Immuno-Ophthalmology (Developments in Ophthalmology, Vol. 30)

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In addition to the scarcity of ophthalmologists globally, another challenge facing the fight against global blindness is the lack of ophthalmic equipment needed for proper eye care. Traditional ophthalmic equipment, such as office-based cameras are expensive, bulky, immobile and unsuitable for reaching patients in rural areas. Newer developments in technology are replacing our reliance on large equipment and allowing us to visualize the eye in a mobile and more cost-efficient manner.

Smartphone-based technologies can now act as slit lamps, direct ophthalmoscopes, and indirect ophthalmoscopes.

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Table 1 lists some of the products currently available. While these images will not be as sharp as those achieved with traditional cameras, they are of adequate resolution for interpretation. This development will allow eye care providers to have more access to imaging technologies, which provide imaging of harder-to-reach patients in rural areas with geo-tagging and wireless transfer of results to distantly-located specialists for appropriate management.

One study found that even nonophthalmologists can be trained to effectively capture fundus images in a rural area [ 26 ]. Disadvantages of smartphone-based imaging are the high intensity of the phone light source, which constricts the pupil. However, applications such as Shutter can be used to tailor the intensity and exposure time of the flash for optimal illumination.

Another disadvantage is achieving proper beam alignment.

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In addition to smartphone-based imaging, standalone handheld camera technologies also allow portable image capture. These cameras are lightweight and capture quality retinal images. A limitation of such devices is the need for proper manual alignment of the illuminating beam with the optical axis for good-quality images. They also lack the ability to integrate with various apps as smartphone-based cameras and tend to be fragile.

More importantly, these devices are cost-prohibitive for LICs. VuPad Sonomed Escalon and Accutome offer the only portable laptop size ultrasounds that can be used in low-income countries. Ultrasound US is a noninvasive, very easy to operate tool that plays an important role in clinical ophthalmology.

It is used for the visualization of anatomy and various ocular pathology such as retinal detachment and intraocular tumors. Ultrasound becomes especially important if visualization of fundus becomes obscured by opaque elements including vitreous hemorrhage or dense mature cataracts commonly encountered in LIC. Butterfly iQ is the first portable US probe that can be plugged directly into a smartphone to visualize various parts of the body but is not yet approved for the eye Figure 7.

The probe uses a single silicone chip that replaces traditional transducer system. Clinicians can switch between various types of transducers, such as linear, curved or phased, without the need of switching probes. Moreover, the Butterfly iQ application allows clinicians to organize and remotely access imaging studies through the Butterfly Cloud. The Butterfly Cloud is HIPAA compliant and the application is developed in a way that makes it easy to share studies between various clinicians across the globe.

Butterfly iQ weighs around 0. Butterfly iQ is being utilized for point of care ultrasound by physicians and emergency room physicians but could evolve as the first smartphone based ocular ultrasound. It has future potential to be used by visual care providers in resource poor areas for diagnosing ocular pathology. The Clarus Portable Ultrasound is palm sized, connects to a wireless smartphone or tablet, but is not yet marketed for ophthalmology use.

Butterfly iQ is a portable ultrasound probe that can be plugged into any smartphone to visualize various anatomical features, including the eye. A group from the University of Arizona assessed a new ultrasound system, the Vevo VisualSonics, Toronto, Ontario, Canada and its ability to examine structures of the anterior and posterior segments [ 28 ]. Previous ultrasound technologies used single-element transducers, while the Vevo uses linear array technology with more than piezoelectric elements packed into the face of the transducer probe.

Additionally, it allows the scan to be shown in three-dimensions at different planes with sagittal, transverse, and coronal sections. This allows users to measure the location, dimensions, and volume of lesions or parts of the eye, which could be useful for providing information on the growth of lesions over time. The technology could also be used to determine the extent of traumatic injury and location of foreign bodies.


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A doppler function also allows examination of the temporal artery as well as vessels of the optic nerve head. However, despite the accurate images, the Vevo provides the anterior and posterior segments, and its high cost makes it a limiting factor for use in LIC. Mobile health, also referred to as mHealth, refers to the use of short messaging service SMS , wireless data transfer, voice calling, and smartphone applications to transmit health-related information or direct medical care.

The WelTel Kenyal study found that even weekly SMS text messages inquiring about patient wellbeing is sufficient to increase self-reported medication adherence and HIV viral suppression [ 31 ]. This demonstrates the need for a strong technological infrastructure in regions that mHealth is being deployed.

Based on the results of these studies, mHealth can be an effective and cost-effective means to increase medication adherence in LICs with wireless network coverage. The SIMpill system sends an SMS message to centrally-located servers, recording each time a patient takes their medication. Importantly, this study found that the average cost per communication using SMS was one-fifth the cost of communication in areas without SMS access.

Another study found that common uses of SMS by CHW were patient referral, drug dosing information, emergency support, and reporting patient mortality. This study found that the efficiency of SMS communication substantially increased free time of hospital staff, allowing staff to treat more patients. One study sent an SMS squiz on HIV awareness to 10, cell phone subscribers and found significant challenges associated with the use of mHealth as a patient education tool [ 34 ].

First, the study found that individuals tended to only respond to questions for which they knew the correct answer, while skipping other questions. This demonstrates that it may be difficult to use mHealth to transmit new information to patients. Second, and perhaps more importantly, the study found that respondents were more likely to be men. The authors postulated this to be due to men having higher rates of mobile phone ownership and literacy.

This could indicate future difficulty for mHealth to be used as an education tool for women in LICs. Rapid Assessment of Avoidable Blindness RAAB is a survey system that estimates prevalence of avoidable blindness in a population over age The data gathered from these surveys are stored in a repository, which not only details the prevalence of eye diseases and their causes but also the quality of eye services, resources and barriers to care in a specific geographical area.

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This resource is invaluable to researchers and country ministries of health, as it grants them easy access to data. Moreover, it allows agencies and eye care providers to focus their efforts on regions with the greatest medical need with optimal utilization of limited resources.

The mRAAB application has increased the quality and efficiency of data entry by allowing the data to be entered while the examiner is still with the patient. It has been tested successfully in countries such as Tanzania, the Maldives, Madagascar, Uganda, Zimbabwe, and Nigeria. The Open Data Kit is another mobile data collection application that has facilitated the collection, management, and access to data in remote and resource-limited regions.

Similar to the mRAAB, this is a great resource that allows various eye care organizations and providers to collect and share data that can increase the effectiveness of their efforts. BOOST is an application developed by several nongovernmental organizations and the Aravind Eye Hospital Madurai, India which allows cataract surgeons to measure and benchmark their surgical results against others in a cloud-based database. It also provides advice on how to improve outcomes [ 37 ]. The app uses two rounds of data collection.

The app then suggests changes in practice for users to help improve their most common causes of poor vision. Simulation-based training for cataract surgery is an innovation with substantial promise for treating global blindness in LIC. Cataracts account for nearly half of all cases of global blindness, the majority being in the developing world [ 38 ].

While many of these cases can be cured with inexpensive surgical procedures, there is a shortage of surgeons to handle the caseload. Trainees in developing countries face a lack of equipment and teaching personnel. Simulation-based training could help alleviate this shortage of surgeons by providing practice cases without the requirement for actual patients.

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The Eyesi is the most prevalent of commercially available simulators in U. It is a high-fidelity phacoemulsification simulator. The hardware consists of a mannequin headpiece with a mechanical eye, which is wired to a computer interface and a microscope, allowing the trainee to assume the most realistic posture Figure 9. Eyesi also includes surgical instruments and foot pedals. The system allows users to watch previous surgeries to review and improve upon. It consists of different learning modules, including anti-tremor training, bimanual training, capsulorhexis, cracking and chopping training, forceps training, hydro-dissection maneuvers, intraocular lens insertion, irrigation and aspiration, navigation training, and phacoemulsification training.

VRmagic also produces Eyesi indirect and direct ophthalmoscopes for simulation-based training in ophthalmoscopy Figures 10 and The HMS system includes a platform similar to the Eyesi system with a microscope, monitor, and instruments attached to robotic arms Figure The MicroVisTouch system includes a blunt-tip handpiece attached to a robotic arm, with a mannequin headpiece to practice proper hand placement. The handpiece serves as the appropriate instrument based on the stage of surgery being performed, from a keratome to forceps.

The system also includes haptic feedback, a relatively new addition to the market for surgery simulators. The VRmagic Eyesi surgical simulator allows users to go through modules of high fidelity simulations of phacoemulsification and vitreoretinal surgery steps. The VRmagic direct ophthalmoscope allows users to develop the skillset for direct ophthalmoscopy by progressively moving through skill modules and case pathology. The VRmagic indirect ophthalmoscope allows users to develop the skillset for binocular indirect ophthalmoscopy with a 20D and 28D lens and records the percentage of the retina visualized in focus by the examiner.

Another recent study by Thomsen [ 41 ] tested the Eyesi as a training method of 18 surgeons of varying levels of experience. Each surgeon was graded based on a previously-validated testing tool for cataract surgery Objective Structured Assessment of Cataract Surgical Skill. The study found that novice surgeons benefited by training on the Eyesi, while more experienced surgeons did not.

Compared with no intervention, simulation-based training has been shown to have large improvements in user knowledge, skills, and behaviors, along with moderate improvements in patient outcomes across many surgical and medical fields [ 42 ]. Given the lack of training institutions, wet labs, etc. Despite the aforementioned shortcomings in the research of simulators, the organization is creating training centers around the world that incorporate surgical simulation as well as traditional learning methods, centered around a textbook written at an 8th grade English level.

Their goal is to fight global blindness caused by cataracts. The intended trainee will include health care professionals and individuals without medical training in order to create the manpower necessary to meet the global need for surgeons. Each center will have the capacity to train approximately trainees per year. Only those who successfully complete the cognitive training will move forward to surgical training, where they will be trained in manual small incision cataract surgery MSICS , a safe, low-cost, and rapid method for surgical cataract removal compared to other costlier methods.

The graduates then become part of a network of independently-functioning MSICS practitioners that are responsible for seeking out treatable cataract cases in their practicing area, providing surgical care on a fee-for-service basis, and reporting quality metrics via electronic photographs to HMS. The practitioners will live and work in the underserved areas HMS hopes to serve.

Better skill and outcomes will then drive local credibility and encourage uptake of the program by locals. The review forecast that the HMS is able to train 30, new surgeons. The reductions are more modest in the medium and low uptake assumptions. However, once the cataract surgery backlog is eliminated, there will likely be an oversupply of surgeons. After that point, surgeons would rely on new cases of cataracts for business.

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