Ocular health in Canada's homeless population is a growing area of interest because a higher prevalence of ocular disease has been documented.1Noel CW Fung H Srivastava R et al.Visual impairment and unmet eye care needs among homeless adults in a Canadian city. The prevalence of cataracts was 10.4% in Toronto's homeless shelters, and cataracts accounted for 50% of the visual impairment seen among the inner-city homeless patients in Vancouver.2Jiang S Mikhail M Slomovic J et al.Prevalence and impact of eye disease in an urban homeless and marginally housed population.,3Maberley DAL Hollands H Chang A Adilman S Chakraborti B Kliever G. The prevalence of low vision and blindness in a Canadian inner city.There are several barriers to accessing ocular care and outpatient surgical care, such as perceived discrimination, lack of medical insurance coverage, transportation limitations, and competing priorities for subsistence needs.2Jiang S Mikhail M Slomovic J et al.Prevalence and impact of eye disease in an urban homeless and marginally housed population.,4Zuccaro L Champion C Bennett S Ying Y. Understanding the surgical care needs and use of outpatient surgical care services among homeless patients at the Ottawa Hospital. Further, many ophthalmologists struggle to provide equitable care because of challenges with follow-up, which tends to be lower in the homeless and marginally housed population.4Zuccaro L Champion C Bennett S Ying Y. Understanding the surgical care needs and use of outpatient surgical care services among homeless patients at the Ottawa Hospital. As a result, poor vision continues to have devastating personal, medical, financial, and social consequences.We present a case series of five patients who were referred from our screening program for management of cataracts. Table 1 provides a summary of salient patient clinical characteristics.

Table 1Summary of salient clinical characteristics

NS, nuclear sclerosis; CF, counting fingers; HM, hand motions; PSCC, posterior subcapsular cataract.

Case 1: A 62-year-old female with diabetes, hypertension, hypercholesterolemia, and schizophrenia had preoperative visual acuity of counting fingers at 3 m OD and counting fingers at 20 cm OS. On examination, she had 3+ nuclear sclerosis OD and 4+ nuclear sclerosis OS. There was optic disc pallor in her left eye with a cup-to-disc ratio of 0.8, consistent with glaucomatous optic neuropathy. She underwent phacoemulsification in her left eye at a private independent health facility, which was paid for by the St. Michael's Hospital Foundation because she did not have the Ontario Health Insurance Plan (OHIP). Her case worker arranged postoperative respite care given her comorbid psychiatric illness. Her second surgery was delayed by 1 year because of the cancellation of elective surgeries during the coronavirus disease 2019 pandemic. Postoperatively, her visual acuity was 20/80+1 OD and 20/80–1 OS, which corrected to 20/20 OD and 20/30 OS. Weeks later, she presented to the emergency department with acute psychosis and rebound iritis as a result of abrupt cessation of her postoperative steroid drops. Steroid treatment was restarted, and she was followed closely for resolution.

Case 2: A 62-year-old female presented with hand motions visual acuity OD and counting fingers at 10 cm OS due to the presence of white dense cataracts bilaterally. She was a refugee living in a homeless shelter and secured coverage under the interim federal health program with help from a social worker. Her first surgery was uncomplicated, whereas her second surgery was delayed because social issues arose that led to concerns for her safety. Her final uncorrected visual acuity was 20/20 OD and 20/25–1 OS.

Case 3: A 55-year-old male was referred with visual acuity of hand motions OD and 20/200 OS due to presence of advanced white cataracts. Initially, communication was possible through the patient's friend, who owned a cell phone. The patient underwent surgery in his right eye and developed 2+ corneal edema postoperatively. He was lost to follow-up until he presented 1 year later for low vision in his left eye. A social worker assisted with coordination of his second surgery, but he was again lost to follow-up postoperatively.

Case 4: A 52-year-old male living in a shelter was seen with uncorrected visual acuity of 20/100+1 OD and counting fingers at 5 cm OS. He had 1+ nuclear sclerosis OD and a dense posterior subcapsular cataract with 3+ nuclear sclerosis OS. He was covered under OHIP and underwent surgery in hospital. Postoperatively, his visual acuity was 20/50 OS. Months later, he complained of low visual acuity in his right eye, and the housing harm-reduction specialist coordinated his second cataract surgery. Both procedures were uncomplicated, and the patient's final uncorrected visual acuity was 20/40 in each eye.

Case 5: A 59-year-old male was brought to the clinic by his mental health case manager with hand motions visual acuity secondary to bilateral white dense cataracts. He recently secured subsidized housing and Ontario Disability Support Program support. The patient was previously seen by an optometrist but did not attend his surgical appointment because of inaccessible transportation. Within weeks, he underwent immediately sequential bilateral cataract surgery. Postoperatively, his uncorrected visual acuity was 20/40 OD and 20/70 OS and 20/20 in each eye with spectacle correction.

This is the first communication describing the complexity of providing cataract surgery to homeless patients. All patients presented with more advanced cataracts than typically seen in the general population, and it is common for these patients to have incidental eye disease, such as diabetic retinopathy and glaucoma.2Jiang S Mikhail M Slomovic J et al.Prevalence and impact of eye disease in an urban homeless and marginally housed population. Such encounters are an important time to build a therapeutic relationship to support long-term cooperation, resulting in a positive experience for both the patient and the provider.

Coexisting medical, psychiatric, and social issues may contribute to more severe cataracts at presentation and interfere with adherence to perioperative instructions. In such situations, the patient, substitute decision maker, and social worker should be well informed to seek attention at the earliest signs of an exacerbation.

Ensuring adequate social supports is integral to performing cataract surgery in homeless patients, and a reliable means of communicating directly with the patient is preferred. Social workers play an integral role in the care of homeless patients, and the availability of this service is an important consideration for delivering care, ensuring appropriate follow-up, and overcoming housing and financial obstacles. Additionally, our social workers were familiar with the needs of homeless patients and were aware of services within the community from which a patient might benefit.

At the systems level, efforts should be made to deliver eye care in the most cost-efficient manner for all patients, particularly for patients who are not covered by public health insurance plans. Independent health facilities and ambulatory surgery centres, whether privately owned or managed by a hospital, are designed to increase access and reduce costs by maximizing efficiency by design. For instance, the cost at St. Michael's Hospital is quoted at approximately $3000 compared to $1700 at TLC Yonge Eglinton Laser Eye Centre (October 2020). Of note, these procedures were completed pro bono, and as such, the quoted costs do not include the physician's billing fee.

It is important to consider applications of these insights beyond cataract surgery because the lessons learned may benefit other surgeons in providing adequate health care to homeless and marginally housed patients.

Footnotes and Disclosure

The authors have no proprietary or commercial interest in any materials discussed in this communication.

Supported by: Grant funding received from St. Michael's Hospital Foundation to cover costs of running the mobile eye screening clinics, clinic visits, and cataract surgery for non-OHIP-covered patients. The authors did not receive any funding or compensation for this study.

Author contributions: Verina Hanna: conceptualization, investigation, writing of original draft; Clara Chan: investigation, writing – review and editing; Myrna Lichter: conceptualization, writing – review and editing, supervision, funding acquisition

ReferencesNoel CW Fung H Srivastava R et al.

Visual impairment and unmet eye care needs among homeless adults in a Canadian city.

JAMA Ophthalmol. 133: 455-460Jiang S Mikhail M Slomovic J et al.

Prevalence and impact of eye disease in an urban homeless and marginally housed population.

Can J Ophthalmol. 55: 76-81Maberley DAL Hollands H Chang A Adilman S Chakraborti B Kliever G.

The prevalence of low vision and blindness in a Canadian inner city.

Eye (Lond). 21: 528-533Zuccaro L Champion C Bennett S Ying Y.

Understanding the surgical care needs and use of outpatient surgical care services among homeless patients at the Ottawa Hospital.

Can J Surg. 61: 424-429

Surgical interventions performed outside the hospital operating room [Internet]. CADTH.ca, 2015 (accessed Oct. 12, 2020). Available at www.cadth.ca/surgical-interventions-performed-outside-hospital-operating-room.

Article InfoPublication History

Published online: June 30, 2021

Accepted: May 26, 2021

Received in revised form: May 16, 2021

Received: April 6, 2021

Publication stageIn Press Uncorrected ProofIdentification

DOI: https://doi.org/10.1016/j.jcjo.2021.05.015

Copyright

© 2021 Published by Elsevier Inc. on behalf of Canadian Ophthalmological Society.

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