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February 2009

Clinical Update: Comprehensive
A Look Inside Prison Eye Care
By Barbara Boughton, Contributing Writer

Life behind bars has no privileges. Prisoners lose their right to vote, their right to privacy and their right to any possessions. Perhaps the only tolerable aspect of prison life is an inmate’s right to health care. In fact, a Supreme Court decision in 1976 ruled that providing health care unequal to that available in the outside community was “cruel and unusual punishment.”

Yet do prisoners receive quality health care? In recent years, news reports have lambasted several prison systems around the country. Some systems have been accused of ignoring prisoners with fatal injuries, life-threatening illnesses or chronic illnesses. In fact, California’s system was turned over to federal receivership in 2006 after a lawsuit found that one inmate per week was dying due to medical neglect.

Although care may be substandard in some states, other states seem to have worked out more successful systems for providing care, according to doctors who advocate for prisoners’ health care rights. Yet that’s not to say that providing prison eye care is without its challenges. Although prisoners tend to be younger than the average population, they have a higher incidence of ophthalmic disease and more problematic general health concerns.


General Health Problems

Jody Rich, MD, MPH, is the cofounder of the Center for Prisoner Health and Human Rights at Miriam Hospital in Rhode Island, affiliated with Brown University. He founded the center in 2005 to promote quality care for inmates and to foster research and education about correctional health care. A specialist in community health and infectious disease, Dr. Rich has been providing health care to Rhode Island prisoners half a day each week for 14 years; he treats about 15 to 30 inmates per month. “Not only is there a higher prevalence of diseases such as HIV and addiction but also there’s a higher incidence of ophthalmic disease than in the general population,” he said.

Chronic diseases such as hypertension, asthma and psychiatric illness are also rampant in prisons. “The prison population is one that has a lot of health care needs,” said Dr. Rich.


Common Eye Conditions

In his work with prisoners for the Medical College of Virginia, Christopher T. Leffler, MD, MPH, sees many cases of glaucoma, diabetic retinopathy and cataracts, as well as eye injuries that have resulted from assaults. In Virginia, prisoners are covered by BlueCross BlueShield, and Dr. Leffler believes the eye care they receive is generally good.

Diabetic retinopathy. “The prisoners we treat tend to reflect the population as a whole,” said Dr. Leffler. “We see a lot of diabetic retinopathy, for instance, because half the prison population at our medical center is African American.”

Glaucoma. In two studies published in 2002 and 2003, Dr. Leffler and colleagues found a high prevalence of glaucoma as well as ocular trauma among prison inmates. In the 2002 study, the researchers compared the eye conditions of 193 inmates with 200 control patients at their tertiary care center. They found that one of the most common diagnoses for inmates was glaucoma—9 percent had primary open-angle glaucoma and 6 percent were glaucoma suspects.1 (The NEI estimates the prevalence of openangle glaucoma in the U.S. population aged 40 and older at 1.86 percent.)

Trauma. In the 2003 study, the researchers compared the differences in ocular trauma and subsequent surgical repair between prison inmates and nonincarcerated controls. A retrospective review of the records of 414 prison inmates vs. 400 controls found that more prison inmates than controls experienced eye trauma (16 percent vs. 3.5 percent). More inmates (4.1 percent vs. 0.8 percent of controls) required surgical intervention after ocular trauma.2

“Despite many advances in the recognition and treatment of eye injuries, ocular trauma remains an important problem in the prison inmate population,” Dr. Leffler said. He notes that cases of ocular trauma among prison inmates can include conditions such as traumatic cataracts, ruptured globes and orbital fractures, which require surgical intervention by the facial trauma team, including plastic surgeons.

Retina physician Helen K. Li, MD, associate professor of ophthalmology and visual sciences at the University of Texas Medical Branch (UTMB) in Galveston, also notes high rates of ocular trauma. “We see more evidence of violence in our prison population than in free-world patients. They also tend to be younger, more male than female, more violent,” she said.

Advanced disease. In addition, she said, many inmates have suffered from lack of access to medical care because of socioeconomic problems before they reach prison, and by the time they land behind bars, they have eye conditions that are already quite advanced. “It’s not unusual for us to see some very serious pathology in prisoners,” Dr. Li said.


One Prisoner’s Story

Handwritten letters from Elmer Rivas, an inmate at Pleasant Valley State Prison in Coalinga, Calif., have been arriving at the EyeNet office regularly since October 2007. With great detail, they tell the story of Mr. Rivas’ frustration with the medical system in California prisons.

“I’d like to educate the general public about how our medical system works—especially in prison,” noted Mr. Rivas, who has been at Pleasant Valley since 2006. He said he had been experiencing sharp pain in the back of his eyes for months. Before landing in prison, he had his intraocular pressure checked “and it came out as 22. I was told that if it went any higher I would go blind.”

When he went to see the prison medical staff, he initially was treated with medications for glaucoma. “The medications definitely helped,” he said. However, he was later told that he didn’t have glaucoma but only the symptoms. “That answer left me scratching my head,” he said. “They told me I was born with a large optic nerve and that I was fine!”

But Mr. Rivas hasn’t felt fine. After the medications for glaucoma were discontinued, he was given Visine-A to treat his red and dilated eyes. “They provided me with artificial tears solution. It relieves my pain for about three minutes, but then the pain comes back and my eyes get red,” he said.

Meanwhile, he went for an appointment to the prison optometrist to get new glasses. “But they gave me the wrong prescription,” he said. “I requested to see the optometrist again, but it’s been six months and I’m still waiting.”

Mr. Rivas’ dashed hopes are not uncommon among the incarcerated, said Dr. Li. “He is concerned about his health, but the exams by his health care providers have left him frustrated. Their answers seem incomplete or contradictory to him. Prison health systems must take into account the potential for misunderstanding and feelings of neglect. Physicians face the challenge of providing care to a transient population that has less of a chance of being followed by the same provider or returning for follow-ups than free-world patients. Because of this, I emphasize to my residents and fellows that taking time to communicate thoroughly and in lay terms with inmate patients is especially important.”

By October 2008, Mr. Rivas reported that he had received additional medical care. He had blood work done to assess his lack of energy, bruises and major migraines. “But my vision keeps decreasing. I notice that there are times when my vision is clear and times when it is blurry. I have sharp pain in the back of my eye sockets, and this gives me a migraine,” he said. On top of that, Mr. Rivas has experienced neck and back pain. “Unfortunately, according to the medical doctors, I am fine; there is nothing wrong with me,” he said. “I am only 24 years old and I feel like I am 70 years old.”


Telemedicine to Cut Costs

The University of Texas has contracted to provide medical care for 70 to 80 percent of all Texas inmates. The UTMB at Galveston has a hospital designed just for correctional care. The Texas Department of Criminal Justice secure tertiary care facility offers inpatient and outpatient services, including operating and recovery rooms. Many Texas prison inmates who need ophthalmic care are screened through telemedicine at the UTMB, according to Dr. Li. The hospital uses a video teleconferencing system to interview prisoners with eye conditions as well as their on-site health care providers at Texas prisons. “It’s a better way of getting infor mation than only receiving a written consult,” Dr. Li said. After conducting the interview via teleconference, the ophthalmologists at UTMB can then triage patients and decide who needs to be seen right away. Dr. Li explained that this system saves the state money because transporting a single prisoner for emergency care to a medical center is expensive, requiring specially arranged transportation and security guards. If the eye problem is not emergent, however, and the inmate can come to the medical center on a regularly scheduled prearranged bus along with other prisoners, the cost per prisoner is much less, she said.

Dr. Li, the current chairwoman of the Ocular Telehealth Special Interest Group of the American Telemedicine Association, noted that eye exams via video are time-consuming and require high-bandwidth connections to get good-quality imagery. While any minute movements can degrade the image, she said, “our videoconferencing system is effective. We have also tested supplementing our real-time system with still images to triage some patients.” She also noted that the hardware and software costs have fallen in recent years.

Yet whether prison health care is delivered via telemedicine, in person at an acute care facility or in the prison itself, this field is intrinsically rewarding, according to doctors who work with inmates. Physicians who treat prison inmates know they’re making a real difference in their patients’ lives. Said Dr. Rich: “Providing health care in prison changes you because you’re addressing real health care challenges. You begin to see prisoners as just people, yet they’re treated by our society as a disposable population.”

1 Wu, T. T. et al. Invest Ophthalmol Vis Sci 2002;43:E-Abstract 346.
2 Trivedi, A. M. et al. Invest Ophthalmol Vis Sci 2003;44:E-Abstract 817.

For more on prison health care, visit the Center for Prisoner Health and Human Rights Web site,