# 👓 Online Vision Tests¶

## 💡¶

The optometric sector will be disrupted by the application of tablet-based vision tests. Though some professionals are strongly against this, it is inevitably as 1 billion people worldwide are living with vision impairment because they do not get the care they need.

"Due to weak or poorly integrated eye care services, many people lack access to routine checks that can detect conditions and lead to the delivery of appropriate preventive care or treatment." (World Health Organization, October 8th, 2019).

## Current Stage¶

• No diagnostic value for the professionals to act upon
• Brick-and-mortar solution with geographic boundaries not reaching rural areas
• End-users have to measure screen distance manually while adding their shoe size
• End-users have to go to a brick-and-mortar location for their regular vision tests
• Online vision tests are asymmetric giving minor, if any, value to the end-users
• No convenience of a full-cycle vision test and ordering of contact lenses or glasses online
• Vision tests are expensive for most pockets, averaging $171-$200 for first visits, $128 for recurring patient visits and$46 for refractive vision tests
• Lack of convenience as one have to schedule an appointment for regular vision tests

## Desired Stage¶

• Get a scalable, remote and inexpensive method to conduct pre-screen vision tests
• Provide more impartial pre-screen-data to act upon
• Be able to measure screen distance automatically and accurately to ensure proper conditions
• Enhance convenience for busy people as an on-demand solution
• Get access to elders, disabled and people with social anxiety, on their terms
• Enlarge the scope of *top-of-the-funnel-*screening
• Establish a meaningful, two-way-portal build for the digital natives
• Reach a bigger audience to detect early-stage blindness progression
• Get more proper referrals as top-of-the-funnel-screening is broaden and made better

## Solution¶

• Tablet-based vision tests with embedded attention tracking that actually works
• Track smooth pursuit interactions very precisely with moving stimulus
• Detect worn wearables such as glasses while also detect eye-blinks, clenched eyes, etc.
• Impartially detect the results of instructed tasks being performed (not everything is seen)
• Measure pupillary distance and screen distance constantly and automatically

Online vision test can help provide an extra layer of data for professionals to act upon. Typically, there are five areas of interest when conducting vision tests:

1. Fixation of correctnessability to keep eyesight on a visual stimulus
2. Eyeballs motilityability to trace a moving stimulus
3. Functional visual acuitydistance from which a person recognizes symbols of a given size
4. Contrast and color sensitivityimpact of presented level of contrast/colors on visual ability
5. Field of vision — an area, within which a person is able to see the presented object

Innovative solutions have shifted from internet and desktop-based testing to more portable and virtual methods that help to reduce fixation losses, improve engagement and possibly help reshape the paradigm of repeatable visual field testing—especially in low-resource settings” (Review of Ophthalmology, April 5th, 2019)

OK. You have probably been to an eye doctor or an optician at some point in life. How was the experience? Do you remember the results? Do you remember the specific tests that was carried out? Most importantly, have you scheduled a follow-up appointment to check your vision on a regular basis? If not, what is your reason? Time? Costs? Lack of conveinence?

"Population growth and ageing will increase the risk that more people acquire vision impairment." (WHO, October 8th, 2019).

As humans we are primarily sight-oriented learners where research estimates that eighty to eight-five percent of our perception, learning, cognition, and acitivities are mediated through vision. With this in mind, WHO, the World Health Organization, estimates that at least 2.2 billion people have vision impairment or blindness but what is truely mindblowing is the fact that more than 1 billion people worldwide are living with vision impairment because they do not get the care they need. That equals 13 percent of the entire population!

One of the core strategies of WHO's initiative VISION 2020: The Right to Sight is to make proper infrastructure and appropriate technology development to "(...) make eye care more available and accessible". Thinking of a technology that could help provide this?

If just one of the various kinds of vision impairment could be detected in its early stages through new infrastructures and new technology, we ought to make it. With attention tracking, it is possible to get a remote, scalable, cost-effective and impartial way of conducting this. Obviously, the hardware used for tracking users' attention and eye movements will set the boundaries of what the online vison test will be capable of but some vision impairment can de facto be discovered with the technology. There are solid arguments for having regular vision check-ins but the current infrastructure is old, physical, scheduled and pricey.

"Eye tracking in clinical practice is at the beginning of a long and exciting journey (...) At this stage, no new interventions are being offered but at least the effectiveness of existing interventions can now be properly evaluated. As researchers and clinicians begin to use this new technology in a clinical environment, it seems highly likely new tests and interventions will begin to emerge and eye tracking will gradually become a key part of the optometric/orthoptic examination" (Optician Online, July 21st, 2017).

The optometric sector will undoubtfully be divided in the application of online vision tests. As with every new technology, a window of opportunity opens for some participants while it closes (or threatens) the livelihood of others. Online vision tests are no different.

Up until now, no online vision tests embrace attention tracking technology, which could have shifted the ay-nay-ratio in favor of the company, Visibly (formerly Opternative), that tried to disrupt the plate tectonic of the optometric industry. A recent U.S. lawsuit accused them of not providing good enough data by the very professionals which businesses were threatened. Trusting the lobbying of the American Optometric Assosication, the FDA must have seen enough evidence to demonstrate the misleading of the public. The outcome of Opternative being shut down by the AOA would probably have been different if they have had comprehensive attention tracking technology embedded in their product in which they could provide more data sources.

Just the possibility of constantly measuring screen distance during the full period of a vision test could have changed the result. With comprehensive attention tracking technology it is possible to conduct online pre-screen examination of eye patients. There is an important distinguish to be made, as the technology itself will not replace opticians and eye doctors but support them by delivering valuable and impartial data sources that they can act upon. Numbers without someone with medical school training to interpret them, are just that—numbers.

"(...) this technology is still in its early stages and, if it is to be used in the ways outlined above, we must ensure that it is very robust and resistant to sources of error. For example, when using a tablet alone it is difficult to ensure that the patient remains a constant distance from the screen. That issue can be eliminated by headset use; adjusting for eye movement, however, is trickier, and is one of the key challenges to overcome before tablet-VR systems can be reliably and reproducibly used in a home environment" (The Ophthalmologist, June 7th, 2019).

If we do not get better at expanding the infrastructure of pre-screen-tests of people's vision, the unfortunate alternative is that we will continue to have 1 billion people worldwide that does not get the care they desperately need.

To outline the specific value propositions of online vision tests, both in general, with embedded attention tracking technology, the ability to operate on iOS-devices as well as delivering a true hands-free experience to the end-users, see the following:

1. Online vision tests in general Value of online vision tests
2. With embedded eye tracking Value of vision tests with eye tracking
3. Specifically running on iOS Value of vision test conducted on iOS
4. With a hands-free experience Value of hands-free vision tests

There are so many different eye and vision problems, such as conjunctivitis, retinal detachment, dry eyes, cataracts, and glaucoma, that could potentially be examined at an earlier stage (before the progression is irreversible) which evidently would help decrease the staggering number of people with visual impairment worldwide, as indicated by WHO. Attention tracking technology will not be able to conduct everything but if it is seen as an instrument for top-of-the-funnel-screening, it could help in achieving accessibility, affordability and impartiality.

Value of online vision tests

Value of vision tests with eye tracking

Value of vision test conducted on iOS

Value of hands-free vision tests

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