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TOPLINE:

Unhoused individuals with diabetes were more likely to present with advanced diabetic retinopathy and vision-threatening complications such as vitreous hemorrhage and tractional retinal detachment. They also had reduced follow-up and a higher risk of developing proliferative diabetic retinopathy over time.

METHODOLOGY:

• Researchers evaluated and compared the severity of diabetic retinopathy, vision-threatening complications, treatment patterns, and follow-up outcomes between unhoused and stably housed patients with diabetes.
• They analyzed 9643 unhoused patients and nearly 1.2 million people with housing for baseline characteristics, including diabetic retinopathy severity, vision-threatening complications (proliferative diabetic retinopathy, vitreous hemorrhage, and tractional retinal detachment), and initial treatments such as anti-vascular endothelial growth factor injections, panretinal photocoagulation, and pars plana vitrectomy.
• The unhoused cohort was younger (mean age, 55 vs 60 years) and had a higher proportion of male (60.97% vs 47.05%) than the housed cohort. Unhoused patients were also more likely to be Black (34.4% vs 21.6%).
• A secondary analysis required at least 6 months of ophthalmic follow-up and produced matched cohorts of 2911 patients each, who were followed for new complications and treatment needs at 1 year.
• Statistical analysis examined the independent association between unhoused status and the risk for proliferative diabetic retinopathy over 5 years relative to other social determinants of health, including food insecurity, extreme poverty, insufficient insurance coverage, and education or literacy problems.

TAKEAWAY:

• At presentation, unhoused patients demonstrated significantly higher rates of all diabetic retinopathy subtypes than housed patients: mild nonproliferative diabetic retinopathy (7.36% vs 1.94%), moderate nonproliferative diabetic retinopathy (3.32% vs 0.61%), severe nonproliferative diabetic retinopathy (1.80% vs 0.28%), and proliferative diabetic retinopathy (5.24% vs 1.46%; P < .01 for all). They were also less likely to complete at least 6 months of follow-up (30.3% vs 55.2%; P < .01).
• Unhoused patients had notably higher rates of vitreous hemorrhage (4.04% vs 1.03%) and tractional retinal detachment (1.34% vs 0.24%; P < .01 for both) than stably housed patients; they were less likely to receive anti-vascular endothelial growth factor injections as first-line treatment (63.9% vs 68.2%; P < .01) and instead were more likely to receive panretinal photocoagulation (2.2% vs 0.2%) or vitrectomy (8.6% vs 7.9%).
• In matched analysis at 1 year, unhoused status was linked to an increased risk of developing vitreous hemorrhage (hazard ratio [HR], 1.35; P = .009), diabetic macular edema (HR, 1.28; P < .001), and proliferative diabetic retinopathy (HR, 1.25; 95% CI, 1.08-1.44; P = .003) compared with stable housing.
• Furthermore, unhoused status was an independent risk factor for proliferative diabetic retinopathy (HR, 1.55; P < .0001), as were extreme poverty (HR, 1.25; P = .029) and insufficient health insurance coverage (HR, 1.80; P < .0001).

IN PRACTICE:

“These findings highlight the need for targeted screening strategies, socially informed treatment planning, and multidisciplinary interventions aimed at reducing preventable vision loss in this vulnerable population,” the researchers of the study reported.

SOURCE:

The study was led by Ahmed M. Alshaikhsalama, MD, Department of Ophthalmology, UT Southwestern Medical Center, Dallas. It was published online on June 9 in Retina.

LIMITATIONS:

The study may have missed or incorrectly recorded some housing status information, and the unhoused patients who stayed in the study for at least 6 months may have been more connected to care than others. The housing codes used in the study were more likely to capture people with severe or long-term homelessness, so the unhoused group may have reflected more extreme cases of housing instability rather than everyone with housing insecurity. It also could not measure important factors such as blood sugar stability, how long patients had diabetes, medication use, nutrition, transportation, or social support.

DISCLOSURES:

The study received support from the Challenge Grant from Research to Prevent Blindness, Inc. The authors reported having no financial disclosures or conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.