|
 
 |
| INNOVATION |
|
| Year : 2018 | Volume
: 30
| Issue : 2 | Page : 138-144 |
|
Innovative smartphone apps for ophthalmologists
John Davis Akkara1, Anju Kuriakose2
1 Department of Glaucoma, Westend Eye Hospital, Kochi, Kerala; Department of Glaucoma, Aravind Eye Hospital, Puducherry, India
2 Department of Ophthalmology, Jubilee Mission Medical College, Thrissur, Kerala, India
| Date of Web Publication | 28-Aug-2018 |
Correspondence Address:
John Davis Akkara
Westend Eye Hospital, Kacheripady, Kochi - 682 018, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/kjo.kjo_68_18
The first iPhone was released in 2007 and the first Android phone in 2008. Ten years later, smartphones are becoming ubiquitous. They now have more advanced sensors, cameras and more processing power, which have allowed several innovative apps to be made, which were not possible a few years ago. These apps will change the way we interact with patients and with clinical data, provide affordable and advanced testing, enhance the way we learn, and hopefully improve doctor–patient interactions. However, most of these apps are made without professional input and needvalidation before use. We try to review the current landscape of Smartphone Apps in Ophthalmology. Keywords: Android, apps, iPhone, ophthalmic software, smartphone
How to cite this article:
Akkara JD, Kuriakose A. Innovative smartphone apps for ophthalmologists. Kerala J Ophthalmol 2018;30:138-44 |
| Introduction | |  |
With the proliferation of smartphones in every sphere of life, ophthalmologists are not left behind. In addition to the general apps used for communication, group discussions, reminders, reading eBooks, etc., there are now several hundred apps specifically targeted at ophthalmologists, most of them released in the year 2015 and later. However, many of them are made without professional ophthalmologist involvement in development and finding a good app is difficult.[1]
The advantages of using smartphones are many. It is a matter of convenience as most ophthalmologists already carry a smartphone. Apps can be easily installed and uninstalled, and most of these apps are free. They have internal data storage and cloud storage capabilities built in. In fact, smartphones drive the majority of recent innovations in ophthalmology.[2] High-resolution smartphone screens can help in assessing visual acuity with great accuracy. EyeNetra and Netra-G are smartphone-based autorefractors which use the high-resolution screens of modern smartphones to calculate refractive error using a headset.[3] Gyroscopic sensors have helped in the development of toric intraocular lenses (IOL) marking apps. Better cameras have helped in smartphone slit-lamp and fundus photography. Several complex ophthalmic calculations, including IOL power calculations, are now possible on apps. Virtual reality (VR) perimetry uses smartphones inside a VR headset.
There are several apps for ophthalmologists including patient testing apps, ophthalmic calculators, patient education apps, ophthalmologist education apps, ophthalmologist reference apps, eBook apps, electronic medical record apps, toric marker app, and capsulorhexis training. There are some apps, such as the Eye Handbook [4] [Figure 1], which do a variety of things such as comprehensive patient vision assessment, ophthalmic calculations, international classification of diseases, Vision Atlas More Details, and more. Many other apps are specialized in one or a few tasks only.
| Vision Testing | | |
Several apps help in assessing visual acuity (near [5] and distance),[6] and a recent study concluded that in an emergency setting, visual acuity by a smartphone app is quite reliable [7] though the brightness and contrast of the smartphone screens and the optotype sizes have to be standardized. Unique in visual acuity apps is the Peek Acuity app [8] made for rapid mass vision screening which uses a tumbling E chart and unique gesture-based feedback. Here, the examiner swipes the smartphone screen in the direction the patient points and shakes the phone if the optotype is too small to be visible. This goes on until the app alerts that the visual acuity has been measured [9] [Figure 2]. Another unique visual acuity app is the Eye Chart Pro [10] which pairs an iPhone to act as remote control for an iPad which acts as the display for the visual acuity chart [Figure 3]. | Figure 3: Eye Chart Pro with iPhone app paired to iPad app (image courtesy: Eye Chart Pro)
Click here to view |
There are several apps for color vision testing using Ishihara's chart which is quite useful; however, we need to be aware of their limitations [11] in sensitivity.[12] Moreover, Ishihara's chart is only for the red-green color deficiency.[13] The more accurate but lesser known Farnsworth–Munsell test is available in a few apps such as Color Blind Test [14] [Figure 4]. | Figure 4: Farnsworth-Munsell 15 hue test (image courtesy: Color Blind Test)
Click here to view |
Some apps assess contrast sensitivity and color contrast also. ClinicCSF [15] is unique in that it measures contrast sensitivity using sinusoidal gratings. [Figure 5] Another contrast sensitivity testing app with option for both positive polarity and negative polarity testing was found to do better than the conventional printed chart.[16] | Figure 5: Sinusoidal grating contrast sensitivity (image courtesy: ClinicCSF)
Click here to view |
What is really unique is that there are some innovative apps such as Stereo Acuity Cardboard [17] which can assess stereo acuity, and depth perception using a smartphone-based VR headset such as Google Cardboard [Figure 6]. | Figure 6: Stereo acuity test using virtual reality headset (image courtesy: Stereo Acuity test– Cardboard)
Click here to view |
Dysphotopsia can also be measured with the Aston Halometer app, and a study showed comparable results as the C-Quant straylight meter.[18]
| Optokinetic Nystagmus Drum | | |
Some apps, such as Eye Handbook, OptoDrum, Adjustable Optokinetic Nystagmus (OKN) Strips, and OptoDroid, replicate the Optokinetic drum and can be used to test patients' OKN response [Figure 7].
| Ophthalmic Calculations | | |
Various calculations such as IOL power including toric IOL, surgically induced astigmatism, Visual acuity conversion from meters to feet, corrected IOP, and various optometric calculations such as transpositions can be calculated in the Eye Handbook app [Figure 8].
| Apps for Grading | | |
There are apps for manually grading LOCS III grade of cataract [19] and diabetic retinopathy. [Figure 9] There is even an app for Park's three-step test.[20] A recently published study shows innovation in artificial intelligence [21]-based grading of diabetic retinopathy from smartphone app.[22]
| Slit-Lamp, Gonioscopy, Specular, and Fundus Photography | | |
Slit-lamp photography is helped by affordable smartphone slit-lamp adapters. It can be also be used to take gonioscopy videos and even specular photographs of corneal endothelium [23] [Figure 10]. | Figure 10: Specular reflection photograph of endothelium (image courtesy: Dr. John Davis)
Click here to view |
The technique of smartphone fundus photography has been described in detail by several authors with even open-source documentation for building your own smartphone fundus camera.[24] However, one of the difficulties is that the inbuilt camera app is not ideal for the technique. Ullman Indirect [25] for iPhone and several apps, including HopeScope [26] and Ullman Indirect on Android,[27] have features such as inverted video, focus lock, and flash brightness control [Figure 11]. | Figure 11: Camera app with settings for fundus photography (image courtesy: Ullman Indirect)
Click here to view |
| Smartphone Perimetry | | |
Tablet-based perimeters such as visualFields easy [28] and VR-based perimeters such as Periscreener [29] are in development and testing. Studies have been done on both tablet [30]-based [31] and VR-based perimeters [32] and found promising results especially when conventional perimeters are inaccessible [Figure 12]. | Figure 12:(a) Humphrey field analyzer (HFA) reports (b) Patient doing virtual reality perimetry on periscreener (c) Reports from periscreener (image courtesy: Periscreener.com)
Click here to view |
| For Teaching Ophthalmology | | |
In addition to various eBooks and journals available as apps, there are some unique apps which help in learning ophthalmology. There is an app called cataract surgery,[33] which is a simulator of capsulorhexis and phacoemulsification surgery. [Figure 13] Although it is a very basic app, it would be useful to explain to a fresh student of ophthalmology the intricacies of surgery in an interactive manner. A decision support app called OphthalDSS helped in clinical decision-making and was evaluated in a study.[34] For clinical ophthalmology slit-lamp teaching, a smartphone connected SmartTV-based system was found to be better than the conventional slit-lamp teaching telescope which is restricted to one person at a time.[35] For teaching ophthalmoscopy, another study evaluated a smartphone-based VR headset that had tasks incusing performing eye examinations and diagnosing disease and tests.[36] | Figure 13: Phacoemulsification simulation (image courtesy: CataractMobile app)
Click here to view |
| Screening | | |
Smartphone photographs can be used for screening for leukocoria; however, we need to be aware that false positives may also happen due to off-axis photographs.[37] Screening of children for other risk factors for amblyopia can be done with the GoCheck Kids app with the smartphone attachment.[38] Dry eye disease screening can also be done by apps which can give questionnaire and do a functional visual acuity test.[39]
| Patient Medication Reminder | | |
There are now several apps on which we can set a medication schedule to ring an alarm and remind the patient to follow the correct dosing of medications. Some of these apps are EyeDrop Reminder,[40] MyEyeDrops, eyeDROPS, and RxmindMe. [Figure 14] These are especially useful in chronic diseases such as glaucoma. | Figure 14: MyEyeDrops app (image courtesy: Singapore National Eye Center)
Click here to view |
| Other Innovative Apps | | |
Optical coherence tomography (OCT) browser app [41] made by the University of Pittsburgh can be used to browse all the slices of a spectral-domain OCT in an iPad instead of being restricted to the OCT machine [Figure 15]. | Figure 15: Optical coherence tomography being viewed on iPad (image courtesy: Optical coherence tomography browser app)
Click here to view |
One study used the smartphone to measure anomalous and compensatory head positions.[42] The availability of the gyroscopic sensor in newer smartphones made this easier and more accurate.
Based on the same principle, there are apps to help mark the position for toric IOL insertion.[43]
There are vision simulator apps to show patients the type of vision to be expected in different types of IOLs and other apps to simulate vision due to glaucoma and diabetic retinopathy. There are VR versions of these simulators too.[44] They can be accessed on mobile or desktop and show a 360° view of what is seen by a person with glaucoma, cataract, presbyopia, diabetic retinopathy, macular degeneration, and glare of varying degrees which we can select.[45] [Figure 16]. | Figure 16: Vision of a person with glaucoma (image courtesy: Sight Loss Simulator)
Click here to view |
Another study used a smartphone-based VR glaucoma visual function test to objectively assess activity limitation in glaucoma.[46]
There are also several amblyopia treatment apps which help to exercise the eye, however, a study noted that many of these apps are made without any professional input and so need to be assessed and validated.[47]
Language translator apps for ophthalmologists to communicate specific ophthalmology-related questions and phrases are also available in Tamil [48] and Bangla.[49]
| Conclusion | | |
Smartphone apps are rapidly evolving, and new innovative apps are being released often. However, many of the apps are made without ophthalmologists' guidance and are often not calibrated or validated for use. With currently available technology, we have the resources to make reliable and reasonably accurate apps for many components of ophthalmological evaluation at a much lower cost compared to conventional techniques.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Cheng NM, Chakrabarti R, Kam JK. IPhone applications for eye care professionals: A review of current capabilities and concerns. Telemed J E Health 2014;20:385-7.  |
| 2. | Akkara JD, Kuriakose A. Review of recent innovations in ophthalmology. Kerala J Ophthalmol 2018;30:54. [Full text] |
| 3. | Gaiser H, Moore B, Pamplona V, Solaka N, Schafran D, Merrill D, et al. Comparison of a novel cell phone-based refraction technique (Netra-G) with subjective refraction. Invest Ophthalmol Vis Sci 2013;54:2340. |
| 4. | Lord K, Shah VA, Krishna R. The eye handbook: A mobile app in ophthalmic medicine. Mo Med 2013;110:49-51. |
| 5. | Tofigh S, Shortridge E, Elkeeb A, Godley BF. Effectiveness of a smartphone application for testing near visual acuity. Eye (Lond) 2015;29:1464-8. |
| 6. | Perera C, Chakrabarti R, Islam FM, Crowston J. The eye phone study: Reliability and accuracy of assessing Snellen visual acuity using smartphone technology. Eye (Lond) 2015;29:888-94. |
| 7. | Pathipati AS, Wood EH, Lam CK, Sáles CS, Moshfeghi DM. Visual acuity measured with a smartphone app is more accurate than Snellen testing by emergency department providers. Graefes Arch Clin Exp Ophthalmol 2016;254:1175-80. |
| 8. | |
| 9. | Rono HK, Bastawrous A, Macleod D, Wanjala E, DiTanna G, Weiss HA, et al. Smartphone-based screening for visual impairment in Kenyan school children: A cluster randomised controlled trial. Lancet Glob Health 2018;6:e924-32. |
| 10. | |
| 11. | Dain SJ, AlMerdef A. Colorimetric evaluation of iPhone apps for colour vision tests based on the Ishihara test. Clin Exp Optom 2016;99:264-73. |
| 12. | Sorkin N, Rosenblatt A, Cohen E, Ohana O, Stolovitch C, Dotan G. Comparison of Ishihara booklet with color vision smartphone applications. Optom Vis Sci 2016;93:667-72. |
| 13. | Birch J. Efficiency of the Ishihara test for identifying red-green colour deficiency. Ophthalmic Physiol Opt 1997;17:403-8. |
| 14. | |
| 15. | |
| 16. | Hwang AD, Peli E. Positive and negative polarity contrast sensitivity measuring app. Electron Imaging 2016;16:1-6. |
| 17. | |
| 18. | Buckhurst PJ, Naroo SA, Davies LN, Shah S, Buckhurst H, Kingsnorth A, et al. Tablet app halometer for the assessment of dysphotopsia. J Cataract Refract Surg 2015;41:2424-9. |
| 19. | |
| 20. | |
| 21. | Xu X, Ding W, Wang X, Cao R, Zhang M, Lv P, et al. Smartphone-based accurate analysis of retinal vasculature towards point-of-care diagnostics. Sci Rep 2016;6:34603. |
| 22. | Rajalakshmi R, Subashini R, Anjana RM, Mohan V. Automated diabetic retinopathy detection in smartphone-based fundus photography using artificial intelligence. Eye (Lond) 2018;32:1138-44. |
| 23. | Toslak D, Thapa D, Erol MK, Chen Y, Yao X. Smartphone-based imaging of the corneal endothelium at sub-cellular resolution. J Mod Opt 2017;64:1229-32. |
| 24. | Raju B, Raju NS, Akkara JD, Pathengay A. Do it yourself smartphone fundus camera-DIYretCAM. Indian J Ophthalmol 2016;64:663-7. [ PUBMED] [Full text] |
| 25. | |
| 26. | |
| 27. | |
| 28. | |
| 29. | |
| 30. | Johnson CA, Thapa S, George Kong YX, Robin AL. Performance of an iPad application to detect moderate and advanced visual field loss in Nepal. Am J Ophthalmol 2017;182:147-54. |
| 31. | Prea SM, Kong YX, Mehta A, He M, Crowston JG, Gupta V, et al. Six-month longitudinal comparison of a portable tablet perimeter with the Humphrey field analyzer. Am J Ophthalmol 2018;190:9-16. |
| 32. | Tsapakis S, Papaconstantinou D, Diagourtas A, Droutsas K, Andreanos K, Moschos MM, et al. Visual field examination method using virtual reality glasses compared with the Humphrey perimeter. Clin Ophthalmol 2017;11:1431-43. |
| 33. | |
| 34. | López MM, López MM, de la Torre Díez I, Jimeno JC, López-Coronado M. MHealth app for iOS to help in diagnostic decision in ophthalmology to primary care physicians. J Med Syst 2017;41:81. |
| 35. | Wenting SZ, Samin MM, Sanjay S, Neelam K, Shibli K, Chang S, et al. A comparison of undergraduate clinical ophthalmology learning methods: Smart phone television display versus slit-lamp teaching telescope. Can J Ophthalmol 2017;52:385-91. |
| 36. | Wilson AS, O'Connor J, Taylor L, Carruthers D. A 3D virtual reality ophthalmoscopy trainer. Clin Teach 2017;14:427-31. |
| 37. | Asensio-Sánchez VM, Díaz-Cabanas L, Martín-Prieto A. Photoleukocoria with smartphone photographs. Int Med Case Rep J 2018;11:117-9. |
| 38. | Peterseim MM, Rhodes RS, Patel RN, Wilson ME, Edmondson LE, Logan SA, et al. Effectiveness of the GoCheck kids vision screener in detecting amblyopia risk factors. Am J Ophthalmol 2018;187:87-91. |
| 39. | Uchino M, Kawashima M, Uchino Y, Suzuki N, Mitamura H, Mizuno M, et al. The evaluation of dry eye mobile apps for screening of dry eye disease and educational tear event in Japan. Ocul Surf 2018. pii: S1542-0124(17)30370-1. |
| 40. | |
| 41. | |
| 42. | Farah ML, Santinello M, Carvalho LE, Uesugui CF, Barcellos RB. Using a smartphone as a tool to measure compensatory and anomalous head positions. Arq Bras Oftalmol 2018;81:30-6. |
| 43. | |
| 44. | |
| 45. | |
| 46. | Goh RL, Kong YX, McAlinden C, Liu J, Crowston JG, Skalicky SE. Objective assessment of activity limitation in glaucoma with smartphone virtual reality goggles: A pilot study. Transl Vis Sci Technol 2018;7:10. |
| 47. | Paudel N. Smartphone applications for amblyopia treatment: A Review of current apps and professional involvement. Telemed J E Health 2018; doi: 10.1089/tmj.2017.0220. [Epub ahead of print]. |
| 48. | |
| 49. | |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]
| This article has been cited by | | 1 |
Eye MG 3D Application - A comprehensive ocular anatomy and pathophysiology 3D atlas with real-time true color confocal images to enhance ophthalmology education and e-Counseling |
|
| PrasannaV Ramesh, AjiKunnath Devadas, Tensingh Joshua, Prajnya Ray, ShruthyV Ramesh, PragashM Raj, MeenaK Ramesh, Ramesh Rajasekaran | | Indian Journal of Ophthalmology. 2022; 70(4): 1388 | | [Pubmed] | [DOI] | | | 2 |
Commentary: Digital 3D atlas of ophthalmology |
|
| JohnD Akkara, Anju Kuriakose | | Indian Journal of Ophthalmology. 2022; 70(4): 1394 | | [Pubmed] | [DOI] | | | 3 |
Commentary: Opening eyes to the mixed reality metaverse |
|
| JohnD Akkara, Anju Kuriakose | | Indian Journal of Ophthalmology. 2022; 70(8): 3121 | | [Pubmed] | [DOI] | | | 4 |
Smartphone microscope in eye clinic to visualize fungus and Demodex |
|
| Pawan Prasher,Brahmjot Singh,VipanK Vig,JohnDavis Akkara | | Kerala Journal of Ophthalmology. 2021; 33(2): 217 | | [Pubmed] | [DOI] | | | 5 |
Commentary: Is it time for teleophthalmology, virtual glaucoma clinics and uberization of eye care? |
|
| JohnDavis Akkara,Anju Kuriakose | | Indian Journal of Ophthalmology. 2021; 69(3): 719 | | [Pubmed] | [DOI] | | | 6 |
Commentary: Kitchen ophthalmic surgeon: Recipe for operation success in work-from-home era |
|
| JohnDavis Akkara, Anju Kuriakose | | Indian Journal of Ophthalmology. 2021; 69(10): 2851 | | [Pubmed] | [DOI] | | | 7 |
Commentary: Smartphone-based, wireless, slit-lamp imaging with small footprint – making photodocumentation easy |
|
| JohnDavis Akkara,Anju Kuriakose | | Indian Journal of Ophthalmology. 2021; 69(5): 1262 | | [Pubmed] | [DOI] | | | 8 |
Saving space: Comparing mini - logMAR with standard logMAR visual acuity |
|
| Farnaz Kauser,AbadanK Amitava,Juhi Saxena,SAisha Raza,Anam Masood,MdShahid Alam | | Indian Journal of Ophthalmology. 2021; 69(1): 48 | | [Pubmed] | [DOI] | | | 9 |
Commentary: An app a day keeps the eye doctor busy |
|
| JohnDavis Akkara,Anju Kuriakose | | Indian Journal of Ophthalmology. 2021; 69(3): 553 | | [Pubmed] | [DOI] | | | 10 |
Expanding the scope of tele-ophthalmology from vision centers to home |
|
| Lokeshwari Aruljyothi,Alap Bavishi,ManoharBabu Balasundaram,Anuja Janakiraman,Kritika Shekar,Harshita Atmakur | | Indian Journal of Ophthalmology. 2021; 69(2): 442 | | [Pubmed] | [DOI] | | | 11 |
Development of 3D Printed Smartphone-Based Multi-Purpose Fundus Camera (MultiScope) for Retinopathy of Prematurity |
|
| Arivazhagan Pugalendhi, Rajesh Ranganathan | | Annals of Biomedical Engineering. 2021; | | [Pubmed] | [DOI] | | | 12 |
Smartphone applications in ophthalmology: A quantitative analysis |
|
| Lokeshwari Aruljyothi,Anuja Janakiraman,B Malligarjun,BalasundaramManohar Babu | | Indian Journal of Ophthalmology. 2021; 69(3): 548 | | [Pubmed] | [DOI] | | | 13 |
Commentary: Teleophthalmology is a different ball game for kids |
|
| JohnDavis Akkara,Anju Kuriakose | | Indian Journal of Ophthalmology. 2020; 68(7): 1391 | | [Pubmed] | [DOI] | | | 14 |
Commentary: Teleophthalmology and electronic medical records: Weighing the pros and cons of unavoidable progress |
|
| JohnDavis Akkara,Anju Kuriakose | | Indian Journal of Ophthalmology. 2020; 68(2): 367 | | [Pubmed] | [DOI] | | | 15 |
A smartphone attachment for remote ophthalmic slit lamp examinations |
|
| Phuong Truong,Alex Phan,Buu Truong,Benjamin Suen,Gerrit Melles,Frank Talke | | Microsystem Technologies. 2020; | | [Pubmed] | [DOI] | | | 16 |
Commentary: In case of emergency, Dr MacGyver uses Jugaad illumination |
|
| JohnD Akkara,Anju Kuriakose | | Indian Journal of Ophthalmology. 2020; 68(8): 1660 | | [Pubmed] | [DOI] | | | 17 |
Screening for Stereopsis of Children Using an Autostereoscopic Smartphone |
|
| Yanhui Yang,Huang Wu | | Journal of Ophthalmology. 2019; 2019: 1 | | [Pubmed] | [DOI] | |
|
 |
|
|
|
Search Pubmed for