South Carolina Bans Remote Exams for Eyeglass Prescriptions

Ken Terry

May 23, 2016

The South Carolina legislature has overridden a veto of Gov. Nikki Haley (R) to make South Carolina the 10th state to ban eyeglass prescriptions based solely on remote eye exams.

This action spotlights a major division between the American Optometric Association (AOA), which supports the legislature's decisions based on patient safety grounds, and the American Academy of Ophthalmology (AAO), which maintains that patients are not at risk if only certain categories of people take the remote eye tests.

At issue is a telemedicine service offered by Chicago-based Opternative, which allows patients to use their smartphone and a computer (possibly in a kiosk) to test their eyes. The refractive measures are sent to Opternative, which has a state-licensed ophthalmologist look at the data and issue a prescription within 24 hours.

In Gov. Haley's veto message, she said, "I am vetoing this bill because it uses health practice mandates to stifle competition for the benefit of a single industry, effectively banning eye care kiosks statewide.... Unfortunately, a small group of eye care professionals are seeking to block new technologies that expand low-cost access to vision correction services."

Summarizing the optometrists' argument, she said that they claimed that the remote eye exams "pose a public health risk, which is simply untrue." In addition, she said that optometrists argue that the kiosks create an uneven playing field because licensed providers cannot charge patients for using the same technology in a medical practice. She said she would be willing to sign a potential bill extending the right to use telemedicine to eye care professionals.

The state chapter of the AOA was instrumental in the passage of the South Carolina bill. Other AOA chapters have boosted the passage of similar laws in Michigan, Indiana, Ohio, West Virginia, Maine, Kansas, Alabama, Mississippi, and Georgia.

The AOA argues that the remote eye exams can result in missed diagnoses and inaccurate prescriptions. In an interview with Medscape Medical News, AOA President Steven Loomis, OD, said, "The Opternative device is touted to increase access. But in this case, it's clearly inferior care. Increased access to inferior care is not a step forward."

Opternative has posted a "clinical trial summary report" of a small study involving 30 patients aged 18 to 40 years with no ocular or systemic disease. The study's author claims the results show that remote eye exams are as accurate as in-person exams. But Loomis says the issue has not been adequately studied and cites an anecdotal report from Michigan that a remote eye test missed astigmatism in a patient.

No Evidence of Harm

Dan Briceland, MD, senior secretary for advocacy for the AAO, told Medscape Medical News, "There's no evidence showing that this technology poses any harm to patients. But it should be used for the population aged 18–45; folks who have no medical risk factors such as diabetes or a strong family history of eye diseases. For the average healthy patient, there's no evidence that we found to show that harm is being done. So it doesn't make any sense to restrict the technology."

A key concern of the AAO, he said, is that bans on this kind of telemedicine could also affect similar types of technology that many ophthalmologists use. "It's not just about refraction, it's also about telehealth, and we use similar technology in screening neonates. Some of this [Opternative] technology is not very different from what we use in the [neonatal intensive care unit]."

Even though some ophthalmologists are concerned that Opternative might cut into their revenues from prescribing and selling eyeglasses, he said, most AAO members support the academy's position on remote eye exams.

The optometry association maintains that prescribing glasses through telemedicine could miss certain diagnoses and emergent conditions if patients do not come into the office for a comprehensive eye exam. Opternative states on its website that its service is no substitute for a comprehensive exam, which it says patients should get periodically.

Regarding Dr Briceland's point that only patients of a certain age who have no risk factors are eligible for remote exams, Dr Loomis said, "I have patients who come in on a regular basis who would fall within those guidelines: They're 20–45 years old and have no known risk factors. Yet upon examination, we find hypertension, we find diabetes, we find glaucoma. It's a common thing."

It is very important for patients to visit an optometrist or an ophthalmologist to have their eyes thoroughly checked, Dr Loomis stressed. If they need a new prescription, he noted, it could indicate other problems, such as diabetes, cataracts, or macular degeneration. "So even if Opternative worked," he said, "the notion of separating the refraction from the rest of the eye examination is a problematic premise."

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