0 AAO 2014 Press Briefing iPhones, iPads and 3-D Printers: Five Studies Examine How Innovative...

0AAO 2014 Press Briefing

iPhones, iPads and 3-D Printers:Five Studies Examine How Innovative Consumer Technologies Are Improving Access to Eye Care

October 20, 2014

Jiaxi Ding MD1, Matthew S. Pihlblad MD1

1Ross Eye Institute, Department of Ophthalmology, University at Buffalo, The State University of New York,

Buffalo, New York 14209

iExaminer: a portable and inexpensive option for fundus photography

and videography in the pediatric

population

The authors have no financial disclosures to

report

What’s back there?

Voilà!!!

+ =

iExaminer

25˚ Field of View Undilated

View obtained through the standard direct

ophthalmoscope

View obtained through the PanOptic ophthalmoscope

What is already good…

• Quality imaging convenient at bedside

• Instant electronic transmission of images and videos enable real-time telemedicine consultation

• SmartPhone tele-ophthalmology for diabetic retinopathy assessment and for quick second opinion useful in residency training, in the ED, and amongst general practiioners.2-4

• Fundoscopic images reveal no external facial features, so protects patient identity and privacy

• PanOptic offers a 25˚ scope of field through the undilated pupil, 5x larger than the standard Welch Allyn direct ophthalmoscope can use iExaminer without pharmacologic dilation1,5

• Learning curve to optimal maneuvering of the system

• Micro-movements can be disruptive minimize by bracing hand on patient’s forehead, recline patient to avoid fighting gravity

• Glare artifact use medium range lighting

• View of peripheral retina is difficult

• Battery life of the ophthalmoscope per charge may limit number of patients consecutively imaged on-the-go

• Current iExaminer design only compatible with iPhone 4 and 4S which have 5-8 megapixels camera capacity lower image resolution than the latest models

What could be better…

The iExaminer is an inexpensive, portable, and effective tool for imaging posterior pole pathology with telemedicine potential.

Conclusion:

References

1. Welch Allyn. iExaminer: Eye imaging on your iPhone. 2014. http://www.welchallyn.com/en/microsites/iexaminer.html

2. Kumar S, Wang EH, Pokabla MJ, Noecker RJ. Teleophthalmology assessment of diabetic retinopathy fundus images: smartphone versus standard office computer workstation. Telemed J E Health. 2012 Mar;18(2):158-62.

3. Stanzel BV, Meyer CH. Smartphones in ophthalmology : Relief or toys for physicians? Ophthalmologe. 2012 Jan;109(1):8-20.

4. Teichman JC, Sher JH, Ahmed II. From iPhone to eyePhone: a technique for photodocumentation. Can J Ophthalmol. 2011 Jun;46(3):284-6.

5. Steeles. Welch Allyn Panoptic Ophthalmoscope. <http://www.steeles.com/products/welch-allyn-panoptic-ophthalmoscope-11820>

Images:• Slide 2:

• http://www.sheknows.com/health-and-wellness/articles/836639/kids-health-tips-to-avoid-digital-eye-strain

• http://university.eyecare.org.au/services/facilities.html

• Slide 3:• http://www.medsupplier.com/welch-allyn-iexaminer-adapter-11840.aspx?

gclid=CPSr0rGdlsECFVEQ7AodymQAJw

• https://www.apple.com/lae/iphone-4s/specs/

Andrea Russo, MD

University of Brescia - Italy

Comparison of Smartphone Ophthalmoscopy with Slit-lamp Biomicroscopy for Grading Diabetic

Retinopathy

Prospective Study

Setting: Ophthalmic Diabetic Center of “Spedali Civili di Brescia” – Italy

120 consecutive patients with diabetes

smartphone ophthalmoscopy

retinal slit-lamp examination

Study Design

D-Eye Prototype

D-Eye Prototype

Results

Results

The eye fundus was not gradable for DR in 9 eyes (13.3%) by smartphone ophthalmoscopy and in 4 eyes (3.3%) by biomicroscopy because of cataract and/or small pupil diameter.

An exact agreement was found in 204 (85%) of 240 eyes and an agreement within one step was observed in 232 eyes (96.7%).

Simple κ was 0.78 (95% confidence interval 0.71–0.84; P < 0.001), showing a substantial agreement.

Conclusion

In conclusion, this study shows that smartphone ophthalmoscopy with the D-Eye system can accurately detect retinal lesions for grading DR and might be used as a screening tool for diabetic retinopathy.

Visual Field Screening in Nepal Using an iPad to Test Normal Controls, Persons with Glaucoma

and Individuals with Diabetic Retinopathy

Alan L Robin, MD - Depts of Ophthalmology, Univ of Maryland and Johns Hopkins Univ

Chris A. Johnson, PhD, DSc - Dept of Ophthalmology and Visual Sciences, Univ of Iowa

Suman Thapa. MD, PhD - Nepal Glaucoma Eye Clinic, Tilganga Institute of Ophthalmology, Kathmandu, Nepal

Nothing to disclose

Screening for Glaucoma Controversial – Cost-benefit ratio is not

favorable for general screening. However can target “at risk” populations

(persons of African descent, hispanic latinos, elderly, persons with limited or no access to traditional eye and health care)

The purpose of this study was to perform visual field screening in Nepal using a low-cost program available on the iPad tablet.

Background luminance is31.5 asb (10 cd/m2)

96 test locations (right eyeformat is shown to theRight) – the left eye is amirror image of the righteye format.

Target size is a GoldmannSize V (1.73 deg diameter)

Target luminance is 250 asb,80 cd/m2, or 16 dB)

Each quadrant is tested oneat a time (upper right, upperLeft, lower left, lower right).

A red fixation point moves from one corner of thedisplay to another.

Participants Inclusion Criteria:

Complete Eye Exam (anterior segment biomicroscopy, ophthalmoscopy of the optic nerve head, retinal nerve fiber layer and macula, 20/60 or better visual acuity, fundus photography, no other ocular, neurologic or systemic diseases other than glaucoma or diabetic retinopathy.

More than 400 eyes evaluated with Visual Fields Easy. Most participants also underwent Humphrey Field Analyzer 24-2 SITA Standard tests for comparison purposes.

210 Normal Control Eyes, 198 with HFA results 183 Glaucoma Eyes, 160 with HFA results 18 Diabetic Retinopathy Eyes, 15 with HFA results

Conclusions It is possible to perform visual field screening in remote areas of the

world. The Visual Fields Easy performed quite well on a iPad, and

demonstrated good correlations with HFA test values. Testing time was an average of 3 minutes and 18 seconds for all

three groups.

Future Directions

Optimize target presentation pattern (are 96 visual field locations necessary ?)

Reduce the testing time (the Matrix frequency doubling perimeter performs screening in 30-60 seconds per eye).

Reduce the false positive rate (retest missed points and those that disagree with their neighbors).

Remove the need to tap the screen.

The EyeGo System:MODULAR SMARTPHONE-BASED

OPHTHALMIC IMAGING ADAPTERS

David Myung, MD, PhD,1,2

Brian Toy, MD,1 Alexandre Jais, MS,1

Doug Merrell2, Alison Polkinhorne2, Doug Foster2

Mark Blumenkranz, MD,1,2 and Robert Chang, MD1

1Byers Eye Institute at Stanford2DigiSight Technologies

Anterior Attachment

Posterior Attachment

Dual Adapter System

Simple, Compact, Low Cost

Incremental Additional Cost:Uses Practitioner’s Own Phone and Lenses

User-OwnediPhone

User-OwnedOphthalmoscopy Lens

Posterior Adapter

AnteriorAdapter

How to use the anterior adapter

Light switch

Using the Posterior Adapter

Example View

Foldable, Pocket-Sized Design

Indications

Imaging and photodocumentation of the anterior and posterior segments of the eye

Designed for use in emergency room, urgent care, primary care, and optometrist offices, inpatient/hospital bedside and rural settings where expensive ophthalmic imaging equipment is unavailable.

Intended for use by both eye care specialists and non-eye care specialists as well as non-M.D.’s

Smartphone cameras alone not enough

• Good for adnexa, lid, and conjunctiva

• Poor corneal, iris, chamber, and lens detail

• Requires digital zoom

The phone alone can do 90% of the work…

Just need the right OPTICS and LIGHTING

With EyeGo

Without EyeGo

Optics + LightingMacro Lens Alone

Macro Lens + LED

Pterygium

Pyogenic Granuloma

Subconjunctival Hemorrhage

Subluxed Lens

Corneal Abrasion

Hyphema

Post-Op Corneal TransplantCorneal Ulcer

Contact Lens over Glued Corneal Perforation

Corneal Ulcer

LED

Macro Lens

ADAPTABLE TO DIFFERENT LENS POWERS

Optic Nerve Edema w/ Hemorrhage

Retinal Detachment Peripapillary Hemorrhage Chorioretinal Scars

Branch Retinal Vein Occlusion Retinal Tear w/ Barricade Laser

Normal Retina

Normal Retina

Central Retinal Artery Occlusion

Diabetic Macular EdemaLeukemic Retinopathy Peripapillary Hemorrhage

Papilledema

Posterior adapter optics are based on indirect ophthalmoscopy

Device prototyping, from bench to bedside

External, Variable Intensity LED

Can also be used with phone’s internal flash(no external LED)

The EyeGo advantage: improved field of view

Welch-Allyn iExaminer Stanford EyeGo

EyeGo vs. Optos

Coming soon…

In collaboration with DigiSight Technologies, a HIPAA compliant app is being developedthat captures EyeGo photos and uploads them to secure serveralong with visual acuitytesting data

Diabetic Retinopathy Screening Study

• Study site: Santa Clara Valley Medical Center, San Jose, CA• Dichotomized for referral decision via phone images versus clinical

exam• Data collected on 100 eyes (50 patients) to date• Excellent agreement between phone and clinical exam for both

retinopathy grade and referral decision• Study ongoing

FUNDING SUPPORT

SPECTRUM/Stanford Biodesign Program

Stanford Society of Physician Scholars

Stanford Bio-X Program

Byers Eye Institute at Stanford

Publications

Myung D, Jais A, He L, Chang R. Simple, Low-Cost Smartphone Adapter for Rapid, High Quality Ocular Anterior Segment Imaging: A Photo Diary. Journal of Mobile Technology in Medicine, Vol 3 (1), 2014 pp. 2-8

Myung D, Jais A, He L, Blumenkranz M, Chang R. 3D Printed Smartphone Indirect Lens Adapter for Rapid, High Quality Retinal Imaging, Journal of Mobile Technology in Medicine, Vol 3 (1), 2014 pp. 9-15

Contact Information

David Myung, MD, PhDByers Eye Institute at Stanford eyegotech@gmail.com

Rapid and Cost-effective Orbital Prosthesis Fabrication via Automated Non-contact Facial Topography Mapping and 3-D Printing

Landon Grace, PhD1; Mauro Fittipaldi1; David T. Tse, MD2

1Department of Mechanical and Aerospace Engineering, University of Miami, Coral Gables, FL USA2Department of Ophthalmology, University of Miami School of Medicine, Bascom Palmer Eye Institute, Miami, FL USA

Supported by the Dr. Nasser Ibrahim Al-Rashid OrbitalVision Research Center at Bascom Palmer Eye Institute

Abstract PO467

Financial Disclosure

• No financial disclosures

Purpose• Orbital prosthesis fabrication is a costly, time-intensive process

accomplished by a limited number of trained prosthetists.

• Digital scanning is capable of generating a perfect representation of patient facial topography, including the orbital defect.

• 3D printing is capable of producing a high-resolution, anatomic replication of the patient’s facial topography.

• Access to orbital prostheses is limited by proximity to a prosthetist and the expensive manual fabrication process.

• The proposed method converts prosthesis development to a low-cost, non-contact, standardized protocol which is easily adaptable to a remote setting.

Methods1. Facial topography mapping

A digital representation of the orbital defect and contralateral periorbital region is constructed using a mobile, low-cost 3D laser scanning process.

Facial features are used to automatically determine the plane of symmetry, about which the topography of the periorbital region is mirrored.

2. Symmetry detection

3. Digital data manipulationThe mirrored version of the contralateral periorbital region is merged with the orbital defect scan, enabling the surfaces to be meshed to define the shape of the prosthesis.

4. 3D Printing

Material: PLAResolution: 28 micron

Methods5. Polymer preparation

A biocompatible thermoplastic elastomer (styrene-isobutylene-styrene, or “SIBS”) is reinforced with nanoclay, nanoscale titanium oxide, zinc oxide, and other particulates to match patient’s skin tone while providing protection against degradation.

6. Injection molding and detailingThe resulting polymer nanocomposite is injection molded to form the shape of the prosthesis, followed by the addition of eyelashes and ocular surface. Posterior surface

conforms to contour of exenteration socket

ResultsCosmetic match• Prosthesis color is easily and

successfully tailored to match patient skin tone

Prosthesis fit• Posterior - Patient reports

comfortable and secure fit

Prosthetist hand-fabricatedCost: ≈ $14,000 on averageTime: > 1 week

3D-printing fabricationCost: < $500 + Ocular Time: < 8 hours Prosthesis

• Surface - Exhibits excellent conformity with facial features

Conclusion

Challenges currently being addressed: – Skin tone variation

• Direct 3D printing of full-color elastomeric polymer still in early stages of development

– Post-processing required• Addition of ocular surface and eyelashes requires additional steps

Custom fabrication of an orbital prosthesis is achieved via non-contact anatomy mapping and 3D printing, providing a cost-effective solution to orbital defect rehabilitation which is adaptable to a remote setting.

3D-Printed

Hand-made

WWW.AAO.ORGAMERICAN ACADEMY OF OPHTHALMOLOGY

Questions?