Is optometry ready for the age of smartphone imaging?

Mobile phone users taking selfies can be a common annoyance. Rapidly improving camera features of modern smartphones have not only improved the quality of everyday photos but now made it possible for high-quality medical imaging.

Is optometry at a point where smartphone photography will change the way ODs care for patients, and how eye care is delivered? Is it time for optic nerve and retinal selfies?¹Previously by Dr. Wong: How artificial intelligence is changing the future of optometry 

Clinical applications
Similar to the ophthalmoscope, an otoscope has been the traditional means of viewing the tympanic membrane (TM) as well as an important tool for physicians in the diagnosis of acute otitis media (AOM), a common diagnosis in children under age 5.
Smartphone otoscopes have been found to be effective in high-resolution imaging of the TM, and the subsequent medical management of AOM.²

Research has also shown preference for smartphone otoscopes over the traditional oto-scope by physicians, patients, and parents.²  With smartphone otoscopes, parents can share views with board-certified pediatricians and help to improve outcomes for their children.

Related: Blog: 10 eyecare apps for more efficient patient care 

Smartphone imaging principles
Although smartphones are not specifically designed for medical imaging, innovations in mobile applications and attachments are being developed to improve smartphone imaging capabilities.

Digital imaging and communications in medicine (DICOM) calibration is critical in the fu-ture for storing and viewing quality medical imaging in electronic health records (EHR). Privacy concerns are better regulated with good quality imaging standards.

Proper calibration in different mobile devices-such as tablets-allows for optimal view-ing of medical images important for accurate diagnoses.

The number of pixels is not always important for understanding medical images. Rather, the closer a smartphone is held to an object being imaged, the smaller the pixels should be in order to maximize visualization of the object.³Related: Use technology advancements to modernize your practice

Smartphone use as a direct ophthalmoscope
Portable fundus cameras have been around for decades, but the universal use of smartphones by ODs and patients has created a large market for portable, inexpensive attachments-enabling smartphone use as direct ophthalmoscopes. A smartphone’s auto-focus capability accounts for a patient’s refractive error.

Polarizing filters and photo-absorbing walls in these smartphone attachments allow for the reduction of corneal Purkinje reflections, resulting in quality images of undilated pu-pils.⁴

Newer smartphones allow for high-resolution direct ophthalmoscopy with an unmodified smartphone. JAMA Network has a series of videos demonstrating the technique to take direct ophthalmoscopy selfies with an unmodified iPhone X.⁵

Related: Innovative mobile technology targets low vision 

Smartphone use for glaucoma imaging
Fundus photography of the optic nerve serves two major purposes: to screen patients for potential disease and to use subsequent images to monitor for progression.⁶

With optic nerve photography, an OD can identify swollen nerves, disc pallor, optic pits, and rim/cupping asymmetry-all of which are all essential in the proper diagnosis and management of a patient.⁷

There is no doubt about the importance of optic nerve imaging in glaucoma. The Ocular Hypertension Treatment Study (OHTS) noted that stereoscopic optic nerve photos were essential in picking up disc hemorrhages and that disc hemorrhages were a significant risk factor for the development of glaucoma.⁸

The presence of disc hemorrhages in ocular hypertensives increased glaucoma risk by six times, yet detection of them on fundus examination often falls short. In the OHTS, only 16 percent of disc hemorrhages were identified via funduscopy alone.⁹

The European Optic Disc Assessment Trial (EODAT) found that the identification of glau-coma via fundus photographs showed a high sensitivity for identifying diseases (80 per-cent), and that for expert observers, the difference between monoscopic and stereoscopic photography was minimal.¹⁰Related: Virtual reality, tablet devices capture visual fields in unconventional ways

Smartphone imaging in practice
It is not uncommon for people to have their smartphones tally the number of steps they take or measure their heart rates. It seems likely that in the near future ODs will be using data collected by patients via integrated EHR systems where patients can upload data to their own medical records.

Optic nerve selfies for glaucoma detection and monitoring are no different. As mobile phone cameras and apps improve, so will ODs’ ability to obtain better quality images, in-cluding possible red-free and stereoscopic images from smartphones.

By having patients take optic nerve selfies periodically, ODs can better monitor our glaucoma suspects or glaucoma patients who are progressing by imaging their optic nerves three to four times more per year than traditional approaches. This may allow ODs to pick up on subtle changes or hemorrhages that may indicate disease progression.¹¹Related: Pros and cons of mobile optometry 

Future smartphone uses
As innovative technologies in the modern practice of clinical optometry become more con-vergent, retinal selfies may become powerful tools as patients advocate to more directly participate in their own optometric care.

The longitudinal review of high-quality medical images of the optic nerve and retina-both by patients themselves (selfies) and professionals in eyecare practices-offers new frontiers in the 21st century optometric practice.

As mentioned, attention to privacy concerns and the appropriate use of these technologies (artificial intelligence [AI],12 and smartphone optic nerve and retinal imaging) are essen-tial to improving patient outcomes and creating a more interactive approach to primary eye care.

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References:

1. MIT Media Lab. Time for a retina selfie. American Academy of Ophthalmology. Available at: https://www.aao.org/headline/time-retina-selfie. Accessed 7/11/19.
2. Richards JR, Gaylor KA, Pilgrim AJ. Comparison of traditional otoscope to iPhone oto-scope in the pediatric ED. Am J Emerg Med. 2015 Aug;33(8):1089-92.
3. Hirschorn D, Thanki K. Imaging Technology News. Mobile Devices in Diagnostic Imag-ing. Available at: https://www.itnonline.com/article/mobile-devices-diagnostic-imaging. Accessed 7/11/19.
4. Russo A, Morescalchi F, Costagliola C, Delcassi L, Semeraro F. A Novel Device to Exploit the Smartphone Camera for Fundus Photography. J Ophthalmol. 2015 May 21; 2015:823139.
5. American Medical Association. Smartphone Direct Ophthalmoscopy Technique. JAMA Ophthal. Available at: https://edhub.ama-assn.org/jn-learning/video-player/17051987. Accessed 7/11/19.
6. Spaeth GL, Rahmatnejad K, Zeng L. Is There Still a Role for Optic Disc Photography? Glaucoma Today. Available at: http://glaucomatoday.com/2016/06/is-there-still-a-role-for-optic-disc-photography/. Accessed 7/11/19.
7. Echegaray S, Zamora G, Yu H, Luo W, Soliz P, Kardon R. Automated analysis of optic nerve images for detection and staging of papilledema. Invest Ophthalmol Vis Sci. 2011 Sep 27;52(10):7470-8.
8. Budenz DL, Anderson DR, Feuer WJ, Beiser JA, Schiffman J, Parrish RK 2nd, Piltz-Seymour JR, Gordon MO, Kass MA, Ocular Hypertension Treatment Study. Detection and prognostic significance of optic disc hemorrhages during the Ocular Hypertension Treat-ment Study. Ophthalmology. 2006 Dec;113(12):2137-43.
9. Uhler TA, Piltz-Seymour J. Optic disc hemorrhages in glaucoma and ocular hyperten-sion: implications and recommendations. Curr Opin Ophthalmol. 2008 Mar;19(2):89-94.
10. Myers JS, Fudemberg SJ, Lee D. Evolution of optic nerve photography for glaucoma screening: a review. Clin Exp Ophthalmol. 2018 Mar;46(2):169-176.
11. Chang R. Imaging of the Optic Nerve: What is it and why is it needed? Glaucoma Re-search Foundation. Available at: https://www.glaucoma.org/treatment/imaging-of-the-optic-nerve-what-is-it-and-why-is-it-needed.php. Accessed 7/11/19.
12. Ray T. Artificial intelligence and the future of smartphone photography. ZDNet. Available at: https://www.zdnet.com/article/artificial-intelligence-and-the-future-of-smartphone-photography/. Accessed 7/11/19.