Black eyes matter—do we treat Black patients differently in ophthalmology?

Despite efforts to reduce avoidable blindness by 2020, latest figures from the World Health Organisation report at least 1 billion people still living with a vision impairment that could have been prevented or has yet to be addressed [1]. In the United States, age-related eye diseases are the most common causes of vision loss; however, the prevalences of these diseases vary significantly among different ethnic groups [2].

Whilst age-related macular degeneration predominantly affects White individuals, diabetic retinopathy and glaucoma are more prevalent among Black individuals [2–4]. Furthermore, responses to therapeutic interventions, from medications to surgery, also vary considerably by ethnicity [5]. Addressing such variations in disease burden is made more difficult by lower rates of health insurance cover and poorer access to healthcare among minority groups [6]. Furthermore, regardless of ethnicity, people with lower income are not only less likely to visit an eye doctor, but are also less likely to be able to afford eyeglasses when needed [2].

There are also wider concerns that individuals from ethnic minority groups, particularly those of Black ethnicity, receive different treatment in healthcare settings. Studies have shown that Black people experience lower quality pain management, delays in receiving care within the Emergency Department, disparities in accessing cardiac tests, diagnoses and procedures, and are less likely to be placed on renal transplant waiting lists, compared to their White counterparts [7–10].

Potential reasons for this variation are complex and multifactorial. Ethnicity, older age, reduced mobility, poor baseline vision and fear of the clinical outcome have all been linked to hospital non-attendance and loss to follow-up [11–14]. Language and cultural barriers may play a significant role, particularly where work and family commitments are prioritised over health-seeking behaviours [15]. Similarly, the burden of comorbid diseases and disability might also influence attendance at clinic and treatment appointments. For example, Black people with diabetes have disproportionately greater morbidity related to hypertension and stroke, compared to White people [16]. Competing clinic appointments, hospitalisations and transport difficulties can all hinder the timely treatment of eye disease.

Variation in health outcomes has also been linked to a lack of engagement with healthcare providers and physician bias. People from ethnic minorities and low socio-economic backgrounds report higher levels of physician and healthcare system distrust, which may contribute to a reluctance to accept treatment in eye clinic [17, 18]. Whilst physician bias is difficult to confirm or quantify, studies have shown that Black people with age-related macular degeneration are 23% less likely to receive intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment and 18% less likely to have regular eye examinations compared to their White counterparts [19]. A recent large general practice study conducted in the UK (n = 84,452) reported that both Asian and Black people were much less likely to be prescribed newer medications for diabetes, such as sodium-glucose cotransporter-2 inhibitors (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.58–0.79; OR 0.50, 95% CI 0.39–0.65, respectively) and glucagon-like peptide-1 agonists (OR 0.37, 95% CI 0.31–0.44; OR 0.45, 95% CI 0.35–0.57, respectively) than their White counterparts [20].

Recently, we have also shown that among a diverse metropolitan population with a high prevalence of social deprivation, Black individuals with diabetic eye disease wait longer for treatment than their White counterparts [21]. In our study, the severity of proliferative diabetic retinopathy and diabetic macular oedema was similar in Black and White patients referred to an ophthalmologist, with screening assessments made by image graders without ready access to ethnicity data. Despite this similar baseline burden of disease at the point of referral, after attending a face-to-face consultation with a doctor, the time to treatment with macular laser, intravitreal anti-VEGF or panretinal laser photocoagulation was significantly longer in Black individuals (χ² = 5.67, P = 0.02). Regression analysis revealed that people of Black ethnicity were less likely to receive a therapeutic intervention than their White counterparts (hazard ratio 0.71, 95% CI 0.53–0.95). Thankfully, despite these treatment delays, there were no significant differences in the rates of vision loss between the ethnic groups.

The recent coronavirus pandemic has exacerbated many pre-existing health inequalities among ethnic minority groups, particularly those from low socio-economic backgrounds. For example, ‘gig economy’ workers on zero-hours contracts may be less likely to attend hospital clinic or treatment appointments, for fear of losing income and employment. In a recent UK-wide cross-sectional, clustered-sample survey (n = 12,035), vaccine hesitancy was much higher in Black individuals (OR 13.42, 95% CI: 6.86–26.24) compared to those of White ethnicity [22].

Addressing health inequities and prioritising care to at-risk groups requires collaborative input from physicians, hospital administrators, healthcare regulators and professional bodies to actively engage, listen and communicate effectively with ethnic minority communities. Whilst equality and diversity training can change attitudes, one-off training exercises do not lead to sustained behavioural changes in the workforce [23]. As physicians, we know how to identify bias when appraising research; uncomfortable as it may be, current data suggest that we may also need to look for bias in our clinics. Addressing these difficult issues is the key to narrowing the inequity of care affecting those most in need of it.

Author contributions

This editorial was conceived by VK and TLJ. VK drafted the initial paper and TLJ provided senior oversight and critical appraisal of the final paper. Both authors accept full responsibility for the work and have agreed to the contents of the submitted paper.

Compliance with ethical standards

Conflict of interest

The authors declare no competing interests.