Killakwinn

Is it biotech or is it techbio!!!!!

One could argue that a $79 annual exam is more affordable than paying $200 every month for an injection to manage endstage, out-of-control diabetic eye disease.

That being said, I think annual exams are unnecessary for certain population subsegments (e.g. young healthy folks under 40 years old, have good vision, have no personal or family history of eye disease, have no risk factors for developing eye disease ie poorly controlled diabetes;) for those people who NEED annual eye exams (e.g. those with mild nonproliferative diabetic eye disease,) these should be free. But for those without insurance, this is not the case.

Wow, thanks for the detailed note of support. I agree with all of the above.

Wow, this is super helpful in that it gives me extra context outside of what I'm used to. Also just good to know what else is out there :) Thank you so much!!!

Glad that my training and knowledge base is on point, hehe.

Thank you so much for the kind words. My biggest wish is for my team to use our combined skills and expertise to bring high-impact, scalable solutions to those who can't access an eye doctor (or don't want to go into the office.)

Ok, I’m happy to hear it. This reminds me that another important caveat re: eyecare is this — even within a country, there’s a lot of variation in how ophthalmologists treat the same condition (eg one doctor might choose to do tube surgery on a glaucoma patient, whereas another might choose to do a laser procedure for the same patient.)

I imagine that internationally the differences are even more dramatic! But this doesn’t mean that one country is more “correct” than the other; in fact, I’d hypothesize that for population specific disease variants, geography factors into the trajectory of one’s disease outcome. For example, ophthalmologists in Asia are likely much better at treating normal tension glaucoma (NTG,) which has a higher prevalence in Asian patients. So perhaps these patients tend to do better, but this is only a crude guess.

That is INCREDIBLE. When someone is paying for a full eye exam out of pocket in the US, it can cost anywhere from $69 to $150 USD.

I know right!!! Let’s just say “legit” and “contraband” glasses all come from the same handful of factories in Chinese cities such as Danyang and Shenzhen.

From a clinical standpoint, as long as a person has had the same prescription for years and is happy with their vision, things really ought to be that easy.

Yeah, in the absence of in-person supervision, there are a lot of safety measures that need to be implemented. For example, making sure that people are at the correct testing distance (via a number of potential feedback mechanisms that we're testing) and making sure that people can't zoom in on the optotypes to cheat.

The psychology of how people relate to their vision -- especially the independence that good vision affords -- is very complex and certainly something I wish that our training spent more time emphasizing. There are patients who come into clinic with relatively minor and non-vision threatening problems who are afraid of imminently going blind, and there are patients on the other end of the spectrum who are imminently going to go blind but are in denial about it (or are not terribly bothered by the possibility.) Handling these scenarios and all the gray spaces inbetween is one of the more challenging parts of delivering eyecare (and healthcare in general.)

Ultimately, we're aiming for clinical accuracy and scalability first, with an understanding that there are lots of underlying incentives and potential roadblocks that we will tackle head on when the time is right.

Hi!

I think WP is a great company. I also agree that their vision check UX leaves a lot to be desired -- I ran through it myself a few times, and each time it caused intense frustration. There's something about needing to manipulate laptop and phone and having 14-20 ft of space that is just... impossible lol.

Anyway, our service is similar to WP's app in that we check vision for the purpose of determining if a prescription renewal is appropriate. But that's pretty much it. For us, this is only the tip of the iceberg. Fun times ahead!

I hesitate to provide medical advice here. But if you are 30 and you have a glaucoma diagnosis, you should really be followed by a glaucoma specialist (vs a comprehensive ophthalmologist or an optometrist.)

Thanks! Kristine and I will do some tag-teaming on this.

1) Currently a lot of other services ask people to take "x" number of footsteps away from the screen to approximate "y" feet from the monitor. Using this context, I'd argue that the variation in arm length isn't as dramatic as variation in foot size. Ultimately though, when we're using near vision as a proxy for distance vision, the natural variation in arm length isn't crucial. But! Once we roll out our distance vision check, we won't be relying on arm length.

2) Will leave this to Kristine.

3) Interesting. Hadn't thought about this one. My guess is no because the most important ratio is optotype size:testing distance. (Optotype = the numbers/letters on the screen that a patient is reading)

4) It's possible and we'll need to pressure test this against gold standard in-person maneuvers.

5) Same as #4. Also this is a particularly interesting point because a similar problem exists in person. As an extreme example, I've had patients come in who've memorized the letters in the 20/20 line because they were very motivated by one thing or another (e.g getting their driver's licenses renewed.)

6) Is this the "which is better, 1-or-2" question? All I'll say is that there are a number of interesting ways we could try to simulate these.

Hope this answers some of the q's! Thank you for all the thought that went into them.

Did you do the exam on mobile or desktop? Also, what browser were you using?

We're looking into this circle bug -- very sorry about that!

I won't argue that the current test isn't crude. We're rolling out increasingly sophisticated versions with each update, but I agree that in its current state our exam has a ton of room for improvement.

I do have to mention that the 1) vision check (e.g. do you see 20/20 with you current/expired prescription) and 2) the eye health tests are two different portions of our exam and serve two different purposes.

These latter set of "low-tech" maneuvers (double vision, amsler grid, red desaturation) are very high-level screening mechanisms for more serious underlying issues and do not have much to do with the numbers on a person's prescription. To be more specific, the overlapping circles are meant to assess if someone is having double vision, which in a worst case scenario could be a symptom of acute cranial nerve palsy.

There are very few instances in which a patient with chronic glaucoma needs monthly IOP checks (vs someone who came into clinic with an acute event and goes on to need emergent surgery.) And in those cases where monthly IOP checks are needed, it is definitely not gold standard to use the air puff test.

I'd say that measuring IOP every 3-4 months is a typical regimen for a patient with more advanced glaucoma; these measurements should always be done via the same method (Goldman applanation) at the same time of day (due to AM to PM fluctuations in IOP) to be the most accurate.

I understand why these statements might seem extreme. A few points here:

1) I don't believe I've stated that dilated eye exams should never be done. One of the biggest reasons remote eyecare is relatively far behind compared to other specialties (remote dermatology, for example) is the need to visualize the retina up to the ora, where a lot of pathology (e.g. retinal holes) can hide. Currently, the only ways to visualize the retina this comprehensively are a) scleral depressed dilated eye exams and b) use of wide retinal imaging (e.g. Optos.) Theoretically, "a" can be done in the home via an "on-call" ophthalmologist or optometrist and "b" can be done via an eye van (ZSFG actually has this option,) but neither of these can scale very well. So we're working on a scalable solution that will enable the collection of data on par with what can be gathered via a traditional dilated eye exam.

2) My 2 cents re: cost-saving and efficient glaucoma screening methods is that we need portable IOP measurement devices. Since we're currently limited by existing technology, my vote is for a using tonopen (portable, affordable, accurate) over non-contact tonometry (nonportable, expensive, not accurate) when it comes to rapid remote screening.

Oh hello! I’ve come across easee before and think what you guys are doing is awesome. You’re based in Sweden, right?

Re: coffee, I believe the two of us have interacted on LinkedIn. So nice to be working in the same space — let’s definitely sync!

Thanks, that’s what we love to hear. Please do let us know if you have any feature requests/ideas :)

There’s a lot of good stuff to unpack here, and thank you for bringing all of it up!

I’ll highlight the main point, which is that these “check your vision at home” tests never screen for disease. This is 100% true and is one of the biggest issues I have with the “exams” that are currently out there.

There’s a critical element of good vision that exists outside of needing glasses or needing contacts, and that is, are your eyes healthy and functioning well? Are there underlying, silent issues that don’t bother you day to day but may turn into serious problems down the line? All of these are serious considerations that my team and I are thinking through very carefully, and I want to make it quite clear that our end product will at the very least be able to screen for all the major categories of disease (eg diabetic eye disease, AMD, glaucoma, optic neuropathy, etc.)

I’ll leave the tech stack specifics to Kristine.

From clinical standpoint, the algorithms (re: vision testing and beyond) we design and implement will need to be tested against the gold standard (eg whatever method is used in person.) Fortunately this is fully in my wheelhouse, hehe.

I support this! :D

I think that there are many scenarios in which there shouldn't be a 1 year expiration date for glasses or contacts. For example, if someone has a very straightforward glasses/contact lens prescription (<2D, no astigmatism) that has not changed in years and if that person has also never had an abnormal eye exam, then there is an argument to be made about having a more open-ended expiration date.

Good question. Right now everything is out of pocket. The ideal scenario is for this service to be covered by employers as well as payers; don't worry, we'll make this happen in the future!

Yes, we got the email -- thank you for the input!

I am not familiar with this organization and will look into it. Thanks for bringing them to my attn!

Re: working with orgs, we're interested in partnering with those committed to advancing quality eyecare for all population segments. We're currently working with nonprofits like LightHouse for the Blind to bring eyecare to those with low vision. I've personally referred many patients to LightHouse and think that they provide a valuable resource to an otherwise overlooked portion of eye patient population!

One last point here. Re: slowing down myopia progression, I personally think atropine is the most promising intervention!

Thank you so much -- love the enthusiasm from this community :)

There are several difficulties when it comes to managing glaucoma: 1) There are different types of glaucoma that have different diagnostic criteria 2) Different people have different risk factors for glaucoma development, disease progression, and treatment response. What works for one person may be completely ineffective for another 3) Our glaucoma data (for diagnosis, progression, treatment) is largely based on a cohort of data gathered from Caucasian patients; researchers and clinician are generating population-specific (Blacks, Asians, etc,) data, but there's definitely still a long way to go 4) There is some subjectivity that goes into diagnosing/treating/monitoring glaucoma, which is why one doctor may decide to start you on drops while another may choose to observe without intervention -- in cases that are not clear cut, either approach may be correct

Hi. Thank you for sharing your story. Vision is such a critical part of our daily lives, so receiving a diagnosis like this can be very painful.

Unfortunately, the only way to slow down the damage related to glaucoma is to lower eye pressure (IOP.) This is accomplished via medications, lasers, and surgery. Typically we start with the least invasive option, which is medications (aka eyedrops.) It sounds like you are receiving the standard of care, which is a good thing.

Re: cost of care, I think we can all agree that things need to change.

Good question. These statement applies to patients who have no to very minor eye issues, meaning healthy people under age 40 who have refractive errors of ~1D (ideally less,) who have never been diagnosed with eye disease, who have no family history of eye disease, and who have good vision (that they are happy with.) It sounds like you probably have a refractive error of >6D, in which case yearly dilated exams are good practice.

Re: inaccuracies, what I am referring to is the air puff test. The air puff test is a very crude measurement of eye pressure (aka intraocular pressure, or IOP.) The gold standard is Goldman Applanation, which involves putting yellow fluorescein drops in your eye and then using the applanation tip and a blue light to assess IOP.

More on Goldman Applanation here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2206330/

Hope this helps!

Completely agree, and I would attribute some of this to excellent marketing. Lately I've been thinking about how so much of our behavior and societal/cultural norms (e.g. bacon and eggs are breakfast food! drink milk to prevent your bones from crumbling into a million pieces!) all come down to brilliant longform marketing efforts.