Remote Refractions: Friend or Foe?

“Tele-optometry” has become increasingly popular due to its ability to provide access to patients in remote areas. When it comes to remote refractions, there has been much debate among the eye care community about the pros and cons. 

The most popular type of remote refraction takes place in the exam lane. The tech does all of the pre-testing with the patient and takes a video of the slit lamp exam. In some cases, they will do the refraction. The doctor will receive their virtual list of patients, including their medical history, ahead of time, and then they’ll log in to the system and be able to finalize the patient’s prescription with them and answer any questions they might have. With this technology, the doctor can actually connect into the autorefractor, do the refraction, and then review the images and videos the tech had taken. At that point, the patient and the doctor can discuss the results, and either set up a more in-depth in-person appointment at a later date, or get a referral for a specialist, etc. 

However, there’s also another kind of remote refraction that many optometrists, including myself, wouldn’t recommend to other practitioners or to our patients. When popular online sites, such as 1-800 Contacts, for instance, offer contact lens exams at low costs that entice patients, it is detrimental to our patients’ eye health and can prevent them from getting the proper care they need. These exams don’t include an in-person tech or a doctor remotely accessing a patient’s refraction, but instead they highlight efficiency and the promise of a script for glasses or contacts. 

I’ve had several patients who just want to get prescriptions and save some extra money, so they go this route. In turn, these types of remote refractions fail to take important measurements that monitor comprehensive eye health. It’s frustrating as a practitioner because your patients aren’t seeing doctors. I had a patient recently who came in after several years of doing these remote “exams,” and his pressure was high, his cups were large, and he now needed to be monitored for glaucoma. He didn’t know any of these things because he wasn’t seeing a doctor for years. 

This article will focus on the first type of remote refractions, which include a remote doctor and an in-person technician — but which still shouldn’t take the place entirely of a comprehensive eye exam. 

Friend or Foe?
While “tele-optometry” refractions can be effective, there are limitations to the technology. Here are some pros and cons: 

Pros
For a patient who can’t come in during regular hours, a remote refraction can be beneficial. Additionally, these types of exams expand the access to care for patients who may be in remote or rural areas, and it increases how many patients doctors can reach. If you think outside the box, remote refractions can even be helpful for mission trips for patients in need. 

The biggest pro is getting patients access to services that they need. Sometimes, patients have high prescriptions, their glasses break, and they need something immediately, but they can’t get into the doctor for a couple of days. This advancement in technology has changed how doctors provide care and how patients are able to access care. 

For doctors, remote refractions can be helpful when running multiple practices. We can’t be in two places at once. But with this new technology, you can maximize your time. I’m a big advocate of multiple practices as a means of helping doctors become financially secure, and this could be a way to do that. If the equipment is right, and you have the time to devote to training for yourself and your staff, it can be very effective. 

Remote refractions can also be beneficial for doctors going on vacation, those looking for a stronger work-life balance, or those who may just not want to be in the office for as many hours. This technology allows you to do both — you can be home, be on vacation with your family, be anywhere, but also check in with your patients and provide them a valuable service. 

Cons
On the other hand, remote refractions can’t entirely replace a visit to your eye doctor. Right now, these types of visits are for routine care. Anything that’s more complex or that requires more hands-on medical attention can’t be done virtually. 

There could also be questions regarding patient satisfaction. There will be patients who don’t like it and want to see their doctor in a traditional appointment setting, but then there will be patients who want to go in for a specific purpose — to get their eyeglasses or contact lenses prescriptions filled and move on. But independent practitioners should be mindful of their patients’ reactions, especially when it comes to in-person interactions that can’t necessarily be picked up virtually. Body language, tone, and other in-person cues can be missed entirely, which can ultimately affect your patients’ experience, or affect your ability to properly treat your patients. It’s important to remember that we go to school to take these measurements — we take tests on how to successfully capture these measurements. There are certain things that get lost over a computer screen or over the phone. 

As powerful as technology is, it can also come with some drawbacks. Slit lamp photos and videos or retinal images may not be as clear as you’d like them to be when reviewing them virtually. If the tech doesn’t perform the exam correctly, the pictures and videos can be blurry or unusable. WiFi connections can get lost, creating more inconvenience for you and your patients. These are also considerations for practitioners thinking of adopting remote refraction systems. 

Utilizing Your Star Players
One of the other big things that can negatively affect the patient experience with a remote refraction is the tech who’s in the room with them during the exam. If the tech isn’t up to date on the technology or their training, that can affect the quality of the measurements that are taken, which then affects your patient’s vision — and their experience in the office, if images and testing have to be redone several times.  

For me, I would put my star players in that remote exam lane. I wouldn’t hire just anybody and stick them with this task, because that not only destroys the patient’s experience, but as the doctor, you might think that person is a liability. You want your staff who have been with you for a long time, who have shown themselves to be effective with patients, and who care deeply about their work. 

An OD’s Perspective
I work with many optometrists who utilize these types of remote refractions day in and day out. While it’s impossible to be in the room with every single remote OD or tech, from the conversations I’ve had with doctors in the field, many of them do their due diligence in explaining to patients that these aren’t comprehensive exams. One OD told me this: 

“When I’m doing these exams, I always remind them I’m only seeing a portion of the eye, and this does not take the place of a comprehensive eye exam. It allows them to get their glasses if they’re waiting weeks to get in just to get a routine pair of glasses. However, if we find something on the imaging, we’re referring them on the spot for further evaluation. 

“Remote care is not for everyone. Many patients require further testing that we can’t do in these types of screenings. Remote refractions help facilitate the process of getting patients glasses and contacts, but it does not in any way take the place of a traditional eye exam. Remote care often gets a bad reputation, and there are certainly limitations, but we need to be reminding patients that we’re just providing a screening and it’s not comprehensive.” 

Should I Use a Remote Refraction?
Something else for practitioners to consider is which patients they’re going to offer these virtual services to. It might be helpful, especially at the beginning, to only open up remote refractions to your established patients you’ve known for years. You might find more success restricting newer patients to traditional in-person exams so they think of your practice in the strongest light. 

It’s also important to trust your gut as a practitioner. If it’s your day off and a patient calls you with a red eye, and we know it’s probably going to be bacterial conjunctivitis, but we can’t technically prescribe anything without looking at it, what do you do? In my practice, I’d likely have that patient come in and check them out. This way, I’m ensuring that I’m treating the correct issue, I don’t lose them as a patient, and I don’t have them waste half their day in the emergency room.  

As doctors, we want to provide the highest level of care to our patients. While this new technology expands our options as practitioners, it’s also important to get a full picture of what that process will look like in your practice.