Complexity and Barriers to Vision Care: A Narrative Review Informed by a Mobile Eye Program

Abstract

Highlights: Public health relevance—How does this work relate to a public health issue? Preventable vision loss disproportionately affects underserved communities due to both patient-level barriers (e.g., language, insurance, financial hardship) and system-level failures that delay or interrupt medically necessary, time-sensitive ophthalmic care. By examining real-world cases alongside the literature, this work highlights how health system rigidity, misclassification of ophthalmic conditions as “non-urgent,” and fragmented coordination contribute to inequitable access to essential eye care. Public health significance—Why is this work of significance to public health? Vision impairment directly impacts functional independence, chronic disease outcomes, and quality of life; preventing avoidable delays in time-sensitive eye care is therefore a critical public health priority. This manuscript demonstrates that improving equity requires attention not only to individual barriers but also to the structural and organizational dynamics that shape care pathways, particularly when the system fails to recognize or prioritize medically necessary, time-sensitive ophthalmic treatments. Public health implications—What are the key implications or messages for practitioners, policy makers and/or researchers in public health? Efforts to improve vision-care equity must combine patient-centered strategies (navigation, communication, support for insurance and transportation) with system-level improvements such as adaptive scheduling, cross-agency coordination, and prioritization frameworks that reflect both clinical urgency and the time-sensitive nature of many ophthalmic conditions. Integrating complexity-informed approaches can help health systems recognize early signs of system strain, respond flexibly to patient needs, and ensure that medically necessary, time-sensitive ophthalmic procedures are not delayed simply because they are not classified as emergencies, thereby preventing avoidable vision loss in vulnerable and non-vulnerable populations. Purpose: To describe structural and systemic barriers to ophthalmic care experienced by underserved patients, particularly those facing language obstacles, immigration-related constraints, limited insurance coverage, financial hardship, and navigation challenges in an urban setting, and to examine these barriers through a complexity-informed lens. Methods: We conducted a narrative literature review focused on healthcare disparities, patient navigation, complexity in care delivery, and time-sensitive prioritization frameworks in ophthalmology. Findings were integrated with case vignettes drawn from Eyes on Wheels (EOW), a mobile eye care initiative that provides no-cost examinations at Federally Qualified Health Centers (FQHCs) and free clinics. Cases were identified through routine clinical documentation and used to illustrate how structural barriers described in the literature manifest in real-world care pathways. Results: Three recurring system-level issues were identified across EOW encounters: (A) misclassification of medically necessary, time-sensitive ophthalmic care as “non-urgent”; (B) patient disengagement driven by cumulative structural and logistical barriers; and (C) failures that arise when the healthcare system, functioning as a complex adaptive system (CAS), is unable to adapt to patients’ and systems’ changing circumstances. A review of the literature confirmed that these patterns reflect widely documented challenges faced by underserved urban populations. Three EOW case vignettes, selected from seven patients identified in 2024, are presented as illustrative examples of these systemic patterns. Conclusions: Addressing inequities in eye care requires an approach that recognizes how many parts of the healthcare system interact and affect a patient’s ability to receive timely treatment. Vision loss is often the preventable result of systems that are rigid, fragmented, or unable to adapt to a patient’s circumstances. Improving outcomes will require flexible care models, such as mobile clinics, paired with strong institutional support, patient-centered navigation, and consistent assessment of social needs and barriers to care. Sustained progress will depend on collaboration across organizations, adaptable leadership, and policies that respond to the real-world situations in which patients live.