Visual Acuity Testing for Telehealth Using Mobile Applications

Abstract

Importance: The coronavirus disease 2019 pandemic illustrates the increasingly important role of telemedicine as a method of clinician-patient interaction. However, electronic applications (apps) for the testing of ophthalmology vital signs, such as visual acuity, can be published and used without any verification of accuracy, validity, or reliability.

Objective: To reassess the accuracy of visual acuity-testing apps and assess their viability for telehealth.

Design, setting, and participants: The US Apple App Store was queried for apps for visual acuity testing. Anticipated optotype size for various visual acuity lines were calculated and compared against the actual measured optotype size on 4 different Apple hardware devices. No human participants were part of this study.

Main outcomes and measures: Mean (SD) errors were calculated per device and across multiple devices.

Results: On iPhones, 10 apps met inclusion criteria, with mean errors ranging from 0.2% to 109.9%. On the iPads, 9 apps met inclusion criteria, with mean errors ranging from 0.2% to 398.1%. Six apps met criteria and worked on both iPhone and iPad, with mean errors from 0.2% to 249.5%. Of the 6 apps that worked across devices, the top 3 most accurate apps were Visual Acuity Charts (mean [SD] error, 0.2% [0.0%]), Kay iSight Test Professional (mean [SD] error, 3.5% [0.7%]), and Smart Optometry (mean [SD] error, 15.9% [4.3%]). None of the apps tested were ideal for telemedicine, because some apps displayed accurate optotype size, while others displayed the same letters on separate devices; no apps exhibited both characteristics.

Conclusions and relevance: Both Visual Acuity Charts and Kay iSight Test Professional had low mean (SD) errors and functionality across all tested devices, but no apps were suitable for telemedicine. This suggests that new and/or improved visual acuity-testing apps are necessary for optimal telemedicine use.

Figure.. Mean (SD) Error of Apps That Work on Either iPhones, iPads, or Both

Software versions include (from top to bottom) Visual Acuity Charts, version 2.5; Kay iSight Test Professional, 2.1; Smart Optometry, 4.0; EyeTesterFree, 1.5; Eye Handbook, 8.2.12; Vision Scan Lite, 1.3; EyeCuity, 1.0; OcularCheck: Visual Acuity, 1.2.0; Eye Chart HD, 2.3.1; and Eye Test Snellen Ishihara, 4.0.2. Error bars indicate SDs.