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
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.
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.
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.
> 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?
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.
More info on buying glasses/contacts: https://www.consumer.ftc.gov/articles/buying-prescription-gl...
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.
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.)
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.
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.
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.
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!
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.
> 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!
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 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 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 kristine@quadranteye.com, happy to take a look.
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.)
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.
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.
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.
Sent you an email on a visual nit (from nandyal)
Congrats on the launch, I can see the value in this.
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.
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!
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!
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: coffee, I believe the two of us have interacted on LinkedIn. So nice to be working in the same space — let’s definitely sync!
