番茄社区

People with adverse social determinants of health were more likely to present with severe rhegmatogenous retinal detachment (RRD), suggesting they were more likely to delay treatment, a retrospective cohort study suggested.

Among 700 patients who underwent primary repair of uncomplicated RRD at a single center, each decile increase in the Area Deprivation Index (ADI), indicating more socioeconomic disadvantage, was linked to increased odds of presenting with worse visual acuity (OR 1.14, 95% CI 1.04-1.24, P=0.004) and fovea-involving RRD (OR 1.13, 95% CI 1.04-1.22, P=0.005), reported Cindy X. Cai, MD, of Wilmer Eye Institute at Johns Hopkins School of Medicine in Baltimore, and colleagues.

Of note, each $1,000 increase in per capita income was associated with lower odds of presenting with worse vision (OR 0.99, 95% CI 0.98-0.99, P=0.001), they wrote in .

Moreover, patients who presented with worse vision and fovea-involving RRD typically lived in neighborhoods with a higher percentage of workers who drove to work (visual acuity: mean 79.9 vs 77.2, P=0.01; fovea status: 80.4 vs 78.2, P=0.046). Every 1% increase in the percentage of workers who drove to work was linked to increased odds of presenting with worse vision (OR 1.02, 95% CI 1.01-1.03, P=0.005) and fovea-involving RRD (OR 1.01, 95% CI 1.00-1.03, P=0.04).

Co-author Sally S. Ong, MD, of Wake Forest School of Medicine in Winston-Salem, North Carolina, told 番茄社区 that there are about 10 to 18 cases of retinal detachment per 100,000 population per year. RRD is the most common form, and Ong said it occurs "when there is a break or a hole in the retina, and that allows fluid to track under the retina, separating it from the back of the eye wall."

Older people, those with previous cases/family history, and the extremely nearsighted are at higher risk, she noted. Cataract surgery and recent trauma can also increase risk. Typically, older patients have had cataract surgery and younger patients have had trauma or are extremely nearsighted.

This study shows that "patients with more socioeconomic disadvantages oftentimes face greater barriers to access to medical care," Ong said. "As a consequence, they may only go to the doctor when their symptoms become severe, such as when the retinal detachment has progressed with loss of fovea and is starting to affect their vision."

Fovea involvement indicates that a detachment has progressed from the periphery into the center of the retina, she explained. Before a detachment reaches the fovea, it would cause dark shadows on the periphery of vision.

Patients with more socioeconomic disadvantages "do not have the means to access transportation to go to the hospital, or they aren't able to get time off work," said Ong, who works in western North Carolina, a more disadvantaged area. "Or they just don't have the awareness that when you start having a black shadow in your vision, it's very important to get checked."

Patients may delay care for days, weeks, or even months in extreme cases, she noted. Delayed treatment can make it harder to repair the retina, and increases the likelihood of future detachments.

Clinicians should urge disadvantaged patients to understand the importance of returning for care, Ong suggested, or they can ask social workers to help patients with challenges like transportation and getting time off work. Raising public awareness about the importance of prompt treatment of retinal detachment is another strategy, she said.

In an , Patrice M. Hicks, PhD, MPH, of the University of Michigan in Ann Arbor, and colleagues said one of the mysteries in the study is why RRD would be more severe in patients who live in neighborhoods where more people drove to work. They speculated that these areas may have fewer public transit options, and as a result, people without access to cars may find it more difficult to get medical care.

They highlighted a , also conducted by Johns Hopkins researchers, that linked both poverty and Black race/Hispanic ethnicity to lapses in diabetic retinopathy care. "Nuance is revealed when we explore potential patient-level and neighborhood-level interactions," Hicks and colleagues wrote.

The current study tracked 700 adult patients who underwent primary repair of uncomplicated RRD at the Wilmer Eye Institute from January 2008 to December 2018. Mean age was 57.9, 61.7% were men, 78.1% were white, and 11.6% were Black. A little over half (53.2%) had private insurance, 41.9% had public insurance, and 4.9% had no insurance.

Of the patients, 61.4% presented with vision worse than 20/40, although most (68.3%) had fovea-sparing RRD.

The researchers matched patients' addresses to multiple neighborhood-level social determinants of health, including ADI, per capita income, percentage of renters, percentage of people using a food assistance program, percentage of uninsured individuals, mode of transportation to work, and distance to the nearest transit stop, among others.

Study limitations included its focus on a single center in an urban environment and the lack of diversity among patients.

Comment