Viral retinitis is uncommon. Retinal detachment is a rare, but devastating complication of viral retinitis. At a busy academic Retina center, only 19 patients developed viral retinitis associated retinal detachment over a decade. When it does occur, viral retinitis can be devastating, especially with retinal detachment, which can contribute to irreversible vision loss. In our series, viral retinitis severity, retinal detachment characteristics, and surgical approach were similar between the high- and low-ADI groups. However, only patients with high ADIs and thus high socioeconomic disadvantage, who were all female, had more missed appointments and poorer visual outcome among patients who suffered from viral retinitis-associated retinal detachment.
The immunocompromised state, bilateral viral retinitis involvement, area of viral retinitis, and CMV as the viral pathogen especially with retinal detachment, which are associated with poor outcome,40 were similar among the high- and low-ADI groups. Of note, HIV infection was more common in the high-ADI than low-ADI patients, consistent with previous associations between HIV and social determinants of health.41 This difference in HIV status could have influenced their baseline presentation and final outcomes. However, retinal detachment characteristics were similar in the high-ADI and low-ADI groups, with similar rates of macular or foveal involvement and proliferative vitreoretinopathy. PPV alone and PPV/SB were used to a similar extent to repair the retinal detachments in both groups, but silicone oil was more likely to be used in the high-ADI patients. Since silicone oil is often selected as the tamponade agent in complicated retinal detachments, its increased use in the high-ADI group was presumably because the surgeon had perceived severe disease. In our series, it is notable that all but one patient in the high-ADI group did not have the silicone oil removed, perhaps due to factors like poor vision, complex disease, and surgery accessibility. The retention of silicone oil tamponade may have contributed to the significantly poorer final visual acuity in the high-ADI group.
The rates of re-detachment and postoperative complications were also similar in both groups, with the exception of hypotony, which was associated with poor vision and was more common in the high-ADI group. Our results contrast previous studies that demonstrated higher re-detachment rates in patients with socioeconomic disadvantage and rhegmatogenous retinal detachment not exclusive to viral retinitis, but this may be due to our small sample size.42 In addition, all but one high-ADI patient had cataracts at baseline, and the remaining patient developed a cataract following RD repair. In contrast, only two low-ADI patients had cataracts before the RD repair, and only half of the remaining patients developed cataracts, none of which were severe enough to have cataract surgery. This trend is interesting, given that the high-ADI group was on average a decade younger than the low-ADI group, but is consistent with previous research demonstrating increased prevalence and severity of cataract in patients with socioeconomic disadvantage.43
Ultimately, those with higher ADIs were vulnerable due to sociodemographic factors. All of the high-ADI patients were female, and not more likely to be non-White or underinsured. Importantly, the all female high-ADI patients had significantly more missed appointments. These findings agree in part with previous studies that identified low-income, racial minority, female sex, underinsured, and chronically ill patients with more missed appointments, more medical comorbidities, limited health access, and increased morbidity and mortality.44–46 Unlike patients with other uncommon disorders,11 the high ADI-status negatively impacted the compliance of patients with the rare condition of viral retinitis-associated retinal detachment.
Given the similar preoperative visual acuity, viral retinitis profile, RD characteristics, similar surgical approach, and single surgery reattachment rate, we believe that the missed appointments due to gender inequity and the patient’s neighborhood characteristics had a detrimental impact on the final visual outcome due, for example, to suboptimal monitoring of anti-inflammatory and anti-viral medicine. This noncompliance could have worsened control of inflammation and associated ischemia and retinal atrophy, especially given that the majority of high-ADI patients had active retinitis at the time of RD repair. However, we were unable to quantify this effect given only one patient had fluorescein angiography after RD repair. Nevertheless, these results add to the growing understanding of the ways in which the social determinants of health affect access to and outcomes of ophthalmological care.
Despite advances in medical care and policy interventions, socioeconomic disparity is likely to persist, making it crucial that clinicians keep these factors in mind when providing optimal ophthalmological care for patients with a severe disease like viral retinitis. The majority of noncompliant patients in our study cited difficulties with transportation to their appointments. The cost of missed appointments, specifically due to transportation issues, increases both patient morbidity and medical costs, particularly for vulnerable patients.47 National health care studies show that patients who lack access to nonemergency medical transportation are disproportionately female and can be clustered in certain areas, like the patients in this case series.48 Furthermore, women have been shown to suffer a disproportionate burden of visual impairment and blindness, largely due to limited access to eye care services.49
In the future, to improve compliance, consideration should be given to provide transportation to patients with clearly identified need and to offer scheduling flexibility for patients with life stressors, another reason cited for missed appointments. The provision of nonemergency medical transport through healthcare rideshare applications has been demonstrated to effectively reduce no-show rates in patients.50 Given that missed appointments are associated with more costly medical care and acute care utilization, providing transportation to patients could be a cost-effective strategy to improve continuity of care.51–52
In addition, patient education including making patients aware of missed appointments, the impact of missed appointments on patients’ health and the clinic, negotiating a commitment to improved adherence, and modified double-booking such as booking both morning and afternoon slots in order to optimize patient flow, have been shown to improve patient compliance, and should be designed into patient management, especially for high-ADI patients.53 These interventions are similar to those utilized to improve gender equity in eye care.54 Furthermore, HIV was the main causative immunosuppression in high-ADI patients. Given the chronic and complex course of viral retinitis and the underlying immunosuppressive conditions, these patients would benefit from close and regular follow-up. Interventions based on education and assistance have reduced gender inequities in all-cause blindness, clinic attendance, and treatment coverage, and should be considered when designing treatment for patients with viral retinitis-associated retinal detachments.
Limitations of this study include its retrospective nature, which potentially introduced confounding factors and affected the availability of data in the electronic medical record over the decade. For example, visual acuity was impacted by ocular comorbidities such as cataract and some visual acuity measurements, imaging modalities were not available for some patients at certain time points, and because the first presentations of some of the patients were their retinal detachment repair, information characterizing the treatment and course of the viral retinitis prior was not available. Furthermore, statistical analysis and the power of the study were limited by its small sample size due to the rarity of viral retinitis-associated retinal detachments. The Area Deprivation Index (ADI) was used as a proxy for socioeconomic status, but this measure is limited to zip-code level analysis. Though subregional and individual variation are certainly possible, ADI has been validated and has the advantage of including factors such as income, education, employment, and housing quality.39 Previous health outcomes studies, including those evaluating retinal detachments, have utilized similar regionally derived measures of deprivation.10, 55–57