Before COVID-19 shuttered so much of the normal operations of everyday life, many of the industries and services we use had already begun testing online platforms and digitization. But, when the pandemic hit and social distancing was suddenly a priority, many of those tests became everyday operations.
Health care was no exception. According to Medicare claims and encounter data, the number of telemedicine users rose from approximately 910,500 (March 2019- February 2020) to 28.3 million during the height of the pandemic (March 2020- February 2021).1
In eyecare, patients were already being marketed spectacles and contact lenses online. But, a study shows that nearly 10% of prescriptions ordered from 3 different online vendors do not meet national standards for quality.2
And spectacle and contact lens ordering is just the start. Some of those online retailers are also providing online refraction tests. In April 2020, the US Food & Drug Administration (FDA) provided guidance regarding the distribution of visual acuity charts, Amsler grids, and other vision-related phenomena. While using such tools would not create an undue risk during the COVID-19 public health emergency, they asserted, they should not be the basis of a clinical diagnosis or treatment decision.3
These options may provide convenience, but optometrists argue that, in the long run, they deliver inferior correction and can even put patients at risk. Here, optometrists share their views on the dangers online refractions pose and potential solutions for steering patients away from medically unsubstantiated technologies.
With regard to so-called “online vision tests,” “None of these technologies have been evaluated to see if they are legitimate or not,” explained Jeffrey Sonsino, OD, FAAO, American Academy of Optometry Chair and myEyeris Chief Medical Officer. “Online vision tests [which are not exams] are simply a way for unscrupulous companies to get around contact lens prescription requirements.”
Elizabeth Steele, OD, associate dean for clinical affairs at the University of Alabama at Birmingham School of Optometry, shares these concerns stating that, despite improvements in technology, online optometry exams — whether they are computerized vision tests that estimate glasses prescriptions or remote refraction — are no substitute for an eye care provider’s exam.
“These tests [which sometimes rely on patients to perform measurements] do not accurately account for test distance,” she said. “Nor do they account for the flexibility and abilities of the accommodative system, which is dynamic, and of course difficult to nail down even in person. Disorders of the binocular vision system would likely be missed altogether.”
Dr Steele acknowledged that technological advancements may make remote refraction possible, but questions the quality of such examinations compared with face-to-face interactions. She echoed Dr Sonsino’s concern that no strong scientific data supporting the efficacy of online refractions has been established.
“While the refraction is often what the patient remembers, and what drives the patient’s satisfaction with vision, it is typically a very small percentage of what the eye doctor spends [their time] performing,” she explained.
Shalu Pal, OD, FAAO, FSLS, FBCLA suggests that proper refraction is something of an art form that involves subjective components no online technology is capable of recreating.
“[It] takes into account an individual’s optical prescription, their emotions, their personal preferences, and the way in which they want to view the world,” she argued.
Andrew Morgenstern, OD, FAAO, FNAP, Director of the American Optometric Association’s clinical resources group, is concerned that online screenings will fail to allow clinicians the opportunity to diagnose systemic diseases such as diabetes. While some patients opt for online exams to save money, Dr Morgenstern argued that an early diagnosis provided during an in-person, comprehensive exam will ultimately save money for the patient, the insurance company, and any governmental medical coverage program that the patient participates in.
He stated that abandoning the comprehensive eye exam in favor of an online assessment “will create a reversal of the prevention that [optometrists are] really trying to advocate for the public.”
Although Dr Morgenstern acknowledged that patients may see better with the glasses they obtain through an online refraction test, such results are not necessarily comparable to an in-person refraction.
“Is good enough good enough, or do I want the best?” he asks.
Dr Morgenstern also cites the need for opticianry skills, and stated that eyeglasses need to be fitted correctly to avoid detrimental prismatic effects.
Minor Victories for Optometry
While the problems associated with online eye exams continue to persist, the Food and Drug Administration (FDA), and perhaps— to some degree—some of the businesses administering these tests, have heard the concerns of advocacy groups such as the American Optometric Association (AOA).
In August of 2019, the FDA recalled an online vision test from Visibly, a telehealth company based in Chicago, citing “the firm [had] not received authorization from the FDA to market the product.”4 The AOA immediately celebrated the decision as then-president Barbara L. Horn, OD stated, “[Visibly must] comply with the law—that’s exactly what the AOA and our state associations have insisted on through the information we provided to the FDA and other agencies in this matter, and we’re proud that it appears to have made a difference.”5
Although the FDA’s actions may have given the AOA a short-term sense of optimism, government oversight has failed to eliminate these online vision tests altogether. Years after the recall, Visibly is still among several telehealth providers offering this service.
While it may provide little consolation to clinicians, several providers of online vision tests explicitly state the need for patients to schedule routine visits with their eye care provider on their websites. Visibly’s service agreement states patients must “understand that Visibly’s Services do not include a comprehensive eye health examination” and “agree to visit an optometrist or ophthalmologist at least every 2 years to get a comprehensive eye health examination.”6
Nevertheless, online disclaimers and warnings from eye care providers are not a fool-proof method of ensuring patients adhere to routine, in-person exam regimens. Drs Morgenstern, Sonsino, and Pal offer suggestions on how to keep patients in the exam chair and away from what they consider to be potentially harmful online sites.
Dr Morgenstern urges optometrists to advocate the importance of annual eye exams, disease prevention, and proper spectacle fitting. He also suggests providers take advantage of the latest equipment, such as optical coherence tomography angiography (OCT-A), to increase the speed of diagnosis, provide earlier intervention, and prevent vision loss.
Dr Sonsino promotes an educational approach and painstakingly describes each part of the optometric exam to his patients as he leads them through it. He provides an explanation for each test being performed and the ultimate goals behind it.
“When I’m using the biomicroscope to examine the ocular structures, I’m explaining what I’m looking at. And it gets a little tedious to do that 22 times a day, but it is the most important thing to show patients that an eye exam is more important than a vision test,” he said. “What we’re trying to do is to show value in the tests that we’re performing. And if the patient does not perceive the value, then all they see is the eye exam as a barrier to their prescription.”
Dr Sonsino also communicates a real-life scenario to his patients and uses it as a teachable moment to discourage online vision screenings.
One of his patients used an online vendor for 3 years without the seller requiring a prescription. The patient eventually presented to his office with a corneal transplant, he said.
Eye irritation prompted the patient to visit an ophthalmologist, who referred him to a cornea specialist. During the visit, the patient’s eye perforated due to an ulcer, prompting emergency surgery.
The patient will now need to have a corneal transplant every five years. This could have been detected had the patient received a comprehensive eye exam, Dr. Sonsino explained.
“We don’t have the [online] technology available to image the surface of the eye with any kind of resolution required to see the blood vessels that are at the edge of the cornea, and those blood vessels tell us a ton about whether the patient is in the correctly fitting contact lens — the correct material, the correct curvatures, the correct diameter,” he warns.
Dr Pal emphasizes taking patient education to a higher level. She ensures patients understand more about their eyes and any ocular conditions they may have when they leave an appointment compared with when they came in.
“The more that we can demonstrate and educate the patient on what we are looking for and why we are checking, the more value we are demonstrating for them to give us their time,” she states.
She also advocates for greater clinician education. Dr Pal said patients will return if they see that optometrists stay informed of the latest treatments, bring in new equipment, and research new ideas, products, and services.
Dr Pal also urged optometrists to help patients understand how important their vision is, and encourages them to take a preventative approach in maintaining ocular health. She advises optometrists to remind patients when to return for their next eye exam and use social media to teach others about the importance of eye care.
Dr Pal also discussed the importance of a team-oriented approach toward eye care. “The one thing I learned very early on, is that you can’t do this alone. We need good, supportive staff that are well trained and can help you give your patients an incredible experience filled with kindness, knowledge, and care.”
She encourages optometrists to choose staff that align with their values and goals for treating patients, running their business, and creating an enjoyable environment for patients.
“I choose my team members based on personality — kind and happy people,” she said. “I train and teach them as much as I possibly can to rival my own knowledge. The more they know, the more they can help our patients.”
Dr Pal asserted that online assessments cannot replace the service and care optometrists can provide patients in the office.
“As eye care providers, we have to first remind ourselves of our own value,” Dr Pal said. “If we don’t believe that we are worth a visit, then our patients will think the same.”
1. Medicare telehealth snapshot. Centers for Medicare & Medicaid Services. https://www.cms.gov/files/document/medicare-telemedicine-snapshot.pdf. Updated March 3, 2022. Accessed March 15, 2022.
2. Gordon A, Twa MD, Cutter G, Kleinstein RN. Accuracy and repeatability of internet-ordered spectacles. Optom Vis Sci. 2021;98(12):1340-1347. doi:10.1097/OPX.0000000000001817
3. Enforcement policy for remote ophthalmic assessment and monitoring devices during the coronavirus disease 2019 (COVID-19) public health emergency: guidance for industry and Food and Drug Administration staff. United States Food and Drug Administration. https://www.fda.gov/media/136733/download. Updated April 2020. Accessed March 15, 2022.
4. Class 2 device recall refraction test. United States Food and Drug Administration. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfres/res.cfm?id=174633. Updated March 15, 2022. Accessed March 16, 2022.
5. FDA enforcement action disrupts vision test company. American Optometric Association. https://www.aoa.org/news/advocacy/patient-protection/fda-enforcement-action-disrupts-vision-test-company?sso=y. Updated August 22, 2019. Accessed March 16, 2022.