Purpose <p>To investigate post-pandemic private equity (PE) acquisition trends among U.S. ophthalmology and optometry practices from 2022 to 2024, emphasizing rural versus urban distribution and subspecialty services.</p> Design <p>Retrospective cross-sectional study.</p> Participants <p>A total of 550 PE-backed acquisitions of ophthalmology and optometry practices from 2011 to 2024 were identified in the Pitchbook database.</p> Methods <p>All practices were categorized using the Rural-Urban Commuting Area (RUCA) system, with codes 1–3 defined as urban and 4–10 as rural. Subspecialties (e.g., retina, optometry, oculoplastic, etc.) were assigned based on company websites. Data collection included primary practice locations, last financing dates, and any satellite practices linked to acquired companies. Statistical analysis including linear regression and analysis of variance for comparison of variables was performed to assess acquisition trends, subspecialty distribution, and geographic expansion patterns with a significance level of a <i>P</i> value &lt; 0.05.</p> Main outcome measures <p>Annual acquisition counts, urban vs. rural classification, and subspecialty coverage.</p> Results <p>Between 2011 and 2024, 85% of all PE acquisitions targeted urban practices, and acquisitions grew markedly from 2016 to 2021 before peaking in 2021. After that peak, acquisitions declined from 71 in 2022 to 27 in 2024; 96% of the 2022–2024 acquisitions were urban. Geographic analysis showed the Southern region received the highest proportion of recent acquisitions (50%) during 2022–2024, while the Midwest, West, and Northeast received 16%, 19%, and 15% respectively (<i>P</i> = 0.19). Subspecialty distribution indicated that retina, oculoplastic, cataract, and optometry services were most offered by acquired practices, particularly in urban areas. Satellite expansions further demonstrated a strong urban focus, resulting in a threefold higher number of urban satellites compared with rural ones (<i>P</i> = 0.03).</p> Conclusions <p>Private equity activity continues to favor urban, subspecialty-rich practices, while rural investments remain limited. As overall deal volume has declined since 2021—likely influenced by rising interest rates and pandemic-related economic factors—further research is needed to clarify how PE ownership affects care quality, patient outcomes, and practice sustainability. Addressing rural-urban disparities in ophthalmic and optometric care delivery may require targeted policy interventions to ensure equitable access for all patients.</p>