New Smartphone Devices Open the Door to Teleophthalmology

Jennifer Garcia

March 24, 2014

Researchers at Stanford University in California have developed 2 devices that can be used in conjunction with a smartphone to evaluate and capture images of the anterior segment of the eye as well as the fundus. The researchers hope use of these devices will decrease reliance on expensive, in-office equipment and provide a cost-effective and secure way to perform routine ophthalmic examinations.

Researchers led by David Myung, MD, PhD, from the Byers Eye Institute, Stanford University School of Medicine, California, discuss the devices in 2 case reports published online in the Journal of Mobile Technology in Medicine. The first article, published February 28, describes a lens mount adapter that, when attached to the smartphone along with an indirect ophthalmoscopy condensing lens, enables acquisition of high-quality images of the fundus.

In the second article, Dr. Myung and colleagues describe an optical adapter that allows imaging of the anterior segment using a low-cost macro lens and universal smartphone attachment. The device also uses external light-emitting diode (LED) illumination adjacent to the macro lens, which reduces interference by background reflections on the corneal surface caused by ambient lighting. Using this device, the researchers were able to obtain high-quality images of the anterior segment and external ocular structures without the need for a slit lamp.

When asked in an interview with Medscape Medical News about current use of smartphone-based devices for ophthalmic exams, Robert Chang, MD, also from Stanford and one of the developers of the devices, explained that lighting has been the biggest issue in using these devices in the clinical setting. When developing these new devices, "we wanted something inexpensive that you could fit in your pocket, easily attach and remove from the phone in seconds, and have the lighting and magnification already optimized for taking pictures of the anterior segment."

The study authors explain that images obtained using either device can be securely uploaded to the patient's electronic health record through encrypted institutional software or Health Insurance Portability and Accountability Act–compliant messaging systems.

"Most clinician concern has been the security issue of patient images as well as liability involved if not examining the patient directly when interpreting the photos," explained Dr. Chang. "Now, there are emerging solutions for those barriers, and widespread use has been limited by the cost and need for adapters as well as interference with current workflow." By designing low-cost devices that can be used by nonophthalmologists to obtain high-quality images, Dr. Chang hopes to "facilitate remote triage and save cost."

Easy to Use, but In-Office Evaluation Still Preferable

According to independent commentator Mark Spirn, MD, assistant professor of ophthalmology at the Wills Eye Hospital, Philadelphia, Pennsylvania, the main application of these devices is in evaluating patients outside of the traditional office setting. "These adaptors not only ease the documentation process in these locations but they also facilitate documentation by nonophthalmologists, who may otherwise find smartphone ophthalmoscopy and anterior segment imaging difficult to master," Dr. Spirn told Medscape Medical News.

"Although these products are likely to be significantly cheaper than current fundus and slit lamp cameras, they are rudimentary by comparison. Therefore, in the office setting, where quality of care and precise documentation is key, it is unlikely these products will be widely used," added Dr. Spirn.

The researchers note that a limitation to the adapter used for anterior segment evaluation is the inability to estimate the depth of corneal pathology or in capturing cell and flare. The proximity of the adapter to the patient also increases the risk for potential contamination, and the authors note that a lens with a longer focal distance is being evaluated.

In addition, Dr. Spirn commented that "a major limitation of this technology for retinal imaging is that it requires pupillary dilation, which is both time-consuming and can, in rare instances, lead to complications such as angle closure glaucoma."

Although these products are still in the research and development phase, the authors discuss their intent to deploy future versions of these devices "to non-ophthalmologists to determine the efficacy of smartphone-based photography for remotely triaging patients when access to an ophthalmologist is limited," according to the second article. The authors also note that a study evaluating the concordance between clinical decisions made using remotely captured retinal images compared with those based on a standard eye examination is currently underway.

"The smartphone indirect lens adaptor for retinal imaging and the smartphone adaptor for anterior segment imaging are the first devices devised to allow ocular imaging using the common household item: the smartphone," said Dr. Spirn.

"Clinicians will be seeing many new apps and adapters to improve the smartphone to act as a platform for mobile versions of existing diagnostics, as well as improve healthcare delivery directly to the patient through the phone," notes Dr. Chang. "The smartphone is becoming the modern physician's black bag."

Support for the early research and development came from the Byers Eye Institute at Stanford University. The authors and independent commentator have disclosed no relevant financial relationships.

J Mobile Tech Med. Published online February 28 and March 5, 2014. First article full text, Second article full text

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