Opternative? Dangerous Alternative!

Opternative? Dangerous Alternative!

Originally published 3/3/2014:

As a health care provider, it is hard to describe the mixture of shock, disappointment, sadness and fear which overwhelmed me when I first learned of this new business venture, "Opternative."

Opternative is a new concept in removing the eye care provider from the process of obtaining glasses.  In recent years, companies such as Warby Parker have taken the opticianry market by storm, providing a cheap alternative to customized eyeglasses.  These spectacles are produced and dispensed without any guidance for the appropriate size, shape, or style of frame which would best support their patients' needs, without any refining of fit once the lenses are installed in the frames.  If they suffice, a happy consumer will not complain.  Meanwhile, sensitive and dissatisfied patients will likely visit a professional if and when they find their needs are not being met, in the absence of professional care and guidance in the process.  Moreover, I have taken heart that at the least, there is a low likelihood for harm to come to the patient as a result of this entity.

Opternative, however, is an entirely different matter.  The fact that a doctor of optometry, a colleague who has taken the Hippocratic oath, would even consider such an endeavor, is a bleak mark upon our profession.  I am disheartened to see how far a doctor may have fallen, forgetting that his first calling is to DO NO HARM.

You may be wondering, "What harm can be done in providing glasses?"

IT'S NOT ABOUT THE GLASSES!!

Doctors of optometry are Primary Care Providers.  And while many individuals seek out optometrists for eyeglasses, they are likely unaware of the several medical aspects of an eye exam which are being reviewed for their health and well-being on even the most standard visit. Optometrists play a critical role in public health.  Often, optometrists are the ONLY mode of medical monitoring for people who "prefer not to go to doctors," or who are in the unfortunate position of being without health insurance.  Eye exams are affordable with or without medical coverage.   Patients are screened not only for visual maladies, but also for life and sight-saving medical concerns.  In fact, Vision Service Plan (VSP) has shown that people with a VSP vision plan are three times more likely to get an annual eye exam than a routine preventive physical.(1) United Healthcare (UHC) also identifies eyecare providers (ECPs) as "gatekeepers to health," with patients visiting ECPs more frequently than primary medical care providers.(2)  Thus, for diseases which can be commonly detected on a routine vision exam, the rate of early detection and treatment is substantially enhanced with the provision of routine eyecare.

Systemic conditions such as diabetes, hypertension (high blood pressure), high cholesterol, are often first diagnosed on an eye exam.   The back of the eye (retina) provides the only non-invasive, routine means of observing blood vessels in action without invasive techniques.  These recent health care efficiency studies have been able to demonstrate the impact of primary care eye exams on the early detection of disease.(1,2) United Health Care found that ECPs are often the first to detect chronic conditions.  In a study conducted in 2011 and 2012, ECPs were responsible for the initial identification of disease in 5.6% of patients who were diagnosed with chronic conditions in this period of time. (2) Of 72,534 chronic conditions identified, 4,034 or 5.6% of the total were attributable to comprehensive eye exams.(2) Diabetes, high cholesterol and hypertension had the highest volume identified through a comprehensive eye exam. Multiple sclerosis (15.1%), diabetes (14.9%) and juvenile rheumatoid arthritis (12.0%) accounted for the disease most likely to be identified by an ECP.(2)

The complete publication may be reviewed here: Impact of Eye Exams in Identifying Chronic Conditions, directed by Linda M. Chous, O.D., and Thomas L. Knabel, M.D.

Vision Service Plan (VSP) conducted its own study to evaluate the public health impact of vision care on the detection of medical conditions.   VSP providers detected signs of certain chronic conditions before any other healthcare provider recorded the condition—65% of the time for high cholesterol, 20% of the time for diabetes, and 30% of the time for hypertension.(1)

The complete publication may be reviewed here: Vision care investment pays big benefits.

These healthcare insurance companies have conducted studies from a business model, with an interest in the cost-saving rewards of efficient, effective disease detection.  Indeed, UHC's conclusions make a recommendation for a follow-up study to explore the financial impact of early identification for each chronic condition in the study.  VSP has already explored this question, identifying a 127% return on investment per eye exam in the form of future savings and healthcare cost reduction.  

Personally, my concern as a healthcare provider is to place the patient first.

The presence of Opternative undermines public health.  With every fulfillment of an order by Opternative, precious opportunities to protect life, to protect sight, will be cast aside!

Consider Zen McManus, who came in for contact lenses and left with a diagnosis for papilledema, followed by the emergency identification and removal of a brain tumor.

Consider Carly Lindner, a 12 year old whose life and sight were saved at a routine exam conducted at a Walmart.

Consider Sarah Slingsby, a young girl whose complaint of different vision between the eyes revealed a retinal blastoma (tumor in the eye).

Consider the cost it would have been to Olive Marrs, had she decided to just check her vision online, and waited until her glasses proved ineffective before seeing a professional.  Her symptom of blur, typical for a 64 year old, led to the identification and timely treatment of a brain aneurysm.

I ask you, do you believe it is reasonable to bypass the public safeguard of routine eye care?

At what cost??!!

(1) Vision Service Plan. VSP White Paper:  Vision care investment pays big benefits. 2011. Last accessed, March 3, 2014: https://visionplans.vsp.com/dms-inline/pdfs/HCMS_2010_White_Paper.pdf

(2) United HealthCare Services, Inc. Impact of eye exams in identifying chronic conditions. 2014. Last accessed, March 3, 2014:  http://www.uhc.com/live/uhc_com/Assets/Documents/EyeExams_ChronicConditions.pdf

(3) The American Academy of Optometry (AOA) expressed its concerns in a position statement, here.
 

24 comments on “Opternative? Dangerous Alternative!”

Lynette Kline, O.D. says:

March 4, 2014 at 12:09 am  (Edit)

I agree that prescriptions for glasses should not be given without a comprehensive eye exam. How often is a patient unaware that they have a sight-threatening problem when all they wanted was a change in their glasses.

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Barry Santini says:

March 4, 2014 at 3:14 pm  (Edit)

Then, to be consistent, you’d have to outlaw over-the-counter readers too, yes?

Q: Where are the bodies? Over 46 million pairs of OTC readers were sold last year

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Samantha Slotnick says:

March 4, 2014 at 3:45 pm  (Edit)

Hi Barry,
Thanks for posting. You bring up a reasonable question, but I disagree with your conclusion.
Over the counter (OTC) readers are a non-specific, non-customized implement. Whether or not they effectively help a person is immediately evident, without purchase.

Patients who are not aided by readers will seek a professional opinion, which may well uncover an unexpected problem. (Refer to reference on Olive Marrs, above.) Furthermore, problems identified on an eye exam are not limited to the cause of underlying blur.

Offering a person a customized, automated evaluation which purports to help resolve a complaint of blur eliminates the opportunity for people to be medically screened, particularly if the blur complaint resolves on receipt of glasses. This does not discount the lost opportunity to be screened for medical conditions which may not induce any visual symptoms or complaints.
As far as a body count, there are myriad manageable, treatable healthcare concerns which do not pose an immediate threat to life or sight; this does not make such problems insignificant. It may be as simple as a confirmed diagnosis of hypertension, or identification of diabetes in a person who is unaware that his/her health is at all compromised.

Again, thank you for raising the point.

Samantha Slotnick

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Barry Santini says:

March 4, 2014 at 8:11 pm  (Edit)

Thanks for continuing the discussion, Dr. Slotnick. I might see your point ” People who are not aided by readers will seek a professional opinion” flipped around: People who ARE aided by readers will NOT tend to see a professional opinion.

The point all this discussion is heading to I think is should refraction be available a la carte, on demand, separate from a complete eye (health) exam.

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Samantha Slotnick says:

March 5, 2014 at 10:07 pm  (Edit)

Likewise, Barry.
I appreciate the converse issue, that when OTC readers are effective, these folks do not get helped/ evaluated either. And while I believe that is unfortunate, it really does not fall in the same class of concern. OTC readers are not customized, not validated with any seemingly objective test, and they are not marketed as anything more than a convenience. Basically, they are on the order of magnifiers which do not have to be hand-held.

On the other hand, there are multiple problems with this “pseudo-refraction,” particularly as a customized test, with a significant price tag (relative to OTCs), with the backing of a doctor as a designer, and with a time-delay before any support can be provided as a result. In this blog, I have focused on the public health concern for lost opportunities to evaluate medical status in the great many people who do not have or seek standard medical coverage. This, I maintain, is the greatest disservice which will result from this technology.
In addition (no pun intended), as a behavioral optometrist, I perceive prescribing as an art. I take into account binocularity, accommodative facility, comfort and performance when I prescribe– none of which can be accounted for in an automated online test.

Thanks for playing devil’s advocate, Barry. Would you prefer to see this technology succeed? Can you offer benefits which outweigh the risks?

Samantha Slotnick

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Kelly says:

March 5, 2014 at 1:53 am  (Edit)

How interesting that tonight’s episode of The Voice had a contestant who had her regular eye exam with her OD and was discovered to have the rare VHL disease.. she required 2 very long brain surgeries to survive. http://www.nlm.nih.gov/medlineplus/vonhippellindaudisease.html

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Samantha Slotnick says:

March 5, 2014 at 10:08 pm  (Edit)

Thank you for sharing the link, Kelly!

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Peter Guhl says:

July 3, 2014 at 7:37 am  (Edit)

Barry, there is a body count for OTC readers as well, 2 so far this week. One with previously undiagnosed end stage glaucoma. The other had dangerously high blood sugar from diabetes. She compensated for variable vision with readers. Like smoking, it is a risk but already out there and we probably can’t change that. Do we want to introduce a new one, particularly one that has a “doctor’s” blessing? For what they deliver, the cost is much higher than what most insurers pay for refractions. There is no cost savings, just money to be made from people ignorant to this model’s limitations.

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Samantha Slotnick says:

July 8, 2014 at 8:39 pm  (Edit)

Dr. Guhl, thank you for sharing your direct experience of the pitfalls of “self-serve” vision care. It is true, what patients are electing to give up for the limited savings may well be priceless.

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Malcolm Hume says:

January 13, 2015 at 11:19 am  (Edit)

Maybe people should just go to their PCP. I’m not being facetious, an eye doctor is not a substitute.

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Samantha Slotnick says:

February 15, 2015 at 4:19 pm  (Edit)

Thank you for commenting, Malcolm. Agreed, an eye doctor is not a substitute for a primary care physician. However, there are a great number of people who “avoid doctors” and have no opportunity for routine care or disease detection. Many uninsured people avoid doctor visits, or wait until there is a medical urgency. Some of these people, however, will make time to go to an eye doctor because it may serve a functional purpose for them. These are the people whose pathology we are able to detect, if and only if they are at the office of a clinician.

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Samuel Pesner, OD says:

July 28, 2015 at 6:11 pm  (Edit)

One day in my optometric practice, a 43 year old patient came with a complaint of blur at near; far was OK. “When was your last eye exam?” “I’ve never had one – I’ve always seen fine.” “When was your last physical?” “I’ve never had one – I’ve always felt fine.” Vision far was 20/20 and there was blur at near from presbyopia, the normal decrease in focus ability that occurs as we age. Reading glasses were necessary. Then I looked inside the eyes: Hemorrhages everywhere and a swollen optic nerve in both eyes. This was very advanced high blood pressure, with no signs or symptoms and the patient unaware. I made an appointment with a physician who admitted the patient, who was told that if I had not made that diagnosis, the patient would have been dead in two or three days. The point is obvious: an on line refraction or self-prescribed reading glasses would have killed this person. Enough said!

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Samantha Slotnick says:

July 28, 2015 at 8:25 pm  (Edit)

Thank you for sharing your example, Dr. Pesner. This is exactly the sort of reason that eye-and-vision exams are so tremendously valuable to the average non-symptomatic adult!

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eye doctor buzz says:

August 8, 2015 at 9:47 am  (Edit)

Forgetting the obvious perils of bypassing the eye care professional, has there been any assessment of the accuracy of opternative?

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Samantha Slotnick says:

August 8, 2015 at 10:19 am  (Edit)

Anecdotally, many ODs have been trying the process and sharing their experiences. I have read several reports of the test taking 25 minutes, and concluding that “the system needs to verify the prescription, please retake the test.” After an additional 25 minutes of testing, the system may offer a prescription, or it may find that it is unable to determine one.

The test-taker can decide whether they wish to pay for the Rx at that time, in order to obtain the results.

After 50 min of interrupting blurry images on a screen, would you rather have a $40 guesstimate Rx, or an appointment with a professional?

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Il Anso says:

October 14, 2015 at 4:51 pm  (Edit)

There is also the issue of Opternative’s requiring your old prescription, which seems like cheating (aren’t they confident in their own exam?). My reason for doing it was to compare it with my optometrist’s, before ordering expensive glasses (to keep both honest). It would be interesting to send them a bogus Rx and see how influenced they are.
Another problem is the age limitation to under 40 yo.

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Samantha Slotnick says:

October 24, 2015 at 1:43 am  (Edit)

Thank you for commenting. Comparison is an interesting reason to try it out. It would be worth knowing whether your bogus Rx might invalidate the Opternative findings so that they withhold your Rx. But as I see it, I do not believe that the information you gain from Opternative would be valuable in keeping your optometrist “honest.” Your optometrist has direct access to objective measures of your eye and refractive state. The rest of the prescribing is based on art and practice, to help assure that patients will find their Rx to be comfortable.

The age limitation is a safety precaution… which is really a liability precaution for Opternative.

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Will Hughes says:

December 16, 2015 at 2:39 am  (Edit)

I’m glad I found this. I took their 20/20 Vision Challenge, which was only a few minutes long, and was considering the eye exam. I found this page after searching for reviews. I hadn’t even considered the other tests that come with a regular eye exam.

I’ve had 2 prescriptions so far from normal eye exams and I wasn’t completely satisfied with either one of them. The first one failed to correct an astigmatism in one eye. Even after I went back a week later the doctor refused to change it.

The second prescription, 2 or so years later, only partially corrected it. This time the axis is off about 15 deg which I didn’t notice until a few months later because there was some improvement.

Both doctors used a dimly projected image for me to test my vision as they made adjustments. I am not a fan of this. I would much rather look at something printed, with better contrast and a clear, focused edge.

I thought I might have better luck with Opternative but I guess I just need to find a better eye doctor. I can’t talk through these issues with a computer screen.

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Samantha Slotnick says:

December 16, 2015 at 3:09 am  (Edit)

Thank you for commenting. I appreciate the comments regarding the quality of the images on which you base your decisions. Hopefully, the medical aspects of the exam are also of value to you.

Prescribing is a mix of art and science, particularly when accounting for a two-eye system resulting in a single image. Just because testing reveals better clarity with astigmatism compensation does not mean you will be comfortable wearing the full compensation, or even wearing the power at the same axis that is measured.

I hope you find a doctor who listens to your concerns and helps you towards the outcome you seek.

Sincerely,
Dr. Samantha Slotnick

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Emily K says:

January 6, 2016 at 1:26 am  (Edit)

I was looking up articles to present to our pre-optometry club at an undergrad campus and came across your post. Really interesting opinion, thank you!

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Samantha Slotnick says:

January 6, 2016 at 1:35 am  (Edit)

My pleasure!

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Teresa says:

April 20, 2016 at 5:43 am  (Edit)

I admit a regular exam would be good, but for someone with extreme handicap who CANNOT get to a doctor’s office and is already a dozen years late for new glasses, an online alternative is a god send. I’ve called various agencies and doctors and no help from anyone. Explain how I am to get better vision NOW as I can’t read anymore without closing one eye. (gradual fuzzy due to aging and recent pink eye, I should have had 3 or 4 new Rx, going by the previous 30 years) I have GP and other care but no eye doctor.

Some people have legitimate reason for an online option.

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Samantha Slotnick says:

May 24, 2016 at 1:17 pm  (Edit)

Patients with extreme handicaps may have other factors requiring care and supervision from a specialist.
Requesting a house call would be a more appropriate option.

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Samantha Slotnick says:

May 24, 2016 at 1:36 pm  (Edit)

Sadly, you are a perfect example of an individual who requires a specialist. Perhaps seek a house call, if you cannot get to a doctor’s office.
Best wishes.
Dr. Slotnick

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