Pediatric Eye Care ‘Deserts’ Pervasive in the U.S.

The vast majority of U.S. counties are pediatric eye care “deserts,” a cross-sectional study found.

Of the more than 3,000 counties in the nation, just 9.7% had at least one pediatric ophthalmologist and 6.5% had at least one pediatric optometrist in 2023. Furthermore, 87% had neither of the pediatric providers, reported Kara Cavuoto, MD, of the Bascom Palmer Eye Institute in Miami, and colleagues in JAMA Ophthalmology.

Poorer counties were most likely to not have any at all. Counties that were home to these specialists had a more than $20,000 higher median household income than those that didn’t ($78,389 vs $57,714, P<0.001).

The study follows a 2023 report that revealed pediatric ophthalmologists were concentrated in urban areas. The new findings revealed that pediatric optometrists are not taking up the slack, co-author Nora Siegler, a medical student at the University of Miami Miller School of Medicine, told MedPage Today. “It appears the issue is in part due to sheer lack of providers.”

However, the study methods might have undercounted those providers, an accompanying commentary cautioned.

Many optometrists identifying as pediatric specialists are not registered on either optometry professional society site used for the study, noted Olivia Bass, OD, and Alejandra G. de Alba Campomanes, MD, MPH, both of the University of California San Francisco (UCSF). And others — including the four pediatric optometrists practicing at UCSF — aren’t listed in a way that would be captured by the study methods. The American Academy of Optometry provider search tool only filters diplomates of the Academy when it comes to concentrations, not fellows, thus “possibly omitting a large group of members,” they pointed out.

“This partially may explain the low number of pediatric optometrists detected in this study. The professional pediatric ophthalmology databases used to determine service coverage may have similar limitations,” they wrote.

The lack of a comprehensive pediatric eye care database may prevent patients and referring practitioners from finding pediatric eye specialists, Bass and de Alba Campomanes noted.

Specialized eye care for children is crucial, Cavuoto told MedPage Today, because “conditions affecting children may drastically differ in presentation and management from those in their adult counterparts. Pediatric ophthalmologists and pediatric optometrists are specifically trained to adapt testing and evaluation methods to children’s varying stages of cognitive and visual development.”

In addition, she said, “pediatric patients can be challenging and may not be able to tolerate equipment and examinations appropriate for adult patients. Without training in how to appropriately address these differing developmental stages, problems may go undiagnosed.”

Across the entire country, the study found more pediatric ophthalmologists than pediatric optometrists (3.3 vs 2.5 per million people under age 19, respectively, P=0.047).

“Among counties with pediatric eye care providers, the median number of pediatric optometrists per million people [under age 19] was higher than that of pediatric ophthalmologists, at 7.8 compared to 5.5,” Siegler said. “This is surprising and may indicate that pediatric optometrists may be serving counties with lower population density than pediatric ophthalmologists. This is encouraging, but given the sheer low numbers of providers overall, it is not enough to fill in the large geographic deserts in access to care.”

Why might pediatric eye care specialists be drawn to work in urban areas? Siegler said they may want to work where they’re more likely to see privately insured children instead of facing the potential lack of reimbursement from insurers such as Medicaid. Higher volumes of patients may also be a factor, she said.

Cavuoto pointed out that “financial constraints also pressure pediatric ophthalmologists to operate in large group practices or academic institutions rather than being solo providers in geographically underserved regions. These opportunities are more prevalent in and surrounding large academic institutions and urban areas.”

She said potential solutions to narrow the geographic gap in care include boosting Medicaid reimbursement for pediatric eye care, supporting practitioners who treat underserved or “lower-resource” regions by forgiving medical student debt or providing additional stipends, and offering more telehealth screenings.

It may also be helpful to increase trainee exposure to pediatric ophthalmology in both medical school and residency, said Cavuoto. And training in pediatric care can be provided to non-pediatric specialists, especially those who serve lower-resource populations.

Bass and de Alba Campomanes wrote that the study findings “demonstrate a remarkable overlap in geographic distribution of pediatric eye care practitioners while exposing the continuing and substantial lack of access to pediatric eye care across the U.S.”

They added that the study highlighted how “children living in pediatric eye care deserts also face other barriers in access to subspecialty eye care, like the ability to travel to receive in-person care or the infrastructure to receive virtual care.”

Study Details

The researchers identified pediatric eye care specialists — 586 pediatric optometrists and 1,060 pediatric ophthalmologists — in April 2023 via search tools on the websites of the American Optometric Association, American Academy of Optometry, American Academy of Ophthalmology, and American Association for Pediatric Ophthalmology and Strabismus.

The five states with the most identified pediatric optometrists were Illinois (61), Colorado (42), Ohio (34), Texas (33), and California (32). Five states had just one pediatric optometrist: Georgia, Idaho, New Mexico, Rhode Island, and South Carolina. No pediatric optometrists were listed in Washington, D.C.

Pediatric ophthalmologists were most plentiful in California (115), New York (90), Florida (64), Texas (56), and Massachusetts (52); Vermont and Wyoming had none.

As for limitations, the study authors noted that true practitioner counts may be different due to “the dynamic nature of databases used to collect practitioner information along with the time frame in which demographic data from national surveys are collected and published.” They added that the study relied on demographic information from the U.S. Census, which may fail to include members of certain groups, such as immigrants who are in the country illegally.

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