Online Refractions: Four Actions To Protect Our Patients and Profession

By Lisa Shin, OD

Sept. 16, 2015

In July, Opternative’s online refraction launched, much to the dismay and consternation of the eyecare community. Are you ready to take action to better regulate this new area of health care? Here are key actions you can take today to protect your patients and our profession.

Opternative boasts “disruptive technology” with the ability to bypass the traditional, in-person eye examination. It is the first to give a prescription for glasses and contact lenses, signed by an ophthalmologist. Just last year, there was conjecture around the idea, but uncertainty as to whether it would actually go live.

But now, it is available in 27 states, with more expected soon. With an internet connection, a smartphone and 10 feet of space, Opternative takes a brief medical history, uses a credit card and shoe size for calibration, and asks a series of multiple-choice questions. Contact lens prescriptions are given only to existing wearers, who must submit their lens parameters. A previous glasses prescription can be submitted to Opternative, but is not required, for a new prescription.

There’s been a flurry of activity since its launch. Co-founder Steven Lee settled with the National Board of Examiners in Optometry in a lawsuit involving stolen test questions. The Michigan Optometric Association has requested that the state’s licensing and regulatory affairs department issue a cease and desist order. Its Senate Bill 853 specifically requires an evaluation of ocular health for all prescriptions issued in the state. The AOA is questioning the status of FDA approval, and has written the American Academy of Ophthalmology, pointing out “dangerously inaccurate product claims” and “the essential nature of eye health and vision care.”

The refraction is entirely subjective, without the necessary objective component. It appears that the prescription is determined solely by visual acuity tests. The scope of refractive error is limited: myopes must fall between .25 and -6.00, while hyperopes and astigmats cannot exceed 2.50 D. Consumers must understand that Opternative does not include a comprehensive eye health examination. They must agree to visit an optometrist or ophthalmologist every two years for a comprehensive eye health examination. Consumers must agree that they do not have acute ocular symptoms, such as pain, flashes and floaters. They must also agree that they do not have a history of amblyopia, diabetes, hypertension, glaucoma, cataracts, retinal detachment and neurological issues. Consumers must be between 18-40 years of age.

Fortunately, Opternative has not gained much traction since its launch. Contrary to the notion that there would be a widespread and enthusiastic demand for online refractions, the public is mostly unaware and skeptical. “Barely a blip in the digital health hype machine,” according to the editor of iMedicalApps. Therefore, the time to act is now. Here are several steps you can take:

Continue to build your medical model. With online retailers and refractions, adopting the medical model is no longer optional, but necessary for survival. Remember that not all medical services are covered by insurance, nor should they be. Our patients must understand why our services are valuable and worth the time, the commute and the wait.

Aggressively market the integrated medical eyecare you offer. We must take the holistic approach. Too many times, my patients have ended up in the ER or urgent care, for a problem I could have easily treated. In response, I have written a short guide, detailing the symptoms, causes and treatments for pink eye. I have distributed this to the school nurses, pediatricians and urgent care clinics in my area. I have also written articles on eye health and comprehensive care for my local newspaper, as well as a newsletter for senior citizens. In November, I am scheduled to give a talk on “Preserving Vision Throughout Life” at the senior center. I have a new hand-out, “The Elements of an Eye Exam” for my waiting room. I emphasize the fact that a refraction is only a small component of the exam. I encourage my staff to also communicate this to our patients.

Start your own blog about eye health. It’s amazing that someone like me, with no computer programming or web designing experience, could start a blog! There are so many resources and publishing tools out there, such as Google’s Blogger. I use WordPress, which offers a free platform for blogging. A $99 premium upgrade has been worth every penny. I regularly post cases that highlight the importance of comprehensive eyecare. Assigning the right tags and categories to your posts maximizes their reach.You can also link your blog to Facebook, Twitter and your practice web site.

Ask your state medical board to investigate Opternative. State optometry boards do not have jurisdiction over ophthalmologists, so all complaints must be addressed to state medical boards. Last year, I wrote the New Mexico Board of Medicine on behalf of concerned ODs. We were able to get Opternative on the agenda for their meeting. A veteran ophthalmologist on the Board became an ally, fully supporting our position. A surprisingly positive and in-depth discussion followed, with the concluding remark: “There’s nothing here that we support.”

Here are key points about online refraction that were made in the meeting with New Mexico’s Board of Medicine:

• Opternative’s technology is considered the practice of medicine, and is, therefore, subject to the requirements of the New Mexico Medical Practice Act and Rules.

• Ophthalmologists are required to issue a contact lens prescription only after it is determined that the patient’s ocular health would not be compromised or the eye itself be harmed by the use of contact lenses.

• We are concerned over the absence of a protocol for appropriate eye health history and physical examination, as well as liability and insurance.

• The New Mexico Board considers prescribing drugs or medical supplies over the Internet, via an online questionnaire, unprofessional and dishonorable conduct.

• We urge Opternative to reach out to national and state professional societies, including optometrists and ophthalmologists. Telehealth providers must be evaluated according to the standards of care applicable to those in traditional, in-person settings, according to specialty.

• Medical boards are required to discipline licensees who do not follow established standards of care for their specialty.

As you speak to your medical board, remember the following:
• All providers of telehealth are expected to place the welfare and health of the patients first.

• While ophthalmologists may delegate the refraction to another trained professional, it is the well established and accepted standard of care that a refraction is not to be independent from an ocular health exam. This is vital for the detection of eye diseases that result in permanent vision loss, as well as serious systemic diseases.

• While the refraction itself is a low-risk procedure, bypassing an ocular health evaluation that generally accompanies a refraction, poses serious risk.

• To protect the public from improper, unsafe, and unethical practices, propose the following regulatory measures:

• Require the submission of a complete ocular health evaluation for the release of a contact lens prescription.

• Do not allow Opternative prescription services to be used more than four consecutive times within a two-year period without an eye health examination. Currently, it is four consecutive times in a five-year period, which falls outside the recommendations of The American Academy of Ophthalmology.

Opternative is a shoddy and time-consuming attempt at a refraction. There are many legitimate and appropriate telehealth ventures. This is not one of them. We do not need to accommodate for bad technology. Optometric services are largely convenient, accessible and affordable. However, there will always be those who want to “self-refract,” in the comfort of their own home. They are also the ones who get very annoyed when their prescriptions expire. It’s no surprise that Opternative wants to partner with online retailers.

We must effectively communicate why comprehensive eyecare is far superior to any visual acuity app. We need to propose measures that safeguard the public and enforce professional accountability. To do so is not self-serving, a losing battle, or anti-consumerism, but a call to medical ethics and responsibility. The risk with all telehealth is quackery and substandard care. We cannot be passive; we must be proactive. The time to act is now!

Do you plan to take action to encourage greater regulation of online refractions? What is the best way for independent ODs to address this challenge?

Lisa Shin, OD, is the owner of Los Alamos Family Eyecare, P.C., in Los Alamos, N. M. To contact her:

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