Do Socioeconomic Inequalities Exist Within Ophthalmology and Orthoptics in the UK?: A Scoping Review

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TL;DR

This scoping review finds that socioeconomic disadvantage in the UK is associated with reduced visual acuity, delayed presentation of glaucoma, cataracts, and diabetic retinopathy, and lower attendance at diabetic retinopathy screening. For orthoptic conditions, there is limited evidence of increased amblyopia prevalence and treatment barriers for disadvantaged children, as well as reduced quality of life for disadvantaged adults with strabismus. These findings highlight health inequalities within ophthalmology and orthoptics, warranting further research into underlying causes and interventions.

Full summary

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**Background:** Socioeconomic disadvantage is well-documented to adversely affect general and ocular health globally. In the UK, indices such as the Index of Multiple Deprivation (IMD) and Townsend Deprivation Index are used to measure deprivation. While clinicians in orthoptics recognize a link between socioeconomic status and treatment outcomes, no prior UK-specific literature review had addressed this issue for ophthalmology or orthoptics. This scoping review aims to evaluate evidence for an association between socioeconomic situation and ophthalmic/orthoptic conditions and their treatment outcomes within the UK.

**Methods:** Keyword searches were conducted on Google Scholar and the University of Liverpool library catalogue, which includes over 500 databases. Search terms included 'amblyopia', 'treatment outcome', 'socioeconomic', 'social deprivation', 'deprivation', 'compliance', 'vision', 'visual', 'refract', 'cataract', 'glaucoma', 'age-related macular degeneration', 'diabetic retinopathy', 'ophthalmology', 'orthoptic', 'strabismus', 'diplopia', 'binocular', and 'ocular motility'. Results were screened by title, abstract, and full article. Additional articles were identified from reference lists and forward citation searches. Inclusion criteria were full papers from this century (pre-2000 only if recent evidence insufficient), specific to the UK, and written in English.

**Key Results:** - **Visual Acuity:** Multiple studies (Rahi et al. 2009; Dawes et al. 2014; Yip et al. 2013; McKibbin et al. 2018) found higher incidence of visual impairment in disadvantaged individuals. Odds ratios ranged from 1.06 to 3.28 for various measures. Yip et al. (2013) reported an odds ratio of 1.7 (95% CI 1.1–2.6, p=0.03) for reduced VA (0.3 logMAR or worse) in disadvantaged areas. - **Refractive Error:** Goverdhan et al. (2011) found shorter axial length (0.24mm) and greater astigmatism (0.12D) in disadvantaged groups, but no association with spherical refraction. Foster et al. (2010) and Rahi et al. (2011) found myopia associated with non-manual occupations and higher education. - **Cataract:** Worse presenting VA was reported in disadvantaged patients (Chua et al. 2013; Goyal et al. 2004; Johnston et al. 2020). Johnston et al. (2020) found 23.6% of most disadvantaged had VA ≥1.0 logMAR vs 12.5% in least disadvantaged. Keenan et al. (2007) found higher cataract surgery rates in disadvantaged areas (r²=0.24). - **Glaucoma:** Strong evidence of delayed presentation and more advanced disease at diagnosis in disadvantaged individuals. Ng et al. (2010) found severe glaucoma in 45% of most deprived vs 10% of least deprived. Rathore et al. (2023) reported odds ratio 1.41 (p<0.001) for advanced visual field loss in least advantaged decile. King et al. (2023) found younger age at diagnosis (mean 62 vs 70 years) and worse baseline visual field (mean deviation -17 vs -13) in disadvantaged groups. - **Age-Related Macular Degeneration (AMD):** Mixed evidence. More et al. (2019) found odds ratio 4.07 (95% CI 1.5–11.0, p=0.006) for severe AMD at presentation in disadvantaged. Relton et al. (2022a) reported 0.09 logMAR worse VA at treatment initiation. However, Vassilev et al. (2015) and Yip et al. (2021) found no association with Townsend index. - **Diabetic Retinopathy:** Nine of twelve studies found lower screening attendance in disadvantaged individuals. Odds ratios ranged from 0.58 to 1.37. Leese et al. (2008) found disadvantaged were 2.32 times more likely to miss appointments. Lawrenson et al. (2020) reported odds ratio 0.73 for attendance and 1.42 for retinopathy requiring referral. - **Orthoptics:** O'Colmain et al. (2015) found children 1.4 times more likely to pass vision screening if advantaged (p=0.017). O'Colmain et al. (2020) reported poor attendance odds ratio 2.19 (p=0.003) by SIMD and 3.94 (p=0.002) by HPI. Non-compliance odds ratio 9.97 (p<0.001) by HPI. Poor attenders had odds ratio 6.42 (p<0.001) for residual amblyopia. For adult strabismus, Durnian et al. (2010) found lower AS-20 quality of life scores in disadvantaged (r²=-0.3, p=0.006).

**Clinical Implications:** The review identifies clear health inequalities in UK ophthalmology and orthoptics. Socioeconomic disadvantage is associated with worse visual outcomes, delayed presentation, and reduced treatment adherence. For diabetic retinopathy, lower screening attendance in disadvantaged groups may explain delayed presentation and higher referral rates. In orthoptics, barriers to treatment for disadvantaged children include poor attendance and compliance, leading to worse visual outcomes. The findings suggest that targeted interventions—such as improving access to screening, addressing barriers to attendance, and enhancing support for treatment adherence—could reduce these inequalities. Further research is needed to explore underlying mechanisms and develop effective strategies.