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.
[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...
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.
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.