Launch HN: Quadrant Eye (YC W21) – Tackling online eye exams and at-home eyecare

[Killakwinn]

Hey HN --

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

[schoen]

This is really neat!

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.)

[Killakwinn]

Thanks! Kristine and I will do some tag-teaming on this.

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.

[entee]

Just got a postcard from my optometrist the other day saying it’s time for my annual prescription check. My eyes are no different, but my glasses are scratched, so I need to spend an hour or two to get this fixed instead of just reordering glasses online. Can’t wait to use a service like this instead, much faster and easier, good luck!!

[codegeek]

"unnecessary pupillary dilations and air puff tests (which by the way are wildly inaccurate,) "

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.

[542458]

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.

[Killakwinn]

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!

[alex-lx]

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

[trashface]

I'm a former programmer, now in mid forties, and recently diagnosed with low-tension glaucoma, so I appreciate the value in your service. I have no family history so I wonder if my long years of staring at screens had something to do with it, though I realize the causes are complex and not well understood.

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.

[alex-lx]

I'm a programmer and was diagnosed glaucoma 3 years ago and I'm 30 now. My doctor prescribed me 2 medicines, tafluprost and carteolol, which cost 130 CNY per month. I see the doctor and do an air puff test once a month. This costs 80 CNY. Doing an OCT once a year requires 500 CNY, and a total of 3000 CNY (approximately 470 USD) per year. Recently, my doctor suggested that I have an operation. It may prevent me from using eye drops in the future. I am considering it.

[conqrr]

I was diagnosed with glaucoma at the age of 17 by a doctor. It was hard for me to comprehend that I'd have to take drops for the rest of my life. I do have pretty bad myopia and astigmatism. This was in the middle east. On doing a recheck back in India, I had a very comprehensive testing with multiple doctors checking for glaucoma and retinal damage and was told that while I'm a suspect, there's no reason for me to take drops. My IOP was calculated taking into account the diameter of the pupil (I think) and Goldman test which wasn't done previously. The doctors proceeded to explain that in the west, doctors are more likely to prescribe treatment for glaucoma because of all things around insurance etc. At minimum, I recommend getting a second opinion, if possible from a country that's not riddled with such insurance schemes.

[Killakwinn]

Hi. Thank you for sharing your story. Vision is such a critical part of our daily lives, so receiving a diagnosis like this can be very painful.

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.

[flanbiscuit]

What were your symptoms? or was this only noticed during an exam and you had not realized anything was going before the exam?

> 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?

[LorenPechtel]

Not wanting you to make an insurance claim sounds very shady indeed. As in being ripped off.

[bobawu]

Congrats on the launch! So what technology or design are you using that allows you to have the same kind of accuracy as an in person office visit?

[100kristine]

We'll be using a blend of computer vision techniques and portable hardware devices in the future. What is in our online exam right now is just a quick proof of concept that we rolled out to assess market fit. The more novel bits of tech are either in development or in the early stages of clinical trials. Excited to share more on that soon!

[Killakwinn]

I’ll leave the tech stack specifics to Kristine.

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.

[jb1991]

Interesting, I went through it, but then it got to this slide:

> 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!

[100kristine]

Hmm, we have actually never gotten that! Can dig into it.

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.

[minibronco88]

Congrats on launching! As someone whose parents have been increasingly having eye issues in the past few years, this is a godsend. So excited to see how the product continues to develop!

[Killakwinn]

Thanks, that’s what we love to hear. Please do let us know if you have any feature requests/ideas :)

[hhw3h]

Is your service available at this time? The website suggests that it is, but based on your post here it sounds like you are pre-beta?

Congrats on the launch, I can see the value in this.

[Killakwinn]

Yes, we are in fact live and have been renewing prescriptions! The beta signup link is for our full software + hardware exam, which is currently still in the works.

[dilatedmind]

cool, so this is like warby parker's app for renewing prescriptions?

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.

[Killakwinn]

Hi!

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!

[shkkmo]

I haven't had an eye exam on over a decade (since my mid 20s). I use my old prescription and order cheap glasses online. The extreme savings and arguably higher utility of this approach had always given me the strong impression that the eyecare industry is fundementally broken and full of rent seeking.

[Killakwinn]

There really is a lot that we can do to improve how people get eyecare and eyewear. I did want to point out that there's an entire other side of the eyecare industry -- eye health -- that gets overshadowed by the eyewear/optical aspect of eyecare. Obviously all sides of the eyecare industry need fixing, but I do I think part of the puzzle is bringing the eye health portion more front and center. (But ultimately there's no argument that things are broken.)

[shkkmo]

The eye exam layout on mobile Firefox is broken, stuff is being pushed off the left side of the screen but you don't allow scrolling to bring it into view. It still doesn't work properly if I switch to desktop mode.

[100kristine]

That's our bad! The exam is only built for desktop - we don't allow mobile in the usual flow because the vision charts need to be displayed at a certain height (*will add to our post).

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 [email protected], happy to take a look.

[Killakwinn]

Sorry about this, we're looking into it. It's optimized for desktop/laptop viewing, so it's strange that you're having desktop issues.

[KingMachiavelli]

I love this. At least in the US, ophthalmology & dentistry seem ripe for disruption/improvement as they have some really strange rules yet 90% of people's interactions with them are very routine.

[Killakwinn]

Completely agree, and I would attribute some of this to excellent marketing. Lately I've been thinking about how so much of our behavior and societal/cultural norms (e.g. bacon and eggs are breakfast food! drink milk to prevent your bones from crumbling into a million pieces!) all come down to brilliant longform marketing efforts.

[bruceb]

I think its cool to have more options. But what is the difference between this and the ones that are free online at the moment?

[100kristine]

Great question!

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!

[somberi]

Quinn and Kristine : Congrats on what seems to be an useful service. All the best.

Sent you an email on a visual nit (from nandyal)

[Killakwinn]

Yes, we got the email -- thank you for the input!

[100kristine]

Appreciate the feedback so much! :)

[BrianB]

Would you work with endmyopia.org to progressively reduce prescription strength?

[Killakwinn]

I am not familiar with this organization and will look into it. Thanks for bringing them to my attn!

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!

[yatacct1]

Looks promising. Like the site design; Will try this today.

[Killakwinn]

Amazing -- thanks so much :D

[ingend88]

Would $30 be covered by the insurance as well ?

[Killakwinn]

Good question. Right now everything is out of pocket. The ideal scenario is for this service to be covered by employers as well as payers; don't worry, we'll make this happen in the future!

[hsiaosquad54]

Awesome! Excited to see the progress!

[Killakwinn]

Appreciate the support :)

[100kristine]

yay thank you! :D

[ottermax8]

congrats on the launch Kristine and Quinn!

[Killakwinn]

Thank you so much -- love the enthusiasm from this community :)

[100kristine]

Thank you!!! :)

[jtwaleson]

Welcome to the digital eye test club! I'm CTO at easee.online and we've been in this space for a couple of years. Let me know if you want to have a virtual coffee! I'd be happy to have a chat and see how we can improve eyecare together.