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.

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.

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...

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

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.

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!

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.