Smartphone-Based Dilated Fundus Photography and Near Visual Acuity Testing as Inexpensive Screening Tools to Detect Referral Warranted Diabetic Eye Disease

Toy, Brian C.; Myung, David; He, Lingmin; Pan, Carolyn K.; Chang, Robert; Polkinhorne, Alison; Merrell, D. Scott; Foster, D T; Blumenkranz, Mark S.

doi:10.1097/iae.0000000000000955

Cited by 86 publications

(102 citation statements)

References 36 publications

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“…Although Myung et al demonstrated that the EyeGo is easy for medical professionals to use, the device remains relatively untested by users without training in eye care 1–4. Consequently, our primary aim was to evaluate the ability of untrained users to quickly capture high-quality images of the front of the eye, and our secondary aim was to assess the relationship between a user’s age, comfort using a smartphone, and comfort in assessing problems with the eye and the user’s ability to capture high-quality images of the front of the eye.…”

Section: Introductionmentioning

confidence: 99%

Training time and quality of smartphone-based anterior segment screening in rural India

Ludwig¹,

Newsom²,

Jais³

et al. 2017

OPTH

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ObjectiveWe aimed at evaluating the ability of individuals without ophthalmologic training to quickly capture high-quality images of the cornea by using a smartphone and low-cost anterior segment imaging adapter (the “EyeGo” prototype).MethodsSeven volunteers photographed 1,502 anterior segments from 751 high school students in Varni, India, by using an iPhone 5S with an attached EyeGo adapter. Primary outcome measures were median photograph quality of the cornea and anterior segment of the eye (validated Fundus Photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department [FOTO-ED] study; 1–5 scale; 5, best) and the time required to take each photograph. Volunteers were surveyed on their familiarity with using a smartphone (1–5 scale; 5, very comfortable) and comfort in assessing problems with the eye (1–5 scale; 5, very comfortable). Binomial logistic regression was performed using image quality (low quality: <4; high quality: ≥4) as the dependent variable and age, comfort using a smartphone, and comfort in assessing problems with the eye as independent variables.ResultsSix of the seven volunteers captured high-quality (median ≥4/5) images with a median time of ≤25 seconds per eye for all the eyes screened. Four of the seven volunteers demonstrated significant reductions in time to acquire photographs (P1=0.01, P5=0.01, P6=0.01, and P7=0.01), and three of the seven volunteers demonstrated significant improvements in the quality of photographs between the first 100 and last 100 eyes screened (P1<0.001, P2<0.001, and P6<0.01). Self-reported comfort using a smartphone (odds ratio [OR] =1.25; 95% CI =1.13 to 1.39) and self-reported comfort diagnosing eye conditions (OR =1.17; 95% CI =1.07 to 1.29) were significantly associated with an ability to take a high-quality image (≥4/5). There was a nonsignificant association between younger age and ability to take a high-quality image.ConclusionIndividuals without ophthalmic training were able to quickly capture a high-quality magnified view of the anterior segment of the eye by using a smartphone with an attached imaging adapter.

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Section: Introductionmentioning

confidence: 99%

Training time and quality of smartphone-based anterior segment screening in rural India

Ludwig¹,

Newsom²,

Jais³

et al. 2017

OPTH

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“…There is particularly great interest in the validation and integration of smartphone-based retinal photography in local community screening programs for diseases such as glaucoma and diabetic retinopathy (DR) [13][14][15][16] , as well as in the emergency department and inpatient settings where the fundus examination is under-performed [17][18][19] . DR is the most common microvascular complication of diabetes and the leading cause of vision loss in working-age adults aged 20 to 74 in the United States, accounting for 12% of new cases annually [20][21][22][23] .…”

Section: Introductionmentioning

confidence: 99%

“…Importantly, imaging by non-expert operators may affect image quality and is an important consideration for community-based screening efforts 37,38 . Several studies have investigated smartphone-based screening of DR 4,16,39 and reported sensitivities of ≥80% with high specificities, as recommended by the British Diabetic Association for new imaging devices in population-based screening 40 . However, other investigators have found insufficient sensitivities of below 60% for detecting DR 37 suggesting smartphone imaging is not universally reliable.…”

Section: Introductionmentioning

confidence: 99%

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A smartphone-based tool for rapid, portable, and automated wide-field retinal imaging

Kim

Myers

Reber

et al. 2018

Preprint

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PurposeHigh-quality, wide-field retinal imaging is a valuable method to screen preventable, vision-threatening diseases of the retina. Smartphone-based retinal cameras hold promise for increasing access to retinal imaging, but variable image quality and restricted field of view can limit their utility. We developed and clinically tested a smartphone-based system that addresses these challenges with automation-assisted imaging. MethodsThe system was designed to improve smartphone retinal imaging by combining automated fixation guidance, photomontage, and multi-colored illumination with optimized optics, user-tested ergonomics, and touch-screen interface. System performance was evaluated from images of ophthalmic patients taken by non-ophthalmic personnel. Two masked ophthalmologists evaluated images for abnormalities and disease severity. ResultsThe system automatically generated 100-degree retinal photomontages from five overlapping images in under 1 minute at full resolution (52.3 pixels per retinal degree) fully on-phone, revealing numerous retinal abnormalities. Feasibility of the system for DR screening using the retinal photomontages was performed in 71 diabetics by masked graders. DR grade matched perfectly with dilated clinical examination in 55.1% of eyes and within 1 severity level for 85.2% of eyes. For referral-warranted DR, average sensitivity was 93.3% and specificity 56.8%. ConclusionsAutomation-assisted imaging produced high-quality, wide-field retinal images that demonstrate the potential of smartphone-based retinal cameras to be used for retinal disease screening. Translational RelevanceEnhancement of smartphone-based retinal imaging through automation and software intelligence holds great promise for increasing the accessibility of retinal screening.

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“…11 Toy et al compared images taken with a subsequent iteration of this device with in-person slit-lamp biomicroscopy for grading diabetic retinopathy and found 90% agreement between the two methods; moreover, they found that the photograph grade was 91% sensitive and 99% specific, with a 95% positive predictive value and a 98% negative predictive value, for diabetic disease in their patient population. 12 These devices were the early prototypes of a now-commercially available device known as Paxos Scope™ (DigiSight Technologies, San Francisco, CA, USA) that was registered in 2015 with the United States Food and Drug Administration (FDA) as a 510(k) Class II exempt ophthalmic camera for both anterior and posterior segment photography. In parallel efforts, Maamari et al (2014) described a digital fundus imaging device for taking high quality wide field retinal photographs, 13 while Russo et al (2015) published a study using a direct ophthalmoscopy adapter (D-Eye) for diabetic screening, which also showed excellent agreement between in-person and smartphone image-based retinopathy grading.…”

Section: Introductionmentioning

confidence: 99%

Clinical Application of a Smartphone-Based Ophthalmic Camera Adapter in Under-Resourced Settings in Nepal

et al. 2017

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Background:The ability to obtain high quality ocular images utilizing smartphone technology is of special interest in under-resourced parts of the world where traditional ocular imaging devices are cost-prohibitive, difficult to transport, and require a trained technician for operation. Purpose:The purpose of this study was to explore potential anterior and posterior segment ocular imaging use cases for a smartphone-based ophthalmic camera adapter (Paxos Scope, Digisight Technologies, San Francisco, CA, USA) in under-resourced settings in Nepal.Methods: From September to November of 2015 we utilized the Paxos Scope smartphone camera adapter coupled with an iPhone 5 to explore anterior and posterior segment clinical applications for this mobile technology. We used the device at a tertiary eye care facility, a rural eye hospital and a rural cataract outreach camp. We tested the device's capability for high quality photo-documentation in clinic, in the operating room, and in the outreach camp setting. Images were automatically uploaded to a secure, cloud-based electronic medical record system that facilitated sharing of images with other providers for telemedicine purposes.Results: Herein we present 17 ocular images documenting a wide variety of anterior and posterior segment pathology using the Paxos Scope from clinical cases seen in a variety of settings in Nepal. Conclusions:We found the quality of both the anterior and posterior segment images to be excellent in the clinic, the operating room, and the outreach camp settings. We found the device to be versatile and user-friendly, with a short learning curve. The Paxos Scope smartphone camera adapter may provide an affordable, high-quality, mobile ocular imaging option for under-resourced parts of the world.

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Smartphone-Based Dilated Fundus Photography and Near Visual Acuity Testing as Inexpensive Screening Tools to Detect Referral Warranted Diabetic Eye Disease

Abstract: The authors report a smartphone-based telemedicine system that demonstrated sensitivity and specificity to detect referral-warranted diabetic eye disease as a proof-of-concept. Additional studies are warranted to evaluate this approach to expanding screening for diabetic retinopathy.

Cited by 86 publications

References 36 publications

Training time and quality of smartphone-based anterior segment screening in rural India

Training time and quality of smartphone-based anterior segment screening in rural India

A smartphone-based tool for rapid, portable, and automated wide-field retinal imaging

Clinical Application of a Smartphone-Based Ophthalmic Camera Adapter in Under-Resourced Settings in Nepal

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