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0 AAO 2014 Press Briefing iPhones, iPads and 3-D Printers: Five Studies Examine How Innovative Consumer Technologies Are Improving Access to Eye Care October.

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Presentation on theme: "0 AAO 2014 Press Briefing iPhones, iPads and 3-D Printers: Five Studies Examine How Innovative Consumer Technologies Are Improving Access to Eye Care October."— Presentation transcript:

1 0 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 Jiaxi Ding MD 1, Matthew S. Pihlblad MD 1 1 Ross Eye Institute, Department of Ophthalmology, University at Buffalo, The State University of New York, Buffalo, New York The authors have no financial disclosures to report

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10 View obtained through the standard direct ophthalmoscope View obtained through the PanOptic ophthalmoscope

11 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 dilation 1,5 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 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. Conclusion:

12 1.Welch Allyn. iExaminer: Eye imaging on your iPhone 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 Mar;18(2): Stanzel BV, Meyer CH. Smartphones in ophthalmology : Relief or toys for physicians? Ophthalmologe Jan;109(1): Teichman JC, Sher JH, Ahmed II. From iPhone to eyePhone: a technique for photodocumentation. Can J Ophthalmol Jun;46(3): Steeles. Welch Allyn Panoptic Ophthalmoscope. Images: Slide 2: strain Slide 3: AodymQAJw https://www.apple.com/lae/iphone-4s/specs/

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

14 Prospective Study Setting: Ophthalmic Diabetic Center of “Spedali Civili di Brescia” – Italy 120 consecutive patients with diabetes smartphone ophthalmoscopy retinal slit-lamp examination Prospective Study Setting: Ophthalmic Diabetic Center of “Spedali Civili di Brescia” – Italy 120 consecutive patients with diabetes smartphone ophthalmoscopy retinal slit-lamp examination Study Design

15 D-Eye Prototype

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17 Results

18 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. 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.

19 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.

20 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 Suman Thapa. MD, PhD - Nepal Glaucoma Eye Clinic, Tilganga Institute of Ophthalmology, Kathmandu, Nepal Nothing to disclose

21 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 low- cost program available on the iPad tablet.

22 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.

23 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

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26 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 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.

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28 Anterior Attachment Posterior Attachment Dual Adapter System Simple, Compact, Low Cost

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

30 How to use the anterior adapter Light switch

31 Using the Posterior Adapter Example View

32 Foldable, Pocket-Sized Design

33 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

34 Smartphone cameras alone not enough 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 Without EyeGo

35 Optics + Lighting Macro Lens Alone Macro Lens + LED

36 Pterygium Pyogenic Granuloma Subconjunctival Hemorrhage Subluxed Lens Corneal Abrasion Hyphema

37 Post-Op Corneal Transplant Corneal Ulcer Contact Lens over Glued Corneal Perforation Corneal Ulcer

38 LED Macro Lens

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

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

42 Posterior adapter optics are based on indirect ophthalmoscopy

43 Device prototyping, from bench to bedside

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

45 The EyeGo advantage: improved field of view Welch-Allyn iExaminerStanford EyeGo

46 EyeGo vs. Optos

47 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

48 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

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

50 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

51 Contact Information David Myung, MD, PhD Byers Eye Institute at Stanford

52 Rapid and Cost-effective Orbital Prosthesis Fabrication via Automated Non-contact Facial Topography Mapping and 3-D Printing Landon Grace, PhD 1 ; Mauro Fittipaldi 1 ; David T. Tse, MD 2 1 Department of Mechanical and Aerospace Engineering, University of Miami, Coral Gables, FL USA 2 Department of Ophthalmology, University of Miami School of Medicine, Bascom Palmer Eye Institute, Miami, FL USA Supported by the Dr. Nasser Ibrahim Al-Rashid Orbital Vision Research Center at Bascom Palmer Eye Institute Abstract PO467

53 Financial Disclosure No financial disclosures

54 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 low- cost, non-contact, standardized protocol which is easily adaptable to a remote setting.

55 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. Facial features are used to automatically determine the plane of symmetry, about which the topography of the periorbital region is mirrored. 2. Symmetry detection

56 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

57 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 eyelashes and ocular surface. Posterior surface conforms to contour of exenteration socket

58 Results Cosmetic match Prosthesis color is easily and successfully tailored to match patient skin tone Prosthesis fit Posterior - Patient reports comfortable and secure fit Prosthetist hand-fabricated Cost: ≈ $14,000 on average Time: > 1 week Prosthetist hand-fabricated Cost: ≈ $14,000 on average Time: > 1 week 3D-printing fabrication Cost: < $500 + Ocular Time: < 8 hours Prosthesis 3D-printing fabrication Cost: < $500 + Ocular Time: < 8 hours Prosthesis Surface - Exhibits excellent conformity with facial features

59 Conclusion 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 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

60 ACADEMY OF OPHTHALMOLOGY Questions?


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