Patient and Practice Level Visual Acuity Prior to Cataract Surgery in the United States: An IRIS® Registry (Intelligent Research in Sight) Analysis

Purpose: To examine the influence of patient demographic characteristics and ophthalmic practice composition on access to cataract surgery in the United States as measured by preoperative best-corrected visual acuity (BCVA). Patient and Methods: This retrospective cohort study analyzed data from the IRIS ® Registry (Intelligent Research in Sight) for patients age > 50 who had at least one BCVA measurement in the six months preceding cataract surgery performed between January 1, 2016, and December 31, 2020. We used mixed-effects models to estimate the relationship between individual-level demographic factors and practice-level composition factors and preoperative BCVA. Results: A total of 2,387,045 individuals met the inclusion criteria. The mean BCVA prior to surgery was 0.23 (SD: 0.32) logMAR. The worst pre-operative BCVA was observed in patients with Hispanic race and ethnicity, while White patients had the best [0.34 (SD: 0.43), 0.21 (SD: 0.30); p< 0.001]. Grouping patients in terms of percentage of BCVA worse than 20/50 prior to surgery, Hispanic patients, active smokers, and uninsured patients had higher percentages of worse preoperative vision (33.7%, 23.5%, 34.9%). Analysis of compositional effects of race and ethnicity, smoking, and insurance status showed that, regardless of an individual patient’s demographic, patients treated at practices serving higher proportions of White patients showed better BCVA (b = − 0.008 per 10 percentage points, P < 0.001), while patients at practices with higher percentages of actively smoking patients showed worse BCVA (b=− 0.016 per 10 percentage points active smoking patients, P < 0.001). There was no compositional effect of insurance status. Conclusions and Relevance: Overall differences exist with regard to the visual acuity at which cataract surgery is initiated at both the level of the individual patient and the composition of the practice in which they are treated. Plain Language Summary: Demographic disparities and geographic variation in access to cataract surgery in the United States have been previously described in large national studies of insurance data. Smaller studies of single institutions expanded upon these studies by showing differences in preoperative visual acuity – an important measure of access to cataract surgery – based on factors such as race and insurance status but were limited by the size and scope of their study patients. The IRIS ® Registry (Intelligent Research in Sight) is the nation’s first comprehensive ophthalmic clinical registry with data from both individual patients as well as ophthalmic group practices. Using data from this registry, we show differences in preoperative visual acuity prior to cataract surgery at both the level of the patient and the practice in which they are treated. Keywords: cataract, preoperative visual acuity, access to surgery