Rethinking Refractive Tech

A few weeks ago we got the not so surprising news that Opternative, the online refraction technology that's seen significant legal battles over the past few months, is now partnering with 1-800 Contacts to offer online contact lens prescription services.  Not a surprise that a partnership would blossom between these two companies since they seemingly share a desire to avoid patients entering a doctor's office at all, but still, I have to admit when I read the news I took it with a morbid sense of pseudo-shock.  Despite legislation making Opternative illegal in 3 states (Georgia, Indiana, and South Carolina), in today's world, tech business deals can move much quicker than our own legal system. And if you feel like you've been bombarded by new technologies attempting to replace traditional refractions, you're correct.  This past year has seen not just Opternative, but portable refraction technology from Eyenetra, and  SVONE PRO by Smart Vision Labs also enter the "subjective autorefraction" marketplace.  Five years ago when I was wrapping up my optometric medical education at the Southern College of Optometry, if you would have told me that in just a few more years patients would be offered prescriptions right from their home computer, I wouldn't have believed you.  It seems so reckless, so impractical, so insane.  But that's just an eye doctor talking; to the general public, it's obviously not so dangerous sounding.  And that's where the problem lies.

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This week Dr. Darryl Glover and I got a chance to sit down with Vitor Pamplona, the designer and founder of Eyenetra for our new optometry podcast, Defocus. I was expecting to talk to someone who would be casually dismissal of ocular health exams, who didn't understand that refractions and vision correction often had nothing to do with the actual health of a patient's eye.  What I found was a man who not only had an far-reaching command of the physics of our eye's optical system, but an impressive understanding of the healthcare issues facing the introduction of new tech like his.  Vitor is clear he has designed software that is not a replacement for a doctor, and that the NETRA is marketed as nothing but a portable auto-refractor.


His tech doesn't write prescriptions; doctors write prescriptions.  He paints a picture of a doctors using the Eyenetra smartphone-powered autorefractor just like any other work up test currently used in office, with the doctor choosing to additionally perform a phoropter based refraction to verify results.  His pitch is if you can speed up refraction with his system, you can see more patients or spend more time on what really matters, the ocular health assessment and discussion.  He talks about using this system remotely for mobile clinics, concierge care, or in areas or countries where the access to healthcare is limited.  He talks about a future where patients with conditions like diabetes might even have an Eyenetra device at home; not to get their own prescriptions, but to check themselves regularly for Rx changes that could mean they need a trip to the doctor sooner for better blood sugar control than their yearly comprehensive.  His vision is one that doctors would struggle to find fault with, but I had to remind myself during our interview that this is the same company that I saw illustrations circling on the internet for auto-refractor stations in a prominent online glasses retailer where patients could sit on couches sipping a latte during their refraction.  No doctor; no exam room.  It's a future that is easy to envision too; insanely lucrative for both the tech companies behind these inventions and the online and big box optical retailers that could offer in office Rxes without having to employ a doctor on site to do so.

Could you refract yourself and order a drink at the bar at the same time? Oh wait, that bar is really an optical display.

Vitor understands that replacing ocular healthcare with only refractive care is not in the best interest of the patient, but he points out that it's optometry that has failed patients if there is a concern that patients would chose to skip a health exam. I'm sure not many ODs are going to take his idea of spinning off a new name for ocular healthcare providers, separate from the title of optometry, in order to rebrand our profession's image in the minds of patients, but the truth is, maybe we need a disruptive outside voice saying that optometry has a problem that we aren't successfully fixing.  Our problem isn't new technology entering the marketplace; our problem is what patients think about what we do (glasses prescriptions, right?) and why they should care (they can see fine, so of course their eyes are healthy, right?).  As a profession, we have been able to dilate our patients and assess and treat ocular health since the 1970s, but due to a complex history of propaganda from outside groups and in a not-so distant past even our MD colleagues, our public image has never expanded fully to that of comprehensive ocular healthcare providers, despite the fact that's what we've been doing since PCO first handed out the Doctorate of Optometry title in 1923.

Vitor Pamplona with the NETRA auto-refractor device

I entered this interview thinking I was going to skewer Vitor for creating a product that is a public health risk (very nicely, politely, and enthusiastically based on the sound of my voice on playback apparently). Instead, I realized that the problem isn't his product; it's me, it's all doctors -- optometrists and ophthalmologists.  We are the ones that write the prescriptions, and in the US, prescriptive medical devices like glasses and contact lenses require our signature.

• Ethically, is it in our patient's best interest to perform a refraction (either in person or remotely) without assessing ocular health?  

• Ethically, is it in our patient's best interest to give them a contact lens prescription without actually assessing if that contact lens fits properly on the eye or if the patient has corneal health issues putting them at risk for significant vision loss with the wrong type of contact lens (I'm looking at you Opternative!!)? 

As a doctor, we're educated that we should never, ever give a prescription for anything without assessing my patients' ocular health (or getting records proving they've had that done within the last year), and I'm wondering, what doctor would? Who are these doctors who would sign an Rx for any medical device without assessing ocular health themselves or verifying that health had been assessed by another doctor within a year's time?  We're all worried about refractive tech confusing our patients into thinking their eyes are healthy when they haven't even been checked, but it's doctors that would be to blame if a medical condition was missed. It's that doctor who compromised and offered refractive care without ocular healthcare who is at fault when a condition goes undiagnosed, maybe even blinds or kills someone -- no, I'm not being extremist.  So as doctors, I ask you to think about what you do and why you do it.  A prescription is more than just a print out from an autorefractor; it's your signature that you have evaluated this patient and given them your care. Stand for something bigger than your paycheck; stand up for those millions of Americans with undetected glaucoma, early retinopathy or retinal diseases, or even ocular tumors -- conditions that in early, treatable stages aren't going to present with any vision issues on a refraction.  You won't find these conditions if you don't look for them. And looking for them, that's our job. We have to claim this new autorefracting technology and all new tech innovations for what their true place is in the role of our exam.  The tech is not more than us; it isn't an exam but just a tool, and it can't operate to give anyone a prescription without us.  None of this new tech bypasses a doctor or bypasses an ocular health exam; only a doctor can chose to bypass an ocular health exam.  So I ask you, use this tech like it was designed.  It's a refractive tool to aid in your exam.  It's not an exam.  It doesn't even pretend to be an exam. The only person in the room that can make it replace an exam is you.

I encourage all of us to think about our part in the future of our profession, and act now as a group to legislate ourselves about what is required of a doctor to give a prescription for glasses or contact lenses.  We should all have personal ethics keeping the best interest of our patients in mind, and we should legislate and define those ethics in our own professions. Optometrists and ophthalmologists can legislate what's required for a prescription so no loopholes exist for a doctor that might be willing to compromise their personal ethics for a paycheck.  The technology doesn't control our profession, our pens, or our patients.  We are the caregivers, and the prescription is our care.  What does your prescription stand for?