Many readers will be familiar with visiting an eye doctor to receive a range of exams to evaluate attributes such as visual acuity, color blindness, eye movement, depth perception, or the presence of glaucoma. These vision tests focus on the eyes themselves and how well they are functioning. Perhaps less familiar to our readers are vision tests in which providers go beyond the eye itself to understand how issues with vision are related to other impairments or neurological issues, such as concussions or traumatic brain injury. Across the board, all vision tests are typically quantitative and generate important insights to the provider, but may not always be very informative or contextual to the patient.
Offering a new option for vision assessment is RightEye, a Maryland-based business that has developed eye-tracking technology designed to capture and score eye movement for prediction, evaluation, and improvement in patient outcomes. RightEye’s goal is to make vision testing more objective and comprehensive for patients. In addition to in-office vision assessments, RightEye is also making it easier for patients to practice vision exercises at home with the recently announced EyeQ Trainer.
Medgadget was invited to try out the RightEye vision tests and EyeQ Trainer, which is still in its limited beta release, at The Center for Vision Development in Annapolis, Maryland, which specializes in neurovision rehabilitation. The following is a review of this editor’s experience, results, and impressions as well as an interview with Dr. Jennifer Kungle who facilitated the RightEye demos at The Center for Vision Development. A follow-up interview with RightEye after this first-hand experience will be appearing on Medgadget soon, so stay tuned if you’re interested in more details about the technology behind RightEye’s offerings.
As someone with lifelong vision impairment, I was keen to try out the RightEye system. For reference, I started wearing glasses during early elementary school and eventually switched to gas permeable, or hard, contact lenses, followed by a second switch to soft contact lenses after a series of sports injuries. I’ve been considering laser eye surgery but currently wear contact lenses during the day and glasses in the evening. Despite an astigmatism in one eye, I would not claim that I experience any regular vision issues and my contact lens prescription has stabilized with age.
The RightEye EyeQ tests are performed at a dedicated RightEye console in the clinic’s screening room where many of the other, traditional vision tests are performed. A number of EyeQ evaluations are available including Brain Health, Sports Vision, Functional Vision, and Reading. Each evaluation includes a series of vision tests, though there is overlap between the vision tests associated with each evaluation. For example, selecting a Sports Vision evaluation would include some of the same vision tests as the Brain Health evaluation, though a patient does not need to complete the same test twice during a given session. In addition to the EyeQ tests, the RightEye console also has Vision Training Games. For my session, Dr. Kungle recommended I try the Brain Health EyeQ and Reading EyeQ evaluations, which would cover many of the typical vision tests, and try out the Vision Training Games.
Vision Tests: Brain Health EyeQ and Reading EyeQ
After some administrative setup screens, the RightEye system calibrated the console’s cameras with my eye location and movement. To do this, the system presented me with a visual reference of where my eyes were located relative to the screen. By adjusting my chair closer or farther and higher or lower, I could position my eyes in the optimal location using the visual reference. After this, the system walked me through a calibration exercise by asking me to remain still while looking at different points on the screen. During my session, the calibration process was only partially successful and had to be redone a couple times. Perhaps one reason, and an interesting insight, was that at rest the system showed one of my eyes sitting slightly higher than the other, potentially indicating a slight head tilt. Despite this, with Dr. Kungle’s help, I was able to progress past the calibration process to the vision tests.
The vision tests I completed for the Brain Health EyeQ evaluation included the following. For each test I was required to keep my body and head position fixed while performing the task.
- Circular Smooth Pursuit involved tracing the outline of a circle on the screen
- Horizontal Smooth Pursuit involved tracing a horizontal line on the screen
- Vertical Smooth Pursuit involved tracing a vertical line on the screen
- Horizontal Saccades involved looking back and forth between two points positioned horizontally on the screen as fast and as many times as possible within a time limit
- Vertical Saccades involved looking back and forth between two points positioned vertically on the screen as fast and as many times as possible within a time limit
- Fixation Stability involved focusing on a fixed point on the screen for a set period of time
- Choice Reaction Time involved seeing, processing, and responding to three different images with one of three options on a keypad
- Discrimination Reaction Time involved seeing, processing, and responding to three different images in different ways on a keypad (i.e. pressing a button or doing nothing)
The Reading EyeQ evaluation involved just two parts. First, I read a short text passage on the screen. Second, I responded to a series of questions about the passage. Dr. Kungle set the passage content, reading difficulty, and passage length at the beginning of this evaluation.
Results: Brain Health EyeQ
After each of the evaluations, results were immediately available on the RightEye console. Dr. Kungle walked me through my results, adding clarification and defining some of the more technical details presented. Additional results with more metrics were available following the session through RightEye’s website and are shared at the end of this article in the Appendices section. For all Brain Health EyeQ tests, apart from the two reaction time tests, results included video playback of the tracks made by my eyes while following different patterns on the screen. While Medgadget readers will not be able to see this dynamic visualization of eye motion, this was a unique, engaging aspect of RightEye’s results.
For the circular, horizontal, and vertical tracking tests, results include an SP% and an Efficiency value. SP%, or smooth pursuit percentage, represents the amount of time during the test that the patient’s eyes are tracking the target within an “acceptable distance and speed,” higher values are better. The Efficiency value represents the patient’s error from the ideal pathway, lower values are better. My SP% was above 97% in each eye for circular and horizontal tracking which matches up well with the population (ages 17-28) average of 93-94% for circular tracking and 91-92% for horizontal tracking. While my SP% was notably lower in vertical tracking, the score still matches up well with the population average of 55-56%. Dr. Kungle noted that vertical tracking is not well developed in certain cultures. In the United States, most text is read horizontally, accounting for the significant disparity in population scores between horizontal and vertical tracking. In cultures where text is written vertically, individuals are much better at vertical tracking. There were no population averages to compare my Efficiency values to, though Dr. Kungle described my results as typical.
The fixation stability test results break down the percentage of time the patient’s fixation points falls within less than or equal to 2 degrees, between 2 and 4 degrees, and greater than 4 degrees of the target. The more detailed results, located in the Appendices, present these numbers with even greater granularity. These results define fixation location based on the percentage of fixation points within 2 degrees of the target as follows:
- Greater than 50% represents predominantly central location
- Less than 50%, but more than 25% represents poor central location
- Less than 25% represents predominantly eccentric location
Similarly, these results also define fixation stability as follows:
- Greater than 75% within 2 degrees represents stable fixation
- Less than 75% within 2 degrees, but more than 75% within 4 degrees represents relatively stable fixation
- Less than 75% within 4 degrees represents unstable fixation.
My results showed predominantly central location with relatively stable fixation.
Next, the horizontal and vertical speed and targeting test results measure the speed and accuracy of saccades, or the movement of the eye between fixation points. The TA values represent the target accuracy of the saccades. The is an aggregate value based on the number of on-target, overshot, undershot, and missed fixation points. While the aggregate values do not have a population comparison, the more detailed results in the Appendices show my success on these tests. Overall, my speed was high, represented by 33 and 36 completed saccades compared to population averages of 21 and 22 in the vertical and horizontal tests respectively. However, my accuracy was low, with only 3-8 on-target points depending on the eye. Interestingly, my left eye was at least twice as accurate as my right eye in both horizontal and vertical tests. Further documentation of my low accuracy were the 17 and 14 missed points (out of 36) in the horizontal saccade test for my right and left eye respectively. In my vertical speed and targeting test, a pronounced arch in the eye track between fixation points is noticeable. Dr. Kungle commented that this may indicate that my concept of midline is off, as my gaze leaves a fixation point and corrects itself back to center as I approach a new fixation point.
From these six vision tests, RightEye provides an overall score and percentile for pursuits, saccades, and fixations, as well as a Brain Health indicator. While I fell into middle percentiles for pursuits (62nd) and fixations (58th), my saccade score was high (90th). Educational content in the report associates these three actions with associated areas of the brain. For example, weak pursuit scores could be tied to issues in the cerebellum or parietal lobe. That said, I took away from the experience that my middling scores on pursuits and fixations are not currently cause for concern. My overall Brain Health indicator score was 69, falling squarely in the functional range of 60-75. While these results determined that my eyes were “working optimally,” Brain Health EyeQ would have also identified eye muscle groups which may not have been functioning optimally if there was persistent evidence of issues across tests.
Not reviewed during the session, but available afterwards through the RightEye website, were my choice and discrimination reaction time results. These tests were more visually engaging. Instead of basic eye movement, I was asked to move my eyes to an image of an alien, a planet, or an astronaut, and press or not press a numbered button on a keypad based on what I saw. These tests also resulted in a number of quantitative measures including saccadic latency, or the lag in time between when the image was presented and my eye moved from the center mark and the presented image, and processing speed, or the time it took me to make a selection once I registered the image. My saccadic latency was consistently slower than the population average, 521 ms and 378 ms for me compared to 280 ms and 273 ms for the population, in choice and discrimination reaction time tests respectively. Conversely, my processing speed was consistently faster than the population average, 413 ms and 256 ms for me compared to 528 ms and 304 ms, for the population in choice and discrimination reaction time tests respectively. In both tests, my response accuracy was 100%, above the population average of 88% and 95% on the two tests.
Results: Reading EyeQ
While I completed the Reading EyeQ test during the session with Dr. Kungle, unfortunately the results were not saved in the RightEye system to share in this article. Luckily, Travis from the helpful support team at RightEye provided a sample Reading EyeQ report, which looks like the report I reviewed with Dr. Kungle, though the results are not my own.
As the sample report shows, much of the analysis is based on tracking eye movement from word to word, from the end of a line to the beginning of a new line, and to previous words or lines that the reader needed to revisit. The pressure of answering questions about the text enforces a need for comprehension and encourages patients not to skim the material. In addition to the post-reading questionnaire and reading metrics, vision indicators such as dry eye, fatigue, and binocular vision issues are assessed based on eye movement during the test. A binocular vision issue can refer to under crossing or over crossing of the eyes when trying to look at a location, or in this case a word, together.
Vision Training Games
Before completing my session at the RightEye console, Dr. Kungle had me try out the four Vision Training Games. The tasks completed up until this point were straightforward and easy to understand, but were very much “tests” in the sense that I was conscious that the outcome would be quantified and analyzed. Conversely, while completing the Vision Training Games, I was less focused on the evaluation and instead was engrossed in the experience of the games themselves.
- Cosmos Combat: train peripheral range and recognition by matching central and peripheral images
- Space Storm: train speed, accuracy, and inhibition by protecting one of more spaceships from aliens and asteroids
- Bubble Blast: practice saccades and pursuits by focusing on moving bubbles
- Maze Master: tied to Reading EyeQ, exercise oculomotor function by following numbers to complete a maze
The games were very fun though, to be honest. Who wouldn’t enjoy blowing up aliens and completing puzzles with their eyes? The games were a great way to complete the RightEye session and seem like a perfect tool for patients to exercise their vision while waiting to transition to the review phase of their clinic visit. Unlike the EyeQ Trainer discussed below, the Vision Training Games are currently only available for patients in the clinic through the RightEye console, not at home.
EyeQ Trainer (beta)
Before I left my session with Dr. Kungle, we talked about the EyeQ Trainer and Vision Training Exercises. The EyeQ Trainer is a library of exercises that can be performed by patients at home. The new offering from RightEye is still in beta and only available through select providers. Dr. Kungle explained that currently she does not assign specific exercises to her patients. Instead, the RightEye system selects which training exercises the patient should complete based on their vision test results and provides a link for the patient to access the exercises at home after their clinic visit. Patient compliance and engagement with the exercises are completely self-motivated, there are no reports on patient interaction with the exercises for the provider to review.
Back at home, I logged into the RightEye website and found the link to the EyeQ Trainer associated with my Brain Health EyeQ results. Launching the exercises, I was prompted to complete four horizontal pursuit exercises all in series. These exercises were related but not identical to the horizontal pursuit test completed in clinic. After these four exercises were complete, the system told me to come back in 90 minutes for 9 additional exercises. Upon returning, I was prompted to complete the same four horizontal pursuit exercises again, after which I was again prompted to return, this time in 60 minutes for 9 additional exercises. It was unclear, at this point, what the “9 additional exercises” were referring to, since I had been given the same exercises to complete twice in a row, and what period of time I was expected to complete all nine exercises within. Returning to the RightEye portal for a third time, I again completed all four horizontal pursuit exercises. However, at the conclusion, a new prompt stated that I had completed all of the day’s exercises and that I now had “8 exercises remaining.” It seemed like I was starting to make progress.
Unfortunately, the next morning I was again prompted with the same horizontal pursuit exercises, after which I was told that I had completed all tests for the day, after one session instead of three, and still had 8 exercises remaining, the same number I had left at the end of the previous day. At this point, I assume there are a few kinks to be worked out, which is completely fair for the beta release. Lingering questions include: What happens at the end of potentially nine days of exercise? Will I be able to choose specific tests to practice? Does the intelligence of the EyeQ Trainer algorithm go deeper than assigning exercises based on tests completed in the clinic?
Vision Training Exercises
In addition to individually-selected exercises, the RightEye portal also provides a long list of Vision Training Exercises organized by sport and skill. Unlike the EyeQ Trainer exercises, which walk the patient through each exercise step-by-step with on-screen queues to perform the task, the Vision Training Exercises are videos showing the motivation for and performance of each exercise with the expectation that the patient will perform the exercise on their own.
This content aligns with Dr. Kungle’s comment, below, that the a good deal of vision training is focused on athletics. She believes these additional at-home exercises could be effective for sports teams and individuals seeking to improve their athletic performance. Currently, the RightEye portal provides vision exercises for the following categories:
- Baseball Hitting Drills
- Basketball Free Throws
- Golf Putting
- Soccer Penalty Kicks
- Tennis Groundstrokes
- Tennis Returning Serve
- Warm-Up Drills
- Weight Room Drills
This sports-centric view highlights a potential area of focus for RightEye and is something I intend to learn more about in my interview with the company. Note that there was a Sports Vision evaluation that I did not demo during my RightEye session which may relate more directly to these exercises.
The combination of visual and real-time quantitative results provided the basis for a rich, engaging conversation between patient and provider. As a patient, I could actually see my test performance and have that performance contextualized in a way I could understand. For the provider, the RightEye system offers a guide to systematically assess and educate patients about their vision performance based on their interest or clinical needs.
Beyond the clinic, RightEye already has a rich library of vision training exercises for the motivated athletes seeking to improve performance. More broadly, RightEye is working on personalized treatment with selected, step-by-step exercises based on in-clinic performance. These exercises were quick and easy to complete, though I am interested in learning more from RightEye about how their algorithm pairs patients with exercises, how the feature plans to scale, and if they will offer reporting tools on exercise adherence and engagement.
In conclusion, I really enjoyed the opportunity to use the RightEye system. Working with Dr. Kungle and the RightEye system resulted in the most comprehensive, informative session I’ve ever had about my own vision and left me with clear areas to improve, as well as some initial tools to realize that improvement.
Interview with Dr. Kungle
Mike Batista, Medgadget: How did you initially engage with RightEye?
Dr. Jennifer Kungle: My engagement with the team at RightEye began as part of an initiative for better vision screenings in schools. Most vision screeners just look at acuity, but patients can still have vision problems that impact reading and their ability to learn. We eventually wrote some legislation to make certain vision screenings mandatory in schools. The original legislation passed the state senate, but not the house so last year we revamped the bill. The second time it passed both the state senate and the house and was enacted in Maryland as the Atticus Act earlier this year. The RightEye team and I testified together for passage of the bills.
Medgadget: Can you tell us a little more about your practice.
Dr. Kungle: At the Center for Vision Development, we’re not a typical vision care office. We focus on patients with developmental or neurological issues such as concussion, stroke, Parkinson’s, autism, ADHD, and lazy eye among other things. Broadly, we support patients who have some sort of condition where the vision system is part of the problem. Working with the patient, we assess their vision challenges and devise a program to help address the condition. Many of the vision issues our patients face are treatable with our programs.
Medgadget: How do you use RightEye EyeQ tests in your practice? What do you get out of the tests and do they replace screenings you would normally perform?
Dr. Kungle: For our practice, all patients are pre-screened using the RightEye EyeQ tests. These tests do not replace any of the current eye exams we perform today but supplement them with more precise measurement of eye movement. RightEye’s EyeQ tests provide information to both patients and their healthcare provider or coach on how the patient’s your and brain are working together. Understanding this relationship leads to the identification of early indicators for a broad range of treatable vision, health and performance conditions.
Medgadget: How does payment for RightEye tests work, are there reimbursement codes for this kind of screening?
Dr. Kungle: There are billing codes available for assessment of eye tracking so tests using the RightEye EyeQ tests can be billed against that.
Medgadget: What has been the biggest benefit of the RightEye tools for patients?
Dr. Kungle: The biggest benefit of the RightEye system is for the patient to be able to see their problem. A lot of patients may have a head injury that causes a vision problem but they don’t really understand what’s wrong with how they are seeing. When they see the eye tracking lines and visualizations of how their eyes are moving, they can see a lot more directly that they have a real issue. Similarly the parents of children often cannot comprehend what their child is seeing. While other tests can measure a child’s, or any patient’s, vision issues, they are not as good as the EyeQ tests at allowing a patent to fully understand the extent of the problems their child might be dealing with.
Medgadget: How do you ensure accuracy with the EyeQ tests? For the Reading EyeQ test for example, how do you know if I am actually reading through the text passage and generating a valid result?
Dr. Kungle: For the Reading EyeQ test, we watch the eye tracking in the post-test report to see if the patient is following the words. More quantitatively, unless the patient scores 80% comprehension or higher on the questions after they read the text passage, we do not consider the eye movement data to be accurate. This helps reinforce the validity of the eye tracking evaluation. If the patient does score below 80% comprehension, we reduce the reading level of the text and try again until we get the comprehension above that bar. Redundancy also helps establish the validity of the tests patients perform. For the Reading EyeQ test, we almost always will have the patient read two different stories on two different days to see if there is consistency in their results.
Medgadget: Right now the EyeQ Trainer is in beta, so it’s fairly new. Do you receive any feedback or insight into how your patients are using the trainer outside of the clinic? Who is the EyeQ Trainer designed for?
Dr. Kungle: Right now, there isn’t a way for providers to get information about patient compliance or how they are doing using the EyeQ Trainer system outside of the clinic. The EyeQ Trainer system seems geared towards a team or group that needs to educate and train their athletes. Hospitals, rehabilitation groups, and sports teams that don’t have what we have access to in our clinic would find these types of training elements helpful for the people they work with.
Medgadget: That’s interesting that you mention athletes. Can you elaborate on the importance of vision training for athletes?
Dr. Kungle: Top level athletes are actually the ones with the most advanced visual skills. If you test athletes and non-athletes, athletes will generally score much higher on all visual tests. Even if an athlete does not have a diagnosed vision impairment, using the EyeQ Trainer system exercises can actually help boost athletic ability as the athlete becomes better at different visual skills used in their sport such as tracking, scanning, depth perception, visual thinking, and prediction.