By Pippa Wysong

People with a lower socio-economic status (SES) in Canada tend to present with more advanced glaucoma, and are often in a more deteriorated state with the disease than those with higher SES—even though both groups live in a country with a publicly funded healthcare system.
This problem is being confirmed by multiple studies trying to get to the source of apparent inequities between the rich and poor in the country’s health care system.
Glaucoma is the second leading cause of blindness in the world and presenting late means an increased risk for blindness, according to Dr. Yvonne Buys, professor of ophthalmology at the University of Toronto. She has published a series of studies which confirm there is a tendency for people living in poorer areas, or who have attained lower education levels, to present later with the disease.
But why there is a difference between people living in poorer or richer areas accessing services is a puzzle. Even taking geography and access issues related to distance, SES stands out as an independent issue related to inequities, according to studies from the Canadian Institute for Health Information.
It’s also a phenomenon that happens in other areas of medicine and in other countries. And Canada isn’t the only country with socialized medicine where people with lower income tend to present late—studies show the same thing happens in England and Scotland. Evidence shows the issue is not limited to just eye diseases. The reasons are complicated.
“Individual health care attitudes are complex, but some possible reasons could be lack of symptoms, poor health knowledge such as understanding of the importance of preventative health care, poor understanding to navigate a health care system, and cost of taking time off work for an examination,” said Dr. Buys.
Yet detecting the disease and starting treatment early can make a huge difference.
A study she coauthored in the Canadian Journal of Ophthalmology (CJO) in April 2013 was the first to show that socioeconomic deprivation in Canada was associated with glaucoma being more severe when patients first presented to an eye care specialist. In the study, researchers looked at 290 patients from 18 study centres across Canada who were newly diagnosed with open-angle glaucoma. The postal codes of where patients lived were correlated with patient age and severity of disease.
Postal codes helped indicate median household incomes through use of the 2006 Canadian census data.
Of the patients, 52.1 per cent had mild disease, 26.9 per cent moderate and 21 per cent advanced disease at initial diagnosis. Of those who presented with late stage glaucoma, 36 per cent were in the highest income range, and 55 per cent in the lowest income range. The effect was even stronger among rich versus poor
among people 65 years of age or older.
“Whatever the cause, our study provides evidence for a possible barrier to vision care related to socioeconomic status that contradicts the fundamental principle of universal access of the Canadian health care system,” Dr. Buys said.
Another of her studies found that people with lower SES were 2.5 times more likely not to go to have other sorts of vision problems checked as well, ranging
from uncorrected vision problems to blindness.
The full and partial delisting of eye examinations in some of the provinces likely exacerbates the problem. In fact, one study from 2012 by researchers from the
University of Toronto show this is indeed the case in Ontario where routine eye examinations were delisted in 2004. Here, researchers used data from the Canadian
Community Health Survey from the years 2000 to 2001 (prior to delisting) and 2007 to 2008 (after delisting) and compared how many Ontarians went for eye exams during those years.
They found that among people aged 40 to 64, there was a drop in eye exam visits of 7.2 per cent among people who had not attained a high school diploma. Of people who had a high school diploma, eye exam visits dropped only 0.7 per cent—an order of significant difference. There was also a significant drop of just over five per cent among people with lower income.
“The disparity in utilization between those in the highest and lowest income groups increased nearly threefold from before delisting to after delisting,” said Dr. Graham Trope, professor of ophthalmology at the University of Toronto, and a coauthor of the study.
He notes that shifting costs to out-of-pocket for individuals creates a barrier for people with tighter finances to getting access to health care providers. Indeed, the study found increasing numbers of people reported that cost was a reason they did not seek eye examinations in the past two years.
Partial and full delisting of eye care services began in early 1992 when Saskatchewan delisted eye examinations for middle aged patients.
Since then, several other provinces followed suit. While delisting services such as eye exams saves government expenses in the short-term, some argue it leads to substantially greater costs later on. According to Dr. Buys, from a health economic standpoint, the cost of treating glaucoma increases with the severity of the disease, plus there are quality of life cost factors to the individual and family.
On the bright side, optometrists in five provinces can now prescribe glaucoma medications. Theoretically, this makes treatment more accessible to patients in rural and remote communities, said Dr. Thomas Freddo, professor of optometry at the University of Waterloo. But, in many places patients have to pay out-of-pocket for these services, which creates a barrier for patients with fewer financial resources.
Having Ministries of Health reinstate coverage of both eye exams and glaucoma care would be a step forward, Freddo said. But even if more patients came in for screening, detecting glaucoma is tricky since it is now recognized that in many cases, intra-ocular pressure alone won’t catch the disease since optic nerve
damage can happen with normal range pressures.
Participants at the recent World Glaucoma Congress in Vancouver now describe glaucoma as a chronic, multi-factorial neuro-degenerative disease of the central nervous system.
A study released in 2009 by the Canadian National Institute for the Blind (CNIB) placed the financial cost of vision loss due to glaucoma at a total of $907-million per year in Canada. That includes hospital visits, pharmaceuticals, vision care, rehabilitation, lost productivity and more.
According to the 2005 report A Clear Vision, also from the CNIB, costs to care for an individual with moderate stage vision loss (20/80 to 20/16) run about $6,414 per year, and jump to $22,633 per year in people with highly impaired vision (20/200 to having light perception only).
The vast majority of referrals to ophthalmologists for glaucoma come from optometrists. In fact, of newly presenting glaucoma cases, 82 per cent came from optometrists, compared to only seven per cent from family physicians and seven per cent from other ophthalmologists, Dr. Buys said. This reinforces the important role optometrists play in the care of glaucoma patients, plus in some provinces they can administer and prescribe glaucoma medication.
“Optometrists play a large role. Optometrists really are primary eye care providers and play a vital role in screening for eye disease,” Dr. Buys said.