Everyone with diabetes needs regular access to eye services, but these services are not equally accessible to everyone in Aotearoa. Underserved populations include Māori and Pacific people, younger and older age groups (compared to people in their 50s), and those living in areas with higher deprivation. To develop more equitable services we need to collect better information on service access and outcomes for different population groups
Diabetes can cause diabetic retinopathy—damage to the blood vessels at the back of the eye, which if not treated can lead to vision loss. Fortunately, regular retinal screening can detect early changes to the retina before vision loss occurs. In Aotearoa New Zealand, retinal screening is provided by the public health system and is usually recommended once every two years. People who develop diabetic retinopathy are referred to ophthalmology services for closer monitoring, or to receive treatment with laser or injections that can slow down the disease.
Why did we do this research?
To understand whether services are accessible to New Zealanders living with diabetes. Our aim was to identify any inequities in access to diabetes services between different population groups.
What did we do?
Using routinely collected data from 14 (of 20) District Health Boards that had provided data to the Ministry of Health, we identified everyone aged 15 years or over with a scheduled appointment at a diabetes screening or ophthalmology clinic between 2006 to 2019. We calculated how often people accessed diabetes eye care appointments, and whether there were any differences between genders, age groups, ethnicity groups, deprivation levels, and regions across Aotearoa.
What did we find?
~250,000 people had at least one scheduled diabetes eye care appointment between 2006 and 2019. Less than two-thirds (62.1%) of people accessed retinal screening every two years (as recommended).
A relatively low number of people never attended any retinal screening (1.5%) or follow-up ophthalmology appointments (0.8%) once they had been scheduled. Approximately 1 in 10 people (9.4%) accessing any diabetes eye care appointments received treatment (either laser or injections) for diabetic retinopathy over the study period.
Compared with NZ Europeans, Māori were about twice as likely to never receive diabetes eye care or to access ophthalmology when referred from retinal screening, and 9% relatively less likely to receive biennial screening. Māori received the fewest anti-VEGF injections when treatment was commenced
What is missing?
The available data had several limitations, which meant we could not estimate:
How many people were never offered an appointment.
A population-level national diabetic retinopathy screening rate.
Outcomes from eye service appointments or barriers to access
Citation: Silwal PR, Lee AC, Squirrell D, et al. Use of public sector diabetes eye services in New Zealand 2006–2019: Analysis of national routinely collected datasets. PLoS One. 2023;18:e0285904. doi: 10.1371/journal.pone.0285904
Buchanan Charitable Foundation Postdoctoral Fellow Dr Pushkar Silwal (middle) pictured with team members A/Prof Jacqueline Ramke (left) and Dr Braden Te Ao (right).
Pushkar Silwal, a member of the School of Optometry and Vision Science’s Community Eye Health team and the inaugural Buchanan Charitable Foundation’s Postdoctoral Fellow hopes that our transforming health system will better support eye care services that are accessible to everyone.
Although 1.1 billion people experience impaired vision globally, eye health is often overlooked as a public health concern. The ongoing health sector reforms that began in mid-2022 provide a unique opportunity for Pushkar and his colleagues to build on previous research findings and generate much-needed evidence on how eye care services can be more accessible and equitable in New Zealand.
In February 2023, Pushkar began a three-year postdoctoral fellowship funded by the Buchanan Charitable Foundation—a home-grown, philanthropic foundation that supports community development. During his Fellowship, Pushkar will undertake a series of research projects that will investigate how to strengthen our health system, with the goal of improving eye care services in Aotearoa. He will also engage with academics, programme managers, and policy makers to identify opportunities to promote the inclusion of eye health in health system monitoring.
“We hope this will allow us to translate the knowledge we generate into practice,” says Pushkar.
This work will follow on from Pushkar’s PhD research, where he examined whether the measures we use to monitor our health system are appropriate. During his Fellowship, Pushkar will maintain an honorary appointment within the School of Population Health and will be mentored by A/Prof Jacqueline (Jacqui) Ramke from the School of Optometry and Vision Science (SOVS) and Dr Braden Te Ao from SOPH.
“We are very excited to have Pushkar commence his fellowship with us and welcome his commitment to generate evidence to support equity-focused decision-making in eye health. We are very fortunate for this ongoing support from The Buchanan Charitable Foundation and thank them for their commitment to improve eye health for all New Zealanders”, says Jacqui.
To advocate for improved eye care, Pushkar will draw on a growing body of evidence that New Zealand eye care services are lacking. Last year, he co-authored a report titled “Eye care in Aotearoa New Zealand 2022” that found a range of areas where our eye care services could be strengthened. Commissioned by Eye Health Aotearoa and funded by Blind Low Vision New Zealand, the report systematically assessed our eye care services using an analysis tool developed by the World Health Organization. Importantly, the report provided a list of 81 recommended actions for policy makers to improve our eye care services.
“Our report shows that access to eye care services needs major strengthening,” he says.
Pushkar has a long-standing interest in health systems research. He completed his Master of Public Health in 2016 at The University of Auckland under the Manaaki New Zealand Scholarships Programme and has actively contributed to teaching public policy and health systems at The University of Auckland. This will continue during his fellowship when Pushkar, alongside Jacqui, will integrate a new public health teaching module within The University of Auckland’s Bachelor of Optometry programme. He hopes that this will help build eye health in Aotearoa from the ground up, so that future optometrists can advocate for and deliver accessible eye health services for everyone.
A collaboration between the Fred Hollows Foundation and The University of Auckland’s Centre for Pacific and Global Health and School of Optometry and Vision Science aims to assess the state of eye health in the Pacific using locally-driven research.
In July 2021, the Community Eye Health team conducted a pilot eye health survey in the Glen Innes, Panmure and Ōrākei areas of Auckland. This survey gave us the opportunity to collect information about the state of eye health in a small group of New Zealanders, before we embark on our more ambitious population-based eye health survey in 2023.
Lead Optometrist and PhD candidate Jaymie Rodgers played a key role in the day-to-day operations of this pilot study.
“As part of my research project, I am delivering comprehensive eye examinations to people in this community where we believe there may be unmet eye health needs. In particular, we want to know if there are any differences in access to eye care,” says Jaymie.
Throughout the pilot study, Jaymie together with Optometrist and Professional Teaching Fellow Veeran Morar supervised a team of clinical optometry students as they conducted eye examinations at the Te Whare Piringa community centre in Glen Innes.
Watch Jaymie and team set up the eye clinic at Te Whare Piringa community centre in Glen Innes, above.
Currently, Jaymie is busy analysing data from the survey pilot, and enrolling a cohort of participants for further follow-up. Her PhD research will continue within the population-based eye care survey that will begin in 2023, where she will will follow a group of participants with vision impairment over a 12-month period to understand the barriers that they face in accessing follow-up eye care services.
See inside the pop-up eye clinic, below:
Jaymie speaks with a survey participant who is picking up her new glasses
Jaymie examines a survey participant at the pop-up clinic
A student optometrist with two survey participants, who are picking up their new glasses
As part of the survey, we offer a full eye examination to all people identified with distance or near vision impairment.
The research team:
Jaymie and Veeran with BOptom students
L to R: Joanna Black, Jaymie Rogers, Jacqui Ramke and Matire Harwood
Funding:
The research team would like to acknowledge Peter and Rae Fehl, Blind Low Vision New Zealand and New Zealand Association of Optometrists for their support.
Participants in this project are benefiting from the SOVS Community Spectacle Scheme, which is supported by Helen Blake, Barbara Blake and Essilor.
In 2020, the Government of Aotearoa New Zealand proposed free annual “eye health checks” for New Zealand’s ~700,000 SuperGold card holders aged ≥65 years. To assess the evidence for this policy, we conducted a systematic scoping review of primary eye care services in Aotearoa New Zealand and ten similar high-income countries. We found that most of the countries included in the review provided subsidised eye examinations for older people. New Zealand was the only country that did not provide any eye care services for older people.
Citation: Goodman L, Hamm L, Tousignant B, et al. Primary eye health services for older adults as a component of universal health coverage: a scoping review of evidence from high income countries. Lancet Reg Health West Pac. 2023;35:100560. doi: 10.1016/j.lanwpc.2022.100560
A collaboration between the Fred Hollows Foundation and The University of Auckland’s Centre for Pacific and Global Health and School of Optometry and Vision Science aims to assess the state of eye health in the Pacific using locally-driven research.
