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
Jiaxi Ding MD1, Matthew S. Pihlblad MD1
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
+
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View obtained through the
standard direct ophthalmoscope
View obtained through the
PanOptic ophthalmoscope
• 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
Conclusion:
• 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
The iExaminer is an inexpensive, portable, and effective tool for
imaging posterior pole pathology with telemedicine potential.
1.
2.
3.
4.
5.
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.
Stanzel BV, Meyer CH. Smartphones in ophthalmology : Relief or toys for physicians?
Ophthalmologe. 2012 Jan;109(1):8-20.
Teichman JC, 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-eyestrain
• http://university.eyecare.org.au/services/facilities.html
• Slide 3:
• http://www.medsupplier.com/welch-allyn-iexaminer-adapter-11840.aspx?gclid=CPSr0rGdlsECFVEQ7
AodymQAJw
• https://www.apple.com/lae/iphone-4s/specs/
Comparison of Smartphone Ophthalmoscopy with Slitlamp Biomicroscopy for Grading Diabetic Retinopathy
Andrea Russo, MD
University of Brescia - Italy
Study Design
Prospective Study
Setting: Ophthalmic Diabetic Center of
“Spedali Civili di Brescia” – Italy
120 consecutive patients with diabetes
smartphone ophthalmoscopy
retinal slit-lamp examination
D-Eye Prototype
D-Eye Prototype
Results
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.
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.
Visual Field Screening in Nepal Using an iPad to
Test Normal Controls, Persons with Glaucoma
and Individuals with Diabetic Retinopathy
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
Suman Thapa. MD, PhD Nepal Glaucoma Eye Clinic,
Tilganga Institute of
Ophthalmology, Kathmandu,
Nepal
Screening for Glaucoma



Controversial – Cost-benefit ratio is not
favorable for general screening.
However can target “at risk” populations
(persons of African descent, hispanic
latinos, 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 lowcost program available on the iPad tablet.
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.
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
Conclusions



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.
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.
The EyeGo System:
Dual Adapter System
Anterior
Attachment
Posterior
Attachment
Simple, Compact, Low Cost
Incremental Additional Cost:
Uses Practitioner’s Own Phone and Lenses
User-Owned
Ophthalmoscopy Lens
Posterior Adapter
User-Owned
iPhone
Anterior
Adapter
How to use the anterior adapter
Light
switch
Using the
Posterior Adapter
Example View
Foldable, Pocket-Sized Design
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
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
Macro Lens Alone
Optics + Lighting
Macro Lens + LED
Subluxed Lens
Pterygium
Corneal Abrasion
Hyphema
Subconjunctival Hemorrhage
Pyogenic Granuloma
Corneal Ulcer
Contact Lens over Glued Corneal Perforation
Corneal Ulcer
Post-Op Corneal Transplant
Macro
Lens
LED
Branch Retinal Vein Occlusion
Retinal Detachment
Optic Nerve Edema w/ Hemorrhage
Peripapillary Hemorrhage
Retinal Tear w/ Barricade Laser
Chorioretinal Scars
Normal
Retina
Leukemic
Retinopathy
Peripapillary Hemorrhage
Diabetic Macular Edema
Normal Retina
Central Retinal Artery Occlusion
Papilledema
Posterior adapter optics are based
on indirect ophthalmoscopy
Device prototyping,
from bench to bedside
External, Variable
Intensity LED
Can also be used with
phone’s internal flash
(no external LED)
The EyeGo advantage: improved field of view
Welch-Allyn iExaminer
Stanford EyeGo
EyeGo vs. Optos
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
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
•
•
•
•
FUNDING SUPPORT
 SPECTRUM/Stanford Biodesign Program
 Stanford Society of Physician Scholars
 Stanford Bio-X Program
 Byers Eye Institute at Stanford
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
Contact Information
David Myung, MD, PhD
Byers Eye Institute at Stanford
eyegotech@gmail.com
Rapid and Cost-effective
Orbital Prosthesis Fabrication
via Automated Non-contact
Facial Topography Mapping
and 3-D Printing
Landon Grace, PhD1; Mauro
Fittipaldi1; David T. Tse, MD2
Supported by the Dr. Nasser Ibrahim Al-Rashid Orbital
Vision Research Center at Bascom Palmer Eye Institute
1Department
Abstract PO467
of Mechanical and Aerospace Engineering,
University of Miami, Coral Gables, FL USA
2Department of Ophthalmology, University of Miami School of Medicine,
Bascom Palmer Eye Institute, Miami, FL USA
Financial Disclosure
• No financial disclosures
Purpose
• Orbital prosthesis fabrication is a costly, time-intensive process
accomplished by a limited number of trained prosthetists.
• Digital scanning is capable of generating a perfect representation
of patient facial topography, including the orbital defect.
• 3D printing is capable of producing a high-resolution, anatomic
replication of the patient’s facial topography.
• Access to orbital prostheses is limited by proximity to a prosthetist and
the expensive manual fabrication process.
• The proposed method converts prosthesis development to a lowcost, non-contact, standardized protocol which is easily adaptable
to a remote setting.
Methods
1. Facial topography mapping
A digital representation of the orbital
defect and contralateral periorbital
region is constructed using a mobile,
low-cost 3D laser scanning process.
2. Symmetry detection
Facial
features
are
used
to
automatically determine the plane of
symmetry, about which the topography
of the periorbital region is mirrored.
3. Digital data manipulation
The mirrored version of the
contralateral periorbital region is
merged with the orbital defect scan,
enabling the surfaces to be meshed to
define the shape of the prosthesis.
4. 3D Printing
Material: PLA
Resolution: 28 micron
Methods
5. Polymer preparation
A biocompatible thermoplastic elastomer
(styrene-isobutylene-styrene, or “SIBS”) is
reinforced with nanoclay, nanoscale titanium
oxide, zinc oxide, and other particulates to
match patient’s skin tone while providing
protection against degradation.
6. Injection molding and detailing
The resulting polymer nanocomposite is
injection molded to form the shape of the
prosthesis, followed by the addition of
Posterior surface
eyelashes and ocular surface.
conforms to contour of
exenteration socket
Cosmetic match
Results
• Prosthesis color is easily and
successfully tailored to match patient
skin tone
Prosthetist hand-fabricated
Cost: ≈ $14,000 on average
Time: > 1 week
3D-printing fabrication
Cost: < $500
+ Ocular
Time: < 8 hours
Prosthesis
Prosthesis fit
• Posterior - Patient reports
comfortable and secure fit
•
Surface - Exhibits excellent conformity with facial features
Conclusion
Custom fabrication of an orbital prosthesis is achieved via non-contact anatomy
mapping and 3D printing, providing a cost-effective solution to orbital defect
rehabilitation which is adaptable to a remote setting.
3D-Printed
Hand-made
Challenges currently being addressed:
– Skin tone variation
• Direct 3D printing of full-color elastomeric polymer still in early stages of development
– Post-processing required
• Addition of ocular surface and eyelashes requires additional steps
Questions?
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