EyeSpy 20/20 is designed to vision-screen large numbers of students while also obtaining accurate and reliable results.

VisionQuest 20/20 was founded by children's eye surgeon Dr. James O'Neil, right, and technologist Richard Tirendi.

The randomness of the game ensures children can't cheat by memorizing a static document or by peeking between their fingers.

In three years, EyeSpy 20/20 has been used to screen more than 200,000 students for amblyopia, strabismus (eye misalignment), cataracts, and focusing problems (nearsightedness, extreme farsightedness, and astigmatism).

"Getting every child's vision examined by a professional eye doctor every year is impossible," Tirendi said. "There's simply not enough optometrists and ophthalmologists, nor is there enough money because a full eye exam, as you can appreciate it, is very expensive. There had to be a better way."

Tirendi considers EyeSpy a much-needed update to the 150-year-old eye chart: "It's like, instead of getting on an airplane, you take a horse and buggy. This is bringing vision screening to the 21st century," he said.

EyeSpy Gamifies The Vision Test

EyeSpy 20/20 is a 21st-century answer to the 150-year-old wall chart used in vision screenings.

The problem with amblyopia, commonly known as lazy eye, isn't treatment. If caught early enough in children, the condition can be easily addressed, often with something as simple as a pair of glasses. Instead, the issue lies with detection: If caught too late, amblyopia can lead to blindness in one eye.

Traditionally, schools have been responsible for screening students for vision disorders, referring those with issues to an eye doctor. But as school nurses can attest, the process can be fraught with problems. Tiffany Vold, head nurse at Sevilla Primary School in Phoenix, said her eight-year-old son consistently passed wall-chart exams, scoring 20/20 both at her office and the optometrist. Yet when she sat him down in front of a computer to play a vision-screening game, the results were much different: He failed--twice. "Now he's in glasses, and he can see," she said.

The game that Vold and her assistant administer to 1,000 students each year is called EyeSpy 20/20, designed by pediatric eye surgeon Dr. James O'Neil and technologist Richard Tirendi, whose work with childhood vision disorders began after he sold a semiconductor company. Though the test is intended to handle volume, the randomness of the game ensures children can't cheat by memorizing a static document--as Vold's son did--or by peeking between their fingers, another common way children outsmart the wall chart.

O'Neil and Tirendi formed the nonprofit organization VisionQuest 20/20 in 2003 to educate and advocate for childhood vision disorders. "Getting every child's vision examined by a professional eye doctor every year is impossible," Tirendi told Fast Company. "There's simply not enough optometrists and ophthalmologists, nor is there enough money because a full eye exam, as you can appreciate it, is very expensive. There had to be a better way."

Gamifying vision exams, EyeSpy 20/20 has been used to screen more than 200,000 students in three years for amblyopia, strabismus (eye misalignment), cataracts, and focusing problems (nearsightedness, extreme farsightedness, and astigmatism). To commemorate Blindness Awareness Month, the game has added color-blindness screening and will begin testing for the deficiency Friday at an event held at the Children's Museum of Phoenix.

Independently validated by the Storm Eye Institute in Charleston, South Carolina, and the American Association for Pediatric Ophthalmology and Strabismus, EyeSpy is essentially a two-minute matching game. Using accredited age-appropriate symbols in vision screening, students ages 4 and up are seated about 10 feet away from a computer screen. They're tasked with matching a character on the bottom of the screen to the options displayed on top. The bottom character, referred to as a target, is randomized and shrinks slightly in size with each correct answer. When students get an answer wrong, the target enlarges to keep them engaged. Students first play the game with both eyes open to test for binocular visual acuity. To test for each eye, they wear a disposable eye patch. Afterward, they don special red-and-blue glasses to detect shapes from a pattern. Tirendi considers EyeSpy a much-needed update to the 150-year-old eye chart: "It's like, instead of getting on an airplane, you take a horse and buggy. This is bringing vision screening to the 21st century," he said.

Dr. Debora Lee, an assistant clinical professor at UC Berkeley's School of Optometry, said there are advantages to letter and picture wall charts, considered "a gold standard" in vision screening. While she acknowledges issues with such charts--such as children memorizing, peeking, or getting distracted--she said the standard method is designed to give doctors insight beyond correct or incorrect answers.

"There's an art to figuring out what someone can see, how they respond, how fast they respond, and what letters they get and don't get," Lee said. "You get qualitative information on how a child reads, whether they miss the ones on the end or the ones in the middle. This more qualitative information you may or may not get if it's automated." Still, with millions of children to screen in America, she sees the benefits of gamification and automation.

To achieve EyeSpy's public-health goals, the game was designed to be as simple as possible while still obtaining accurate and reliable results. Children have no trouble picking up the rules of EyeSpy, which runs on PCs and Macs. The game can be administered by lay personnel without special training, and with 10 computers, a school can screen about 100 students in an hour. EyeSpy can be scaled so the cost breaks down to $5 a child, compared with $10 to $15 for traditional vision screenings. "As we achieve economies of scale, it will approach $2 a child," Tirendi said. "For less than the cost of a school lunch, we can ensure every child gets an annual vision screening."

Because VisionQuest isn't a technology development company, focused instead on education and advocacy, EyeSpy isn't given away to schools. The software is licensed to an unlimited number of computers at each school for $3,800 during the first year and $800 every year thereafter. Results are managed in the cloud by VisionQuest, allowing schools to search and filter HIPAA-compliant reports. Even with comparatively lower costs, Tirendi recognizes there's a barrier to entry and encourages schools to apply for grants and enlist local businesses to underwrite the program, which can recognize sponsors on the vision-screening reports sent home to parents.

"Poor vision has devastating consequences in children's lives academically, psychosocially, and ultimately economically," said Tirendi, whose passion for childhood vision disorders stems back to his own bout of blindness. As a 4-year-old, he went without sight for two and a half weeks as a result of a poisonous insect bite. "It's really important that childhood vision disorders are detected as early as possible," he said.

[Image: VisionQuest 20/20]

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