Market disrupters are having a moment. Disrupters—companies that subvert established business models, often using modern technology—purport to better serve the consumer. In some industries, they make a strong case. You can buy a quality mattress online without being hounded by commission-hungry salespeople. You can hail an affordable ride that arrives in minutes. You can stream a near-infinite collection of music and movies for a flat rate and never pay a late fee. Of course, the conveniences of this brave new world are predicated upon the losses of the traditional outlets for these services (for evidence: try to find your nearest record store; then, consider how close the nearest one was 15 years ago). 

Harvard Business School professor Clayton Christensen defined the term “disrupter” in his 1997 book The Innovator’s Dilemma. He says these companies anticipate the consumers’ unstated, future needs.¹ In other words, they offer consumers something they didn’t even know they wanted. 

For example, Warby Parker launched in 2010 and, by 2014, CNBC had ranked it second on its list of top 50 disrupter companies for “taking on the Luxottica eyewear machine.”² Giving the consumer a way around your optical shop—something they may have seen as a “middleman”—opened a market previously inaccessible to the average consumer. 

Today’s new threat is online refraction. These companies are crossing a barrier into patient care, according to many optometrists. The online refraction industry has the potential to create a system wherein patients obtain a refraction from the website (which relies on prescriptions written by an ophthalmologist, since they can operate across state lines—optometrists can’t) and use it to order frames or contact lenses from an online retailer. Notice anyone missing in that equation?  

Optometrists have plenty of questions about the new modality’s clinical validity and its impact on their brick and mortar practices. This article addresses those concerns, explains what these companies provide and how optometry is fighting back legislatively, individually and technologically.  

Meet the Disrupters

You may have heard of one or two companies looking to become the “Netflix” of refraction, but even a cursory survey of the market shows there are many outlets available for patients to obtain their prescription online. The most visible company currently offering this service, Opternative—its name a portmanteau of “optometry” and “alternative”—provides a vision test patients can take at home, which is reviewed by an ophthalmologist. A short time later, the company delivers a lens prescription that can be used at any optical shop. 

For its part, Opternative stresses that its refractive test is not an eye exam and that patients should still see their optometrist. In fact, the site says it “prohibits patients from taking an Opternative test more than four consecutive years without certifying that they have received a comprehensive eye health exam first.” 

Opternative has even partnered with another well-known disrupter, 1-800 Contacts. As part of the deal, 1-800 Contacts customers can take Opternative’s refraction test and obtain a prescription on the 1-800 Contacts website.³ Their apparent hope, and many optometrists’ fear, is that patients will take their refractive test online, order contacts from 1-800 Contacts (or frames from Warby Parker) and never visit the optometrist. 

Another company, 2020Now, takes a different approach. Rather than an at-home exam, 2020Now provides an in-store exam, presumably at an optical shop, with an ophthalmologist who teleconferences in on an HD video. 

And that’s not nearly the end of the list. Eyenetra, GlassesOn and Simple Contacts are making in-roads, and each puts its own spin on the test. The entirely app-based Simple Contacts blatantly states in its advertisements: “Skip the office! Renew your prescription with an app.” 

Take it as a sign of the times. The disrupters have targeted eye care and they’re convincing patients they want to avoid the optometrist. Your move.

LEGISLATION
Take Action
In the face of a disrupter, a Harvard Business Review article proposes traditional businesses evaluate three necessary points: 

1. Identify the strengths of your disrupter’s model.

2. Identify your own relative advantages.

3. Evaluate the conditions that would help or hinder the disrupter from co-opting your current advantages in the future.⁴ 

Online refraction companies’ strengths are their convenience and novelty. Unless optometrists find a way to evaluate patients on demand and from the comfort of their homes, they’re never going to beat the convenience of a website. 

Naturally, optometry has a relative advantage—the ability to provide a comprehensive eye exam using both objective and subjective tests. But ODs have another powerful tool that can hinder the disrupter from co-opting its current advantages: organized optometry. 

“When Opternative got together with 1-800 Contacts and started trying to deceive the public into thinking that they have a system that is standard of care, that’s when I got involved,” says Jeffrey Sonsino, OD, chair of the Contact Lens and Cornea Section of the American Optometric Association (AOA). In fact, he relates the story of a patient who presented to him with some irritation. The 30-year-old had ignored optometric evaluations and opted to simply reorder contacts for three years without seeking in-person care. The patient had a Pseudomonas ulcer caused by Acanthamoeba that ate through his intact cornea within 24 hours. “He had to get a corneal transplant that was 10.5mm in diameter,” Dr. Sonsino explains. “Because of the size of the graft, for the rest of this guy’s life he’s going to have a repeat corneal transplant until, ultimately, he loses the eye.”

“When they provide a service that is sub-standard of care, the public is invariably harmed,” says Dr. Sonsino. “My position in the AOA is to protect the public.”

He, along with the AOA, is certainly building the case against online refraction testing. To that end, they’ve provided an email address—[email protected]—where any optometrist can recount their horror stories of harm caused when patients opt for online tests over OD visits. 

The AOA has also launched a campaign to educate the public about the risks of online exams. The group has talked to reporters for Politico, Medscape Medical News and published in The Hill.^5-7 State chapters, such as the California Optometric Association, have created YouTube videos for patients who like to do their own research.⁸ The AOA has also partnered with the Vision Council to launch the site thinkaboutyoureyes.com, a resource to help patients and parents understand the value of an eye exam and put patients in touch with local ODs.

Organization

While outreach is important, the AOA’s real power comes from its ability to educate legislators. The group filed a complaint with the FDA against the concept of online refraction testing.⁹ “The entire claim—and the reason for the complaint that was filed—is that the standard of care is a face-to-face eye exam in which an eye health assessment and a refractive assessment are done at the same time,” says Clarke Newman, OD, chair of the Federal Relations Committee at the AOA. “That being said, a refractive evaluation is still a face-to-face test that includes both objective and subjective testing.” He says relying on blind subjective data alone—as online outlets do—often misses the refractive endpoint and delivers a flawed prescription. “We advocate across the board that the standard of care must be maintained and that all these conveniences are at the expense of the accuracy of the refraction and at the expense of eye health.” 

The complaint—filed April 4, 2016—also took issue with some of the claims sites have made concerning the efficacy of the technology.⁹ “The self-administered nature of the test is uncontrolled, and that can lead to errors that significantly alter the prescriptions,” he says. 

“The FDA is looking at it and the FTC will look at it and see if the claims that they’re making are valid and, if not, we have a deceptive trades claim,” Dr. Newman says. “We’re not advocating for these things to be made illegal; what we’re saying is they shouldn’t be available if they’re not approved by the FDA. They shouldn’t be exempt from going through the standards every other device does.”

State-by-state efforts are taking effect, too. In Connecticut, for example, new legislation aims to prohibit prescribing contact lenses “using information obtained from a test using a ‘remote refractive device’ as the sole basis.”¹⁰

While the AOA is taking on the online refractive threat legislatively, there’s something you can do everyday to keep your patients where they belong: talk to them.

As these Simple Contacts advertisements—culled from popular-with-Millennials social networking platform Instagram—clearly show, online refraction testing casts visiting an optometrist as an unpleasant, time-consuming chore, as opposed to their convenient alternative. While organized optometry challenges that portrayal nationally, ODs can talk up visiting an in-person doctor with patients individually.

FACE TO FACE

Win Patients Back 

The AOA’s stance on these companies prompts the question: Does online refraction actually threaten optometry’s model? Consider the lesson of Google Maps.¹¹ Google managed to topple the navigation device market (remember your Tom Tom GPS?) on four main selling points: price, quality, convenience and personalization. Improving on all four of these aspects disrupted the personal navigation device market forever.¹⁰ 

It may be worth discussing with patients whether online refraction companies can beat optometry in any of these selling points. 

Price. No optometrist would provide a refraction separate from a comprehensive eye exam, explains John Rumpakis, OD, CEO of Practice Resource Management, Inc. However, since that’s what these companies are doing, a hypothetical price-by-price comparison may be an appropriate point to discuss with patients. Opternative offers a glasses or contacts prescription for $40 ($60 for both). Although optometry offers a comprehensive exam at an average Medicare reimbursement of $120 to $150, the line-item for the refraction aspect of the exam averages between $20 and $25, says Dr. Rumpakis. Specifically, “The 2017 National Average Allowable from CMS for 92015 (Determination of Refractive State) is $20.13.” In addition, while employer-based health insurance options often cover vision, no insurer currently covers online refraction tests.

Quality. Online services can offer subjective tests, but none are yet able to offer an objective measurement. Conversely, programs such as the VA TECS program—which employs an autorefractor and sends test results to an off-site ophthalmologist—uses only objective tests.¹² According to Dr. Newman, that’s not nearly enough. “The face-to-face refraction using a confluence of both objective and subjective measurements is something that has developed organically over 200 years,” he says. 

Let’s say a patient has an eye deviation that requires prismatic correction: They can’t address that online. Even if they get the exact sphere and cylinder power, they can’t get the prismatic power, Dr. Sonsino adds.

Another example is cyclorotation. “When some patients test themselves, their eyes rotate when they cover one eye,” Dr. Sonsino says. “If you don’t account for that, the axis will be off. There is an entire paradigm that accounts for what we do in an exam room when we’re trying to control for things such as an accommodative spasm, cyclorotation and for prismatic induction. In the absence of those controls, patients end up with the wrong prescription.”

Convenience. In a March 2016 interview with the podcast Tech in Chicago, Aaron Dallek, co-founder of Opternative, made a strong argument for the online convenience.¹³ Mr. Dallek offers the scenario of a busy parent who believes they have a better chance of setting aside an hour for a new prescription once their kids are in bed and, since the patient won’t have to leave the house, no babysitter is required.¹³ Marc Taub, OD, a fellow with the College of Optometrists in Vision Development, understands that appeal, “It’s ease of care and time. We all live very busy lives, and patients may think, ‘Any way that I can get even a half an hour back, that’ll be easier,’” he says. Convenient? Sure, so long as the patient is confident they don’t have any indications of glaucoma, retinal disease or other syndromes a simple vision test won’t detect. As Dr. Sonsino points out, catching those issues later in their development will naturally require a much lengthier time commitment and a greater cost to the patient’s health as well as to their wallet. 

Personalization. This is where the optometrist has a clear advantage. A visit to the OD provides a one-on-one interaction with a doctor. Patients just sit back and let the ODs and support staff do most of the work. For example, contact lens fitting and follow up is an essential aspect of patient care that a website could never provide. Dr. Sonsino’s Acanthamoeba patient probably developed his disease from poor contact lens hygiene. “Pseudomonas ulcers are highly associated with contact lens wear,” Dr. Sonsino says. “I can’t tell you how many patients I have that I use that opportunity when they’re in the chair to talk about the risks associated with contact lens wear and, in an evaluation, I’ll find things on the surface of the eye that an iPhone can’t find. It can only be done under high magnification under stereo vision. I’ll find signs that tell me that we need to change the patient’s contact lenses, maybe into something that provides more oxygen or a lens that fits the eye differently. That can only be done in person.”

Jack Schaeffer, OD, of Schaeffer Eye Center in Hoover, Ala., echoes that concern. “If you follow the research, the majority of complications in contact lenses are due to noncompliance by patients,” he says. “Online sales can’t do a proper contact lens evaluation.” 

An analogy that Dr. Sonsino shares with his patients: “It’s like a timing belt in a car. If you fail to replace that timing belt as you should, you’ll go along perfectly fine, until that timing belt breaks. When it breaks, you will be stuck on the side of the road. So, you can either choose to maintain your car or wait until something bad happens and address it then. The problem is, when you wait until something bad happens with your vision, a lot of times, there is no recovery.”

It seems implicit that an online refraction test provides only an automated relationship that has no way of recreating the level of curation an optometrist can provide, and that curation can be the difference between healthy and unhealthy ocular habits.

Just to be sure, though, I took the test myself.

Putting it to the Test: My Take on Online Refraction Every company’s approach is a bit different, but for the purposes of this article, I took the Opternative test. Here’s how it went: In interviews, Mr. Dallek noted that the test begins by asking two questions: the patient’s cell phone number and their shoe size. In fact, it starts with a few other questions that may not seem important to patients, but optometrists will recognize their value. First, patients are presented with a questionnaire to determine whether they have any systemic diseases, such as diabetes or hypertension (if you answer yes to any, you’re not permitted to take the test. However, I had no problem going back to the start of the questionnaire and changing my answer until I was permitted). “They don’t want to be on the hook for not doing a comprehensive eye health exam,” according to Dr. Newman. The test also asks your home state, since online refraction is barred in 11 states. Interestingly, I had no issue using a banned-state billing address as long as I claimed to be from a state where online refractions are not barred. After those disqualifiers (toothless though they may be) weed out some prospective customers, the test does ask for the patient’s shoe size—to help them measure the distance they should step away from the computer—and cell phone number. The site essentially turns the patient’s smartphone into a remote control the patient can use to respond to the test questions. Patients will require 10 feet of clearance. The test requires them to stand at varying distances and use a smartphone to answer, for instance, which way the “E” on the screen is facing. Opternative also uses a modified duochrome test to determine the sphere. After the test, it asks patients to submit their previous prescriptions, provided by their own optometrists. Results Twenty-four hours after taking the test and submitting my old prescription, I received an email with a downloadable new prescription. It was convenient. I could take that prescription, signed by an ophthalmologist, and start shopping for new glasses online. But I wanted to be sure the new prescription was accurate. The online prescription was suspiciously similar to my 2015 Rx. In fact, the only change was in the axis of my astigmatic right eye, which the site measured 140 (in 2015, my OD measured it at 135). So, I phoned my doctor, who agreed to participate in my experiment. After completing both objective and subjective tests, she noted that myopia had progressed, by a greater amount than the website detected. Instead of the website’s recommendation of sticking with the -4.25 OD and -4.75 OS, my doctor measured my eyes at -4.75 OD and -5.00 OS. She also noticed astigmatism in my left eye for the first time (0.25x015) and a change in my right eye from 0.50x135 in 2015 to 1.00x155. Sure, it’s possible I could have gone to yet another optometrist and probably received a third prescription different than either the website or my doctor, but my doctor was able to do something a website can’t. She used her phoropter to demonstrate my 2015 prescription, then she flipped to the website’s recommendation and, finally, her recommendation. My choice was crystal clear. It wasn’t as convenient, but I left the office with a significantly superior product, plus a dilated exam, visual fields test and IOP measurement, assured of my visual health.

INNOVATION

If You Can’t Beat ‘Em…

We’re living in a do-it-yourself era. Consumers in a variety of fields are looking to dispose of barriers between them and the product they’re after—and that extends to all branches of medicine. To wit, a consumer hearing loss group—The Hearing Loss Association of America—is pushing for over-the-counter hearing aides (there’s a bill in Congress now).¹⁴ Some ODs speculate that maybe trying to prevent patients from embracing these technologies is the wrong approach. Indeed, online refraction companies have their own consumer groups pushing legislation and attempting to control the narrative. Like the AOA, they’re making their voices heard, and their characterization of optometry isn’t pretty. The AOA is cast as “Big Eye” and optometrists as regulation-dependent “crony capitalists.” One clickbait headline even reads, “How Eye Doctors Are Robbing Us Blind.”^15-17 

Maybe, this is the time for optometry to develop a response to online refractions—to win back patients while maintaining the standard of care. “Imagine if patients could take an accurate refractive exam in the waiting area before even seeing the doctor, or if they could arrive with results in hand” from a home test, speculates Gary Gerber, OD, practice consultant with Power Practice in New Jersey. Dr. Gerber and others envision a future wherein the optometrist can redirect patients from today’s bare-bones tests to a system monitored—not rubber stamped—by individual doctors. Rather than depend on the evaluation of a subjective test by an algorithm and an out-of-state ophthalmologist, patients would be able to more efficiently use that waiting time to take the subjective portion of their exam. 

“At some point in time, there will be a sufficiently advanced technology,” says Dr. Newman. “It’s just not today.”

Online refractions are, as Dr. Taub succinctly puts it, “not really eye care.” But many of the outlets providing it are touting it as a way to avoid your optometrist. In that sense, the threat is real. It’s going to require a keen analysis of your patient base to see if you, individually, are losing patients to this modality. And, perhaps, in a not too distant future, a salesman will appear in your office with a sufficiently advanced technology that you can add to your practice to offer an alternative to online refraction platforms. Until that day, patients need you to explain that they need an in-person doctor visit, because “there’s a human aspect to putting all the data from a comprehensive eye exam together,” says Dr. Taub. 

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