In our new world of technological innovations, smart phones, and inter-connectedness, the latest idea in the world of eye care is an on-line eye examination.
Can this work, will this be something that is widely accepted, and what are the pros and cons of such an idea? What exactly is the definition of an eye examination?
ECP’s have a defined database for every patient as to what they must do to satisfy a patient’s chief complaint. Department of States’ Bureaus of Professional and Occupational Affairs have a defined list as to what equipment is required in every ECP’s office and what is required for an eye exam.
A website at http://www.eyeexamonline.com/ claims that an eye exam and an eye test are exactly the same thing. I totally disagree. I sometimes hear in my office that the screenings that are done at school was an eye exam. Again, screenings are good at detecting potential problems that need to be evaluated by an ECP. A screening is definitely not an eye exam. And the definition of an on-line eye exam should be more appropriately defined as a screening or a visual acuity check.
There are certainly a few things that can be checked by someone viewing an on-line “eye exam” website. Visual acuities and color vision can certainly be determined by an on-line site. But what happens to a prospective on-line viewer when cover testing, extra-ocular muscle testing, pupillary testing, biomicroscopy, a dilated retinal exam, visual field testing, and intraocular pressures are not done nor tested for when doing an on-line “eye exam”?
Do cataracts go undetected, does the chance for vision loss develop due to undetected glaucoma which may have no symptoms, or are there retinal signs of undiagnosed diabetes or hypertension? If a small eye turn can be improved with a small amount of prismatic lenses, how can this be determined on-line?
Essilor has a website where you can check your vision located at http://www.essilor.com/en/EyeHealth/LensesForYourVision/TestyourEyes/Pages/home.aspx. With the proper directions, the viewer can test for myopia, hyperopia, far vision, near vision, astigmatism, and the Ishara (color vision) test. The tests state, “take the test to discover if you have myopia or hyperopia.
Do you sometimes squint in order to read road signs? Your far vision might have decreased. Check your “visual acuteness” by taking our test. Your sight becomes blurred when reading? You can hardly distinguish small characters? This might be a problem of near vision. Do you have trouble driving at night? Do you have problems perceiving some letters? These might be the first signs of astigmatism.”
In the September edition of the Review of Optometry, the American Optometric Association (AOA) has urged the FDA to investigate an online eye exam provider. “We have a serious concern about separating the refraction from a comprehensive eye examination” says Dr. Steven Loomis who is the AOA president. “A refraction does not simply yield an eyeglass or contact lens prescription. A refraction is a diagnostic test that yields information about potential health concerns like diabetes, cataracts, and retinal issues, to name only a few. These on-line “exams” are completely insufficient to meet those needs.”
Opternative is another one of these online eye exam sites located at https://www.opternative.com/. The site begins with “get your glasses or contacts prescription online. The online exam is free, only pay for your prescription. Opternative is as accurate as an in-person refractive eye exam. View our clinical study. Sign up free, take our exam, doctor review, pay $40, get your prescription”.
The clinical study page also states, “in an IRB-approved side-by-side clinical trial, the Opternative eye exam was as accurate as a traditional refractive exam performed by an optometrist or ophthalmologist using a phoropter.” An IRB is an institutional review board which is also known as an independent ethics committee that has been formally designated to approve, monitor, and review biomedical research.
I decided to proceed with this online eye exam in order to uncover the pros and the cons. The site had to determine if I was “eligible” to take the exam. Unfortunately, prescriptions are only provided to those people between ages of 18-40. Being over 40, I did not qualify. Plus, there were 26 medical qualifiers. If you had just one of these, you did not qualify including using bifocals or progressive lenses, sphere power greater than minus 6.00 D or greater than plus 2.50 D, or cylinder power greater than minus 2.50 D, cataracts, color blindness, having current or frequent pain in your eyes, double vision, eye infections, eye surgery within the past 12 months, flashes or floaters, foreign object in the eyes, glaucoma, hereditary eye disease, lazy eye, macular degeneration, migraines, retinal detachment, sudden vision loss, diabetes, heart disease, high blood pressure, high cholesterol, pregnant or nursing, recent head trauma or surgery, or taking a medication that affects your vision.
Many of the patients that I see in my office have several of the above conditions, quite often many at the same time. It seems to me that these online exams are making an attempt to market to the younger or naïve audiences who may be unaware that an online eye exam is not a comprehensive eye exam.
There are some on-line sites that do not differentiate between an eye test, an eye exam, a comprehensive eye exam including dilation, or receiving a prescription where the prescription has been determined by a computer.
Every ECP should have a problem in equating what we do in a personalized, in-office, one on one setting with a patient, compared to having a computer do something “similar”. There is no basis for equating a doctor or ECP who fully examines every component of the human eyes compared to someone receiving a prescription for glasses or contact lenses.
There may be legal issues based on what someone may assume was accomplished during an on-line eye exam and what may have been determined later during a comprehensive eye exam. These undetected problems may include glaucoma resulting in permanent vision losses, not changing a contact lens prescription correctly when provided with an eye glass prescription resulting in an accident, injury or vision loss, the failure to detect diabetic retinopathy, lattice degeneration, or a suspicious pigmented retinal nevus which has the potential to be sight or life threatening.
If someone does receive an on-line prescription for glasses and has 20/30 corrected visual acuities; the question that should be asked is why is this person not correctable to 20/20? Might there be a small, micro eye turn that with the use of a small amount of prism, the visual acuity may also be improved? Is there a long standing history of decreased vision which always needs to be documented and explained? Are there cataracts present affecting visual acuities? Are there retinal or vitreous problems such as a retinal tear or a vitreous detachment? Is there an undiagnosed neurological problem that needs serious evaluations such as a CT scan? Is there some form of an eyelid problem such as a ptosis? Is there an extraocular muscle problem or a nerve innovation problem causing decreased visual acuity?
Opticians have spent years in becoming educated and trained through college opticianry programs, becoming licensed, and have years of experience providing vision care and optical expertise for their patients.
Most optometrists have undergraduate degrees and many have advanced Master’s degrees or PHD degrees who spend 4 years in optometry school and years providing patients with the eye care based on education, required continuing education, and experience.
Ophthalmologists have undergraduate degrees and may also have Master’s or PHD degrees. They have spent years in medical school as well as time spent in their residencies and internships perfecting their skills at treating serious eye problems and eye diseases. The idea that a computer-based, on-line eye “test or exam” will ever, or appropriately replace the years of experience and the personal expertise of any ECP should not be debatable.
In a recent study published by the National Institute of Health (NIH) at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3223553/, a study was done on the non-compliance with contact lens wear and contact lens practices. “While most patients consider themselves to be complying with standard practitioner guidelines for lens wear and care practices, essentially all contact lens wearing patients exhibit behavioral non-compliance with resulting increased risk for significant complications.”
If an on-line eye exam does provide a contact lens prescription to a patient, how will it be determined that the base curve, the fit, the diameter of the contact lens, the Dk value/ oxygen levels, and the scheduled use for wearing are all appropriate for this specific patient? Is the prescription accurate or has the patient been over-minused or under-plussed?
The fact is that ECPs provide personal and professional care. Unfortunately, there is still misuse, over-wear, and non-compliance with patients who present annually for an in-office eye exam. What will be the more serious outcomes if these same patients do not visit their ECP on an annual basis? One area that every ECP prides themselves upon is education, especially when it comes to communication with their patients directly and properly. A computer-generated “eye exam” will never provide the personalized care that every patient should demand, let alone the verbal or written instructions that a patient needs.
There may be some limited appeal to those people who do not know any better, and the surprise may occur when these same people enter the office of their ECP and receive a “real” comprehensive eye examination. The fact that there is a charge for these on-line exams attempts to show that there is some “value” for this service. I do not agree with and it always comes down to the well-known phrases, “you pay for what you receive” and “buyer beware.”
Jason Smith OD,MS
