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 [email protected]
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
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