Originating from basic teleconferencing models, technology-enabled tele-optometry has revolutionized the optical industry creating both a more patient-centric model of care and expanding ECPs’ practices in a quintessential win-win. With remote eye testing, optical companies are focusing their gaze on a novel approach—involving the consumer in their own health care journey, increasing their access to eyecare and reducing wait times, two major pain points in eyecare. In addition to self-administered, online visual acuity testing for prescription renewal, these companies are increasingly providing remote diagnostic services, expanding their reach into previously uncharted territory such as ultra-wide field digital retinal imaging. At the same time, eyecare providers have established effective guardrails to protect patients’ eye health, ensuring patient referrals to a specialist when needed, for example.

Ross Goukler, OD

Remote testing is being marketed directly to consumers or is performed in-store by a technician, with the patient in-store and the ECP in a remote location. Test results are reviewed by an optometrist or ophthalmologist, depending on the company. Patients are referred to an ECP if their prescription has changed, or ocular conditions requiring follow-up are detected.

New York-based Warby Parker has expanded its services to cover all bases with comprehensive online and in-store testing. “Telehealth enables us to provide care and access to patients in a way that works for them. According to the U.S. Department of Labor, there is a critical shortage of roughly 6,000 optometrists across the country and that gap is expected to grow, with 60 percent of current ODs planning to retire within the next 10 years,” stated Ross Goukler, OD, and vice president, eyecare.

“We’ve built a seamless shopping experience that meets customers and patients where and how they want to shop, whether that’s on our website, on our mobile app, or in our 245 retail stores. Having an omnichannel presence is what we’re focused on. It’s critical to achieving our goal of making holistic vision care more accessible and convenient.”

Warby Parker initiated online testing, subsequently adding an in-store model. Their Virtual Vision Test app allows eligible users—those with no eye or health problems that have had a recent eye exam—to renew a glasses or contact lens prescription from anywhere, anytime, using just an iPhone. By wearing the glasses or contacts with the prescription that is to be renewed, users can take a simple quiz to ensure the test is a good fit for them. If eligible, they’re guided through a 10-minute vision test, reading an eye chart as they would in the doctor’s office. Within 48 hours, an ophthalmologist reviews their results and provides a renewed prescription if the user’s vision hasn’t changed.

“We’ve designed our Virtual Vision Test with a robust eligibility survey to identify patients for whom the test isn’t a fit, for example if someone has a history of diabetes, if they’re experiencing symptoms like headaches, or if they have issues with their current prescription. We don’t offer the test for patients wearing readers or progressives. We encourage those patients to get a comprehensive eye exam,” added Dr. Goukler. Warby Parker’s Virtual Vision Test is not available in every state.

“While telehealth existed prior to COVID, the mindset for practitioners and patients shifted significantly during the pandemic,” Dr. Goukler continued. “Across health care sectors, virtual care became much more accepted and commonplace during the pandemic, and we continue to see that post-pandemic. Nearly one-third of the population in the United States, over 120 million people, lives in a health care desert, representing nearly 80 percent of all U.S. counties. That number is growing, with the pandemic’s fallout threatening the closure of even more hospitals and care delivery systems.”

ECPs are levering technology in a variety of ways, “but we don’t want or expect telehealth to replace doctors,” Dr. Goukler noted. Warby Parker views telehealth as a triage mechanism for patients who might otherwise resist care because it can be intimidating. Over the past year the company has introduced digital retinal imaging across select locations, enabling advanced disease diagnostics without pupil dilation, resulting in a better experience for patients. Retinal imaging elevates the level of care doctors are able to provide, enables comparison of retinal health at subsequent visits, and improves the management of various ocular and systemic diseases.”

Click here to read Part 1 of Remote Eye Exams exclusively on VisionMonday.com.

Improving Accessibility and Convenience Through an Enhanced Toolkit

According to Raj Ramchandani, president of EyecareLive in California and Visibly in Illinois, telehealth facilitates the remote assessment of non-emergent conditions such as dry eye, conjunctivitis and other common ocular issues, allowing greater efficiency and eliminating the need for in-person visits for minor concerns. Additionally, patients with chronic eye conditions such as glaucoma, diabetic retinopathy and macular degeneration benefit from remote monitoring solutions.

Visibly’s online vision test can be completed using a tablet, laptop or cell phone.

Earlier this year, Visibly introduced the first FDA-cleared online vision test, merging with EyeCareLive, resulting in the launch of real-time video consultations with a synchronous chat function. “Our patented online vision test technology suite helps ECPs remotely assess a patient’s visual acuity,” stated Brent Rasmussen, CEO of Visibly, which operates in 40 states. “Our online portal connects patients with optometrists or ophthalmologists, depending on the state they’re in. They review the test results and either renew the patient’s prescription, or refer or triage them to a doctor for follow-up care if needed.”

Visibly’s online vision testing portal, one of the largest e-commerce platforms in the world, compliments their in-store version of the tests. Their client base includes large omnichannel retailers as well as independent ODs who find it helpful in increasing accessibility and affordability for patients.

Raj Ramchandani

In terms of state and federal regulations, Rasmussen noted that remote eyecare is continuing to gain greater acceptance, with less regulatory pushback against the technology. “As consumers’ acceptance increases and cameras improve, we’ll continue to see innovation in additional services used to evaluate patients.”

Consumers can use Visibly to renew their glasses or contacts prescription from the comfort of their home in about six minutes.

Integrating telehealth services requires minimal upfront investment for eyecare practices, while offering significant potential for revenue growth and increased patient satisfaction, Ramchandani noted. The return on investment for telehealth implementation can be significant and some practices have seen revenue increases ranging from $50,000 to $250,000 or more, depending on the type of remote services they offer.

Standardization and implementation of consistent telehealth regulations across states would simplify telehealth adoption and lower the cost of delivery of care. Advocating for the expansion of telehealth-eligible services, including the ability to diagnose and triage a broader range of eye conditions remotely, would enable practitioners to leverage this technology more effectively. At the same time, reimbursement models for such services must change to incentivize providers to increase the use of telehealth options. “Relaxing rules for remote patent monitoring and reimbursements will help providers to care for chronic eye conditions remotely and consistently,” suggests Ramchandani.

Brent Rasmussen

“Myopia is growing at an alarming rate around the world and with the increase in diabetes we see the need for technologies that can be used by eyecare providers to scale their resources to attend to these patients,” commented Moshe Mendelson, OD, a former EyecareLive executive who is now developing a new ocular artificial intelligence venture. “Remote monitoring and telehealth technologies will have to evolve to cater to patients with glaucoma and other chronic conditions.”

The emergence of the COVID pandemic fundamentally changed how doctors and patients viewed telehealth technology. “In response to the pandemic lockdown of 2020, we recognized the need to provide our patients with uninterrupted access to eyecare, regardless of the severity of their condition,” stated Pamela Wu, OD and Diplomate, American Board of Optometry in Irvine, Calif. “By leveraging EyecareLive telehealth technology, we were able to deliver seamless and efficient care to those in need, whether they had broken their only pair of glasses, were down to their last pair of contact lenses, or experiencing red and itchy eyes.

“Even post-pandemic, we continue to utilize this technology exclusively to monitor our numerous orthokeratology patients who have moved away from the area. The online eye test has been a helpful tool in assessing their myopia management progress. With its user-friendly interface, auto texting reminder appointment link, timer function for billing purposes, photo documentation ability for charting, and self-generating visit summary, this platform has been a valuable asset to our practice. It provides peace of mind for patients and practitioners alike, ensuring the privacy of sensitive information. Telehealth enhances the way we practice and it can only improve our level of care for our patients,” Dr. Wu said.

EyeQue’s website states, “We’re on a mission to bring safe, accurate, simple and affordable eyecare to everyone,” describing the California-based company’s efforts to democratize health care through novel technologies. In addition to increasing patient access and flexibility, and reducing cost, CEO and co-founder John Serri pointed out that telehealth may also be used to follow post-operative patients who won’t need to be seen as often if the doctor can check in with them. It can also be used to screen patients for elective and cosmetic procedures.

(Top) Frequent Vision Monitoring with EyeQue’s Insight. (Bottom) Estimating refractive error for vision marker screening with EyeQue’s VisionCheck.

John Serri

“Having spent most of my life building and studying the evolution of technologies, I firmly believe the adoption of AI and virtualization in eyecare is inevitable. Look around. We shop, get entertained, correspond, do our banking, invest and pay taxes in a virtual manner. I formed EyeQue in part to serve as a catalyst for this process.

“The eye is a rather well-defined optical structure which makes it well suited to digital diagnostics,” said Serri. “I see the day where one handheld, universal self-diagnostic vision device will be able to refract, image and assess the retina, determine acuity, assess color sensitivity, and measure the degree of glaucoma and cataracts an individual may have. The device would also be able to advise and when necessary, refer patients. The patient’s eyecare provider would have full visibility into the test results.”

EyeQue offers low-cost, handheld devices that consumers can use to monitor their eye health at home using their smartphone. Its EyeQue Insight device, for example, is a class 1 FDA-registered medical device device that tests visual acuity, color vision and contrast sensitivity.

EyeQue also offers a vision-centric telehealth platform called EyeQue Connect that is used by retailers, pharmacies and corporate wellness providers. The platform tests visual acuity, contrast sensitivity, color sensitivity, refraction testing and it captures retinal images. This information is securely used by optometrists who partner with EyeQue. The company provides the testing devices, network, training and customer support.

Serri pointed out that there isn’t substantial data on direct-to-consumer eyecare. “My assessment based on EyeQue-related activity is that direct-to-consumer eyecare is growing in magnitude and the solutions are becoming more seamless, comprehensive and accepted by providers and patients. Nevertheless, the home vision testing market remains in an early stage of development. As a comparison, I think home vision testing today is where online banking was 25 to 30 years ago.” Like many optical firms that have implemented remote vision care models, Serri feels that the financial investment has made sense. A practice or an optical store can start to use their platform for $200 USD per month, and purchase their screening devices ranging in price from $100 to up to $1,700. EyeQue’s objective is to provide solutions at a relatively low cost.

Are state and federal regulations keeping pace with the growth of the market? Serri feels that regulators are gradually warming up to virtualization and AI, but it is taking longer than one might expect, with state and federal regulations restricting the adoption process. “Small companies have a hard time affording complex clinical trials and providing extensive documentation that I think nobody ever fully reads,” said Serri.

It’s a catch-22 type of situation. Without FDA clearance getting investment is difficult, yet without substantial investment medical devices can’t be cleared by the FDA. “A medical device clearance pathway should be composed of two distinct serial components, evaluation of safety and evaluation of effectiveness.

“Today they typically are treated as one in a 510(k) or de novo filing,” he continued. “I propose that the first phase aim to evaluate safety and, if safe, allow the medical device provider to enter a provisional phase of field testing as virtual diagnostic devices will improve over time through field use. The benefits of this approach far outweigh the risks.

“The second phase would be to evaluate the effectiveness using both clinical and validated field data if the final improved solution is developed. The FDA controls the spigot of medical innovation, and I hope there will be increasing future support by them for small companies as innovation stems from small entrepreneurial companies. Perhaps the U.S. government should support promising start-up medical device companies through a competitive federal funding program. This would also help to maintain the United States as a leader in medical innovation.”

Clear Horizons Optometry is owned and operated by Clayton Tyler Boyd, OD, who uses the EyeQue EyeConnect tele-medicine platform. The data captured is reviewed by the optometrist to complete an encounter and the results are sent back to the patient and the optical or digital health provider.

Dr. Boyd said, "Patients can perform screenings from anywhere using the EyeQue Insight devices connected to their smartphones. The test results are securely stored in the HIPAA- and SOC 2-compliant EyeQue Connect cloud. As an eyecare provider, I can access this health data through EyeQue Connect to evaluate the results and determine if further action or adjustments to the treatment plan are necessary. With EyeQue Connect and EyeQue devices, patients can monitor their vision health under expert guidance. The results generated provide medical professionals with better insights into the factors that impact vision and enable comprehensive eye health education."

Erica Goldberg

Erica Goldberg, head of U.S. operations for U.K.-based, IbisVision, observed that telehealth solutions open up a wealth of opportunities in eyecare. “Online retailers, large groups, small practices, and brick-and-mortar eyewear chains are looking for synchronous and asynchronous models for implementing ocular telehealth based on their individual needs and patient base,” said Goldberg. “Our health care providers and technology experts are working closely together to create our end goal, a virtual online clinic.”

Ibis-Engage from IbisVision is a cloud-based platform that provides online testing services with the optometrist leading the appointment and testing remotely. Ibis-Engage can be accessed via a laptop, desktop, smartphone or tablet.

Ibis Re-Check from Ibis Vision is an online patient prescription checker.

Earlier this year at Vision Expo East in New York, IbisVision introduced a new product, Ibis Re-Check, an online patient prescription checker. “Our platform empowers patients to effortlessly verify their own prescriptions online, allowing them to monitor changes in vision between appointments,” explained Goldberg. “With the convenience of checking prescriptions from home, patients can stay on top of their eye health every month, every six months, one year, or even 18 months after their initial examination.

“Implementing Ibis Re-Check not only enhances sales opportunities but also provides a patient-centric self-serve option, elevating customer health and retention.” The Ibis Re-Check platform is available in the United States. Ibis-Engage, the company’s cloud-based platform, provides online testing services with the optometrist leading the appointment and testing remotely. IBISengage can be accessed via a laptop, desktop, smartphone or tablet.

State and federal regulations concerning tele-optometry are gradually adapting to the expanding market, according to Goldberg. Many states have implemented telehealth-friendly policies through laws mandating equal reimbursement for telehealth services and specific licensure requirements for practitioners.

Challenges persist in regions with outdated or overly restrictive regulations. Federal initiatives, like the Centers for Medicare & Medicaid Services (CMS) expanding telehealth coverage, have improved access for Medicare beneficiaries. However, ongoing advocacy efforts aim to enact further federal support, such as reimbursement reforms and interstate licensure reciprocity, to better accommodate the evolving tele-optometry landscape.

Goldberg said, “In a world where telehealth exists, policies that allow optometrists to practice across state lines through licensure reciprocity or streamlined processes would expand access to care. Also, a flexible regulatory framework allowing for rapid deployment of ocular telehealth services during public health emergencies or natural disasters would improve our health care system’s resilience. As health care evolves, we can only hope that regulations will change to meet the changing needs of the market.”

In the ocular sector, disruptive technology in the form of tele-health is improving vision care and building ECPs’ practices. It delivers a three-pillar model for advancement in vision care: a premium patient experience, remote testing and diagnostic capabilities that previously didn’t exist, and the ability to elevate ECPs’ practices to new heights in optometric testing and diagnosis.