Findings from a recent study published in the American Journal of Ophthalmology evaluated racial and ethnic differences in the use of microinvasive glaucoma surgery (MIGS) to manage mild to moderate primary open-angle glaucoma (POAG) in the United States (US).
Give me some background.
MIGS has gained popularity in recent decades as a surgical approach to lowering intraocular pressure (IOP) earlier in the disease course—potentially delaying the need for more invasive traditional glaucoma surgeries.
MIGS procedures are primarily used to treat mild to moderate POAG and offer advantages such as:
- Faster operation times
- Relative procedural simplicity
- Quicker patient recovery
However: Healthcare disparities persist in the surgical management of glaucoma that are influenced by layered socioeconomic factors.
For example?
In the U.S., Black patients are at a higher risk of advanced ocular disease and visual impairment due to challenges in receiving quality healthcare. These may include:
- Lower rates of diagnostic testing
- Fewer outpatient visits
- Decreased trust in healthcare providers
Further: Studies have indicated that rates of glaucoma surgery in Black patients are significantly lower than expected, despite higher observed rates of glaucoma compared to white patients.
- As such: This study sought to examine disparities in MIGS use within a vulnerable population and highlight the need for extended support for at-risk marginalized populations.
Now, talk about the study.
In this retrospective cohort study, investigators included patients with a diagnosis of mild or moderate POAG (as defined by Current Procedural Terminology [CPT]).
The experimental group was made up of Black patients, while the control group consisted of non-Black patients from the TriNetX database.
- Note: The TriNetX database contains 64 healthcare organizations and deidentified electronic health records of over 113 million U.S. patients.
Anything else?
The main outcome measure was the incidence of MIGS over 1 year of follow-up after a POAG diagnosis.
To compare the cohorts, the research team utilized propensity score matching for the following characteristics:
- Age at diagnosis
- Charlson Comorbidity Index
- Sex
- Nicotine dependence
- Glaucoma medications
- Family history of POAG
- Body mass index (BMI)
- Weight
Findings?
In total, 63,418 POAG patients (50% Black, 50% non-Black) were included.
Black patients were found to undergo MIGS at a significantly lower rate (1,268 / 31,709) compared to non-Black patients (1,508 / 31,709; odds ratio [OR] 0.834, 95% confidence interval [CI] 0.773-0.900).
Expert opinion?
The lower rate of MIGS procedures in Black patients could be due to the fact that Black patients are more likely to be diagnosed with POAG at later stages, the study authors noted.
Plus: POAG is known to progress at a greater pace and more severely in Black patients.
- Meaning: Black patients may be less likely to qualify as eligible candidates for MIGS due to these factors.
Limitations?
These included:
- The timeline of this study (1 year after POAG diagnosis) may have contributed to potential disparities, as medical management is generally the first-line treatment for most cases of mild to moderate glaucoma
- The TriNetX database did not allow for investigation of specific clinical features (ex., IOP, cup-disc ratio, etc.)
- These results did not account for patients who were uninsured or did not see a provider
Take home.
These findings suggest that while POAG is understood to be more prevalent in African American patients, this patient population displays lower use of MIGS—indicating a nationwide racial disparity in the management of POAG.
The results from this study underscore the necessity for widespread early screenings and equitable healthcare access for Black patients in the United States.
Next steps?
Additional studies with comprehensive data sets that feature the characteristics below are needed to further elucidate why disparities exist in the early treatment of POAG with MIGS:
- IOP measurements
- Retinal nerve fiber layer (RNFL) thickness
- Visual field indices
- Patient demographics