Breaking down the barriers: Ophthalmic care in the incarcerated population | Ophthalmology Times

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The US has the highest incarcerated population globally, with Black, Indigenous, or Hispanic individuals significantly more likely to be imprisoned than White individuals. These racial disparities mirror those seen in vision health and access to eye care.^1,2 Nearly two-thirds of incarcerated individuals requiring ophthalmic follow-up care did not receive it, with a statistically significantly higher chance of missing their appointment when they underwent a procedure or required more urgent follow-up.³ Among incarcerated individuals with glaucoma, over 50% returned more than 1 month late.⁴

The question behind the numbers

These facts lead to the question: Why is this population less likely to receive what most providers deem adequate care? Several systemic barriers have been postulated, from delayed transportation and staff shortages to a lack of onsite equipment and frequent facility transfers.^4,5 Moreover, there are also individual financial barriers. More than 90% of state prison residents are responsible for co-payments when they see a health provider.⁶ Here, we summarize and discuss several proposed actionable interventions to address barriers to eye care in the incarcerated population, including telehealth, mobile clinic implementation, and several wide-scale policy interventions.

Telemedicine and mobile clinics: Bridging the gap

Among the proposed solutions to address the access-to-care issue among incarcerated individuals requiring ophthalmic care is the integration of telemedicine.^7-9 Currently, it may be one of the most commonly explored interventions to decrease barriers to care. However, with the ever-evolving and -expanding technological landscape, it is perhaps the most difficult to capture. According to the Pew Research Center, 96% of Americans use the internet. With the widespread implementation of the internet and the improvement in high-speed internet coverage over the past 20 years, areas with remote prisons should be able to access telemedical platforms. However, a special consideration exists for the role of telemedicine in eye care, and that is the difficulty in achieving a fully virtual model.¹⁰ Given the importance of the eye exam and corresponding imaging, a skilled technician would likely need to gather imaging or a basic exam for a successful hybrid telehealth campaign for this population. However, there may be potential for future technologies to address this barrier.

It is well established that telemedicine is a relatively cost-effective method to prevent avoidable vision loss in incarcerated populations by addressing limited and delayed access to specialty eye care. Imaging may be captured onsite within the prison and transmitted to specialists offsite. This care delivery method decreased costly and logistically challenging referrals, enabling the timely detection and treatment of eye disease.¹¹ According to data in a recent 2025 publication, researchers employed an orthoptist to take fundus, anterior segment, and optical coherence tomography images of incarcerated individuals. The orthoptist traveled to a French penitentiary and sent all these tests to be reviewed by ophthalmologists asynchronously, with 95% of cases managed exclusively via telemedicine. Patient feedback from this study was largely positive regarding access to care and patient adherence to treatment plans.⁷ Furthermore, with established and emerging smartphone-based imaging tools, the cost of care is decreased, and the ease of implementation is increased. As these tools become more widespread, correctional health systems can adopt ophthalmology-oriented telemedicine to improve outcomes, reduce costs, and promote equitable access to eye care.¹²

Another proposal, mobile clinics, brings the ophthalmologists and their specialized equipment to the patients in prisons. Mobile eye clinics have been shown to provide an efficient and flexible means of delivering vision care, including screening and early diagnosis of ophthalmic conditions, to various low-resourced populations.^13,14 This model may be valuable in prison settings, where transporting patients to outside facilities presents logistical and security challenges.^5,14 By deploying directly to correctional facilities, these clinics overcome such barriers and deliver comprehensive care services in a secure, onsite environment.^13,14 Broader outreach efforts in both prison and rural settings have shown that onsite eye care builds trust, increases adherence to follow-up care, and removes major barriers to access.^4,15,16 By leveraging mobile technology and established outreach models, correctional health systems may utilize mobile eye clinics to reduce preventable vision loss, enhance patient satisfaction, and address logistical and security concerns.

Policy reform and provider advocacy

Several policy and system-wide changes have been proposed to improve access to care for incarcerated individuals. Reducing or eliminating medical co-payments for incarcerated individuals may improve access to needed care, including specialty services like ophthalmology.^6,17 In facilities that charge higher co-payments relative to wages, those with chronic health conditions are significantly more likely to go without any clinician visit. This likelihood increases further when fees exceed a week’s prison wage and, given that prison wages can be just cents per hour, even small fees may function as substantial barriers to seeking care.⁶ Removing co-payments would eliminate this barrier and encourage timely evaluation and follow-up care.^6,17

In addition to removing medical co-payments, per the 2022 recommendation of the National Commission on Correctional Healthcare, more aggressive regulatory interventions have been proposed. Additional proposals include expanding the Medicaid Reentry Act, which allows for Medicaid payment of medical services furnished to an incarcerated individual during the 30 days preceding the individual’s release, and establishing a regulatory body to oversee prison health services.^6,18,19

Various factors limit access to ophthalmic care in the incarcerated population. The proposed solutions to these barriers involve implementing telehealth technologies, mobile clinics, large-scale systems, and policy-based solutions. From a technological perspective, the widespread introduction of new technologies poses an exciting opportunity to advance care in this population, especially with the widespread implementation of artificial intelligence in the past several years. Furthermore, using mobile clinics can address the barriers associated with transporting incarcerated individuals to health care centers and encourages trust within the patient-provider relationship.

Finally, widespread policy interventions have been proposed, such as eliminating co-payments, expanding the Medicaid Reentry Act, and establishing a regulatory body to oversee prison health services. These policy and system-wide changes require the participation and action of ophthalmologists and other eye care providers at the state and federal levels to achieve implementation. This can be accomplished through writing letters to state representatives, lobbying state or federal government representative offices, and contributing expertise and resources to organized medical societies such as the American Medical Association and the American Academy of Ophthalmology.

References

1. Alsan M, Yang CS, Jolin JR, Tu L, Rich JD. Health care in US correctional facilities – a limited and threatened constitutional right. N Engl J Med. 2023;388(9):847-852. doi:10.1056/NEJMms2211252

2. Elam AR, Tseng VL, Rodriguez TM, et al. Disparities in vision health and eye care. Ophthalmology. 2022;129(10):e89-e113. doi:10.1016/j.ophtha.2022.07.010

3. Abou-Jaoude MM, Crawford J, Kryscio RJ, Moore DB. Accuracy of ophthalmology clinic follow-up in the incarcerated patient population. J Acad Ophthalmol (2017). 2022;14(2):e258-e262. doi:10.1055/s-0042-1758562

4. Kanu LN, Jang I, Oh DJ, et al. Glaucoma care of prison inmates at an academic hospital. JAMA Ophthalmol. 2020;138(4):358-364. doi:10.1001/jamaophthalmol.2020.0001

5. Sraj SA. Providing orthopaedic care for the incarcerated: obstacles and challenges.
   J Am Acad Orthop Surg. 2016;24(9):607-614. doi:10.5435/JAAOS-D-15-00215

6. Lupez EL, Woolhandler S, Himmelstein DU, et al. Health, access to care, and financial barriers to care among people incarcerated in US prisons. JAMA Intern Med. 2024;184(10):1176-1184. doi:10.1001/jamainternmed.2024.3567

7. Villain P, Mouriaux F, Soethoudt M. Feasibility study of tele-ophthalmology in a prison setting. Article in French. J Fr Ophtalmol. 2025;48(6):104512. doi:10.1016/j.jfo.2025.104512

8. Senanayake B, Wickramasinghe SI, Eriksson L, Smith AC, Edirippulige S. Telemedicine in the correctional setting: a scoping review. J Telemed Telecare. 2018;24(10):669-675. doi:10.1177/1357633X18800858

9. Yogesan K, Henderson C, Barry CJ, Constable IJ. Online eye care in prisons in Western Australia. J Telemed Telecare. 2001;7(suppl 2):63-64. doi:10.1258/1357633011937173

10. Internet, broadband fact sheet. Pew Research Center. November 13, 2024. Accessed August 9, 2025. https://www.pewresearch.org/internet/fact-sheet/internet-broadband

11. Aoki N, Dunn K, Fukui T, Beck JR, Schull WJ, Li HK. Cost-effectiveness analysis of telemedicine to evaluate diabetic retinopathy in a prison population. Diabetes Care. 2004;27(5):1095-1101. doi:10.2337/diacare.27.5.1095

12. Lord RK, Shah VA, San Filippo AN, Krishna R. Novel uses of smartphones in ophthalmology. Ophthalmology. 2010;117(6):1274-1274.e3. doi:10.1016/j.ophtha.2010.01.001

13. McMaster D, Clare G. Designing a mobile eye hospital to support health systems in resource-scarce environments. Disaster Med Public Health Prep. 2022;16(4):1618-1622. doi:10.1017/dmp.2021.108

14. Mobile eye: about us. UCLA Health. Accessed August 9, 2025. https://www.uclahealth.org/departments/eye/mobile-eye/about-us

15. Khairat S, Wallace E, Bohlmann A, et al. Digital health experiences of incarcerated populations using telemedicine in North Carolina prisons. J Patient Exp. 2022;9:23743735221092611. doi:10.1177/23743735221092611

16. RMU optometry students provide eye care at Utah State Prison. Rocky Mountain University of Health Professions. June 10, 2025. Accessed August 8, 2025. https://rm.edu/news/utah-state-prison-optometry-care/

17. Widra E. New research links medical co-pays to reduced healthcare access in prisons. Prison Policy Initiative. August 29, 2024. Accessed August 9, 2025. https://www.prisonpolicy.org/blog/2024/08/29/fees-limit-healthcare-access/

18. Eliminating financial assessments for health care services during incarceration. National Commission on Correctional Health Care. Accessed August 9, 2025.https://ncchc.org/position-statements/eliminating-financial-assessments-for-health-care-services-during-incarceration-2/

19. Reentry Act of 2023, S 1165, 118th Cong (2023). Accessed August 9, 2025. https://www.congress.gov/bill/118th-congress/senate-bill/1165