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Research Letters |

Nonmydriatic Digital Ocular Fundus Photography on the iPhone 3G: The FOTO-ED Study FREE

Cédric Lamirel, MD; Beau B. Bruce, MD, MS; David W. Wright, MD; Nancy J. Newman, MD; Valérie Biousse, MD
[+] Author Affiliations

Author Affiliations: Departments of Ophthalmology (Drs Lamirel, Bruce, Newman, and Biousse), Neurology (Drs Bruce, Newman, and Biousse), Emergency Medicine (Dr Wright), and Neurological Surgery (Dr Newman), Emory University, Atlanta, Georgia.


Arch Ophthalmol. 2012;130(7):939-940. doi:10.1001/archophthalmol.2011.2488.
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Published online

The widespread use of smartphones provides a unique opportunity for telemedicine. In ophthalmology, smartphones are used for visual acuity assessments and to document examinations, particularly in settings like the emergency department, where the usual ophthalmic tools and photographic services are unavailable.1 However, to our knowledge, these devices have not been used for systematic, remote review of clinical photographs in ophthalmology as they have in radiology and dermatology.2,3 We performed a pilot investigation to compare the quality of nonmydriatic fundus photographs displayed on an iPhone 3G (Apple Inc) vs a desktop computer.

Three hundred fifty patients with headache, focal neurologic deficit, visual changes, or diastolic blood pressure 120 mm Hg or higher were prospectively enrolled during the Fundus Photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department (FOTO-ED) study.4,5 Nonstereoscopic, nonmydriatic, single-field photographs of the ocular fundus were obtained using the Kowa α-D camera. All photographs were stored as JPEG lossy compression images (resolution, 2528 × 1936 pixels; compression ratio, 1:5). Photographs were graded for general quality by 2 neuro-ophthalmologists (C.L. and B.B.B.) on a computer monitor (Figure) using a previously validated 5-point scale.6 Six weeks after initial review on the computer display, 100 photographs were chosen by a pseudorandom sequence and graded on an iPhone 3G (Figure) by both neuro-ophthalmologists. Zoom level could be adjusted on both devices. Photographs were transferred to the iPhone via the wired interface without modification. One year later, 1 neuro-ophthalmologist (C.L.) regraded the same 100 photographs on the iPhone.

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Comparison of a nonmydriatic fundus photograph on a computer monitor vs an iPhone 3G (Apple Inc). A, A 19-inch computer liquid crystal display (HP W1907; Hewlett-Packard Development Company, LP; resolution, 1440 × 900; pixels per inch, 89.1; brightness, 300 cd/m2) displaying a nonmydriatic fundus photograph. B, An iPhone 3G (resolution, 320 × 480; pixels per inch, 164.6; brightness, 480 cd/m2) displaying the same nonmydriatic fundus photograph. C, Screenshot taken from the iPhone 3G while displaying the photograph at the actual size and resolution of the screen. D, Screenshot taken from the iPhone 3G while displaying the photograph zoomed in on the device at the actual size and resolution of the screen.

Agreement was assessed by quadratic (Fleiss-Cohen) weighted κ. Systematic differences in ratings were assessed by the Bishop, Fienberg, and Holland modification of the McNemar χ2 test. P values were Bonferroni corrected.

The quality ratings on the computer display for the 100 randomly selected photographs were the following: 31 photographs, grade 1 (inadequate for any diagnostic purpose); 19 photographs, grade 2; 13 photographs, grade 3; 16 photographs, grade 4; and 21 photographs, grade 5 (ideal quality). There was no difference in quality ratings of photographs with vs without abnormalities. The 2 reviewers had excellent interreviewer and intrareviewer agreement on either the desktop computer or the iPhone display without evidence of systematic differences (κ = 0.93-0.97; 95% CI, 0.68-1.00; χ2 ≤ 4.3; P ≥ .19) (eTable 1). The agreements for the same reviewer on the desktop computer vs the iPhone were also excellent (κ = 0.82-0.91; 95% CI, 0.56-1.00). Both reviewers tended to rate an image's quality on the iPhone as superior to that same image viewed on the computer display (χ2 = 36.4-43.1; P < .001) (eTable 1 and eTable 2).

We expected equal- or lower-quality ratings for photographs displayed on the iPhone compared with the desktop computer, but instead we found that reviewers assigned higher ratings on average for photographs displayed on the iPhone. Because the magnitude of this difference was similar for both reviewers and no bias in the other ratings was observed, we believe this occurred because the advantages of the iPhone's display (eg, higher dot pitch and brightness) outweighed its disadvantages (eg, lower resolution and smaller screen area). The factors contributing to this difference warrant additional investigation. It also remains to be seen whether relevant abnormalities found on the computer display would also be found on the iPhone display under routine conditions. This was not studied directly because currently no iPhone software exists to transfer and review a large number of photographs grouped by patient. However, our results support the iPhone's display as a potential component in a telemedicine network. We are not suggesting using the iPhone to screen for subtle conditions (eg, diabetic retinopathy) or as a replacement for in-person ophthalmologic consultation. Rather, we believe the iPhone, and similar devices, in combination with nonmydriatic photography can complement ophthalmologic consultations in settings such as the emergency department4,5 by allowing for rapid and remote identification of obvious conditions affecting the posterior pole such as papilledema and malignant hypertension.

Correspondence: Dr Newman, Department of Ophthalmology, Emory Eye Center, Emory University, 1365-B Clifton Rd NE, Atlanta, GA 30322 (ophtnjn@emory.edu).

Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Financial Disclosure: None reported.

Funding/Support: This study was supported in part by a departmental grant (Department of Ophthalmology) from Research to Prevent Blindness and core grant P30-EY06360 (Department of Ophthalmology). Dr Lamirel is supported by Institut Servier, Fondation Planiol, and the Philippe Foundation. Dr Bruce is supported by grants KL2-RR025009 and UL1-RR025008 from the US Public Health Service and K23-EY019341 from the National Eye Institute, by the Knights Templar Eye Foundation, and by the American Academy of Neurology Practice Research Fellowship. Dr Wright is supported by grant KL2-RR025009 from the US Public Health Service. Dr Newman is a recipient of the Lew R. Wasserman Merit Award from Research to Prevent Blindness. Dr Biousse is supported by grant UL1-RR025008 from the US Public Health Service.

Role of the Sponsors: The sponsors had no role in the design or conduct of the study; in the collection, analysis, or interpretation of data; or in the preparation, review, or approval of the manuscript.

Lord RK, Shah VA, San Filippo AN, Krishna R. Novel uses of smartphones in ophthalmology.  Ophthalmology. 2010;117(6):1274-1274.e3
PubMed   |  Link to Article
Modi J, Sharma P, Earl A, Simpson M, Mitchell JR, Goyal M. iPhone-based teleradiology for the diagnosis of acute cervico-dorsal spine trauma.  Can J Neurol Sci. 2010;37(6):849-854
PubMed
Ebner C, Wurm EM, Binder B,  et al.  Mobile teledermatology: a feasibility study of 58 subjects using mobile phones.  J Telemed Telecare. 2008;14(1):2-7
PubMed   |  Link to Article
Bruce BB, Lamirel C, Wright DW,  et al.  Nonmydriatic ocular fundus photography in the emergency department.  N Engl J Med. 2011;364(4):387-389
PubMed   |  Link to Article
Bruce BB, Lamirel C, Biousse V,  et al.  Feasibility of nonmydriatic ocular fundus photography in the emergency department: phase I of the FOTO-ED study.  Acad Emerg Med. 2011;18(9):928-933
PubMed   |  Link to Article
Lamirel C, Bruce BB, Wright DW, Delaney KP, Newman NJ, Biousse V. Quality of nonmydriatic digital fundus photography obtained by nurse practitioners in the emergency department: the FOTO-ED study.  Ophthalmology. 2012;119(3):617-624
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure. Comparison of a nonmydriatic fundus photograph on a computer monitor vs an iPhone 3G (Apple Inc). A, A 19-inch computer liquid crystal display (HP W1907; Hewlett-Packard Development Company, LP; resolution, 1440 × 900; pixels per inch, 89.1; brightness, 300 cd/m2) displaying a nonmydriatic fundus photograph. B, An iPhone 3G (resolution, 320 × 480; pixels per inch, 164.6; brightness, 480 cd/m2) displaying the same nonmydriatic fundus photograph. C, Screenshot taken from the iPhone 3G while displaying the photograph at the actual size and resolution of the screen. D, Screenshot taken from the iPhone 3G while displaying the photograph zoomed in on the device at the actual size and resolution of the screen.

Tables

References

Lord RK, Shah VA, San Filippo AN, Krishna R. Novel uses of smartphones in ophthalmology.  Ophthalmology. 2010;117(6):1274-1274.e3
PubMed   |  Link to Article
Modi J, Sharma P, Earl A, Simpson M, Mitchell JR, Goyal M. iPhone-based teleradiology for the diagnosis of acute cervico-dorsal spine trauma.  Can J Neurol Sci. 2010;37(6):849-854
PubMed
Ebner C, Wurm EM, Binder B,  et al.  Mobile teledermatology: a feasibility study of 58 subjects using mobile phones.  J Telemed Telecare. 2008;14(1):2-7
PubMed   |  Link to Article
Bruce BB, Lamirel C, Wright DW,  et al.  Nonmydriatic ocular fundus photography in the emergency department.  N Engl J Med. 2011;364(4):387-389
PubMed   |  Link to Article
Bruce BB, Lamirel C, Biousse V,  et al.  Feasibility of nonmydriatic ocular fundus photography in the emergency department: phase I of the FOTO-ED study.  Acad Emerg Med. 2011;18(9):928-933
PubMed   |  Link to Article
Lamirel C, Bruce BB, Wright DW, Delaney KP, Newman NJ, Biousse V. Quality of nonmydriatic digital fundus photography obtained by nurse practitioners in the emergency department: the FOTO-ED study.  Ophthalmology. 2012;119(3):617-624
PubMed   |  Link to Article

Correspondence

March 1, 2013
Rahul Chakrabarti, MBBS(Hons), BMedSc(Hons); Chandrashan Perera, MBBS(Hons), BMedSc(Hons)
JAMA Ophthalmol. 2013;131(3):405-406. doi:10.1001/jamaophthalmol.2013.826.
March 1, 2013
Beau B. Bruce, MD, MS; Nancy J. Newman, MD; Valérie Biousse, MD
JAMA Ophthalmol. 2013;131(3):405-406. doi:10.1001/jamaophthalmol.2013.1943.
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Lamirel C, Bruce BB, Wright DW, Newman NJ, Biousse V. Nonmydriatic digital ocular fundus photography on the iPhone 3G: the FOTO-ED study. Arch Ophthalmol. 2012;130(7). doi:10.1001/archophthalmol.2011.2488.

eTable 1. Intra-device (inter- and intra-reviewer) and inter-device agreement and testing for a systematic difference (bias) between the reviewers or devices being compared.

eTable 2. Confusion matrixes of the agreements between desktop computer display and iPhone 3G quality ratings by the same reviewer. There are significantly more observations above the diagonal than below demonstrating systematically higher quality ratings on the iPhone than the desktop computer by both reviewers (p<0.001).

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