Launch HN: Quadrant Eye (YC W21) – Tackling online eye exams and at-home eyecare
93 comments
This is really neat!
A few questions after trying the prototype:
(1) Is there enough variation in people's arm lengths that it would be beneficial to give another way to describe the distance to the monitor?
(2) Is there any impact from the monitor's dot pitch or contrast settings on which lines people will be able to read, even at a constant size and distance? Are some monitors effectively just better quality in a way that could lead to a different result?
(3) Is there any impact from the monitor's physical aspect ratio because some people are looking more straight ahead and some are looking more to one side (when using a wide-screen monitor in landscape mode)?
(4) How well can people who have double vision or retina problems correctly match the test images they see to one of the intentionally-distorted samples? Could their vision problems also distort the samples so that they end up picking the wrong one?
(5) Could having the intentionally-distorted samples visible at the same time as the test image bias people's perceptions, since they can guess which one is most normal (least distorted) and then optimistically claim to have seen that one?
(6) Will you be able to realistically simulate the effects of a proposed prescription change, even without having physical lenses for the user to look through? (I didn't upload my prescription to the prototype, so I don't know exactly what happens after that step.)
A few questions after trying the prototype:
(1) Is there enough variation in people's arm lengths that it would be beneficial to give another way to describe the distance to the monitor?
(2) Is there any impact from the monitor's dot pitch or contrast settings on which lines people will be able to read, even at a constant size and distance? Are some monitors effectively just better quality in a way that could lead to a different result?
(3) Is there any impact from the monitor's physical aspect ratio because some people are looking more straight ahead and some are looking more to one side (when using a wide-screen monitor in landscape mode)?
(4) How well can people who have double vision or retina problems correctly match the test images they see to one of the intentionally-distorted samples? Could their vision problems also distort the samples so that they end up picking the wrong one?
(5) Could having the intentionally-distorted samples visible at the same time as the test image bias people's perceptions, since they can guess which one is most normal (least distorted) and then optimistically claim to have seen that one?
(6) Will you be able to realistically simulate the effects of a proposed prescription change, even without having physical lenses for the user to look through? (I didn't upload my prescription to the prototype, so I don't know exactly what happens after that step.)
Thanks! Kristine and I will do some tag-teaming on this.
1) Currently a lot of other services ask people to take "x" number of footsteps away from the screen to approximate "y" feet from the monitor. Using this context, I'd argue that the variation in arm length isn't as dramatic as variation in foot size. Ultimately though, when we're using near vision as a proxy for distance vision, the natural variation in arm length isn't crucial. But! Once we roll out our distance vision check, we won't be relying on arm length.
2) Will leave this to Kristine.
3) Interesting. Hadn't thought about this one. My guess is no because the most important ratio is optotype size:testing distance. (Optotype = the numbers/letters on the screen that a patient is reading)
4) It's possible and we'll need to pressure test this against gold standard in-person maneuvers.
5) Same as #4. Also this is a particularly interesting point because a similar problem exists in person. As an extreme example, I've had patients come in who've memorized the letters in the 20/20 line because they were very motivated by one thing or another (e.g getting their driver's licenses renewed.)
6) Is this the "which is better, 1-or-2" question? All I'll say is that there are a number of interesting ways we could try to simulate these.
Hope this answers some of the q's! Thank you for all the thought that went into them.
1) Currently a lot of other services ask people to take "x" number of footsteps away from the screen to approximate "y" feet from the monitor. Using this context, I'd argue that the variation in arm length isn't as dramatic as variation in foot size. Ultimately though, when we're using near vision as a proxy for distance vision, the natural variation in arm length isn't crucial. But! Once we roll out our distance vision check, we won't be relying on arm length.
2) Will leave this to Kristine.
3) Interesting. Hadn't thought about this one. My guess is no because the most important ratio is optotype size:testing distance. (Optotype = the numbers/letters on the screen that a patient is reading)
4) It's possible and we'll need to pressure test this against gold standard in-person maneuvers.
5) Same as #4. Also this is a particularly interesting point because a similar problem exists in person. As an extreme example, I've had patients come in who've memorized the letters in the 20/20 line because they were very motivated by one thing or another (e.g getting their driver's licenses renewed.)
6) Is this the "which is better, 1-or-2" question? All I'll say is that there are a number of interesting ways we could try to simulate these.
Hope this answers some of the q's! Thank you for all the thought that went into them.
Cool! I can see there's a lot of creativity that goes into replicating in-person vision tests with a reasonably valid unsupervised version on people's home equipment. I hope you have success replicating as many of them as possible.
It's interesting to think of the adversarial element in #5 where vision test results are used to qualify for something. In this case a completely unsupervised test is really easy to cheat on -- people can just lean in close to the monitor! If you're not giving people something that they can use to receive a benefit like a job or a license, that incentive to cheat seems weaker, but maybe people will present their fresh prescriptions (!) as purported proof that they have very acute vision.
I was thinking more about psychological aspects where people might not want to admit that they have certain vision problems, so they might feel an incentive to convince themselves that they saw the correct thing. The order and context of presentation might affect how easy it is for people to convince themselves of that. I know I've taken similar tests in person at the optometrist (like looking at a grid to see if any portions appear distorted), but I don't remember exactly how the optometrist asked me to confirm what I'd seen.
This may be an underappreciated soft skill on the part of medical professionals -- getting people to tell the truth about their perceptions in diagnostic tests, or noticing when people may be dishonest or simply uncertain. So that may be pervasively tricky for you to address, at least with a small percentage of patients: if they want to think of themselves as having good vision, they may consciously or unconsciously fudge the results a bit so the assessment comes back better.
It's interesting to think of the adversarial element in #5 where vision test results are used to qualify for something. In this case a completely unsupervised test is really easy to cheat on -- people can just lean in close to the monitor! If you're not giving people something that they can use to receive a benefit like a job or a license, that incentive to cheat seems weaker, but maybe people will present their fresh prescriptions (!) as purported proof that they have very acute vision.
I was thinking more about psychological aspects where people might not want to admit that they have certain vision problems, so they might feel an incentive to convince themselves that they saw the correct thing. The order and context of presentation might affect how easy it is for people to convince themselves of that. I know I've taken similar tests in person at the optometrist (like looking at a grid to see if any portions appear distorted), but I don't remember exactly how the optometrist asked me to confirm what I'd seen.
This may be an underappreciated soft skill on the part of medical professionals -- getting people to tell the truth about their perceptions in diagnostic tests, or noticing when people may be dishonest or simply uncertain. So that may be pervasively tricky for you to address, at least with a small percentage of patients: if they want to think of themselves as having good vision, they may consciously or unconsciously fudge the results a bit so the assessment comes back better.
Yeah, in the absence of in-person supervision, there are a lot of safety measures that need to be implemented. For example, making sure that people are at the correct testing distance (via a number of potential feedback mechanisms that we're testing) and making sure that people can't zoom in on the optotypes to cheat.
The psychology of how people relate to their vision -- especially the independence that good vision affords -- is very complex and certainly something I wish that our training spent more time emphasizing. There are patients who come into clinic with relatively minor and non-vision threatening problems who are afraid of imminently going blind, and there are patients on the other end of the spectrum who are imminently going to go blind but are in denial about it (or are not terribly bothered by the possibility.) Handling these scenarios and all the gray spaces inbetween is one of the more challenging parts of delivering eyecare (and healthcare in general.)
Ultimately, we're aiming for clinical accuracy and scalability first, with an understanding that there are lots of underlying incentives and potential roadblocks that we will tackle head on when the time is right.
The psychology of how people relate to their vision -- especially the independence that good vision affords -- is very complex and certainly something I wish that our training spent more time emphasizing. There are patients who come into clinic with relatively minor and non-vision threatening problems who are afraid of imminently going blind, and there are patients on the other end of the spectrum who are imminently going to go blind but are in denial about it (or are not terribly bothered by the possibility.) Handling these scenarios and all the gray spaces inbetween is one of the more challenging parts of delivering eyecare (and healthcare in general.)
Ultimately, we're aiming for clinical accuracy and scalability first, with an understanding that there are lots of underlying incentives and potential roadblocks that we will tackle head on when the time is right.
Adding a few things from the engineering side of things! :)
1. We're currently exploring doing a distance check via the webcam using triangulation and face detection to tell folks how far from the camera they are.
2. The average monitor won't add much noise - if we're going by in person eye exams as the gold standard - there's actually a lot of variance between various doctor's offices (lighting, use of a projector/mirror to simulate distance vs placing the chart on the wall).
There's an interesting angle to doing eye exams digitally where we may be able to be more accurate than in in person exam (based on institutional research studies - not something we've yet personally explored).
5. Really interesting and valid point - making these types of questions more interactive is definitely on our roadmap.
6. Clinical trials will help vet any methods we build to show how they compare to existing practices
1. We're currently exploring doing a distance check via the webcam using triangulation and face detection to tell folks how far from the camera they are.
2. The average monitor won't add much noise - if we're going by in person eye exams as the gold standard - there's actually a lot of variance between various doctor's offices (lighting, use of a projector/mirror to simulate distance vs placing the chart on the wall).
There's an interesting angle to doing eye exams digitally where we may be able to be more accurate than in in person exam (based on institutional research studies - not something we've yet personally explored).
5. Really interesting and valid point - making these types of questions more interactive is definitely on our roadmap.
6. Clinical trials will help vet any methods we build to show how they compare to existing practices
Just got a postcard from my optometrist the other day saying it’s time for my annual prescription check. My eyes are no different, but my glasses are scratched, so I need to spend an hour or two to get this fixed instead of just reordering glasses online. Can’t wait to use a service like this instead, much faster and easier, good luck!!
In the US at least, you can order glasses online as long as you know the prescription. It's contacts that require a 'valid' prescription which only lasts a year and they will only let you buy a 'years' worth of contacts at a time.
The rules around this vary state by state. In states like CA, it's unfortunately illegal to sell glasses/contacts to someone with an expired prescription.
More info on buying glasses/contacts: https://www.consumer.ftc.gov/articles/buying-prescription-gl...
More info on buying glasses/contacts: https://www.consumer.ftc.gov/articles/buying-prescription-gl...
That's wild! I'm lucky enough to never having needed glasses, but the country of limited regulation being so captured by the eyewear industry of all things is crazy.
My wife orders hers by dropshipping from possibly China and just enters her measurements from her latest prescription. Is that illegal? Contraband glasses.
My wife orders hers by dropshipping from possibly China and just enters her measurements from her latest prescription. Is that illegal? Contraband glasses.
I know right!!! Let’s just say “legit” and “contraband” glasses all come from the same handful of factories in Chinese cities such as Danyang and Shenzhen.
From a clinical standpoint, as long as a person has had the same prescription for years and is happy with their vision, things really ought to be that easy.
From a clinical standpoint, as long as a person has had the same prescription for years and is happy with their vision, things really ought to be that easy.
I'm in WA, and I have to upload a photo of my prescription to buy glasses from a popular online eyeglass vendor whose name rhymes with Warby Parker. My impression is that it's a state-by-state thing. In my opinion it's pretty silly require this for eyeglasses (contacts are a different matter).
Same here in TX. Got a nice bold expiration date on my prescription too, but can't remember if it's one year after I uploaded the picture or one year after the scrip was issued.
I think that there are many scenarios in which there shouldn't be a 1 year expiration date for glasses or contacts. For example, if someone has a very straightforward glasses/contact lens prescription (<2D, no astigmatism) that has not changed in years and if that person has also never had an abnormal eye exam, then there is an argument to be made about having a more open-ended expiration date.
There are two parts to this. One, yeah the optometrist wants your money, sure. You probably don’t need your script checked annually unless you’re old or there’s something serious already known to be wrong with your eyes.
But... Not perceiving a change in your vision doesn’t mean your eyes are healthy - there are all sorts of diseases that a decent optometrist is screening for during an eye exam. Most notably glaucoma, which is irreversible and often presents no symptoms. Your eyes are really really good at working around flaws in your vision, which means that you can feel like you are seeing fine when really your vision is failing. This is what a lot of “check your vision at home” things miss - they can hand you an eyeglass prescription (so long as your vision isn’t too far outside the norm) but they almost never screen for disease, and catching those diseases early can be the difference between seeing and legally blind.
But... Not perceiving a change in your vision doesn’t mean your eyes are healthy - there are all sorts of diseases that a decent optometrist is screening for during an eye exam. Most notably glaucoma, which is irreversible and often presents no symptoms. Your eyes are really really good at working around flaws in your vision, which means that you can feel like you are seeing fine when really your vision is failing. This is what a lot of “check your vision at home” things miss - they can hand you an eyeglass prescription (so long as your vision isn’t too far outside the norm) but they almost never screen for disease, and catching those diseases early can be the difference between seeing and legally blind.
There’s a lot of good stuff to unpack here, and thank you for bringing all of it up!
I’ll highlight the main point, which is that these “check your vision at home” tests never screen for disease. This is 100% true and is one of the biggest issues I have with the “exams” that are currently out there.
There’s a critical element of good vision that exists outside of needing glasses or needing contacts, and that is, are your eyes healthy and functioning well? Are there underlying, silent issues that don’t bother you day to day but may turn into serious problems down the line? All of these are serious considerations that my team and I are thinking through very carefully, and I want to make it quite clear that our end product will at the very least be able to screen for all the major categories of disease (eg diabetic eye disease, AMD, glaucoma, optic neuropathy, etc.)
I’ll highlight the main point, which is that these “check your vision at home” tests never screen for disease. This is 100% true and is one of the biggest issues I have with the “exams” that are currently out there.
There’s a critical element of good vision that exists outside of needing glasses or needing contacts, and that is, are your eyes healthy and functioning well? Are there underlying, silent issues that don’t bother you day to day but may turn into serious problems down the line? All of these are serious considerations that my team and I are thinking through very carefully, and I want to make it quite clear that our end product will at the very least be able to screen for all the major categories of disease (eg diabetic eye disease, AMD, glaucoma, optic neuropathy, etc.)
Hi! This is the perfect use case and one that we keep hearing over and over again from friends/ family/ colleagues/ acquaintances. Really looking forward to helping you out! :)
"unnecessary pupillary dilations and air puff tests (which by the way are wildly inaccurate,) "
How true is this ? I am not refuting this as I have no credentials in this space but as someone who is very near sighted, I depend on these exams to make me feel safe and I do them once every year as the doctors have suggested over the years. It is scary to know that they are wildly inaccurate.
How true is this ? I am not refuting this as I have no credentials in this space but as someone who is very near sighted, I depend on these exams to make me feel safe and I do them once every year as the doctors have suggested over the years. It is scary to know that they are wildly inaccurate.
I strongly object to these statements.
Dialation may not be necessary every single time for a healthy adult, but it’s good to do occasionally as there are serious diseases that can only realistically be checked by getting a good look at the back of the eye.
Puff test can be vision-saving. It takes almost no effort, and is an excellent screen for glaucoma. Glaucoma is irreversible, and catching it early is essential to saving your vision. It’s not as accurate as other measures, but it’s fast (they’re usually doing other tests simultaneously) and easy so why not do it? But if you want the extra accuracy you can ask for the applanation - any decent optometrist will do it for you if you want. Some people prefer it.
Dialation may not be necessary every single time for a healthy adult, but it’s good to do occasionally as there are serious diseases that can only realistically be checked by getting a good look at the back of the eye.
Puff test can be vision-saving. It takes almost no effort, and is an excellent screen for glaucoma. Glaucoma is irreversible, and catching it early is essential to saving your vision. It’s not as accurate as other measures, but it’s fast (they’re usually doing other tests simultaneously) and easy so why not do it? But if you want the extra accuracy you can ask for the applanation - any decent optometrist will do it for you if you want. Some people prefer it.
I understand why these statements might seem extreme. A few points here:
1) I don't believe I've stated that dilated eye exams should never be done. One of the biggest reasons remote eyecare is relatively far behind compared to other specialties (remote dermatology, for example) is the need to visualize the retina up to the ora, where a lot of pathology (e.g. retinal holes) can hide. Currently, the only ways to visualize the retina this comprehensively are a) scleral depressed dilated eye exams and b) use of wide retinal imaging (e.g. Optos.) Theoretically, "a" can be done in the home via an "on-call" ophthalmologist or optometrist and "b" can be done via an eye van (ZSFG actually has this option,) but neither of these can scale very well. So we're working on a scalable solution that will enable the collection of data on par with what can be gathered via a traditional dilated eye exam.
2) My 2 cents re: cost-saving and efficient glaucoma screening methods is that we need portable IOP measurement devices. Since we're currently limited by existing technology, my vote is for a using tonopen (portable, affordable, accurate) over non-contact tonometry (nonportable, expensive, not accurate) when it comes to rapid remote screening.
1) I don't believe I've stated that dilated eye exams should never be done. One of the biggest reasons remote eyecare is relatively far behind compared to other specialties (remote dermatology, for example) is the need to visualize the retina up to the ora, where a lot of pathology (e.g. retinal holes) can hide. Currently, the only ways to visualize the retina this comprehensively are a) scleral depressed dilated eye exams and b) use of wide retinal imaging (e.g. Optos.) Theoretically, "a" can be done in the home via an "on-call" ophthalmologist or optometrist and "b" can be done via an eye van (ZSFG actually has this option,) but neither of these can scale very well. So we're working on a scalable solution that will enable the collection of data on par with what can be gathered via a traditional dilated eye exam.
2) My 2 cents re: cost-saving and efficient glaucoma screening methods is that we need portable IOP measurement devices. Since we're currently limited by existing technology, my vote is for a using tonopen (portable, affordable, accurate) over non-contact tonometry (nonportable, expensive, not accurate) when it comes to rapid remote screening.
I'm not an American, but I've had eye tests in both Canada and Israel. Just how expensive are these? In Canada they're free - covered by health care (Glaucoma). Regular eye tests in Canada cost ~$49 (clearly, Queen Street). In Israel they cost 22 NIS, about $6.
For some more comparisons, the UK has free eye-tests for certain groups (children and at-risk) [1], but it costs around £20-25 (~$28-$35 at current exchange rate).
[1] https://www.nhs.uk/nhs-services/opticians/free-nhs-eye-tests...
[2] https://www.specsavers.co.uk/help-and-faqs/how-much-is-an-ey...
[1] https://www.nhs.uk/nhs-services/opticians/free-nhs-eye-tests...
[2] https://www.specsavers.co.uk/help-and-faqs/how-much-is-an-ey...
Additionally for the UK, if you do work using a computer (which I imagine most people on HN do), your employer is legally required to pay for an eye test if you request it.
https://www.hse.gov.uk/msd/dse/eye-tests.htm
https://www.hse.gov.uk/msd/dse/eye-tests.htm
Wow, this is super helpful in that it gives me extra context outside of what I'm used to. Also just good to know what else is out there :) Thank you so much!!!
That is INCREDIBLE. When someone is paying for a full eye exam out of pocket in the US, it can cost anywhere from $69 to $150 USD.
For something that's preventative? Why would it cost a lot for preventative treatment that reduces overall health care spending?
One could argue that a $79 annual exam is more affordable than paying $200 every month for an injection to manage endstage, out-of-control diabetic eye disease.
That being said, I think annual exams are unnecessary for certain population subsegments (e.g. young healthy folks under 40 years old, have good vision, have no personal or family history of eye disease, have no risk factors for developing eye disease ie poorly controlled diabetes;) for those people who NEED annual eye exams (e.g. those with mild nonproliferative diabetic eye disease,) these should be free. But for those without insurance, this is not the case.
That being said, I think annual exams are unnecessary for certain population subsegments (e.g. young healthy folks under 40 years old, have good vision, have no personal or family history of eye disease, have no risk factors for developing eye disease ie poorly controlled diabetes;) for those people who NEED annual eye exams (e.g. those with mild nonproliferative diabetic eye disease,) these should be free. But for those without insurance, this is not the case.
Good question. These statement applies to patients who have no to very minor eye issues, meaning healthy people under age 40 who have refractive errors of ~1D (ideally less,) who have never been diagnosed with eye disease, who have no family history of eye disease, and who have good vision (that they are happy with.) It sounds like you probably have a refractive error of >6D, in which case yearly dilated exams are good practice.
Re: inaccuracies, what I am referring to is the air puff test. The air puff test is a very crude measurement of eye pressure (aka intraocular pressure, or IOP.) The gold standard is Goldman Applanation, which involves putting yellow fluorescein drops in your eye and then using the applanation tip and a blue light to assess IOP.
More on Goldman Applanation here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2206330/
Hope this helps!
Re: inaccuracies, what I am referring to is the air puff test. The air puff test is a very crude measurement of eye pressure (aka intraocular pressure, or IOP.) The gold standard is Goldman Applanation, which involves putting yellow fluorescein drops in your eye and then using the applanation tip and a blue light to assess IOP.
More on Goldman Applanation here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2206330/
Hope this helps!
Because I was diagnosed with glaucoma, I do an air puff test per month to monitor my eye pressure. I'm not sure how inaccurate it is, but it still a very useful method, which is easy to run and unharmful
There are very few instances in which a patient with chronic glaucoma needs monthly IOP checks (vs someone who came into clinic with an acute event and goes on to need emergent surgery.) And in those cases where monthly IOP checks are needed, it is definitely not gold standard to use the air puff test.
I'd say that measuring IOP every 3-4 months is a typical regimen for a patient with more advanced glaucoma; these measurements should always be done via the same method (Goldman applanation) at the same time of day (due to AM to PM fluctuations in IOP) to be the most accurate.
I'd say that measuring IOP every 3-4 months is a typical regimen for a patient with more advanced glaucoma; these measurements should always be done via the same method (Goldman applanation) at the same time of day (due to AM to PM fluctuations in IOP) to be the most accurate.
I'm a former programmer, now in mid forties, and recently diagnosed with low-tension glaucoma, so I appreciate the value in your service. I have no family history so I wonder if my long years of staring at screens had something to do with it, though I realize the causes are complex and not well understood.
In my case it was caught reasonably early but I feel it could have been caught earlier. Its a bit surprising to me since I did have regular dilated eye exams. If screen time is indeed implicated, I do wonder if there is an epidemic of eye/optic nerve damage brewing, especially since those who don't wear corrective lenses probably aren't getting regular exams and may not realize they have risk factors or even damage.
Perhaps its not the screens themselves, but what's on them. The stress of social media causing everyone's IOP to randomly skyrocket.
I'm still coming to grips with my diagnosis and its repercussions. Not the least of which is the cost of the drops I need to take now for the rest of my life. $110 for a three month supply, and I also have to agree to not make a claim on my insurance to reimburse me, so its all out of pocket. Its pretty shady, but they are what my ophthalmologist wants me to use, and I don't want to mess around with blindness.
In my case it was caught reasonably early but I feel it could have been caught earlier. Its a bit surprising to me since I did have regular dilated eye exams. If screen time is indeed implicated, I do wonder if there is an epidemic of eye/optic nerve damage brewing, especially since those who don't wear corrective lenses probably aren't getting regular exams and may not realize they have risk factors or even damage.
Perhaps its not the screens themselves, but what's on them. The stress of social media causing everyone's IOP to randomly skyrocket.
I'm still coming to grips with my diagnosis and its repercussions. Not the least of which is the cost of the drops I need to take now for the rest of my life. $110 for a three month supply, and I also have to agree to not make a claim on my insurance to reimburse me, so its all out of pocket. Its pretty shady, but they are what my ophthalmologist wants me to use, and I don't want to mess around with blindness.
I'm a programmer and was diagnosed glaucoma 3 years ago and I'm 30 now.
My doctor prescribed me 2 medicines, tafluprost and carteolol, which cost 130 CNY per month. I see the doctor and do an air puff test once a month. This costs 80 CNY. Doing an OCT once a year requires 500 CNY, and a total of 3000 CNY (approximately 470 USD) per year. Recently, my doctor suggested that I have an operation. It may prevent me from using eye drops in the future. I am considering it.
I hesitate to provide medical advice here. But if you are 30 and you have a glaucoma diagnosis, you should really be followed by a glaucoma specialist (vs a comprehensive ophthalmologist or an optometrist.)
Thanks for your kind advice. I'm very serious about my eyes and will do my best to protect it. However my docker is considered as a glaucoma specialist in one of the best hospital in our city..(though she's also treating other eye diseases)
Ok, I’m happy to hear it. This reminds me that another important caveat re: eyecare is this — even within a country, there’s a lot of variation in how ophthalmologists treat the same condition (eg one doctor might choose to do tube surgery on a glaucoma patient, whereas another might choose to do a laser procedure for the same patient.)
I imagine that internationally the differences are even more dramatic! But this doesn’t mean that one country is more “correct” than the other; in fact, I’d hypothesize that for population specific disease variants, geography factors into the trajectory of one’s disease outcome. For example, ophthalmologists in Asia are likely much better at treating normal tension glaucoma (NTG,) which has a higher prevalence in Asian patients. So perhaps these patients tend to do better, but this is only a crude guess.
I imagine that internationally the differences are even more dramatic! But this doesn’t mean that one country is more “correct” than the other; in fact, I’d hypothesize that for population specific disease variants, geography factors into the trajectory of one’s disease outcome. For example, ophthalmologists in Asia are likely much better at treating normal tension glaucoma (NTG,) which has a higher prevalence in Asian patients. So perhaps these patients tend to do better, but this is only a crude guess.
Aha, it's interesting that your example 100% fit my case, Asian and NTG.
BTW, What you guys are doing is very impressive. It could be very useful for whom not able to go to the doctor's office.
BTW, What you guys are doing is very impressive. It could be very useful for whom not able to go to the doctor's office.
Glad that my training and knowledge base is on point, hehe.
Thank you so much for the kind words. My biggest wish is for my team to use our combined skills and expertise to bring high-impact, scalable solutions to those who can't access an eye doctor (or don't want to go into the office.)
Thank you so much for the kind words. My biggest wish is for my team to use our combined skills and expertise to bring high-impact, scalable solutions to those who can't access an eye doctor (or don't want to go into the office.)
I was diagnosed with glaucoma at the age of 17 by a doctor. It was hard for me to comprehend that I'd have to take drops for the rest of my life. I do have pretty bad myopia and astigmatism. This was in the middle east. On doing a recheck back in India, I had a very comprehensive testing with multiple doctors checking for glaucoma and retinal damage and was told that while I'm a suspect, there's no reason for me to take drops. My IOP was calculated taking into account the diameter of the pupil (I think) and Goldman test which wasn't done previously. The doctors proceeded to explain that in the west, doctors are more likely to prescribe treatment for glaucoma because of all things around insurance etc. At minimum, I recommend getting a second opinion, if possible from a country that's not riddled with such insurance schemes.
There are several difficulties when it comes to managing glaucoma:
1) There are different types of glaucoma that have different diagnostic criteria
2) Different people have different risk factors for glaucoma development, disease progression, and treatment response. What works for one person may be completely ineffective for another
3) Our glaucoma data (for diagnosis, progression, treatment) is largely based on a cohort of data gathered from Caucasian patients; researchers and clinician are generating population-specific (Blacks, Asians, etc,) data, but there's definitely still a long way to go
4) There is some subjectivity that goes into diagnosing/treating/monitoring glaucoma, which is why one doctor may decide to start you on drops while another may choose to observe without intervention -- in cases that are not clear cut, either approach may be correct
Thanks for your story. I hear what you are saying and I do plan to get a second opinion. Apparently here in the US there are some people who have had their glaucoma un-diagnosed.
But I have some confidence that its real. First, my doc wasn't eager to do it, she just suspected it at first, and we did some tests and waited for a while. But later, a followup visual field test did show some actual loss in one of my eyes, but not something I noticed.
The whole business with the drops is annoying, but its not unexpected. Still, that would be a business model worth disrupting.
But I have some confidence that its real. First, my doc wasn't eager to do it, she just suspected it at first, and we did some tests and waited for a while. But later, a followup visual field test did show some actual loss in one of my eyes, but not something I noticed.
The whole business with the drops is annoying, but its not unexpected. Still, that would be a business model worth disrupting.
Hi. Thank you for sharing your story. Vision is such a critical part of our daily lives, so receiving a diagnosis like this can be very painful.
Unfortunately, the only way to slow down the damage related to glaucoma is to lower eye pressure (IOP.) This is accomplished via medications, lasers, and surgery. Typically we start with the least invasive option, which is medications (aka eyedrops.) It sounds like you are receiving the standard of care, which is a good thing.
Re: cost of care, I think we can all agree that things need to change.
Unfortunately, the only way to slow down the damage related to glaucoma is to lower eye pressure (IOP.) This is accomplished via medications, lasers, and surgery. Typically we start with the least invasive option, which is medications (aka eyedrops.) It sounds like you are receiving the standard of care, which is a good thing.
Re: cost of care, I think we can all agree that things need to change.
What were your symptoms? or was this only noticed during an exam and you had not realized anything was going before the exam?
> and I also have to agree to not make a claim on my insurance to reimburse me, so its all out of pocket. Its pretty shady, but they are what my ophthalmologist wants me to use, and I don't want to mess around with blindness.
I'm not too familiar with the all the inner workings of insurances but curious why you had to do this?
> and I also have to agree to not make a claim on my insurance to reimburse me, so its all out of pocket. Its pretty shady, but they are what my ophthalmologist wants me to use, and I don't want to mess around with blindness.
I'm not too familiar with the all the inner workings of insurances but curious why you had to do this?
I did have some eye discomfort, dryness, etc. I chalked this up to allergies. I wasn't immediately diagnosed, but she said it was suspect. About a year later the visual field test showed that it had worsened, so the diagnosis became official.
As far as the drops go, its a a brand-name drug. My doc suggested that there was a generic option available but it was also clear that it wasn't her preference. The signup process was online and as part of it I had click through on an agreement that said I wouldn't try to claim it on my insurance. I don't know what happens if you violate that. Maybe they refuse to give you refills. There were other suspicious aspects and dark patterns in the UI of the signup process; it smelled like a moneymaking scheme.
As far as the drops go, its a a brand-name drug. My doc suggested that there was a generic option available but it was also clear that it wasn't her preference. The signup process was online and as part of it I had click through on an agreement that said I wouldn't try to claim it on my insurance. I don't know what happens if you violate that. Maybe they refuse to give you refills. There were other suspicious aspects and dark patterns in the UI of the signup process; it smelled like a moneymaking scheme.
Hi! I'm an optometrist. There are usually no symptoms for glaucoma, which is why it's known as a "silent thief of sight." Dryness and irritation are not symptoms of glaucoma. It is usually suspected when your doctor looks inside your eye at the optic nerve and sees that the cup in the middle of the optic nerve looks larger than they think it should be and your eye pressure (measured with either the air puff test or little probe that quickly touches your eye) seems a higher than normal. There's also a machine called the OCT which can help to see if you might be suspect for glaucoma. The visual field test checks your side vision to see if there is functional damage from the glaucoma. Your doctor may monitor it and make it an official diagnosis if they see progression on any of these things (optic nerve, OCT, visual field).
There is one kind of high eye pressure (acute angle closure) that can lead to glaucoma that may be accompanied with redness and eye pain, but this is more rare and happens more quickly. Otherwise, most forms of glaucoma (normal tension and open angle glaucoma) are extremely slowly progressing and don't have any symptoms until it's too late, when lose your side vision and are left with tunnel vision.
Quadrant Eye uses some tests which can help to screen for glaucoma even when you have no symptoms. Thank you Quadrant Eye for making a higher quality online screening! I can't wait for the entire comprehensive eye exam to be available at home and reach more people who otherwise may not have easy or convenient access to a doctor's office on a regular basis.
There is one kind of high eye pressure (acute angle closure) that can lead to glaucoma that may be accompanied with redness and eye pain, but this is more rare and happens more quickly. Otherwise, most forms of glaucoma (normal tension and open angle glaucoma) are extremely slowly progressing and don't have any symptoms until it's too late, when lose your side vision and are left with tunnel vision.
Quadrant Eye uses some tests which can help to screen for glaucoma even when you have no symptoms. Thank you Quadrant Eye for making a higher quality online screening! I can't wait for the entire comprehensive eye exam to be available at home and reach more people who otherwise may not have easy or convenient access to a doctor's office on a regular basis.
Wow, thanks for the detailed note of support. I agree with all of the above.
Not wanting you to make an insurance claim sounds very shady indeed. As in being ripped off.
Congrats on the launch! So what technology or design are you using that allows you to have the same kind of accuracy as an in person office visit?
We'll be using a blend of computer vision techniques and portable hardware devices in the future. What is in our online exam right now is just a quick proof of concept that we rolled out to assess market fit. The more novel bits of tech are either in development or in the early stages of clinical trials. Excited to share more on that soon!
I’ll leave the tech stack specifics to Kristine.
From clinical standpoint, the algorithms (re: vision testing and beyond) we design and implement will need to be tested against the gold standard (eg whatever method is used in person.) Fortunately this is fully in my wheelhouse, hehe.
From clinical standpoint, the algorithms (re: vision testing and beyond) we design and implement will need to be tested against the gold standard (eg whatever method is used in person.) Fortunately this is fully in my wheelhouse, hehe.
Interesting, I went through it, but then it got to this slide:
> look at the image of the circle at the top of the page.
And there is no circle whatsoever on that page, so I didn't know if it was a typo, a browser problem... or my eyes went blind!
> look at the image of the circle at the top of the page.
And there is no circle whatsoever on that page, so I didn't know if it was a typo, a browser problem... or my eyes went blind!
Hmm, we have actually never gotten that! Can dig into it.
What browser/device are you on? We don't support mobile (added this to post!) because the vision charts need to be displayed at a certain size. There's usually a warning that pops up for mobile, but it's earlier in the flow than what we posted to HKN.
What browser/device are you on? We don't support mobile (added this to post!) because the vision charts need to be displayed at a certain size. There's usually a warning that pops up for mobile, but it's earlier in the flow than what we posted to HKN.
I'm using Mac OS 10.15.7
I don't see any circles.
As a general comment, this whole test procedure seems very crude. If I saw overlapping circles with my glasses on, like in some of your tests, I would say that my prescription was way off. A better prescription is necessary long before you get to that point.
I don't see any circles.
As a general comment, this whole test procedure seems very crude. If I saw overlapping circles with my glasses on, like in some of your tests, I would say that my prescription was way off. A better prescription is necessary long before you get to that point.
We're looking into this circle bug -- very sorry about that!
I won't argue that the current test isn't crude. We're rolling out increasingly sophisticated versions with each update, but I agree that in its current state our exam has a ton of room for improvement.
I do have to mention that the 1) vision check (e.g. do you see 20/20 with you current/expired prescription) and 2) the eye health tests are two different portions of our exam and serve two different purposes.
These latter set of "low-tech" maneuvers (double vision, amsler grid, red desaturation) are very high-level screening mechanisms for more serious underlying issues and do not have much to do with the numbers on a person's prescription. To be more specific, the overlapping circles are meant to assess if someone is having double vision, which in a worst case scenario could be a symptom of acute cranial nerve palsy.
I won't argue that the current test isn't crude. We're rolling out increasingly sophisticated versions with each update, but I agree that in its current state our exam has a ton of room for improvement.
I do have to mention that the 1) vision check (e.g. do you see 20/20 with you current/expired prescription) and 2) the eye health tests are two different portions of our exam and serve two different purposes.
These latter set of "low-tech" maneuvers (double vision, amsler grid, red desaturation) are very high-level screening mechanisms for more serious underlying issues and do not have much to do with the numbers on a person's prescription. To be more specific, the overlapping circles are meant to assess if someone is having double vision, which in a worst case scenario could be a symptom of acute cranial nerve palsy.
I also had no circle, just a red square.
Did you do the exam on mobile or desktop? Also, what browser were you using?
Desktop, using Firefox on Windows, with no-script active. That last part might be the issue - everything seemed to work until the end - it would not let me submit, then I disabled no-script, and I submitted, but it never asked me for contact info?
Not sure how you'll get back to me, it never asked for an email or anything.
The no-script might be at fault though. You might consider not using any CDN for scripts, only host locally.
I did not try again because I don't have a prescription (I submitted an image saying "no prescription"), and I realized it can't do anything for me (I just wanted a checkup basically - just tell me how I did on the various sized letter thing).
Not sure how you'll get back to me, it never asked for an email or anything.
The no-script might be at fault though. You might consider not using any CDN for scripts, only host locally.
I did not try again because I don't have a prescription (I submitted an image saying "no prescription"), and I realized it can't do anything for me (I just wanted a checkup basically - just tell me how I did on the various sized letter thing).
Thank you, really appreciate the detailed feedback! It seems like it is likely the no-script, will look into this soon.
The exam we provided is just a free sample for folks to play with - contact information is collected for paying customers (in a slightly different flow).
The exam we provided is just a free sample for folks to play with - contact information is collected for paying customers (in a slightly different flow).
I’m on a Mac desktop with Firefox.
Congrats on launching! As someone whose parents have been increasingly having eye issues in the past few years, this is a godsend. So excited to see how the product continues to develop!
Thanks, that’s what we love to hear. Please do let us know if you have any feature requests/ideas :)
Is your service available at this time? The website suggests that it is, but based on your post here it sounds like you are pre-beta?
Congrats on the launch, I can see the value in this.
Congrats on the launch, I can see the value in this.
Yes, we are in fact live and have been renewing prescriptions! The beta signup link is for our full software + hardware exam, which is currently still in the works.
cool, so this is like warby parker's app for renewing prescriptions?
that really saved my ass recently, when my glasses broke and I found my prescription was expired. Apparently, they let you use an expired prescription up to 18 months, and mine had expired like 20 months ago.
Their app worked, but was pretty painful. Required holding my phone 14 feet from my monitor- had to move my desktop to a different room to get the app to approve.
that really saved my ass recently, when my glasses broke and I found my prescription was expired. Apparently, they let you use an expired prescription up to 18 months, and mine had expired like 20 months ago.
Their app worked, but was pretty painful. Required holding my phone 14 feet from my monitor- had to move my desktop to a different room to get the app to approve.
Hi!
I think WP is a great company. I also agree that their vision check UX leaves a lot to be desired -- I ran through it myself a few times, and each time it caused intense frustration. There's something about needing to manipulate laptop and phone and having 14-20 ft of space that is just... impossible lol.
Anyway, our service is similar to WP's app in that we check vision for the purpose of determining if a prescription renewal is appropriate. But that's pretty much it. For us, this is only the tip of the iceberg. Fun times ahead!
I think WP is a great company. I also agree that their vision check UX leaves a lot to be desired -- I ran through it myself a few times, and each time it caused intense frustration. There's something about needing to manipulate laptop and phone and having 14-20 ft of space that is just... impossible lol.
Anyway, our service is similar to WP's app in that we check vision for the purpose of determining if a prescription renewal is appropriate. But that's pretty much it. For us, this is only the tip of the iceberg. Fun times ahead!
I haven't had an eye exam on over a decade (since my mid 20s). I use my old prescription and order cheap glasses online. The extreme savings and arguably higher utility of this approach had always given me the strong impression that the eyecare industry is fundementally broken and full of rent seeking.
There really is a lot that we can do to improve how people get eyecare and eyewear. I did want to point out that there's an entire other side of the eyecare industry -- eye health -- that gets overshadowed by the eyewear/optical aspect of eyecare. Obviously all sides of the eyecare industry need fixing, but I do I think part of the puzzle is bringing the eye health portion more front and center. (But ultimately there's no argument that things are broken.)
This is true amd something that I had not strongly considered. While my prescription still seems fine, it us probably worth scheduling an exam to check my eye health now that I am in my 30s.
I support this! :D
The eye exam layout on mobile Firefox is broken, stuff is being pushed off the left side of the screen but you don't allow scrolling to bring it into view. It still doesn't work properly if I switch to desktop mode.
That's our bad! The exam is only built for desktop - we don't allow mobile in the usual flow because the vision charts need to be displayed at a certain height (*will add to our post).
I can't seem to replicate the issues you're having on firefox/desktop, it displays normally for me. If you shoot me a screenshot at [email protected], happy to take a look.
I can't seem to replicate the issues you're having on firefox/desktop, it displays normally for me. If you shoot me a screenshot at [email protected], happy to take a look.
I sent a screenshot to your support chat widget when it happened.
Oh seeing the screenshot now, thank you! It's not meant to be done on mobile - our bad for not including in the post earlier (have added!).
Sorry about this, we're looking into it. It's optimized for desktop/laptop viewing, so it's strange that you're having desktop issues.
I love this. At least in the US, ophthalmology & dentistry seem ripe for disruption/improvement as they have some really strange rules yet 90% of people's interactions with them are very routine.
Completely agree, and I would attribute some of this to excellent marketing. Lately I've been thinking about how so much of our behavior and societal/cultural norms (e.g. bacon and eggs are breakfast food! drink milk to prevent your bones from crumbling into a million pieces!) all come down to brilliant longform marketing efforts.
I think its cool to have more options. But what is the difference between this and the ones that are free online at the moment?
Great question!
All existing online eye exams focus on prescription renewals and omit the eye health checks that you would get in an in-person visit. (An optometrist can catch all sorts of issues - eye tumors, early signs of glaucoma etc.) We're working to build a better and safer way to access the full spectrum of eye care online, going beyond just prescription renewals.
The current exam has some eye health maneuvers that flag unusual symptoms and intake answers that should be investigated more closely. This is just the start though - much more in the works!
All existing online eye exams focus on prescription renewals and omit the eye health checks that you would get in an in-person visit. (An optometrist can catch all sorts of issues - eye tumors, early signs of glaucoma etc.) We're working to build a better and safer way to access the full spectrum of eye care online, going beyond just prescription renewals.
The current exam has some eye health maneuvers that flag unusual symptoms and intake answers that should be investigated more closely. This is just the start though - much more in the works!
Quinn and Kristine : Congrats on what seems to be an useful service. All the best.
Sent you an email on a visual nit (from nandyal)
Sent you an email on a visual nit (from nandyal)
Appreciate the feedback so much! :)
Yes, we got the email -- thank you for the input!
Would you work with endmyopia.org to progressively reduce prescription strength?
I am not familiar with this organization and will look into it. Thanks for bringing them to my attn!
Re: working with orgs, we're interested in partnering with those committed to advancing quality eyecare for all population segments. We're currently working with nonprofits like LightHouse for the Blind to bring eyecare to those with low vision. I've personally referred many patients to LightHouse and think that they provide a valuable resource to an otherwise overlooked portion of eye patient population!
One last point here. Re: slowing down myopia progression, I personally think atropine is the most promising intervention!
Re: working with orgs, we're interested in partnering with those committed to advancing quality eyecare for all population segments. We're currently working with nonprofits like LightHouse for the Blind to bring eyecare to those with low vision. I've personally referred many patients to LightHouse and think that they provide a valuable resource to an otherwise overlooked portion of eye patient population!
One last point here. Re: slowing down myopia progression, I personally think atropine is the most promising intervention!
Looks promising. Like the site design; Will try this today.
Amazing -- thanks so much :D
Would $30 be covered by the insurance as well ?
Good question. Right now everything is out of pocket. The ideal scenario is for this service to be covered by employers as well as payers; don't worry, we'll make this happen in the future!
Awesome! Excited to see the progress!
Appreciate the support :)
yay thank you! :D
congrats on the launch Kristine and Quinn!
Thank you!!! :)
Thank you so much -- love the enthusiasm from this community :)
Welcome to the digital eye test club! I'm CTO at easee.online and we've been in this space for a couple of years. Let me know if you want to have a virtual coffee! I'd be happy to have a chat and see how we can improve eyecare together.
Oh hello! I’ve come across easee before and think what you guys are doing is awesome. You’re based in Sweden, right?
Re: coffee, I believe the two of us have interacted on LinkedIn. So nice to be working in the same space — let’s definitely sync!
Re: coffee, I believe the two of us have interacted on LinkedIn. So nice to be working in the same space — let’s definitely sync!
This is Quinn and Kristine of Quadrant Eye (https://www.quadranteye.com). We’re a cataract surgeon and software engineer duo who are spearheading the at-home eyecare revolution. Our goal is to provide comprehensive eyecare to people at home, and as a first step, we're tackling online glasses/contact lens prescriptions renewals.
I (Quinn) started the company after I took care of a grandfather who tragically went blind during the Covid lockdown. This could have been prevented if he had had access to reliable at-home eyecare. During my training, I had seen countless similar scenarios play out around the country, but to have it happen in my own clinic was the last straw.
Eyecare is a weird and tricky space. On the one hand, there are legitimate reasons why eye doctors and their patients are tied to a physical office, and they mostly center on bulky hardware limitations (e.g. the slit lamp biomicroscope.) On the other hand, there are actually few legitimate reasons healthy people without eye disease need to be making routine in-office visits. In fact, the American Association of Ophthalmology (AAO) recommends that folks with healthy eyes, good vision, and no risk factors for eye disease get a comprehensive exam just once in their 20s and twice in their 30s.
With this context, it’s absolutely wild that while millions of people are overexposed to eyecare via unnecessary pupillary dilations and air puff tests (which by the way are wildly inaccurate,) millions more can’t access even basic eyecare services, including refractions (aka the measurement of one’s eye prescription.) After all, 24% of U.S. counties have no optometrists or ophthalmologists!
Online eye exams are a first step toward addressing this pervasive access and resource allocation problem. We’re building our own version (feel free to play around with the prototype but please access via deskop/laptop only: https://app.quadranteye.com/va/creditcard) which is an asynchronous exam that assesses your vision and eye health; the exam results, along with a glasses/contact lens prescription uploaded by the patient, always get reviewed by an offsite MD/OD. Our online exam is live and we've been renewing prescriptions for a few weeks now!
Unfortunately, online eye exams are limited in their scope and utility -- for one, they are unable to measure essential eye vitals such as pupillary response and eye pressure. These exams also happen to be extremely controversial, especially since they disrupt the traditional "go into the eye doctor's office, renew your prescription, buy your glasses/contacts from your eye doctor" model. For evidence that the $18B domestic optical industry stirs up strong emotions, check out this previous HN thread: https://news.ycombinator.com/item?id=21653437 (and dang tells us there have been many others!)
We believe online eye exams are a good catalyst for change, but they are definitely just a stepping stone. We’ve got our eyes on a much bigger vision — true at-home eyecare, including the ability to measure eye vitals — and we’re excited to have everyone follow along!
Thanks for reading and see you in the comments below. :)
Cheers, Quinn and Kristine
P.S. We’re in the middle of a redesign and would love your feedback on how to improve the flow + ux!
P.P.S. We can't talk much about the details right now, but if you want to be notified when we roll out the beta version of our comprehensive exam (which includes hardware,) please fill out this survey: https://qhqh.typeform.com/to/whuiAFHo