and loss of productivity.3 It is estimated that blindness and visual impairment cost the U.S. federal government more than $22.0 billion annually in direct cost of treatment, loss of personal income, and associated costs such as Social Security disability benefits.4 (3) Has the problem recently increased or will it increase in the future? The current burden of eye disease is considerable. As the U.S. population ages and changes demographically, the impact of vision loss and visual disability will grow substantially in the future. Projections estimate that the number of blind and visually impaired people will double by 2030 unless corrective action is taken. (4) Is vision loss perceived to be a threat by the public? Yes. Visual impairment is one of the 10 most common causes of disability in the United States, and it is one of the most feared disabilities. These perceptions and fears will likely increase with the release of the recent NEI report.1 (5) Is it feasible to act on the condition at a community or public health level? Scientific evidence shows that early detection and treatment can prevent much blindness and visual impairment. Efficacious and cost-effective strategies to detect and treat diabetic retinopathy are available,5,6 but among people with diabetes screening is received only by about two third of persons to whom the exam is recommended and varies significantly across health care settings.7 Cataract removal surgery can restore vision and this surgery is highly cost-effective;8,9 however, among African Americans, unoperated senile cataracts are still a major cause of blindness.10 Glaucoma can be controlled and vision loss stopped by early detection and treatment. Nevertheless, half of the people with glaucoma are not diagnosed and glaucoma is still the number-one blinding disease among African Americans.11 Finally, treatment with zinc and antioxidants has been shown to reduce the risk and progression to advanced AMD among people aged 50 years and older.12 Strategic public health approaches to address vision loss are needed. First, standardized diagnostic criteria are needed for clinical diagnosis and public health surveillance. Second, concerted efforts should be made to create national and international ongoing surveillance systems that use standardized methods to monitor trends over time and assist in the setting of priorities. Third, the public health community and interested voluntary organizations must raise awareness of vision loss among the general public, health care providers, policy makers, and the scientific community. Fourth, the burden of disability and the social and economic costs of vision loss need to be better assessed. The relative contribution of the causes of vision loss also needs to be better defined; similarly, differences according to age, sex, and racial/ethnic groups need to be evaluated, and causes for such differences, if they exist, need to be better understood. Fifth, translation research is needed to help public health planners, policy makers, and researchers understand the extent to which available interventions are implemented, to explore barriers to implementation of effective interventions, and to formally test strategies to overcome such barriers. Finally, the cost and cost-effectiveness of interventions to reduce vision loss must be better understood. Greater life expectancy is a national marker of successful health, economic, and social policies. However, the 253
Ophthalmology Volume 110, Number 2, February 2003 aging of a population brings with it new challenges. Vision loss is one such challenge. Our paradigm of what constitutes public health must be adapted to include such conditions as vision loss within the ambit of public health. In the meantime, primary care physicians, optometrists, and ophthalmologists should be especially alert to the most common and treatable eye conditions in their patients including, cataracts, glaucoma, diabetic retinopathy, and macular degeneration. References 1. Vision Problems in the U.S.: Prevalence of Adult Vision Impairment and Age-Related Eye Disease in America. Schaumburg, IL: Prevent Blindness America, 2002. Available from URL: www.usvisionproblems.org. [accessed May 8, 2002]. 2. Vinicor F. Is diabetes a public health disorder? Diabetes Care 1994;17(Suppl 1):22–7. 3. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1998;319:1701–7. 4. A Vision of Hope for Older Americans: Progress and Opportunities in Eye and Vision Research. An official report to the White House Conference on Aging Washington, DC: National Alliance for Eye and Vision Research, 1995. 5. Early photocoagulation for diabetic retinopathy ETDRS. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology 1991;98:766 – 85. 6. Javitt JC, Aiello LP, Chiang Y, et al. Preventive eye care in people with diabetes is cost-saving to the federal government. Implications for health-care reform. Diabetes Care 1994;17:909 –17. 7. Saaddine JB, Engelgau MM, Beckles GL, et al. A diabetes report card for the United States: quality of care in the 1990’s. Ann Intern Medicine 2002;136:565–74. 8. Klein BEK, Klein R, Moss S. Change in visual acuity associated with cataract surgery. The Beaver Dam Eye Study. Ophthalmology 1996;103:1727–31. 9. Busbee BG, Brown MM, Brown GC, Sharma S. Incremental cost-effectiveness of initial cataract surgery. Ophthalmology 2002;109: 606 –12, discussion 612–3. 10. Sommer A, Tielsch JM, Katz J, et al. Racial differences in the cause-specific prevalence of blindness in East Baltimore. N Engl J Med 1991;325:1412–7. 11. Smith SD, Katz J, Quigley HA. Analysis of progressive change in automated visual fields in glaucoma. Invest ophthalmol Vis Sci 1996;37:1419 –28. 12. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zink for agerelated macular degeneration and vision loss: AREDS report number 8. Age-Related Eye Disease Study Research Group. Arch Opthalmol 2001;119:1417–36.
JINAN B. SAADDINE, MD, MPH K.M. VENKAT NARAYAN, MD, MPH, FRANK VINICOR, MD, MPH Atlanta, Georgia