Editorial

Eye (2012) 26, 343–354; doi:10.1038/eye.2012.6

iPhones for eye surgeons

A Bastawrous1, R C Cheeseman2 and A Kumar2

  1. 1Clinical Research Fellow in International Eye Health, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
  2. 2St Paul's Eye Hospital, Royal Liverpool University Hospital, Liverpool, UK

Correspondence: A Bastawrous, Clinical Research Fellow in International Eye Health, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Tel: +44 (0)20 7636 8636; Fax: +44 (0)20 7436 5389. E-mail: andrew.bastawrous@gmail.com

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Introduction

In a survey of mobile phone ownership, 99% of health professionals own a mobile phone, with 81% of these being a smartphone.1 The most popular smartphone currently being the Apple iPhone. Mobile phones and the internet have arguably been two of the most important developments in recent decades and the development of smartphones has combined these to allow many handheld capabilities beyond basic voice and text communication including advanced computing, digital photography, and geo-positioning.

Such devices are popular because of their high quality graphical user interfaces and intuitive control. The felt necessity by most adults to carry a mobile phone device with them at all times has meant that the increased capabilities of smartphones have come at no extra pocket space and in many cases for medical professionals has replaced the trusted handbook that once sat there.

Ophthalmologists are notorious for their interest in technology and gadgetry and so it comes as no surprise that the use of smartphones such as iPhones by ophthalmologists is wide spread.

For the purpose of this article we will look at the currently available applications and uses for an iPhone by an ophthalmologist (other platforms exist that provide the same or similar smartphone applications).

The potential functions of the ophthalmology related iPhone applications currently available can be divided into the following broad categories:

  1. Patient assessment tools
  2. Patient education/visual aids
  3. Health care profession education and reference
  4. Patient records/administrative tools and
  5. Multiple functionalities.

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Patient assessment tools

Comprehensive assessment and examination of patients with ocular problems require the use of an array of diagnostic tools. In the ophthalmology, clinical setting of these tests are readily available but in the accident and emergency setting with an exiguous ‘Eye Examination Room’ or during emergency call outs these tools can be available at a touch of a button. There are several applications, which can assess visual acuity using either the familiar Snellen visual acuity test or modern interactive visual acuity tests. Some of the applications have tests for colour vision, astigmatism, pupil size, oculomotor reflexes, and red desaturation (see Table 1).


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Patient education/visual aids

Patients will often ask questions in clinic about their condition; What is it? Why do I have it? How is it treated? Some clinics even employ specialist nurses to undertake patient counselling activities, such as with macular degeneration and glaucoma. Providing patients with narrated video content can help answer all these questions in a way that discussion alone cannot. The portability of the iPhone makes this ideal for providing information to patients in clinic, but for the more technologically confident patient, they can download the application to their own iPhone device and review the information at their leisure, and show it to friends and relatives, relieving them of the burden of translating the sometimes complicated explanations of their ophthalmological condition (see Table 2).


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Health care profession education and reference

Learning and professional development for health care professionals and students is changing since the introduction of the smartphone.2 With the limited number of hours available to catch up on the latest results from landmark studies this information can be distributed quickly and effectively with the use of modern technology. Applications that offer reference material may eliminate the need to carry heavy ‘text books’ and indeed provide essential reading material on the ‘go’. Some of the applications provide videos and colour atlas quizzes, which will be useful for training and examination preparations. Others help plan refractive and intraocular lens calculation for cataract surgery and analysis of postoperative results, such as plots of surgical induced astigmatism (see Table 3).


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Patient records/administrative tools

There is a demand for greater productivity and so being able to access patient information remotely and securely is paramount. Some products are flexible enough to allow information to be passed from a remote location, such as an optometrist, for advice to be fed back about management and referral in true telemedicine fashion. A number of solutions exist for this problem to suit every budget (see Tables 4 and 5).



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Future hardware and possibilities

As well as downloadable software applications, there are in development several additional hardware tools. These include an autorefractor (NETRA), cataract grader (CATRA) and ultrasound scanner. The NETRA autorefractor has in two separate pilot studies demonstrated good accuracy as compared with subjective refraction (mean difference in spherical equivalent of 0.18D3 and 0.24D,4 respectively), the same group who developed the NETRA at the Massachusetts Institute of Technology are developing the CATRA for self-grading of cataracts. MobiUS have created an FDA approved smartphone ultrasound imaging device, which uses a hand held wand and the smartphone as a portable imaging system. With small adaptations this could be suitable for ocular ultrasound examination.

Imaging of the eye via a slit lamp has been described previously,5 with recently developed adaptors (Keeler Apple iPhone 4 PSL-imaging adapter, London, UK) now on the market. Imaging the fundus using an iPhone, indirect lens and ophthalmoscope6 and an alternative technique without the need for the ophthalmoscope have been described.7 iPhones have been used in tele-ophthalmology retinopathy of prematurity outreaches in India with success,8 but to date have required large imaging devices such as the RetCam. With future developments it is likely that an attachable fundus camera will fit directly on to a smartphone with wide field images created by existing photo-stitching packages and making it a truly portable fundus camera.

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Concluding remarks

Rapidly advancing technology has literally put knowledge in the palm of our hands. The possibilities for investigations, teaching, information sharing, research, collaboration, and ultimately improved patient care are endless.

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References

  1. Retrieved from: http://www.d4.org.uk/research/survey-mobile-phone-use-health-professionals-UK.pdf (accessed on 12.07.2011).
  2. Retrieved from: http://www.bbc.co.uk/news/education-11427317 (accessed on 03.08.2011).
  3. Pesala V. Comparison of a Novel Cell Phone-Based Refraction Technique (NETRA) with Objective Clinical Retinoscopy. Presented at ARVO 2011 (available at http://www.abstractsonline.com/plan/ViewAbstract.aspx?mID=2684&sKey=0b899b6c-74f0-491c-9aee-a318c404505b&cKey=51454242-89c0-499c-83ff-b981caf0b71a&mKey=%7B6F224A2D-AF6A-4533-8BBB-6A8D7B26EDB3%7D).
  4. Bastawrous A. Validation of Near Eye Tool for Refractive Assessment (NETRA) – Pilot Study. Presented at NEOS 2011 (available at http://www.neos.org.uk/NoE_Programme_-_spring_2011.pdf).
  5. Barsam A, Bhogal M, Morris S, Little B. Anterior segment slitlamp photography using the iPhone. J Cataract Refract Surg 2010; 36(7): 1240–1241. | Article | PubMed |
  6. Lord RK, Shah VA, San Filippo AN, Krishna R. Novel uses of smartphones in ophthalmology. Ophthalmology 2010; 117(6): 1274.e3–1274.e3.
  7. Bastawrous A. Smartphone Fundoscopy. Accepted to Ophthalmology 2011; July 2011 (in press).
  8. Kreatsoulas J. Progress in ROP management through tele-ophthalmology. Retina Today 2010; November/December: 18–20.