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 for your kind advice. I'm very serious about my eyes and will do my best to protect it. However my docker is considered as a glaucoma specialist in one of the best hospital in our city..(though she's also treating other eye diseases)
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.
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.)
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.
Cool! I can see there's a lot of creativity that goes into replicating in-person vision tests with a reasonably valid unsupervised version on people's home equipment. I hope you have success replicating as many of them as possible.
It's interesting to think of the adversarial element in #5 where vision test results are used to qualify for something. In this case a completely unsupervised test is really easy to cheat on -- people can just lean in close to the monitor! If you're not giving people something that they can use to receive a benefit like a job or a license, that incentive to cheat seems weaker, but maybe people will present their fresh prescriptions (!) as purported proof that they have very acute vision.
I was thinking more about psychological aspects where people might not want to admit that they have certain vision problems, so they might feel an incentive to convince themselves that they saw the correct thing. The order and context of presentation might affect how easy it is for people to convince themselves of that. I know I've taken similar tests in person at the optometrist (like looking at a grid to see if any portions appear distorted), but I don't remember exactly how the optometrist asked me to confirm what I'd seen.
This may be an underappreciated soft skill on the part of medical professionals -- getting people to tell the truth about their perceptions in diagnostic tests, or noticing when people may be dishonest or simply uncertain. So that may be pervasively tricky for you to address, at least with a small percentage of patients: if they want to think of themselves as having good vision, they may consciously or unconsciously fudge the results a bit so the assessment comes back better.
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.
Adding a few things from the engineering side of things! :)
1. We're currently exploring doing a distance check via the webcam using triangulation and face detection to tell folks how far from the camera they are.
2. The average monitor won't add much noise - if we're going by in person eye exams as the gold standard - there's actually a lot of variance between various doctor's offices (lighting, use of a projector/mirror to simulate distance vs placing the chart on the wall).
There's an interesting angle to doing eye exams digitally where we may be able to be more accurate than in in person exam (based on institutional research studies - not something we've yet personally explored).
5. Really interesting and valid point - making these types of questions more interactive is definitely on our roadmap.
6. Clinical trials will help vet any methods we build to show how they compare to existing practices
Desktop, using Firefox on Windows, with no-script active. That last part might be the issue - everything seemed to work until the end - it would not let me submit, then I disabled no-script, and I submitted, but it never asked me for contact info?
Not sure how you'll get back to me, it never asked for an email or anything.
The no-script might be at fault though. You might consider not using any CDN for scripts, only host locally.
I did not try again because I don't have a prescription (I submitted an image saying "no prescription"), and I realized it can't do anything for me (I just wanted a checkup basically - just tell me how I did on the various sized letter thing).
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.
I'm not an American, but I've had eye tests in both Canada and Israel. Just how expensive are these? In Canada they're free - covered by health care (Glaucoma). Regular eye tests in Canada cost ~$49 (clearly, Queen Street). In Israel they cost 22 NIS, about $6.
For some more comparisons, the UK has free eye-tests for certain groups (children and at-risk) [1], but it costs around £20-25 (~$28-$35 at current exchange rate).
Additionally for the UK, if you do work using a computer (which I imagine most people on HN do), your employer is legally required to pay for an eye test if you request it.
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!!!
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.
