The gap for vision is closing

Refractive error, diabetic retinopathy, cataract and trachoma, account for 94 per cent of vision loss in Aboriginal and Torres Strait Islander adults, yet all these conditions can be readily treated or prevented and vision loss is often restored with timely access to services.

The National Eye Health Survey, 2016, found that lower levels of available eye care, particularly in rural and remote areas where a shortage of health service providers exists, is a major contributor to poorer eye health among Aboriginal and Torres Strait Islander people . Yet, barriers to access and utilisation can be overcome through improvements in coordination of the eye care pathway. A previous Partyline article focused on health promotion initiatives around trachoma and diabetic eye disease. This article discusses coordination of the eye care pathway for refractive error and cataract surgery.

Patients’ eye care journey has been described as a leaky pipe. Patients with an eye or vision problem enter the pathway through the Aboriginal Health Service and need to progress to optometry and ophthalmology and hospital services generally at a different time, in a different location and with a different provider. There are many opportunities for leakage. The lack of access to public cataract surgery creates back pressure through the pipe causing more leakage. If you attend to only one or two leaks, the pipe will still be leaking and so the whole pathway needs to be fixed.

The Roadmap to Close the Gap for Vision is a sector-endorsed, whole-of-system policy framework with 42 recommendations to reduce the eye health inequity between mainstream and Indigenous Australians. To date, 11 of the 42 recommendations are completed and activity has commenced on all 42 recommendations.

Refractive error (need for glasses) is one of the major causes of vision loss that, once identified, is easily, quickly and inexpensively corrected with prescription glasses. Refractive error includes the need for distance vision glasses as well as the loss of near or reading vision people suffer from 40 years of age.

Limited optometry services in rural and remote settings, high demand for replacement glasses and the expense of prescription glasses are some reasons that fewer Aboriginal and Torres Strait Islander people have their refractive error treated. Improving identification of vision problems and referral for eye care needs as part of comprehensive primary health care is key and the MBS item 715 includes an eye assessment. From this point coordinating primary care with eye care services to help patients navigate the referral pathways is vital. Access to low cost spectacle schemes, available in variable forms in each state and territory, also help to eliminate the financial barriers to obtaining prescription glasses.

Better access and coordination of eye care is also vital to ensure that people diagnosed with cataract receive more timely access to surgery. The cataract surgery coverage rate is about 1.5 times lower for Aboriginal and Torres Strait Islander adults compared to non-Indigenous adults. In many jurisdictions, public hospital patients wait for more than a year before cataract surgery is performed, and therefore many people ‘drop out’ of the system or opt for surgery in the private sector. Indigenous Australians are less likely to access private surgery and are four times more likely to wait for more than a year than non-Indigenous Australians in the public sector. Local care coordination and patient transport schemes are vital to support Aboriginal and Torres Strait Islander patients. The gap for un-operated cataract surgery could also be eliminated if jurisdictions routinely assigned higher priority to Aboriginal and Torres Strait Islander patients requiring the surgery. Recent initiatives in Victoria demonstrate that hospital systems can be reformed by implementing a direct cataract referral program from an Aboriginal Health Service. 

Australia is making significant progress to close the gap for vision. The rate of blindness in Indigenous Australians reduced from six times the rate seen in non-Indigenous Australians in 2008 to three times in 2016. The prevalence of trachoma in Indigenous children has gone from 21 per cent in 2008 to 4.6 per cent in 2015 after implementation of the World Health Organisation’s SAFE Strategy. The efforts of all stakeholders, from local communities and health services to the Australian government, have contributed to these outcomes. While many Roadmap recommendations require national policy change and leadership, implementation of recommendations at the local and jurisdictional level will ensure that the gap for vision will be closed.