LI Startups Spearhead Tele-optometry

Patient care coordinator Mohammad Mhana, right, demonstrates the use of a camera to photograph regional optical manager Kelly Krom's eyes for a tele-optometry visit at BJ’s Wholesale Club in Commack. Credit: Barry Sloan

Optometry is changing in the blink of an eye.

Two Long Island startups are at the forefront of a revolution in technology and business practices that lets patients get an eye exam from an optometrist located states — or even half a world — away.

The companies, DigitalOptometrics LLC in Lake Success and 20/20 Vision Center LLC in Holbrook, are in what they describe as a two-dog race to roll out tele-optometry services around the country and beyond.

Unlike the telemedicine that brings a doctor to a patient's home via computer or smartphone, a comprehensive eye exam requires sophisticated instruments on site. That means patients have to go to a clinic or optical outlet. Special software then steers the patient's case to one of the remote tele-optometrists at the ready. That optometrist then can interact with the patient via video link, review test results and operate equipment remotely as needed.

Remote eye examinations are as good as the in-person version, the companies say, but the system squeezes inefficiencies out of the process by deploying optometrists wherever needed. While an optometrist in an office or clinic might have gaps between patients, tele-optometry software queues up patients from multiple locations.

"Our doctors can see more patients per day," said Charles "Chuck" Scott, chief executive of 20/20 Vision Center, which does business as 20/20Now. "We need fewer doctors [and have] higher margins on the exam process."

Remote optometry accounts for only a tiny fraction of the market, but it has been gaining ground rapidly. A May 2022 survey by The Vision Council, a trade association for optical industry manufacturers and suppliers, found that 0.9% of consumers reported having a telehealth eye exam in 2021, more than double the 0.4% rate in 2018.

"We had the wind behind our back before COVID," said Dr. Howard S. Fried, an optometrist and president of DigitalOptometrics, which launched in March 2018. "Once COVID hit it was gale-force winds."

"The pandemic was an accelerant for a lot of telehealth services," said Scott, whose company launched in 2016. "The acceptance by patients... really grew."

20/20Now is on pace to grow year-over-year revenue by 149% and locations by 133%, he said. The company offers its service in more than 300 locations in 34 states, including locations of Costco, Sam's Club, BJ's Wholesale Club and Walmart.

Fried said his company has been doubling revenue in recent years and averaging 2,000 eye exams per day. DigitalOptometrics is providing services in 29 states and parts of Canada. Its 600 locations include outlets of Target and optical chains America's Best and Visionworks of America, he said.

The companies make money by providing eye exams to customers in much the same way an on-site optometrist would.

Eye examinations are crucial to optical retailers because they often lead to the purchase of new glasses or contact lenses.

"Clearly the eye exam is the driver for the material purchases," Fried said. "Without the prescription, you're not selling frames and lenses."

The tele-optometry services get no cut on the sale of glasses or contacts. Clinics or optical shops pay DigitalOptometrics to provide software technology and optometrist services, Fried said, and the shops where it operates set their own prices for eye exams.

20/20Now typically gets paid by clinics or optical shops for providing examinations, or, in some cases, pays a sub-lease to use their space and equipment, Scott said. In the latter instance, 20/20Now sets the exam fee.

Scott said a 20/20Now eye exam typically runs from $45 to $75, depending on the region, a discount of as much as 30% from an in-person exam.

The American Optometric Association maintains that the population of U.S. optometrists, which has risen from 44,103 in 2016 to 48,546 in 2022, is adequate to meet demand.

But the tele-optometry companies argue that coverage is not uniform and that some areas are underserved.

"There are thousands of [retail] locations looking for optometrists," Fried said.

Data from the Bureau of Labor Statistics show that the concentration of optometrists in states such as Tennessee and Louisiana is far below the national average.

Some urban areas are underserved as well.

"You have both urban and rural areas creating a void in access to care," Scott said.

Sean Benson, CEO of Newton, New Jersey-based The Optical and Hearing Center, said he uses DigitalOptometrics to supplement the on-site optometrists at his company's four locations.

"We use tele-optometry when a doctor is sick, is off, has left for the day," he said.

Benson said patients seeking rapid service appreciate tele-optometry and he plans to expand the number of "digital lanes" in his stores to accommodate wider use.

"There's no question that [tele-optometry] is going to grow," he said. "With the labor shortage, this is a tremendous solution."

Fried points to DigitalOptometrics' partnership with the Georgia Lions Lighthouse Federation, a nonprofit that provides eye-care services to the poor and uninsured. In April, Georgia Lions launched a tele-optometry bus program with DigitalOptometrics that it says will cover the 30% of Georgia counties that lack eye care services. The average cost of an exam plus glasses, according to Georgia Lions, is $25.

Tele-optometrics hours roughly mirror those of brick-and-mortar stores.

20/20Now offers services from 9 a.m. to 8 p.m. Monday through Saturday and 11 a.m. to 7 p.m. on Sundays in each U.S. time zone, Scott said.

Optometrists may be attracted by the flexible hours, commuting hours saved and the ability to work from anywhere as long as they have a steady broadband connection.

"Our doctors like this because of the work-life balance," Scott said.

One DigitalOptometrics optometrist stretches remote work across multiple time zones by examining U.S. patients from Kuwait, Fried said, while another operated for a time in Israel.

Optometrists, whether on-site or virtual, are limited by rules that allow them to practice only on patients located in states where they are licensed.

They are paid per diem based on an hourly rate that Fried said can allow them to earn on par with the 2021 median wage for optometrists of $124,300 listed by the Bureau of Labor Statistics.

From a patient's point of view, the tele-optometry exam generally mirrors the in-person version.

The patient comes to an office, clinic, optical store or the optometry section of a big box store. There the patient answers questions about their medical and visual history.

An on-site technician guides the patient to examination devices that feed results into special software programs. The devices typically are operated by a remote technician and the remote optometrist, who are viewed by the patient through a video feed.

The roughly 30-minute examination includes a slit lamp examination, which can expose cataracts, a detached retina and macular degeneration, and a phoropter test, which measures a patient's refraction error and helps determine their prescription.

One common procedure from in-person examinations that is missing from tele-optometry is the dilation of the patient's pupils. Instead, tele-optometry companies use a retinal camera to examine the back of the eye. That camera provides information comparable to what is obtained through a dilation, Fried said.

Optometrists consider a comprehensive examination — whether in person or remote — as an important medical checkpoint, allowing them to refer patients to specialists in conditions such as diabetes, macular degeneration, cataracts or glaucoma.

Ashley Mills, chief executive of The Vision Council, the manufacturers' trade association, hailed the "evolving technology" in vision care, but said a "primary eyecare provider" should provide advice on when to use telehealth and when an in-person visit is preferred.

The position of the American Optometric Association, which represents optometrists, has evolved as the tele-optometry model gains traction.

In 2017, the AOA issued a policy statement calling for an initial optometrist-patient visit to be in-person rather than remote.

By 2020, the AOA's position evolved to acknowledge that in some instances, the initial visit could be established through tele-optometry, said Dr. Terri A. Gossard, a trustee on the AOA board of directors.

A further update on the AOA's tele-optometry policy is expected within a few months, she said.

"We need doctors with the best tools," Gossard said. "We also need to set standards."

The AOA remains opposed to companies that use a patient's computer or mobile phone app to "skip the doctor visit" for contact lens prescription renewals, Gossard said.

Those 10-minute examinations use a mobile phone or computer to take pictures of the patient's eyes and test their vision with an online eye chart.

Fried said such cursory examinations strip optometrists of their "gatekeeper" function in detecting disease.

The two privately held Long Island startups, meanwhile, see an open field for their model of tele-optometry.

20/20Now, with 145 employees plus 27 optometrists employed by an affiliate, has retained a financial adviser and expects to close an outside funding round shortly to fund expansion, Scott said.

DigitalOptometrics, with 175 employees plus about 100 optometrists working as independent contractors, is on the verge of international expansion, Fried said.

"Now that we've gained traction here and in Canada, we have plans to put a pilot in Germany in October," he said.

The Ludwig brothers operate on the opposite side of the spectrum from tele-optometry.

They are part of a contingent of only 93 optometrists nationwide who provide mobile or visiting service, according to data from the American Optometric Association.

Dr. Brian Ludwig believes they are the only traveling optometrists on Long Island. "We go to houses, group homes, nursing homes, assisted living."

He and his brother, Dr. Eric Ludwig, drive around Nassau and Suffolk counties, sometimes logging 200 miles in a day. They carry about 40 pounds of special mobile optometry equipment on carts and duffel bags.

"We like to physically go to see our people," Brian Ludwig said. "It's a unique type of practice."

After Brian earned a bachelor's degree from Stony Brook University and Eric earned his degree from the University of Albany, both earned doctorates in optometry from the New England College of Optometry.

To get Setauket-based Long Island Optometry Care PLLC going, they connected to primary-care doctors who do home visits and could provide referrals. The brothers soon discovered a "whole community of providers" to the homebound including social workers and home health aides.

Once they get inside a house or facility, the Ludwigs often encounter the unexpected.

They have had to navigate the homes of hoarders and one that appeared to be a drug den.

"Patients are in bed, chairs, sleeping," said Eric. "Sometimes you need to open their eyes to see what's going on there. You have to adapt to each person."

At the same time, going into a home can provide insight into patients' problems.

"Maybe they have an old TV," Brian said. "Maybe they need a new TV."

The brothers said that mobile optometry equipment keeps improving and they are constantly trying out new gear. Rather than order lenses for clients, they buy blanks and cut lenses for eyeglasses in Brian's basement.

The brothers accept most common insurance plans, Medicare and Medicaid.

Brian said they have "minimal costs" as a mobile operation.

"Our biggest expense is gas," he said. "We don't have overhead except our equipment...There's no office drama."

The mobile practice filled a yawning need for its immobile clientele, Brian said. "A lot of them just hadn't seen a doctor in years. A lot of patients just went without."

Optometry is changing in the blink of an eye.

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'Our doctors can see more patients per day.'

-Charles "Chuck" Scott, chief executive of 20/20 Vision Center, which does business as 20/20Now.

"We had the wind behind our back before COVID," said Dr. Howard S. Fried, an optometrist and president of DigitalOptometrics, which launched in March 2018. "Once COVID hit it was gale-force winds."

"The pandemic was an accelerant for a lot of telehealth services," said Scott, whose company launched in 2016. "The acceptance by patients... really grew."

The companies make money by providing eye exams to customers in much the same way an on-site optometrist would.

Eye examinations are crucial to optical retailers because they often lead to the purchase of new glasses or contact lenses.

An ad for comprehensive eye exams at BJ’s Wholesale Club in Commack. Credit: Barry Sloan

"Clearly the eye exam is the driver for the material purchases," Fried said. "Without the prescription, you're not selling frames and lenses."

Optician Jessica Velasquez, below, chats with certified ophthalmic technician Samantha Walton during a demonstration of a tele-optometry visit at BJ’s Wholesale Club in Commack. Credit: Barry Sloan

Scott said a 20/20Now eye exam typically runs from $45 to $75, depending on the region, a discount of as much as 30% from an in-person exam.

The American Optometric Association maintains that the population of U.S. optometrists, which has risen from 44,103 in 2016 to 48,546 in 2022, is adequate to meet demand.

8 million The estimated number of Americans with serious visual impairment or blindness by 2050, double the total in 2016.

But the tele-optometry companies argue that coverage is not uniform and that some areas are underserved.

"There are thousands of [retail] locations looking for optometrists," Fried said.

Data from the Bureau of Labor Statistics show that the concentration of optometrists in states such as Tennessee and Louisiana is far below the national average.

Some urban areas are underserved as well.

$11.7 billion The overall economic burden of vision loss in New York State, including nursing home, productivity and medical costs.