Take-home points

  • Socioeconomic barriers reduce timely screening and treatment in diabetic retinopathy, leading to worse vision outcomes.

  • Lower socioeconomic status and minority status are linked to poorer visual outcomes in retinal vein occlusion.

  • Delayed care due to social disadvantage results in more severe detachments and worse prognosis in rhegmatogenous retinal detachment.

  • Partnerships between retina specialists and federally qualified health centers can bridge systemic gaps in access and advance equity in vision health for underserved communities.

Bios

Ranveer Palia is a 2nd-year medical student at the Medical College of Wisconsin, Milwaukee.

Sunny Lang Qin is a 3rd-year ophthalmology resident at Wake Forest University School of Medicine, Winston-Salem, North Carolina. 

Jaron Kai Pruett is a 2nd-year ophthalmology resident at Wake Forest University School of Medicine. (All three of these first authors contributed equally.)

Sally S. Ong is a vitreoretinal surgeon and an assistant professor of ophthalmology at the Wake Forest School of Medicine.

A 46-year-old African-American man with poorly controlled type 1 diabetes presented to clinic with blurry vision. He was diagnosed with proliferative diabetic retinopathy in both eyes, complicated by diffuse capillary nonperfusion involving the macula (Figure 1). His visual acuity measured 20/200 in the right eye and 20/400 in the left. The consulting physician at the time recommended treatment, but the patient was lost to follow-up.

Two years later, the patient presented to our clinic with worsening vision, now reduced to hand motions in both eyes. Examination showed bilateral fovea-involving tractional retinal detachments (Figure 2). Further questioning revealed that the patient was unemployed, faced housing and food instability, and depended on public and Medicaid transportation to get to medical appointments. Surgical intervention was recommended; however, the patient’s prognosis for visual recovery was dismal, and his case illustrates how much worse outcomes can be when patients are lost to follow-up, often due to challenges related to social determinants of health.

Unfortunately, stories like this one aren’t uncommon in retinal practice. Retinal diseases remain a leading cause of vision loss and blindness worldwide. While risk factors such as diabetes, hypertension, aging, smoking and trauma are well established, outcomes are also shaped by SDOH. These include factors such as income, access to care, health literacy, transportation, food insecurity and social support.1 Healthy People 2030 has defined SDOH as “the conditions in the environments where people are born, live, learn, work, play, worship and age,” and further grouped SDOH into five domains: economic stability; education access and quality; health-care access and quality; neighborhood and built environment; and social and community context.2 Together, these conditions often determine whether patients can obtain timely diagnosis, initiate treatment and adhere to follow-up schedules.

There’s growing recognition that SDOH play a pivotal role in ophthalmology, influencing disparities in diagnosis, treatment access, adherence and long-term outcomes. Two patients with the same disease severity may have vastly different prognoses depending on the social and economic contexts in which they live.

In this article, we highlight how SDOH affect the care and prognosis of three key retinal diseases: diabetic retinopathy, retinal vein occlusion and rhegmatogenous retinal detachment. Through these examples, we highlight how non-biological factors drive disease burden and outcomes, and why addressing them is critical to reducing inequities.

 

Diabetic retinopathy

Diabetic retinopathy is one of the leading causes of vision loss globally, with an estimated 9.6 million people living with diabetic retinopathy in the United States, yet awareness and access to medical care remain uneven across populations.3 Growing evidence highlights that SDOH are critical drivers of outcomes for patients at risk of or living with DR. Studies using national data demonstrate both the scale of the disease and the disparities in its recognition and treatment. For example, an analysis of National Health and Nutrition Examination Survey data found that awareness of DR was low overall, and that minority status, unemployment and food insecurity significantly influenced whether patients knew about the disease.4
 
Similarly, population-level analyses of the National Health Interview Survey showed that unemployment, disability and residence in the Southern United States were associated with higher DR burden, underscoring the role of geography and economic stability.5 Large-scale surveys have also demonstrated that individuals facing social vulnerabilities such as unemployment and poor self-rated health were less likely to undergo recommended eye exams, further linking structural disadvantage to gaps in preventive care.6,7


Specific SDOH drivers have been extensively studied. Food insecurity not only worsens diabetes control but also reduces the likelihood of patients pursuing vision care, with both food and housing instability associated with lower odds of DR screening.8,9 Economic stability plays a similar role: Unemployment, disability, and financial hardship decrease access to preventive care.5,6 Race, ethnicity and cultural factors introduce additional disparities, with minority populations less likely to undergo guideline-based monitoring, while childcare responsibilities and perceived provider bias further reduce access.7,10-11

Access to health care and insurance coverage remain central issues: Insurance status and higher education improve the odds of completing annual exams, while lack of coverage, financial insecurity and transportation barriers increase the risk of advanced complications.12-14 Broader reviews emphasize that systemic issues—including language barriers, limited provider availability and fragmented coverage—continue to shape inequities in vision care.15,16

The implications of these findings are clear. Tailoring prevention strategies by employment status, geography or disability may improve screening rates, and increasing awareness of DR in underserved communities could provide an entry point for preventive diabetes care.3-4 Structural barriers must also be addressed through expanded insurance coverage, transportation support and multilingual resources.15 At a systems level, incorporating SDOH into electronic health records may allow clinicians to anticipate patient needs and design interventions accordingly.16 In parallel, culturally sensitive approaches are essential for reducing disparities in racial and ethnic minority groups.10,11

Figure 1. Multimodal imaging of the patient in 2023 when he presented with visual acuities of 20/200 in the right eye and 20/400 in the left eye. Color photos of the right (A) and left (D) eyes show neovascularization of the disc and elsewhere, and severe vascular attenuation. Fluorescein angiograms of the right (B) and left (E) eyes confirm presence of neovascularization of the disc and elsewhere as well as diffuse capillary nonperfusion affecting the macula worse in the left eye. Optical coherence tomography of the macula of the right (C) and left (F) eyes demonstrate diffuse retinal thinning.

Retinal vein occlusion

Central and branch retinal vein occlusions are important causes of vision loss with an estimated 16.4 million adults being affected by retinal vascular occlusions globally (2.5 million by CRVO and 13.9 million by BRVO).17 It’s well known that predisposing factors for RVO include many of the same risks as those for cardiovascular and cerebrovascular disease, namely hypertension, obesity, hyperlipidemia and diabetes mellitus.18-21 In the United States, these systemic risk factors have been shown to be both more prevalent and worse-controlled among patients with markers of low socioeconomic status, possibly placing these patients at increased risk of vision-threatening illness.22 However, further work is needed to determine whether this directly translates into a higher incidence or prevalence of RVOs in socially and economically disadvantaged populations.

While this has yet to be demonstrated, a recent retrospective study found that among patients presenting with BRVO with cystoid macular edema who were treated with intravitreal anti-VEGF injections, those with higher socioeconomic deprivation scores had thicker final central macular thickness.23 Additionally, non-White patients had worse initial and final best corrected visual acuity. Both these results point to disparities in visual outcomes associated with lower socioeconomic status among patients with RVOs.

More recently, an analysis of over 600 cases of RVO from the National Institutes of Health’s All of Us database further highlighted the role of social determinants in disease risk. In addition to confirming traditional medical risk factors mentioned above, the study found that patients who identified as Black and those with opioid use were independently associated with an increased risk of both BRVO and CRVO, highlighting the need for further investigation into how social and behavioral factors contribute to RVO.24

Figure 2. The patient was lost to follow-up and returned two years later with worsening vision in both eyes to hand motions. Fundus photos of the right (A) and left (C) eyes show progressive proliferative diabetic retinopathy with bilateral fovea-involving tractional retinal detachments with thick fibrovascular membranes extending from the optic nerve head to both the superotemporal and inferotemporal arcades. Optical coherence tomography of the right (B) and left (D) eyes through the macula confirm tractional retinal detachments, showing the retinal layers pulled anteriorly in a tent-like configuration with complete loss of the normal foveal contour.
 

Rhegmatogenous retinal detachment

Rhegmatogenous retinal detachment is the most common form of RD, with an estimated incidence of 6.3 to 17.9 per 100,000 persons.25 Multiple studies have demonstrated that socioeconomic factors significantly impact how patients present with RRD and their subsequent outcomes. Research consistently shows that socioeconomically disadvantaged patients are more likely to present with severe disease, including worse visual acuity and fovea-involving detachments.26


Large-scale studies from major U.S. academic centers have found that factors such as older age, male gender, minority race and lower income are independently associated with more severe presentation.26,27 Patients with public insurance (Medicare/Medicaid) or no insurance have worse baseline visual acuity and higher rates of fovea-involving detachments compared to those with private insurance.26-28 Neighborhood-level factors, including area deprivation indices and transportation barriers, also predict worse baseline severity even after controlling for individual characteristics.27 International studies from Scotland and other countries have reported similar patterns, with retinal detachment severity correlating inversely with socioeconomic status.25,29

Beyond initial presentation, socioeconomic disadvantage affects surgical outcomes. Patients from disadvantaged backgrounds face higher reoperation rates and worse long-term visual outcomes, even after accounting for baseline disease severity.26,28 These disparities persist across different health-care systems and geographic regions.

These disparities matter because RRD outcomes have been shown to be closely linked to baseline visual acuity and foveal status.30 Delays in presentation allow progression to foveal involvement, where subfoveal fluid can cause irreversible photoreceptor damage.31-33 Socioeconomic barriers to timely care—including limited health-care access, transportation challenges and delayed symptom recognition—directly compromise visual outcomes in this sight-threatening condition.

 

Bottom line

Diabetic retinopathy, retinal vein occlusion and rhegmatogenous retinal detachment are all vision-threatening conditions for which outcomes can be heavily impacted by SDOH, which include socioeconomic status, access to high quality education and health care, safe and healthy environments, and social connectedness.2 Evidence demonstrates that patients facing financial hardship, unemployment, food and housing insecurity, transportation barriers or systemic inequities are more likely to present with advanced disease, have lower rates of preventive screening, and experience worse visual outcomes.4-6,8-9,12-14,26-28


Addressing these disparities requires multi-level interventions. At the patient level, culturally sensitive education, awareness campaigns, and navigation support can encourage timely care and adherence to screening guidelines. At the system level, telehealth initiatives and integration of SDOH into electronic health records can mitigate barriers, particularly for historically underserved populations. Another promising system-level strategy involves leveraging federally qualified health centers, which are uniquely positioned to extend vision care to communities most affected by social and structural inequities.

FQHCs serve over 30 million Americans, most of whom are uninsured or publicly insured, and yet fewer than 3 percent of patients receive vision services, even though they face disproportionately higher rates of diabetic retinopathy, glaucoma and vision impairment.35 Many patients and providers alike are unaware that FQHCs can be powerful partners in preventing vision loss. Retina specialists and ophthalmology practices can help change this by building closer relationships with local FQHCs—offering on-site or teleophthalmology screening, rotating clinics or streamlined referral networks. Such collaborations can bring retinal expertise directly to patients who might otherwise never see a specialist, while connecting those identified with eye disease to the enabling services FQHCs already provide like transportation, translation and case management.36,37

Beyond improving access, these partnerships can foster awareness within the community that vision care is an important part of comprehensive health care. Moreover, investing in FQHC-based vision programs isn’t only the ethical thing to do but also yields long term economic benefits. FQHCs prevents avoidable blindness, which reduces long-term health costs and helps maintain the independence and productivity of those most affected by social and structural inequities.36,37 By engaging with FQHCs, retina specialists have an opportunity not only to treat disease but to transform the systems that determine who gets to keep their sight, bringing us closer to equitable vision care for all. RS

REFERENCES

1. Braveman P, Gottlieb L. The social determinants of health: It’s time to consider the causes of the causes. Public Health Rep 2014;129(Suppl 2):19-31.
2. Centers for Disease Control and Prevention. Social determinants of health. Public Health Gateway. Published May 15, 2024. Accessed November 4, 2025. https://www.cdc.gov/public-health-gateway/php/about/social-determinants-of-health.html
3. Lundeen EA, Burke-Conte Z, Rein DB, et al. Prevalence of diabetic retinopathy in the US in 2021. JAMA Ophthalmol 2023;141:8:747–754.
4. Nwanyanwu K, Andoh J, Chen E, et al. Social determinants associated with diabetic retinopathy awareness: National Health and Nutrition Examination Survey (2001–2008). Am J Ophthalmol 2025;278:389-401.
5. Zaman M, Zajner C, Xie J, et al. Association between sociodemographic factors and self-reported diabetic retinopathy: A cross-sectional, population-based analysis. Am J Ophthalmol 2025;271:138-148.
6. Silverberg EL, Sterling TW, Williams TH, et al. Associations between social determinants of health and self-reported diabetic retinopathy: Exploratory analysis. Int J Environ Res Public Health 2021;18:2:792.
7. Besagar S, Yonekawa Y, Sridhar J, et al. Association of socioeconomic, demographic, and health care access disparities with severe visual impairment in the US. JAMA Ophthalmol 2022;140:12:1219-1226.
8. Talebi R, Yu F, Tseng VL, Coleman AL. Association between food insecurity and chronic eye disease in the National Institutes of Health’s All of Us Research Program. Ophthalmol Sci 2024;5:3:100697.
9. Ravindranath R, Bernstein IA, Fernandez KS, et al. Social determinants of health and perceived barriers to care in diabetic retinopathy screening. JAMA Ophthalmol 2023;141:12:1161-1171.
10. Chaudhury AS, Ige M, Marwah S. Race, social determinants of health, and the quality of diabetic eye care. JAMA Ophthalmol 2024;142:10:961-970.
11. Huang BB, Saseendrakumar R, Delavar A, Baxter SL. Racial disparities in barriers to care for patients with diabetic retinopathy in a nationwide cohort. Transl Vis Sci Technol 2023;12:3:14.
12. Jotte A, Vander Kooi W, French DD. Factors associated with annual vision exams among diabetic adults: Analysis of the 2019 National Health Interview Survey. Clin Ophthalmol 2023;17:613-621.
13. Andersen JA, Gibbs L. Does insulin therapy matter? Pharmacies’ role in managing diabetes care outcomes. Prim Care Diabetes 2018;12:3:224-230.
14. Chan AX, McDermott JJ, Lee TC, et al. Associations between healthcare utilization and access and diabetic retinopathy complications using all US nationwide surgery data. PLoS One 2022;17:6:e0269231.
15. Solomon SD, Shoge RY, Ervin AM, et al. Improving access to eye care: A systematic review of the literature. Ophthalmology 2022;129:10:e114-e126.
16. Lee TC, Saseendrakumar BR, Nayak M, et al. Social determinants of health data availability for patients with eye disease. Ophthalmol Sci 2022;2:2:100151.
17. Laouri, M, Chen, E, Looman, M, & Gallagher, M. The burden of disease of retinal vein occlusion: Review of the literature. Eye 2011;25:8:981–988.
18. Kolar P. (2014). Risk factors for central and branch retinal vein occlusion: A meta-analysis of published clinical data. Journal of Ophthalmology 2014:2014:724780. doi: 10.1155/2014/724780. Epub 2014 Jun 9
19. Yau JW, Lee P, Wong TY, Best J, & Jenkins A. Retinal vein occlusion: An approach to diagnosis, systemic risk factors and management. Internal Medicine Journal 2008;38:12:904–910.
20. Okonkwo ON, Adenuga OO, Nkanga D, Ovienria W, et al. Prevalence and systemic associations of retinal vascular occlusions in Sub-Saharan Africa. Annals of African Medicine 2023;22:3:279–285.
21. Fiebai B, Ejimadu, CS, Komolafe RD. Incidence and risk factors for retinal vein occlusion at the University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria. Nigerian Journal Of Clinical Practice 2014;17:4:462–466.
22. Powell-Wiley, TM, Baumer Y, Baah, FO, Baez, AS, et al. Social determinants of cardiovascular disease. Circulation Research 2022;130:5:782–799.
23. Woldetensaye AG, Selander JM, Huang H, Patel PV, et al. The impact of social determinants of health on presentation, treatment, and outcomes in branch retinal vein occlusion with cystoid macular edema. Ophthalmic Surgery, Lasers & Imaging Retina 2023;54:7:411–416.
24. McDermott JJ, Lee TC, Chan AX, Ye GY, et al. Novel association between opioid use and increased risk of retinal vein occlusion using the National Institutes of Health All of Us Research Program. Ophthalmology Science 2022;2:1:100099.
25. Mitry D, Charteris DG, Fleck BW, Campbell H, Singh J. The epidemiology of rhegmatogenous retinal detachment: Geographical variation and clinical associations. Br J Ophthalmol 2010;94:6:678-684.
26. Xu D, Uhr J, Patel SN, Pandit RR, Jenkins TL, Khan MA, Ho AC. Sociodemographic factors influencing rhegmatogenous retinal detachment presentation and outcome. Ophthalmol Retina 2021;5:4:337-341.
27. Ong SS, Tran D, Westlund E, et al. Neighborhood-level social determinants of health and presenting characteristics for rhegmatogenous retinal detachments. JAMA Ophthalmol 2024;142:9:845–854.
28. Rahman S, Sharma N, Valentim CCS, et al. Rhegmatogenous retinal detachment: Variations in clinical presentation and surgical outcomes by socioeconomic status and race. Ophthalmic Surg Lasers Imaging Retina 2022;53:10:538-545.
29. Mitry D, Charteris DG, Yorston D, et al. The epidemiology and socioeconomic associations of retinal detachment in Scotland: A two-year prospective population-based study. Invest Opthalmol Vis Sci 2010;51:4963.
30. Saidkasimova S, Mitry D, Singh J, et al. Retinal detachment in Scotland is associated with affluence. Br J Ophthalmol 2009;93:1591e1594.
31. Wykoff CC, Smiddy WE, Mathen T, Schwartz SG, Flynn HW Jr, Shi W. Fovea-sparing retinal detachments: Time to surgery and visual outcomes. Am J Ophthalmol 2010;150:2:205-210.e2.
32. Chang CJ, Lai WW, Edward DP, Tso MO. Apoptotic photoreceptor cell death after traumatic retinal detachment in humans. Arch Ophthalmol 1995;113:7:880-886.
33. Kubay OV, Charteris DG, Newland HS, Raymond GL. Retinal detachment neuropathology and potential strategies for neuroprotection. Surv Ophthalmol 2005;50:5:463-475.
34. Bai P, Burt SS, Woodward MA, et al. Federally Qualified Health Centers as a model to improve vision health: A systematic review. JAMA Ophthalmol 2025;143:3:242-251.
35. Ong SS. Expanding vision services at Federally Qualified Health Centers. JAMA Ophthalmol 2025;143:3:251–253.
36. Bastos de Carvalho A, Lee Ware S, Belcher T, et al. Evaluation of multilevel barriers and facilitators in a large diabetic retinopathy screening program in Federally Qualified Health Centers: A qualitative study. Implement Sci Commun 2021;2:1:54.
37. Yadlapalli N, Hollinger R, Berzack S, et al. Potential gaps in eye care based on evaluation of Federally Qualified Health Centers. JAMA Ophthalmol 2024;142:11:1018–1026.