By Barry Santini, ABOM

Telemedicine is changing many aspects of health care delivery. Fast Internet speeds, combined with advances in digitally-based analysis, measurement and imaging is allowing simultaneous collaboration between health care professionals in different physical locations.

Now telemedicine is beginning to make its mark on vision care. Beginning with the simple refraction, technologies are rapidly evolving that will revolutionize the way consumers routinely experience vision care by the year 2020. Instead of being a passive participant, eyecare consumers will finally be granted an active role in the process of analyzing, diagnosing, treating and fulfilling of their vision needs.

Ultimately, these advancements will be summed into the advent of real-time consultations involving multiple eye specialists, who will quickly arrive at a superior understanding of the person’s vision condition and be able to suggest or prescribe products and treatments in a far more comprehensively tailored manner. At the same time, this is aligning with both medical insurance and vision care plan mandates to reduce the expense associated with the need for multiple office visits, further speeding its broad adoption by health care professionals.

Many eyecare professionals have mixed feelings about these changes. On one hand, they find themselves often responding negatively to these new technologies, reflexively seeing them as threats to both their core livelihoods and traditional ideals regarding standard of care. On the other, they recognize how society as a whole has enjoyed and benefited from technological advancement, rarely shedding a tear for the travel agents, taxi drivers and video rental stores being displaced as Expedia, Uber and Netflix enable people to enjoy more control and convenience in their lives. To best understand the inherent appeal of these new smart refractive technologies, let’s look at the current vision care paradigm through a consumer’s eyes.

AMAZON AND THE TRADITIONAL EYE EXAM
More than ever, the Internet has exponentially expanded consumer choice and defined new levels of expectation surrounding convenience. When one can order just about any product or service with but a few keystrokes and have it at your door in 48 hours without the need to go outside the comfort of your home, you can get really spoiled, really fast. Contrast this level of convenience with the flow chart for accessing traditional vision care today:

1. Make an appointment. You wait.
2. Arrive at office for exam. Update personal information. You wait.
3. Experience multiple technicians who pre-test before you see the doctor. You wait.
4. Proceed with general eye exam, including refraction. During subjective testing, the examiner rarely informs you hat they are seeking the point where you cannot easily differentiate amongst the lens choices presented. You wallow in confusion, often becoming anxious that you didn’t answer “correctly.” You wait.
5. Drops are administered to allow the internal eye health examination. You wait.
6. Evaluation complete. Rx given. You are escorted to dispensary for the Rx “hand-off.” You wait.
7. Blurred by the drops, you are expected to pick out the new frames that you will wear on your face, every day for the next two to three years, while you are blurred and fatigued from the choices presented in the exam room. Frame styles are brought over. Lenses and treatments discussed. Often, staff is interrupted by the adjustment needs, repairs or questions of others. And you wait.
8. The glasses are ordered. And you wait.
9. You have to return to the office to pick up your new glasses. This can take anywhere from three days to two weeks, depending on Rx complexity, back orders, insurance mandates and the occasional lab breakage. Since most eyewear deliveries are done without being pre-appointed, you often have to wait to receive your glasses.
10. As you complete payment, you wait.

Obviously, the traditional system is broken, especially if you benchmark it in terms of convenience alone. Now compare the new levels of ease and convenience that Amazon, Netflix, Uber and others are delivering. This is exactly what John Q Public, albeit subconsciously, is beginning to do. Clearly, not every part of the demands in current process can be avoided. But consumers are increasingly receptive to messages that promise they can regain control of their time, money and their role in a typical vision care encounter. And they are willing to achieve this by entertaining choices that ECPs would trumpet as poor trade-offs. The problem is consumers don’t.

EYEGLASS SATISFACTION: BEYOND THE RX
Of the parts in a traditional vision encounter, the one area that most consumers cite as confusing and having a lack of confidence in is the subjective refractive acuity assessment. Although examiners are often quick to point out that people who are unhappy with the vision of their new glasses helped in making the choices that led to their prescription, it is simply not that simple. Let’s review a list of the factors impacting eyewear satisfaction:

• The starting Rx
• The change in Rx
• The lens design
• The lens material
• The lens treatments
• The “PD”
• The Base Curve
• The OC placement
• The Position of Wear, i.e., pantoscopic tilt, frame wrap and vertex distance
• The cost of the eyewear

Even with styling left out because it is a nonoptical factor, it should be clear that overall eyewear satisfaction can be influenced by an amalgam of factors outside of the starting Rx. But, and here there is almost universal agreement by eyecare professionals, the accuracy of that Rx is generally considered to have the greatest impact on satisfaction in eyewear. If a consumer had more confidence in the refraction process, they will be more likely to adapt to the rest of the recipe. With that said, it is easy to understand why the public finds their passive and confusing role in determining the Rx as an area needing a major overhaul.

ENTER SMART REFRACTION
Today’s smart refraction technologies have evolved to the point where they are not only as efficacious as traditional subjective refraction, they’re ready to supersede it. But smart refraction tech is far more than that. They offer an array of benefits that a 100-plus-year-old legacy system simply cannot:

They are portable. Many models are small in size and lightweight, making them ideal for on the road use in school screenings, missionary field work or examining those who are physically handicapped, unresponsive or who have ailments that make being seated behind a traditional phoropter awkward or impossible.

They are precise. Whether you prefer an objective or subjective refractive approach, the precision of smart refraction devices are levels of magnitude better than having to use 0.25D steps, or visually interpolating exactly where the axis dial is pointing within 5-degree registration marks.

They are comprehensive. Using wavefront analysis, readings beyond the conventional second order terms of sphere and cylinder are not only possible, they represent the next major expansion into releasing the full potential of digitally-optimized, free-form lens technology. For example, only wavefront analysis can help to determine the best profile for correcting the eye’s higher-order aberrations, which have a major impact on the subjective quality of vision at larger pupil sizes, i.e., driving at night.

They are trustworthy. With outcomes so much less dependent on the skill of the operator or the response of the subject, smart refraction technologies can deliver refractive endpoints that engender both confidence and satisfaction for both professional and patient.

They are convenient. Instead of eye testing requiring appointing a trip to the doctor’s office, these compact vision analyzers allow the “doctor” to finally to come to you, whether it be at your home, school, work or computer. This is the promise of telemedicine.

OTHER BENEFITS OF SMART REFRACTION
There are more potential benefits that smart refraction technology can offer. For example, its rapidly evolving capabilities promise to reduce or eliminate many typical perceptual adaptations or unexpected visual surprises that have accompanied the traditional eyeglass experience due to changes in Rx or lens design. How? By using adaptive optics, which allow for more precise prescription analysis, in place of traditional lenses in a visualizer—aka a smart vision tester—which allows consumers to assess the real-world effects of a new prescription or lens design in a landscape beyond that of letters on an eye chart. Indoor and outdoor views can be previewed that integrate the benefits and the boondoggles that changes in astigmatism or progressive lens design can produce. Some technologies even possess the capability of allowing the consumer to adjust sphere, cylinder and lens design variables to arrive at an endpoint best tailored to their comfort and expectation. Consumers will want and seek out practitioners who make these exciting technologies part of their “brand.”

Further, advances in portable imaging technology, often via smartphone, will allow multiple specialists to confer or consult remotely or in real time, in order to develop the best treatment plan for an individual.

SMART REFRACTION AND THE EYE DOCTOR
Smart refraction technology is, at its core, all about delivering an easier, more convenient and ultimately more satisfactory refractive outcome to the patient than the traditional method. Even considering the inherent imprecision and nuance required in a legacy exam, eyecare professionals grudgingly acknowledge the inherent disconnect that often occurs if one patient were to see six different doctors in one day but ends up with six different prescriptions. Proponents of smart refraction suggest that these variable results are often traceable to a latent factor found in every Rx: doctor discretion.
When writing an Rx, the doctor:

1. Reviews the results of the objective and subjective exam.
2. Assesses the prescription delta, or change being introduced.
3. Notes the path of historic change and the acceptance of the same by the patient if known.
4. Assesses the impact on comfort and utility the Rx will deliver.
5. Integrates all of the above to arrive at the best overall plan for that patient, replete with an Rx expiration date forecasting the expected term of efficacious treatment.

Sounds good, right? But that discretion, dispensed in a world filled with so many different types of new lens designs, frame fashions and digitally-compensated free-form lenses, can end up delivering the type of unacceptable results we have all seen. A better scenario would be for the Rx to more closely parallel the true optical state of the eye—power, astigmatism, oblique axis and all—and a dialogue box be available for suggestions, recommendations and notes. If this sounds too cumbersome, then a better way could be to use the enhanced precision of smart refraction technologies to include the patient in the process and arrive at a more efficacious and real-world useful result. Greater consumer involvement is a significant aspect of smart refraction technology that will have great appeal and draw for many eyewear consumers.

THE DOCTOR IS OUT: THE DEBATE ON TELE-REFRACTION
No topic in the optical world prompts more emotionally-charged and controversial debates than the idea of allowing consumers to access a simple refraction outside of a complete eye health exam. But this idea is nothing new. Since the 1980s, there have been many proposals at the state level that float the idea that opticians—rather than optometrists or ophthalmologists—could perform refractions, aka visual assessments, without requiring the immediate involvement of an eye doctor. What’s new is that today, technology can allow consumers to have an accurate visual assessment performed via their smartphone or computer, without being in a doctor’s office.

The arguments against separating refraction are familiar:

• Latent, asymptomatic eye disease might go undetected without physician oversight.
• Consumers would continue to confuse the refraction with the comprehensive eye exam, and not seek out a periodic complete eye health checkup.
• The resulting lens prescriptions would, in some way, always be suspect, especially if not reviewed by an eye doctor within the larger informational pool of the doctor-patient experience.

The arguments in favor of refraction a la carte are equally eloquent:

• Emmetropes, that huge group of individuals who are plano, are not routinely issued prescriptions, and therefore, without an Rx expiration date in hand, are effectively left out of the eye health gatekeeping that expiration dates are intended to engender.
• The prescriptions that result from the traditional subjective refraction process are far from being uniformally accurate by any reasonable stretch of the imagination. They are the output of an inherently imprecise process, colored by both patient doubt and an unknown recipe of individual examiner habit, experience and discretion.

REDEFINING REFRACTION
Passing into law in January 2016, New York State legislators clarified the definition of telehealth to mean the use of electronic information and communication technologies by health care providers to deliver health care services to individuals who are located in a site different than the health care provider. This is quite timely, because consumers are becoming increasingly comfortable using their phones outside the doctor’s office to monitor their fitness and their health. From testing blood pressure to glucose levels and even full body metabolic analysis, consumers will want to expand this technology to other aspects of their health, including their vision.

WHERE ARE WE HEADING?
Starting with an accurate and precise second order sphere, cylinder, axis and add power all the way to custom, higher-order aberration analysis, smart refraction technology will further evolve to include all aspects of binocular, accommodative and color vision testing. As the consumer movement for a la carte refraction gains both speed and attention, doctors caution them to understand that a simple refraction is but a small part of the complete eye exam, and by itself, an inadequate measure of total visual health. But as the benefits of increased confidence, speed and convenience become well-known, consumers are bound to seek out those eyecare professionals who adopt and promote the full potential of smart refraction. These technologies will also allow progressive ECPs to enter a new landscape of eyecare, one finally driven by consumer want rather than need. Because smart refraction is portable, precise, comprehensive, trustworthy and convenient, it fits comfortably into this scenario, which is rapidly emerging as the future of eyecare.

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Contributing editor Barry Santini is a New York State licensed optician based in Seaford, N.Y.