Are we there yet? Eyeing current remote vision tests

31st May 2023

Eye care providers are starting to think about new ways to serve and engage with their patients. The use of video visits, text communications, and remote monitoring apps point to an evolution of how care is delivered. Remote vision tests offer another tool to meet patients where they are, and they have gained popularity over the past few years. Judging by the millions of app downloads and reviews, there is a clear demand for an easy way for patients to check their vision.

These tests generally serve two purposes. One is to sell contacts or glasses. The other is to monitor eye health. There is a tangible benefit to the latter, especially for patients with chronic conditions. A decline in vision can signal a change in disease state, prompting a visit to a provider in between scheduled appointments.

Most remote vision tests currently available are of the asynchronous variety, meaning the test is self-administered by the patient and results are sent to an ECP. These asynchronous remote vision tests tout their ease of access as a way of bringing eyecare to more people around the world. They claim they are easy to use and available 24/7, thereby removing barriers and making eye care easier. Increasing access and removing friction is wonderful but do ECPs agree that these tests solve the unmet need? I informally surveyed optometrists around the globe and universally they feel that asynchronous remote vision tests are good in theory, but they don’t stack up to in clinic testing. They don’t trust the results and would retest in clinic. That left me wondering why so I embarked on using these tests myself and uncovering some of the top shortcomings that lead to this distrust of asynchronous remote vision testing .

  1. Patients can cheat-Self-administered vision tests give a variety of instructions. “Stand back 10 feet. Turn on the lights in your room. Cover your left eye. Hold your phone out at arm’s length” But who is checking that the patient is actually doing those things? I tried many tests myself and some asked me to measure out 10 ft but I was too lazy to find my tape measure, so I guessed. And no one would know if I mixed up my left and right eye when testing. Let’s pretend I’m down to my last pair of contacts, which means I’m super motivated to pass the test, I can easily figure out how to do that. There’s also the question around eligibility. These tests ask a series of screening questions to weed out ineligible candidates. That’s great considering many eye diseases threaten vision and warrant a full comprehensive exam. There are questions around glaucoma, diabetes and other conditions that need to be managed by an ECP. But again, if I am motivated to make a purchase, I can lie if needed. For example, one test asked me how long it’s been since I had an eye exam. I clicked 5 years and it wouldn’t let me continue. I hit the back arrow and changed my answer to 2 and voila! I can proceed. That was curious to me since I live in Ohio and a contact lens prescription is only valid for 1 year. In the end I didn’t get my prescription renewed. I couldn’t identify the letters during the visual acuity test for my right eye (I have uncorrectable 20/200 vision in that eye) so the follow up email stated the doctor could not issue a prescription. The good news, it told me, is that I can take the test again.  And I know what I need to do to pass next time. Ultimately, there are several ways to cheat these tests, consciously or not.
  2. Validation testing is limited-There are very few studies done with patients “in the wild”. Meaning many studies are done in clinic rather than the home environment and patients are guided with the help of trained technicians.[1] [2] [3] [4] When patients don’t have this level of hand-holding, are the same results achieved? One study of 11 different apps, found considerable variability in accuracy and not one app could predict standard Snellen visual acuity within one line. [5] With nothing to ensure instructions are followed, it’s no surprise there is a level of distrust in the results by eye care professionals.
  3. There is no personal hand-off or follow-up-We know that many patients will not pass the online tests, and when that happens almost all platforms encourage the patient to schedule an appointment with an eye care provider. But who ensures they do? Some sites will offer a list of providers, others leave it up to the patient to find their own. In my informal survey, 95% of ECPs say their patients haven’t (or haven’t admitted to) taking an online vision test. I would think if someone didn’t pass an online test, they would mention that as the reason for scheduling an exam. Regardless, there is no further education or formal hand off happening to encourage the next step for patients. If the site is trying to sell a product there’s often a follow-up email with a coupon for the next purchase. When it comes to the apps that offer only remote vision testing without an ecommerce component there is no contact info collected so no follow-up is done. Without reminders, a patient could easily forget to make that call.

So where does that leave us? Well, the good news is that these flaws are all fixable that future versions of remote vision tests will be able to address. Patient demand for ease and convenience will not wain so the challenge is to build a remote vision test that meets the needs of both patients and ECPs. To build confidence amongst optometrists and ophthalmologists, a remote vision test that is clinically validated to be repeatable and accurate, that gives proper guidance to the patient and allows for a personal hand-off for next steps would be the ideal solution. Luckily, we aren’t years away from getting a better version of a remote vision test. In fact, keep a close eye on AOS, something very exciting, dare we say, groundbreaking is coming soon. 

 

[1]  Ritchie, A., Atamian, S., Shah, N., Laidlaw, A. and Hammond, C., 2021. Can Visual Acuity Be Reliably Measured at Home? Validation of Telemedicine Remote Computerised Visual Acuity Measurements. British and Irish Orthoptic Journal, 17(1), pp.119–126. DOI: http://doi.org/10.22599/bioj.179

[2]  Ge  Z, Li  L, Lohfeld  L,  et al.  Validity and feasibility of a self-administered home vision examination in Yueqing, China: a cross-sectional study.   BMJ Open. 2020;10(4):e030956. doi:10.1136/bmjopen-2019-030956

[3]  Han  X, Scheetz  J, Keel  S,  et al.  Development and validation of a smartphone-based visual acuity test (Vision at Home).   Transl Vis Sci Technol. 2019;8(4):27.

[4]  Tiraset  N, Poonyathalang  A, Padungkiatsagul  T, Deeyai  M, Vichitkunakorn  P, Vanikieti  K.  Comparison of visual acuity measurement using three methods: standard ETDRS chart, near chart and a smartphone-based eye chart application.   Clin Ophthalmol. 2021;15:859-869. doi:10.2147/OPTH.S304272

[5]  Perera  C, Chakrabarti  R, Islam  FMA, Crowston  J.  The Eye Phone Study: reliability and accuracy of assessing Snellen visual acuity using smartphone technology.   Eye (Lond). 2015;29(7):888-894. doi:10.1038/eye.2015.60