Is the perfect prescription a Blink away?

Update: The website and project appear to be gone as of 11/15/2017.

In a perfect world everyone would have access to the latest in medical services and procedures, including vision needs. Ideally, each and every person on the planet would lead long and healthy lives, without the hassle and frustration of needing eyeglasses or contact lenses.

According to the Brien Holden Vision Institute, more than 625 million people around the world suffer from blindness or visual impairment because they do not have access to an eye exam and prescription eyeglasses1. Of these estimated 625 million people, 70% live in developing countries and 82% live below the poverty line2. The World Health Organization puts the global cost of these untreated refractive errors at $269 billion annually3.

The seemingly obvious response to this situation would be to increase the number of optometrists and ophthalmologists so that more eye exams can be performed. There is a measurable need for the service, so why is it not being met?

The easy answer is “time and money”. The schooling and continuing education that is required of the doctor and the cost of the various instruments that are necessary to properly detect, diagnose and treat the innumerable factors involved in visual impairment almost necessitate the practitioner have a passion for restoring perfect sight to patients.

However, we are in the 21st century and there are cars that drive themselves, surely there is an automated way of conducting an eye exam!

Enter EyeNetra Inc., the company behind a mobile, smartphone based, “eye exam” that began life as an MIT project (now called the NetraG) and has recently launched in New York City under the name, Blink. This is an “eye exam” that comes to you, for a flat fee, and does not require you to have vision insurance. All that you have to do is schedule an appointment and a technician will arrive at the selected time, in 20 minutes you will go through a series of mobile instruments, a licensed optometrist will review the results of the tests and relay your prescription if you have one.

What NetraG really is though, is a mobile phone app and a set of plastic optical discs in pretty housing. A handheld device that is designed, presented to the patient as such anyway, to replicate a carefully positioned and precision crafted instrument called a phoropter.

As of this writing, EyeNetra claims credit for 36,879 tests performed worldwide4. If you click on the “See more” link near the very bottom of the page you will find that those tests have been performed in India. They also state (under the heading “Accuracy”) that tests were conducted on “more than 1,000 people in IRB approved side-by-side trials”. That is reassuring, until you understand what an IRB is, which you won’t be able to do on their site as they do not follow conventional polite grammar rules and spell the acronym out (I confirmed by having Google search their entire site in the event that I missed it). In the United States, where EyeNetra is based, the Food and Drug Administration (FDA) and the Department of Health and Human Services oversee various ethics committees to ensure that human subjects are not being subjected to physical or psychological harm in the course of research and testing. To clarify EyeNetra’s published statement; no physical or mental harm came to the more than 1,000 people they conducted trials on. Which is great, but it doesn’t testify to accuracy.

Another statement made by EyeNetra does however, they claim that the “NetraG is just as accurate as top-tier autorefractors that cost up to $45,000”. Let me address the dollar amount they afixed first, it is complete hyperbole and designed to make the cost of the Blink “exam” seem insignificant in contrast. The larger point of that statement however is comparing the NetraG to a top-tier autorefractor; nearly every comprehensive eye exam conducted in the United States features the use of an autorefractor. If an optical technician has ever sat you down in front of an instrument and told you to focus on the balloon at the end of the street or the house at the edge of the field and you observed the object go in and out of focus, you have experienced an autorefraction. For a responsible eye care practitioner this is a routine component of the eye exam, emphasis on component. That instrument gives the doctor an objective measurement of your refractive error as well as your pupillary distance. For a “top-tier” device, the measurement is successful less than 70% of the time, at best5.

Your regular optometrist or ophthalmologist will use the autorefractor results as a starting point, then collect your feedback as they go through a series of lenses in a phoropter to find out what your vision needs are, going beyond the median programmed into the mechanical instrument.

Taking that into consideration, the statement that EyeNetra makes on the very top of their Blink FAQ page in response to the question “HOW IS BLINK DIFFERENT FROM WHAT IS DONE BY AN EYE DOCTOR IN AN IN-PERSON OFFICE VISIT?” is this: “First, our visioneers collect the same information to correct refractive errors from your home as is collected in an optometrist’s office, only now the optometrist can help you remotely!”

They might have better stated it as “…collect a portion of the same information to correct…” because even absent the health related data a doctor gathers during a comprehensive eye exam, there is still a wealth of information that a Blink “eye exam” does not collect, such as corneal thickness, corneal defects or pupil size. Aspects that can have an impact on how well a patient is able to see with corrective lenses.

EyeNetra is unable to perform contact lens evaluations as well, something they mention about ⅔ of the way down their FAQ page. They refer people to their local optometrist for that, as well as a comprehensive eye exam every two years. In fact, there is a surcharge of 25% for people that have not had a comprehensive eye exam in the last 2 years, money that EyeNetra keeps as they encourage people to comply with the American Optometric Association’s recommendation. For those in need of an optometrist, EyeNetra will gladly refer you to a doctor in their “partner network” of ZocDoc affiliated optometrists. ZocDoc’s headquarters is conveniently located a few short blocks down Broadway in New York City from Blink’s headquarters.

The old adage “something is better than nothing” does not often ring true, but in the case of EyeNetra and their Blink “eye exam” there is an entire conversation taking place where the “something” being offered is not the “something” being given. Yes, for the more than 625 million people suffering with untreated refractive errors, a Blink “eye exam” for a relatively small fee (relative to the loss of potential income due to uncorrected vision) is worth the +30% chance that their prescription is incorrect. Given the extremely limited access to even the most basic of eye exam facilities, “something” is better than nothing. I have worked with numerous doctors that have spent weeks out of the year in undeveloped countries performing comprehensive eye exams and dispensing glasses that were as close a match as possible to the prescription because that was what was available. And the people that received those glasses were appreciative and grateful.

The people in those villages however, were having the correct conversation, they had no expectations and the slightest improvement of their vision was more than they had hoped for.

EyeNetra does not seem to be having that conversation with their customers in New York (and wherever else they expand to in the future), not according to anything I have found on either of their websites that is. Each site reads as your typical sales pitch, except when you factor in the importance of a person’s vision, then it is misleading and deceptive. People visiting either site have to look for the random word that calls the Blink “eye exam” exactly what it is, a screening. A $75 screening that promises accuracy as good “top-tier autorefractors” as confirmed by over 1,000 people that were not physically or mentally harmed by their experience with Blink.

It is a shame that irresponsible writers such as Antonio Regaldo further complicate the issue by marginalizing doctors in general as happened in his article for Technology Review when he wrote that devices like the NetraG “challenge doctors’ monopoly on diagnosing disease, not just errors in vision.” Thankfully, a reliable outlet, National Public Radio (NPR), summed it up perfectly with their comment that “Nothing Beats A Complete Eye Exam”6.

My only hope is that with the announcement of VSP’s minority stake investment in Blink, that EyeNetra begins focusing on transparency in their US markets. Full and readable disclosure regarding the extreme limitations of their instrument compared to the readily available eye exams in developed countries, so that people can praise it for the services it can provide in areas where a visual health vacuum exists and 625 million people have a need for something, because they have nothing.

1. http://www.brienholdenvision.org/global-eye-care/eye-care-needs.html
2. https://s3.amazonaws.com/b.3cdn.net/orbis/75e8e70e98ab5b18b7_kwm6b0ieu.pdf
3.http://www.who.int/bulletin/volumes/90/10/12-104034/en/
4. http://eyenetra.com/product-netrag.html
5.http://www.eyeworld.org/article.php?sid=293
6. http://www.npr.org/2012/02/06/145909903/where-eye-care-is-a-luxury-technology-offers-access

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