Our world is built on the assumption of vision, posing challenges for the roughly 2·2 billion individuals with vision impairment. Age is a leading risk factor for many eye diseases, including diabetic retinopathy, glaucoma, and age-related macular degeneration. In 2020, there were approximately 34 million adults aged 50 years and older who were blind and 206 million with moderate to severe vision impairment. As our populations continue to age rapidly, eye health will become increasingly relevant.
Jan 4, 2022, marks World Braille Day and is an opportunity to not only draw attention to the importance of access and inclusion for those using braille but also, more broadly, to the importance of eye health. Although people of all ages with vision impairment and blindness face challenges, older people are more likely to have difficulties with mobility, to be disabled, and to have higher risk of falls and fractures. These limitations not only impede access to health services but also impair wellbeing, quality of life, and autonomy. Driving exemplifies the link between vision impairment and wellbeing because the ability to drive not only permits access to basic needs, health-care services, and support networks, but also provides an important sense of independence that older people are often denied. A 2017 survey by the charity Independent Age reports that 44% of drivers aged 70 years and older in the UK feel that losing the ability to drive would mean losing a part of their identify. Being stripped of the right to drive is especially burdensome for older people living in rural areas because it exacerbates existing access barriers and takes a toll on mental health, with the report showing that 54% of older people in these areas say that they would feel lonelier if no longer able to drive. Vision impairment has also been shown to decrease employment rates and productivity across ages. For older workers, who already face impediments in employment due to health issues, caring responsibilities, and structural ageism, the inability to participate in the workforce is detrimental.
Compounding these challenges, treatment and rehabilitative services for eye care are plagued with access barriers due to poor integration within primary health-care services and inefficient referral pathways. In many low-income and middle-income countries (LMICs), eye-care services are restricted to secondary or tertiary hospitals and, as these are disproportionately located in urban settings, many older people living in rural areas receive delayed diagnoses and treatment. Moreover, eye-care diagnosis and treatment, such as cataract surgery or refractive error assessment, are largely not covered by health insurance in LMICs, and out-of-pocket costs are also evident in high-income countries.
However, low uptake of eye-health services is not entirely attributable to these access barriers. Eye-health literacy remains low, leading to low adherence to interventions and overall poor health outcomes. The 2019 WHO World report on vision shows that older people are often unaware that vision problems are treatable and therefore do not report impairments, driven in part by assumptions that these are a normal part of ageing. Given that 50% of sight loss is preventable, early detection is crucial to ensure timely interventions.
The challenges in eye health are nicely summarised in a study in our current issue, in which a global panel of individuals across various disciplines in eye health, including policy makers and patients, identified key priorities in global eye health, including improving access to and uptake of services, increasing integration between care sectors, and reducing out-of-pocket costs. To care for our ageing populations, eye care must be moved to the forefront of health-care and policy planning. The growing burden of vision impairment must be addressed by integrating eye care and by facilitating access to interventions for older people (eg, voice assistant technology).
On a broader level, the future of eye health, and the care of older people more generally, requires perceptions of ageing to be reframed. The under-reporting of eye conditions in older populations reflects the widespread confounding of age as a risk factor for various conditions and the inevitability of these conditions with age. The dismissal of functional decline as an unavoidable by-product of ageing is rooted in societal ageism, which equates ageing with impairment. This dangerous notion leads older people to accept declining health in silence. We must shed these misperceptions and recognise that, although ageing is inevitable, age-related impairment, including loss of vision, is not.