Addressing Inequities in Amblyopia Treatment Outcomes

Amblyopia is the most common cause of permanent unilateral vision loss in children and young adults, affecting up to 3% of the population.1 It is due to an impediment to simultaneous high-quality visual input from the eyes to the developing brain, interfering with cortical visual development during a critical period in early childhood until approximately age 7 years.2 Etiologies include strabismus, asymmetric or high refractive error, cataracts, and ptosis. If not treated within this critical period, amblyopia can have lifelong consequences ranging from poor depth perception and monocular low vision to the risk of severe loss of visual function from an injury or other pathology in the nonamblyopic eye. In this article, we will discuss the reported inequities in the detection and treatment of amblyopia in children and suggest several interventions to reduce and ultimately resolve these inequities.Along with the correction of refractive error with glasses, the most common treatment of unilateral amblyopia is part-time monocular occlusion using a patch on the better-seeing eye. Atropine eye drops, which affect the eye's ability to accommodate, have also shown effectiveness when instilled in the better-seeing eye.1 Treatments are typically prescribed until visual improvement in the amblyopic eye plateaus or until the critical period of visual development has passed. Thus, treatment may continue for months or years depending on the amblyopia severity and the child's age.3 Even when improvement plateaus, glasses may still be needed for optimal vision or to protect the eyes.Unsurprisingly, requiring a child to use the amblyopic eye by occluding or blurring the better-seeing eye is often challenging. Children may peek around the patch or remove it altogether, requiring both direct supervision and financial resources for patch replacements to optimize treatment. As such, adherence to patching has been reported to be less than 50%, and a significant proportion of patients have persistent amblyopia despite treatment.4–6 However, it is difficult to quantify true treatment success rates when barriers such as patch costs ($30–50 per month) limit adherence and may drive inequities. If the child also needs glasses, the likelihood of adherence further declines, because insurance typically only covers poorly durable glasses, if at all, and may not cover replacements despite the known challenges of lost or broken glasses, especially in children.Digital therapies for amblyopia that use simultaneous visual input to both eyes are emerging. Examples include Luminopia®, which uses a virtual reality headset and modified videos, and CureSight™, which uses red–blue glasses and modified internet content. These may benefit children who are intolerant to patching or atropine eye drops, but current out-of-pocket costs for these therapies are significantly higher (up to $149 per month) than patching or drops and risk exacerbating inequities.Repka et al found that children enrolled in Medicaid or who identified as Black had significantly poorer amblyopia treatment outcomes.7 The authors suggested possible causes for the disparities, including diagnosis at an older age, socioeconomic and/or cultural factors, inadequate access to glasses, unconscious physician bias in treatment recommendations, and less frequent monitoring due to reimbursement concerns. These explanations are supported by additional research, which has found the following challenges.Stults et al found that, compared with white children, the likelihood of photoscreener-based vision screening was lower in Black, Asian, and Hispanic children, but the likelihood of amblyopia diagnosis was higher in Hispanic and Asian children, suggesting that those in higher need and with a potentially true disease may be more often missed.8 Rasendran et al found that children enrolled in Medicaid were less likely to receive timely ophthalmology evaluations compared with those with private insurance,9 which may delay or miss amblyopia diagnoses. Furthermore, because patient care–associated costs are often higher than Medicaid reimbursement, there is concern that accepting Medicaid is becoming a barrier to the sustainability of some practices, further limiting access to care.10The pediatric ophthalmology workforce is currently insufficient to meet the needs of at-risk and visually impaired children in the US.11 In addition, ophthalmology is one of the least diverse medical specialties, which is already less diverse than the country as a whole.12 These barriers may impede optimal communication of the lifelong implications of amblyopia and the need for timely treatment.Successful amblyopia treatment is resource intensive, often requiring glasses, patching or atropine drops, monitoring by the child's caregiver, and frequent follow-up appointments, and can significantly impact both the patient's and family's lives.13,14 Anecdotally, Medicaid and private insurance plans rarely cover patches, and coverage for glasses is often limited. Medicaid enrollees may thus experience additional challenges with adherence to treatment recommendations when the cost of patches and durable glasses and their replacements can represent a significant portion of family budgets. Furthermore, they often have less consistent follow-up.15It should be noted that many of these barriers represent or are exacerbated by forms of racism and classism,16,17 which also need to be recognized and addressed at all levels of care for children.To address health care inequities in amblyopia diagnosis, management, and outcomes, we suggest the following complementary interventions to enhance patient engagement, access to quality care, and therapy adherence (Figure 1):Promote insurance coverage of patching and durable glasses and their replacements regardless of plan. Given the lifetime implications of amblyopia13 and visual impairment,18 this upfront investment could reduce overall health care and societal costs.19–21Continued partnerships with the American Academy of Pediatrics and the American Association for Pediatric Ophthalmology and Strabismus to refine vision screening guidelines based on emerging research and technology and ensure screening is applied across populations uniformly. Economic evaluations of vision screening in children have shown it to be a cost-effective public health intervention.22,23Improve insurance reimbursement to expand access to specialized amblyopia care. This is particularly critical for Medicaid, in which reimbursement rates are frequently undervalued,24 affecting access to care. Also, ensure coverage of all types of amblyopia (refractive, strabismic, and deprivation) as well as amblyogenic conditions (including refractive error) as medical diagnoses by payers.Provide incentives to promote pediatric ophthalmology workforce growth and diversification, including expansion of the Pediatric Specialty Loan Repayment Program,25 support for resources to facilitate diagnosis and adherence to recommended treatments (interpreters, orthoptists, social workers, child-life specialists), appropriately valued reimbursement for care, and equitable academic compensation and advancement for faculty in training programs. In a call to action for ophthalmology leaders, Aguwa et al12 called for improving underrepresented populations in medicine representation at all levels in ophthalmology, from trainees to leaders, to improve the eye health of racial and ethnic minority communities, such as by improving patient communication and satisfaction with their ophthalmologists, as well improving cultural competency of the ophthalmology workforce.Ensure all children receive timely and accurate vision screenings by trained staff with appropriate equipment in the medical home, schools, and other community settings to improve early amblyopia and risk factor detection and management.Establish outreach programs to raise awareness about the importance of pediatric vision screenings, follow-up, and treatment adherence to maximize visual outcomes.Engage with government and community entities to ensure that policies and programs are designed to benefit all children.26Provide bias training for clinicians and clinical support staff to reduce system-driven health care inequities.Create easily understandable, multilingual, and accessible educational resources about amblyopia, its consequences, and available treatments to empower families to advocate for their own eye health.Enhance access to interpreter services in health care settings to reduce language barriers in communicating the impact of amblyopia diagnosis and treatment during the critical period. In addition, translation services are needed to ensure patient education materials and prescriptions are provided in the patient's preferred language for health care.Continued development of innovative alternative diagnostic and therapeutic digital tools to help detect and treat amblyopia and its risk factors. These tools will require equitable access to reliable internet and two-way communication devices, as well as insurance coverage to prevent exacerbation of inequities.Optimize telemedicine for vision health assessments in children to enhance access to care.Incorporate artificial intelligence algorithms into old and new tools, ensuring they have been carefully developed, trained, and thoroughly tested in diverse populations to avoid biases in historical data, which may perpetuate or worsen inequities.In conclusion, caregivers, pediatricians, pediatric ophthalmologists, professional organizations, and policymakers will need to continuously collaborate to achieve equity in amblyopia treatment and outcomes, so that avoidable permanent vision loss is not an impediment to the development of any child.