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AAO 2014 Press Briefing

AAO 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. iExaminer : a portable and inexpensive option for fundus photography and videography in the pediatric population.

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AAO 2014 Press Briefing

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  1. AAO 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

  2. iExaminer: a portable and inexpensive option for fundus photography and videography in the pediatric population Jiaxi Ding MD1, Matthew S. PihlbladMD1 1Ross Eye Institute, Department of Ophthalmology, University at Buffalo, The State University of New York, Buffalo, New York 14209 The authors have no financial disclosures to report

  3. What’s back there?

  4. Voilà!!! + =

  5. iExaminer

  6. 25˚ Field of View Undilated View obtained through the PanOptic ophthalmoscope View obtained through the standard direct ophthalmoscope

  7. What is already good… • Quality imaging convenient for bedside use • 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 practioners.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 standard Welch Allyn direct ophthalmoscope (images below)1,5 can use iExaminer without pharmacologic dila What could be better… 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 Conclusion: The iExaminer is an inexpensive, portable, and effective tool for imaging posterior pole pathology with telemedicine potential.

  8. References • Welch Allyn. iExaminer: Eye imaging on your iPhone. 2014. http://www.welchallyn.com/en/microsites/iexaminer.html • 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. • StanzelBV, Meyer CH. Smartphones in ophthalmology : Relief or toys for physicians? Ophthalmologe. 2012 Jan;109(1):8-20. • TeichmanJC, Sher JH, Ahmed II. From iPhone to eyePhone: a technique for photodocumentation. Can J Ophthalmol. 2011 Jun;46(3):284-6. • 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/

  9. Comparison of Smartphone Ophthalmoscopy with Slit-lamp Biomicroscopy for Grading Diabetic Retinopathy Andrea Russo, MD University of Brescia - Italy

  10. Study Design • ProspectiveStudy • Setting: OphthalmicDiabetic Center of “Spedali Civili di Brescia” –Italy • 120 consecutive patients with diabetes • smartphone ophthalmoscopy • retinal slit-lamp examination

  11. D-EyePrototype

  12. D-EyePrototype

  13. Results

  14. 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.

  15. 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.

  16. Visual Field Screening in Nepal Using an iPad to Test Normal Controls, Persons with Glaucoma and Individuals with Diabetic Retinopathy Suman Thapa. MD, PhD - Nepal Glaucoma Eye Clinic, Tilganga Institute of Ophthalmology, Kathmandu, Nepal 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 Nothing to disclose

  17. Screening for Glaucoma Controversial – Cost-benefit ratio is not favorable for general screening. However can target “at risk” populations (persons of African descent, hispaniclatinos, 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.

  18. Background luminance is 31.5 asb (10 cd/m2) 96 test locations (right eye format is shown to the Right) – the left eye is a mirror image of the right eye format. Target size is a Goldmann Size V (1.73 deg diameter) Target luminance is 250 asb, 80 cd/m2, or 16 dB) Each quadrant is tested one at a time (upper right, upper Left, lower left, lower right). A red fixation point moves from one corner of the display to another.

  19. 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

  20. Conclusions 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. 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.

  21. The EyeGo System:MODULAR SMARTPHONE-BASED OPHTHALMIC IMAGING ADAPTERS David Myung, MD, PhD,1,2 Brian Toy, MD,1 AlexandreJais, MS,1 Doug Merrell2, Alison Polkinhorne2, Doug Foster2 Mark Blumenkranz, MD,1,2and Robert Chang, MD1 1Byers Eye Institute at Stanford 2DigiSight Technologies

  22. Dual Adapter System Anterior Attachment Posterior Attachment Simple, Compact, Low Cost

  23. Incremental Additional Cost:Uses Practitioner’s Own Phone and Lenses User-Owned Ophthalmoscopy Lens Posterior Adapter User-Owned iPhone Anterior Adapter

  24. How to use the anterior adapter Light switch

  25. Using the Posterior Adapter Example View

  26. Foldable, Pocket-SizedDesign

  27. 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

  28. Smartphone cameras alone not enough Without EyeGo • 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

  29. Macro Lens Alone Optics + Lighting Macro Lens + LED

  30. Subluxed Lens Pterygium Corneal Abrasion Hyphema Subconjunctival Hemorrhage Pyogenic Granuloma

  31. Corneal Ulcer Contact Lens over Glued Corneal Perforation Post-Op Corneal Transplant Corneal Ulcer

  32. Macro Lens LED

  33. ADAPTABLE TO DIFFERENT LENS POWERS

  34. Retinal Tear w/ Barricade Laser Optic Nerve Edema w/ Hemorrhage Branch Retinal Vein Occlusion Chorioretinal Scars Peripapillary Hemorrhage Retinal Detachment

  35. Normal Retina Peripapillary Hemorrhage Leukemic Retinopathy Diabetic Macular Edema Normal Retina Central Retinal Artery Occlusion Papilledema

  36. Posterior adapter optics are based on indirect ophthalmoscopy

  37. Device prototyping, from bench to bedside

  38. External, Variable Intensity LED Can also be used with phone’s internal flash (no external LED)

  39. The EyeGo advantage: improved field of view Welch-AllyniExaminer Stanford EyeGo

  40. EyeGo vs. Optos

  41. Coming soon… In collaboration with DigiSight Technologies, a HIPAA compliant app is being developed that captures EyeGo photos and uploads them to secure server along with visual acuity testing data

  42. 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

  43. FUNDING SUPPORT • SPECTRUM/Stanford Biodesign Program • Stanford Society of Physician Scholars • Stanford Bio-X Program • Byers Eye Institute at Stanford

  44. 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

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