‘Smartphoneography’ may change eye care

Increasingly, physicians are incorporating the iPhone into ophthalmic photography and videography.

By Bill Kekevian, Senior Associate Editor

When Keeler launched its iPhone slit lamp adapter in 2011, the company didn't anticipate the consumer response. In fact, the response following the announcement so overwhelmed the company's website, Keeler had to removed the adapter from the site. Keeler made the adapter specifically to pair with its other instruments, but the company feared the influx of customers would expect a universal adapter. Creating an adapter was the easy part, according to Keeler's marketing manager, Eugene VanArsdale. Apple took care of the hard part. “It's all about the megapixels,” he says.

With an 8-megapixel camera, the iPhone can provide physicians high-grade images. The creeping ubiquity of the smartphone has opened up a new realm of possibilities in medicine across the board. With ECG/EKG reader apps, glucose meter attachments and EHR capabilities, the smartphone is bound to sit alongside the stethoscope as standard medical equipment. Smartphones are changing the way physicians process, diagnose, treat and communicate with patients.

In ophthalmology, too, these devices are already changing the way physicians practice. “Ophthalmology has always been driven by producing pictures of what we could see, more so than other specialties,” says Mitch Weikert, MD. “The eye is unique; we can actually look through it. We've always been a very visually driven specialty.”

He adds, “Now, with people switching to EHR, it's becoming difficult to rely on hand-drawn pictures. People have always taken photos of the eye, but might have reserved them for special occasions. Now, we have to figure out other, easier ways to document what we're looking at.”

The iExaminer from Welch Allyn incorporates an iPhone into a PanOptic ophthalmoscope for portable fundus imaging.

IMAGING CAPABILITIES

Freeing up real estate

“I work out of four different rooms,” Dr. Weikert says. “I'm constantly moving. But cameras attached to slit lamps are big, expensive pieces of equipment that need to stay in that room. It limits the real estate. If I can just pull my phone out of my pocket, it's a whole lot more convenient.”

Dr. Weikert was part of a trio, along with Christian Hester, MD and Clifford Terry, MD, who presented a well-received lecture at the 2013 ASCRS meeting in San Francisco on iPhone ophthalmic photography and videography, a field given the moniker “Smartphoneography.”

As Dr. Weikert says, reviewing images used to require equipment that took up space that could otherwise be used to examine another patient. Plus, bringing a slit lamp out of the office presented great difficulties. Dr. Terry had hoped to overcome this by employing his iPhone.

Enter EyePhotoDoc

“Dr. Terry was trying to hold the iPhone up to the slit lamp to get a photo, but it's really difficult because the phone moves” says Austin Holmes, one of Dr. Terry's research assistants who is about to enter medical school himself. Mr. Holmes recently received a master's degree in public health. His required research project was on the application of Smartphoneography to improve patient communication and care in an ophthalmic setting. Dr. Terry and his team responded by creating a steady, secure adapter they call the EyePhotoDoc, introduced in April, 2011.

Using smartphone images “allows the clinician to capture a quick photo in the exam lane without having to go to a separate room or bring in a technician to generate an image,” Mr. Holmes says.

He adds that other ophthalmology teams confided how they avoided using slit lamp cameras because they required too much time. “The harder it is to do something, the less likely it's going to get done,” he says. So Dr. Terry's team started using iPhones to capture anterior segment photos of pathology such as cataracts and blepharitis, and for diagnoses, records and education.

Fundus images for the road

“We thought, ‘We see a lot of glaucoma patients, lets start doing fundus photography.’ So, we started trying different lenses,” explains Mr. Holmes.

But his team was not alone in using smartphones for fundus photography. Welch Allyn had already issued its iExaminer System specifically to capture fundus images on an iPhone. Created by Wyche Coleman, MD, a Shreveport, La., ophthalmologist, the iExaminer includes:

• A PanOptic ophthalmoscope (which provides a fundus view five times larger than a standard Welch Allyn ophthalmoscope) that allows users to get a widefield view of the back of the eye through an undilated pupil.
• An adapter designed to encase the iPhone and hold it in place over the ophthalmoscope.
• The iExaminer app, with which users take, store, retrieve and send fundus images using the iPhone.

Welch Allyn's senior global category marketing manager John Haberstock does not have to exaggerate the interest in Dr. Coleman's design. Asked about the reaction of doctors, he bluntly says, “The iExaminer sold out all the inventory we brought to the American Academy of Ophthalmology meeting.”

“Even though every ophthalmologist already has an expensive, high-quality fundus camera in their office, there are going to be times when they find they need a less expensive, more portable option,” Mr. Haberstock adds. “If the room with the camera is tied up and doctors have another patient who needs a fundus image taken, you can use the iExaminer in any other room in the facility and still bill with the same codes and get paid the same amount,” he says.

OUT OF THE OFFICE

Into the community

Dr. Coleman took his iExaminer app to the top of Mt. Kilimanjaro in Tanzania. “If you've been to an ophthalmologist you probably had your picture taken by a camera that sat on a stand in a room by itself connected to a computer. This is the first device that's really affordable to almost anyone, anywhere to be able to capture a picture of the back of the eye,” Dr. Coleman says in a video message sent from Mt. Kilimanjaro.

“This is not replacing the nice piece of equipment ophthalmologists have in their exam room, but it certainly is a nice complement to that,” Mr. Haberstock says. “If you're going out into the community or doing any kind of health fair, the iExaminer can be used for that since there's no dilation required and it's such an inexpensive piece of equipment.”

Adds Dr. Weikert: “Anything that's portable or inexpensive is ideally suited for missions and for health fairs. You can certainly carry your phone to, say, Africa and take all kinds of images. Health screening is really the untapped area for this. They're starting to put these fundus cameras in community clinics.” Dr. Weikert speculates these clinics, run by a technician, could potentially employ iPhones to take an image and send it directly to an ophthalmologist.

EyePhotoDoc mounts an iPhone onto a variety of ophthalmic imaging devices.

Innovation and the FDA

Innovators like Dr. Coleman have been able to get their designs into production, but plenty of room for further development exists as the field progresses. “We like our toys, so there's a ‘gee-whiz’ aspect to it,” says Dr. Weikert. “But, there's also a potential revenue source. Doctors can bill for the photography and the interpretation of those images.” As such, anything that expands that revenue potential by making it portable is bound to interest ophthalmologists.

However, before you start working on your iPhone adapter or app, remember the FDA is going to need to approve it first, “even though it is essentially just a plastic bracket that aligns the optics on the scope with the camera,” says Mr. Haberstock. “It can be frustrating, but it's a necessary step to ensuring our device can be marketed as safe and effective.”

The scrutiny was precisely what drove Keeler to discontinue its Portable Slit Lamp (PSL) iPhone 4 imaging adapter. “We're not in the iPhone adapter business,” says Mr. VanArsdale. “We made [the PSL iPhone 4 adapter] to fit our own products.” He adds that making an adapter to look at the retina means getting FDA approval, an expensive and lengthy process. “We're not going down the route,” he says. However, he says the incentive exists and the popularity of Keeler's adapter attests to it. “There's a need, a want and a reason people want this,” he says.

IMPROVING COMMUNICATIONS

From consulting physicians

One of those reasons involves the iPhone's possible use in telemedicine. The idea is that primary-care physicians or optometrists could use this technology to image patients and send those images to a specialist for interpretation.

“There are not a lot of ophthalmologists in some of these really rural areas, but there are optometrists,” says Mr. Holmes. “They're acquiring this technology and e-mailing images to consulting doctors who can then tell the patient if he needs to drive to the ophthalmologist, or if the optometrist can prescribe treatment.”

Mr. Haberstock offers an example. “Primary-care physicians don't screen for glaucoma,” he says. “Now, you could have these fundus cameras capture an image and send it to the ophthalmologist who can either say, ‘That’s normal,' or, ‘We’re seeing the cup-to-disc ratio looks abnormally high, this patient needs to come in right away.' We're right on the cusp of several large, integrated delivery networks beginning to use devices like these on a broad scale in primary care.”

Similarly, diabetic patients, who should see an ophthalmologist annually, can benefit by having retina images taken at either a clinic or a primary-care office and then forwarded to an ophthalmologist for interpretation. This could prevent ophthalmologists from spending time on patients who really do not need to be in their offices, Mr. Haberstock says.

Clifford Terry, MD, snaps an image using an EyePhotoDoc adapted for use with an iPad mini.

From patients

Using iPhone or Google Android apps to get patients into an ophthalmologist's office does not have to begin at a primary-care physician's or optometrist's office. In fact, an optometrist created a mobile patient engagement platform to help patients find, and connect with, an eye care facility. When Nikki Iravani, OD, noticed friends holding their smartphones at arms-length and wondering aloud if they should see an eye doctor, she got the idea for the EyeXam app. The free app she created, EyeXam includes visual acuity, color testing and AMD screening among other tests.

“It's not a standard Snellen Chart,” she says. Its features include capabilities to save a patient's history of test results. The app also provides a direct connection to eye doctors' offices. For patients just looking for an eye-care specialist, the “doctor finder” searches for nearby locations they can call with a tap of the screen. For subscribing practices, patients can even schedule an appointment or ask questions in real time using an in-app messaging feature. Once in the office, patients can “check-in” to the practice on Facebook, alerting their personal network of their eye-care professional's practice, name and location.

The EyeXam far exceeded Dr. Iravani's expectations with almost 1.5 million downloads to date, she says.

Challenge of the future

“We have the technology to be able to use these smartphones for clinical purposes,” Mr. Holmes says. “The challenge now is organization. Being able to link the photos automatically and efficiently to an EHR system is lacking right now. That's where we need the biggest improvements. A lot of the EHRs will link to an OCT or a fundus camera. I think smartphoneography is so new, they haven't even thought of ways to link up these devices yet.” OM