Conditions such as diabetic retinopathy and glaucoma can be sight threatening, often with irreversible changes. Early intervention and adherence to treatment are key to maintaining good visual health and quality of life for these patients. In the UK, there is a higher incidence of diabetic retinopathy in South Asians and primary open angle glaucoma in people of African descent [1,2].
We are taught that people of these ethnicities are at higher risk of developing eye conditions with earlier onset of disease due to their genetic predisposition from as early as medical school. It makes sense that we would utilise this information to screen for changes in vision of high-risk individuals and intervene early. Yet, despite these well-known associations, the incidence rate remains high.
Ethnic minorities, those from socioeconomically deprived backgrounds and elderly patients are less likely to engage with eye services [2-4]. Ethnic minorities also present at later stages with more advanced ocular disease. They have poor adherence to treatment and are more likely to be lost to follow-up. Inaccessibility, poor health literacy as well as language barriers have been suggested as reasons for this [2,3].
Interventions to address accessibility, early management and shared responsibility have included screening programmes for diabetic retinopathy and public eye health education efforts. Increasing numbers of community and virtual eye services have also been established [5].
A study by Public Health England looking at rates of non-attendance at diabetic retinopathy screening identified patients of Black and other minority ethnicities as ‘hard to reach’ with notably higher rates of ‘did not attend’ at their appointments. Alongside them are people living in rural or more deprived areas as well as elderly patients [3,4]. So why is it that increasing accessibility does not directly translate into increased uptake and earlier disease detection amongst these individuals?
"As clinical practice today shifts towards prevention over treatment, public health measures need to address issues like engagement alongside accessibility"
Studies suggest clinical triggers that prompt patients to seek medical attention or attend health screenings can be subjective and vary between ethnic groups [1,6]. Increasing accessibility through community services without health education that targets these ‘hard to reach’ communities will not equate to engagement with screening. However, there is little research on this within ophthalmology specifically. Ethnic minorities may also have different expectations regarding their outcomes of care and treatment response [1,6]. Without understanding patient perspectives and behavioural patterns, we are unable to address these intangible barriers to access.
Differences in expectations highlight the importance of shared decision making, whereby healthcare professionals assist patients to collaboratively decide on the management of their condition. Through creating tailored treatment plans, educating patients and appropriately managing expectations during consultations, patients are given shared responsibility for managing their eye health.
Interpreter services are widely available across the NHS service, be that through in- person or remote interpreters. The aim is to ensure patients can understand and engage during the consultation without added difficulty. However, interpreter consultations add to clinic time for ophthalmologists.
Virtual clinics have also been integrated into eyecare, often run by allied healthcare professionals [4]. The aim of virtual clinics is to improve accessibility, minimise waiting times and prioritise in person appointments for patients who may need them more. However, a patient’s engagement with virtual services and how this influences their behaviour with future appointments depends on whether their expectations were appropriately managed. Personal preference regarding type of appointment is also a potential factor influencing engagement, with more research regarding cultural perspectives on this needed.
Sense of community is often highly valued amongst ethnic minorities. They may live with multiple generations in a single household and one individual’s behaviour can influence other members within the community. Positive experiences with eye health services may be spread through word of mouth and alongside increasing health literacy, can encourage proactiveness and engagement with eye health. Advocating for eye health in the community through GPs and at cultural events could also be avenues to increase engagement amongst ethnic minorities [7].
As our clinical knowledge grows and new treatments are developed, we need to also investigate behaviour, something that medicine tends to overlook. Beyond diagnosing and prescribing a medication or listing someone for a procedure, there needs to be active patient participation. Unfortunately, it does not look like engagement is equitable amongst patients of minority ethnicities.
Conclusion
We have established that in certain ophthalmology conditions, ethnic minority patients are classed as high-risk. It is important to acknowledge that we can improve visual health outcomes amongst these groups with early detection and treatment to reduce disease severity. As clinical practice today shifts towards prevention over treatment, public health measures need to address issues like engagement alongside accessibility.
Earlier detection and treatment will also lower the costs associated with the management of advanced ophthalmic disease. Investing in research that understands behaviour and motivations amongst patients is how we will be able to do this, especially amongst high-risk groups like ethnic minorities as well as elderly patients and those from more deprived areas who are also known to engage less. This is how we can work towards debunking the theory that genetic predisposition determines the fate of someone’s visual health.
References
1. Safitri A, Konstantakopoulou E, Gazzard G, Hu K. Priorities for health outcomes in glaucoma in an ethnically diverse cohort: an observational study. BMJ Open 2024;14(5):e081998
2. Nugawela MD, Gurudas S, Prevost AT, et al. Ethnic Disparities in the Development of Sight-Threatening Diabetic Retinopathy in a UK Multi-Ethnic Population with Diabetes: An Observational Cohort Study. J Pers Med 2021;11(8):740.
3. Shweikh Y, Ko F, Chan MP, et al. Measures of socioeconomic status and self-reported glaucoma in the U.K. Biobank cohort. Eye (Lond) 2015;29(10):1360–7.
4. Olejkova I, Bourke A. Breaking down barriers to diabetic eye screening attendance. Public Health England Blog 2018 [Online]:
https://phescreening.blog.gov.uk/2018/11/14/
breaking-down-barriers-to-diabetic-eye-screening-attendance/
5. https://www.rcophth.ac.uk/wp-content/uploads/
2021/12/RCOphth-The-Way-Forward-AMD-300117.pdf
6. Rauf A, Malik R, Bunce C, Wormald R. The British Asian community eye study: outline of results on the prevalence of eye disease in British Asians with origins from the Indian subcontinent. Indian J Ophthalmol 2013;61(2):53–8.
7. Viola E, Martorana M, Ceriotti D, et al. The effects of cultural engagement on health and well-being: a systematic review. Front Public Health 2024;12:1369066.
[All links last accessed June 2026]
Declaration of competing interests: None declared.
