A new study by doctors at St. Michael’s Hospital in Toronto, Ontario, has found that one-quarter of homeless people surveyed in Canada’s largest city reported having vision problems up to and including cataracts and blindness. That metric is four times the rate of vision disorders among North America’s overall population.
Prescription eyeglasses or contact lenses would help only two in five of those unfortunate individuals according to ophthalmologist Dr. Myrna Lichter, and a medical student Christopher Noel, investigators in the study published this month in the journal JAMA Ophthalmology, entitled “Visual Impairment and Unmet Eye Care Needs Among Homeless Adults in a Canadian City“ (JAMA Ophthalmol. Published online first February 05, 2015. doi:10.1001/jamaophthalmol.2014.6113).
The study is coauthored by Dr. Lichter, MD; Mr. Noel, BSc; Alan Berger, MD; Henry Fung, BHSc; and Raman Srivastava, MBT of the Department of Ophthalmology at St. Michael’s Hospital Health Centre, University of Toronto; Gerald Lebovic, PhD, of the Applied Health Research Centre at the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, and the University of Toronto Institute of Health Policy Management and Evaluation; and Stephen W. Hwang, MD, MPH, of the Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael’s Hospital and the University of Toronto Department of Medicine’s Division of General Internal Medicine, who observe that while the ocular status among homeless populations remains largely obscure, it’s reasonable to deduce that because heavy correlation between poor visual acuity with reduced well-being and decreased earning potential, it could also have important implications for the health of individuals experiencing homelessness.
Consequently, the study’s objective was to assess prevalence of visual impairment and to identify unmet eye care needs among the adult homeless population of a major North American city.
The investigators recruited 100 homeless persons between January to March 2014 using a stratified random sampling technique, with recruitment venues spread among 10 of Toronto’s 34 adult homeless shelters were selected at random as were bed numbers in those shelters as the beds were filled. Shelter clients were invited to participate in the survey. All participants were English-speaking persons older than 18 years of age (median age of participants was 48 years (interquartile range, 36-56 years), from whom information was obtained regarding the individual’s sociodemographic characteristics, ocular history, and subjective visual acuity. A comprehensive vision screening assessment and an undilated retinal examination were performed for each participant as part of the interview protocol.
Sixty-two percent of the participants were men with a median lifetime duration of homelessness of 12 months (interquartile range, 5-36 months). Based on the participant cohort’s measured visual acuity, the age-standardized rate of visual impairment was 25.2 percent. After pinhole occlusion, this number decreased to 15.2 percent of participants experiencing visual impairment secondary to a correctable refractive error. Not surprisingly the major visual problem found in this demographic was limited access to refractive correction (i.e.; eyeglasses or contact lenses). Among the 61of 100 survey participants who reported having worn prescription eyeglasses in the past, only 18 (30 percent) still had glasses; most explaining that their glasses had been lost, stolen or broken, and they didn’t have the funds necessary to replace them.
However, the coauthors also report that a large degree of nonrefractive pathology such as cataracts, glaucoma and macular degeneration was also observed, with 34.0 percent of participants presenting with one or more abnormal findings during the vision screening, and 8 percent requiring urgent referral to an opthalmologist (access to which is included free-of-charge in Canada’s publicly-funded health care coverage). The researchers note that a large majority of participants (89.0%) indicated interest in accessing free eye examinations. Fourteen percent of survey participants indicated that they had seen an optometrist or ophthalmologist in the past year, compared to 41 percent of the Canada’s population generally. Dr. Lichter advocates establishment of vision-screening programs in Toronto’s shelter system that would include both eye exams and free eyewear, noting that such mobile eye screening programs have been effective in South Africa, Costa Rica, the United States and the United Kingdom.
The study coauthors conclude that their data suggest a high prevalence of visual impairment among homeless adults, and that large inequities exist within Canada’s eye care delivery system, even with a universal, no-charge health insurance system in place. They project that given the observed high level of interest in eye care access among homeless persons surveyed in their study, ongoing vision-screening programs and readily accessible free eye clinics may help address this demonstrated need.
“Homeless people represent one of the most vulnerable groups within our society” Dr. Lichter observes in a St. Michael’s Hospital release. “They are at increased risk of a variety of illnesses and rates of substance abuse and mental illness are typically high. Poor vision in the general population is known to be associated with reduced wellbeing and income potential.” Dr. Lichter adds that while the body of literature on homelessness and health is growing little is still known about the eye health of homeless people.
Coauthor Christopher Noel says the strength of this study lies with its random sampling technique, which allowed the researchers to more accurately assess the scope of visual impairment within the homeless community, and that he believes the study findings can serve to fill an important knowledge gap, providing ophthalmologists with information they can use to better position the profession to develop targeted interventions for improving eye care access for the homeless community.
Dr. Lichter suggests that the study’s findings probably still underestimate the extent of vision acuity disorders among the homeless population, since individuals who actually stay in shelters rather than sleeping in subways or just hunkering down as best they can against the winter cold would generally represent a better fed and healthier subset than those who live on the streets.
This study received support from the Ministry of Health of Ontario Alternate Funding
St. Michael’s Hospital is dedicated to providing compassionate care to all who enter its doors, and is a teaching institution helping educate future health care professionals in 27 academic disciplines, with critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among its recognized areas of expertise. Founded by the Sisters of St. Joseph in 1892, as early as 1894, St. Michael’s Hospital received medical students and, in 1920, negotiated a formal agreement with the faculty of medicine at the University of Toronto. Today the hospital continues to be fully affiliated with the University of Toronto.
St. Michael’s Hospital