eFOCUS 2: A randomised crossover trial of smartphone fundoscopy and direct ophthalmoscopy aiming to improve optic disc interpretation by medical students with e-learning support

Evaluating smartphone fundoscopy as a pedagogical tool in medical education: a narrative review

Direct ophthalmoscopy continues to be the "gold standard" method for retinal and optic nerve evaluation despite known challenges for learners to acquire this clinical skill and minimal opportunities for patient-facing practice. Here we review current literature regarding smartphone fundoscopy (SF) as an alternative learning tool that remains underutilized in Canadian medical schools. SF has significant advantages over direct ophthalmoscopy, such as enhanced learner visualization of ocular structure and pathologies, greater learner usability in comparison, and improved fundus assessment during more difficult ocular examinations such as with pediatric patients. Furthermore, SF provides opportunities for instructor exchange and feedback, group learning, increased learner confidence, and most important, an improved patient experience. Yet challenges remain with SF, including patient confidentiality during data capture and sharing and meaningful integration into an already limited and saturated curriculum. Our review finds SF to be a pedagogic tool with the potential to reinvigorate fundoscopy learning to improve competency in this important clinical skill.

Fundoscopy Use in Neurology Departments and the Utility of Smartphone photography ( FUNDUS ): A prospective prevalence and crossover diagnostic accuracy study amongst neurology inpatients

Background and purpose

Although fundoscopy is a crucial part of the neurological examination, it is challenging, under‐utilized and unreliably performed. The aim was to determine the prevalence of fundus pathology amongst neurology inpatients and the diagnostic accuracy of current fundoscopy practice compared with systematic screening with smartphone fundoscopy (SF) and portable non‐mydriatic fundus photography (NMFP).

Methods

This was a prospective cross‐sectional surveillance and diagnostic accuracy study on adult patients admitted under neurology in an Australian hospital. Inpatients were randomized to initial NMFP (RetinaVue 100, Welch Allyn) or SF (D‐EYE) followed by a crossover to the alternative modality. Images were graded by neurology doctors, using telemedicine consensus neuro‐ophthalmology NMFP grading as the reference standard. Feasibility parameters included ease, comfort and speed.

Results

Of 79 enrolled patients, 14.1% had neurologically relevant pathology (seven, disc pallor; one, hypertensive retinopathy; three, disc swelling). The neurology team performed direct ophthalmoscopy in 6.6% of cases and missed all abnormalities. SF had a sensitivity of 30%–40% compared with NMFP (45.5%); however, it had a lower rate of screening failure (1% vs. 13%, p < 0.001), a shorter examination time (1.10 vs. 2.25 min, p < 0.001) and a slightly higher patient comfort rating (9.2 vs. 8/10, p < 0.001).

Conclusion

Our study demonstrates a clinically significant prevalence of fundus pathology amongst neurology inpatients which was missed by current fundoscopy practices. Portable NMFP screening appears more accurate than SF, whilst both are diagnostically superior to routine fundoscopic practice, feasible and well tolerated by patients.

Utility of video-fundoscopy and prospects of portable stereo-photography of the ocular fundus in neurological patients

Background

Proper evaluation of ocular fundi is an integral part of neurological examination. Unfortunately, neurology residents are increasingly uncomfortable performing fundoscopy and interpreting findings because of diminishing skills and lack of experience. This became more prominent during the COVID-19 pandemic as fundoscopy requires proximity to the patient.

With the recent dramatic improvement of smartphone cameras, fundus photography using the PanOptic Ophthalmoscope (Welch Allyn, Skaneateles Falls, NY) with a smartphone adapter offered an alternative to direct fundoscopic examination. We present the first experience with our own design of a universal smartphone adapter.

Methods

This is a single-center case series, consecutive for a single user and certain presenting neurological symptoms, which is aimed to evaluate the feasibility and practicality of a new, universal PanOptic smartphone adapter. Presenting symptoms included headache, ocular symptoms, seizure, or encephalopathy. We used 3D modeling and printing techniques to create the adapter.

We also developed a methodology of capturing stereoscopic images of the optic disc using a single smartphone camera, but the method was not systematically evaluated in this paper.

Results

Here we present our initial experience of fundus video/photography in patients, who presented with encephalopathy, headache, seizure, vision loss, and other ocular symptoms. Fundoscopic abnormalities were discovered in 11 out of 100 patients. Some were incidental findings and were unrelated to the presentation. In one case, fundoscopy played a critical role in establishing the correct diagnosis.

Conclusions

Our custom-designed smartphone adapter allowed obtaining high-quality video and photo recordings using PanOptic Ophthalmoscope. The acquisition of high-quality photos enables a high-yield diagnostic tool and allows revisiting the image in the patient’s chart. Improvement of smartphone cameras opens vast horizons for stereo-fundoscopy and 3D reconstruction of the ocular fundus without using sophisticated and costly equipment. Microscopic eye movements allow taking snapshots of two side-by-side photos for 3D reconstruction and stereoscopic image viewing, which is the next level of optic disc assessment.