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Wang H, Liao X, Zhang M, Pang CP, Chen H. Smartphone ophthalmoscope as a tool in teaching direct ophthalmoscopy: a crossover randomized controlled trial. Med Educ Online 2023; 28:2176201. [PMID: 36762913 PMCID: PMC9930769 DOI: 10.1080/10872981.2023.2176201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/26/2023] [Accepted: 01/31/2023] [Indexed: 06/18/2023]
Abstract
To evaluate the effectiveness of smartphone ophthalmoscope (SO) in teaching ophthalmoscopy, compared with direct ophthalmoscope (DO). In this cross-over study, 45 final-year medical students attending sessions at a single institution were randomly allocated to two groups (A and B). Both groups attended two training sessions. In the first session, Group A students were taught ophthalmoscopy using DO and Group B students using SO. In the second session, the training sessions were crossed over. A series of eye models with 10 letters placed on the inner surface were designed to assess the students' skill on ophthalmoscopy. Students performed ophthalmoscopy on the eye models, recorded their findings, and completed a questionnaire of feedback on DO and SO. The main outcome measure was the score of ophthalmoscopy, assessed by the student correctly recording each letter (score 1 for each letter). For Group A, the mean score of ophthalmoscopy on the eye model using DO and SO was 3.9±2.4 and 8.2±2.2, respectively. For Group B, the mean score of ophthalmoscopy on the eye model using SO and DO 8.7±1.8 and 5.7±3.5 . Students scored significantly higher in ophthalmoscopy when using SO than DO (P<0.001). They expressed better visualization of the fundus using SO than DO (4.49±0.65 vs 4.13±0.81, P=0.004). Students' performance of ophthalmoscopy was better when SO was used compared with DO. The use of SO as an adjunctive tool is recommended to improve the effectiveness of teaching ophthalmoscopy.
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Affiliation(s)
- Hongxi Wang
- ophthalmology, Joint Shantou International Eye Center of Shantou University and the Chinese University of Hong Kong, Shantou, Guangdong, China
| | - Xulong Liao
- ophthalmology, Joint Shantou International Eye Center of Shantou University and the Chinese University of Hong Kong, Shantou, Guangdong, China
| | - Mingzhi Zhang
- ophthalmology, Joint Shantou International Eye Center of Shantou University and the Chinese University of Hong Kong, Shantou, Guangdong, China
| | - Chi Pui Pang
- ophthalmology, Joint Shantou International Eye Center of Shantou University and the Chinese University of Hong Kong, Shantou, Guangdong, China
- Department of Ophthalmology & Visual Sciences, Chinese University of Hong Kong, Hong Kong, China
| | - Haoyu Chen
- ophthalmology, Joint Shantou International Eye Center of Shantou University and the Chinese University of Hong Kong, Shantou, Guangdong, China
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2
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Kherani IZ, Kritzinger J, Micieli JA, Wong JCY. Evaluating smartphone fundoscopy as a pedagogical tool in medical education: a narrative review. Can J Ophthalmol 2023:S0008-4182(23)00305-8. [PMID: 37865120 DOI: 10.1016/j.jcjo.2023.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 03/05/2023] [Accepted: 07/31/2023] [Indexed: 10/23/2023]
Abstract
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.
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Affiliation(s)
| | | | - Jonathan A Micieli
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont.; Kensington Vision and Research Center, Toronto, Ont
| | - Jovi C Y Wong
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont..
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Jansen LG, Schultz T, Holz FG, Finger RP, Wintergerst MWM. [Smartphone-based fundus imaging: applications and adapters]. Ophthalmologe 2021; 119:112-126. [PMID: 34913992 DOI: 10.1007/s00347-021-01536-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Smartphone-based fundus imaging (SBFI) is an innovative and low-cost alternative for color fundus photography. Since the first reports on this topic more than 10 years ago a large number of studies on different adapters and clinical applications have been published. OBJECTIVE The aim of this review article is to provide an overview on the development of SBFI and adapters and clinical applications published so far. MATERIAL AND METHODS A literature search was performed using the MEDLINE and Science Citation Index Expanded databases without time restrictions. RESULTS Overall, 11 adapters were included and compared in terms of exemplary image material, field of view, acquisition costs, weight, software, application range, smartphone compatibility and certification. Previously published SBFI applications are screening for diabetic retinopathy, glaucoma and retinopathy of prematurity as well as the application in emergency medicine, pediatrics and medical education/teaching. Image quality of conventional retinal cameras is in general superior to SBFI. First approaches on automatic detection of diabetic retinopathy through SBFI are promising and the use of automatic image processing algorithms enables the generation of wide-field image montages. CONCLUSION SBFI is a versatile, mobile, low-cost alternative to conventional equipment for color fundus photography. In addition, it facilitates the delegation of ophthalmological examinations to assistance personnel in telemedical settings, could simplify retinal documentation, improve teaching, and improve ophthalmological care, particularly in countries with low and middle incomes.
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Affiliation(s)
- Linus G Jansen
- Klinik für Augenheilkunde, Universitätsklinikum Bonn, Ernst-Abbe-Str. 2, 53127, Bonn, Deutschland
| | - Thomas Schultz
- Institut für Informatik II, Universität Bonn, Friedrich-Hirzebruch-Allee 5, 53115, Bonn, Deutschland.,Bonn-Aachen International Center for Information Technology (B-IT), Universität Bonn, Friedrich-Hirzebruch-Allee 5, 53115, Bonn, Deutschland
| | - Frank G Holz
- Klinik für Augenheilkunde, Universitätsklinikum Bonn, Ernst-Abbe-Str. 2, 53127, Bonn, Deutschland
| | - Robert P Finger
- Klinik für Augenheilkunde, Universitätsklinikum Bonn, Ernst-Abbe-Str. 2, 53127, Bonn, Deutschland
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Dunn HP, Marks S, Teo KZ, Dunn SM, Healey PR, White AJ. 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. Clin Exp Ophthalmol 2021; 49:704-713. [PMID: 34291862 DOI: 10.1111/ceo.13977] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/04/2021] [Accepted: 07/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ophthalmoscopy and its interpretation are complex. We aimed to compare the diagnostic accuracy of smartphone fundoscopy with traditional direct ophthalmoscopy for optic disc interpretation, with e-learning support. METHODS We conducted a randomised, crossover study of 102 medical students. Students were offered e-learning for optic disc interpretation. A fundoscopy objective structured clinical examination was conducted after an introductory lecture and 10-min practical training session on smartphone fundoscopy and traditional ophthalmoscopy. Participants examined patients and simulator slides with a randomised crossover between smartphone [D-eye (Padova, Italy) or iExaminer (Welch Allyn, Macquarie Park, Australia)] and traditional ophthalmoscopy (Welch Allyn). Optic discs were graded independently by three masked ophthalmologists. The primary outcome was the ability to interpret an optic disc as normal or abnormal. Secondary outcomes included other optic disc aspects; student preferences; and e-learning performance. RESULTS Students' agreement with the gold standard for an abnormal or normal disc was significantly greater using a smartphone (74.4%) than with direct ophthalmoscopy (68.1%, p = 0.032). More students preferred smartphone (74%) over direct ophthalmoscopy (26%, p < 0.001). E-learning led to an improvement in optic disc interpretation scores (mean improvement = 4.5%, 95% CI = 3.7-5.2, p < 0.001). CONCLUSIONS Medical students are more accurate at recognising an abnormal optic disc using smartphone fundoscopy than traditional direct ophthalmoscopy, and have a strong preference for smartphone fundoscopy. E-learning may improve the interpretation of optic disc abnormalities. Smartphone fundoscopy may mitigate some technical challenges of fundoscopy and reinvigorate use of this valuable clinical examination.
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Affiliation(s)
- Hamish P Dunn
- Northern Clinical School, Royal North Shore Hospital, University of Sydney, St Leonards, New South Wales, Australia.,Westmead Hospital, Department of Ophthalmology, University of Sydney, Westmead, New South Wales, Australia.,Rural Clinical School, University of New South Wales, Kensington, Australia.,Department of Ophthalmology, Port Macquarie Base Hospital, Port Macquarie, New South Wales, Australia
| | - Samuel Marks
- Northern Clinical School, Royal North Shore Hospital, University of Sydney, St Leonards, New South Wales, Australia.,Westmead Millennium Institute for Medical Research, Westmead, Australia
| | - Kai Z Teo
- Northern Clinical School, Royal North Shore Hospital, University of Sydney, St Leonards, New South Wales, Australia
| | - Stewart M Dunn
- Northern Clinical School, Royal North Shore Hospital, University of Sydney, St Leonards, New South Wales, Australia.,Pam McLean Centre, University of Sydney, St Leonards, New South Wales, Australia
| | - Paul R Healey
- Northern Clinical School, Royal North Shore Hospital, University of Sydney, St Leonards, New South Wales, Australia.,Westmead Hospital, Department of Ophthalmology, University of Sydney, Westmead, New South Wales, Australia.,Westmead Millennium Institute for Medical Research, Westmead, Australia
| | - Andrew J White
- Northern Clinical School, Royal North Shore Hospital, University of Sydney, St Leonards, New South Wales, Australia.,Westmead Hospital, Department of Ophthalmology, University of Sydney, Westmead, New South Wales, Australia.,Westmead Millennium Institute for Medical Research, Westmead, Australia
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Jansen LG, Shah P, Wabbels B, Holz FG, Finger RP, Wintergerst MWM. Learning curve evaluation upskilling retinal imaging using smartphones. Sci Rep 2021; 11:12691. [PMID: 34135452 PMCID: PMC8209054 DOI: 10.1038/s41598-021-92232-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 05/31/2021] [Indexed: 12/04/2022] Open
Abstract
Smartphone-based fundus imaging (SBFI) is a low-cost approach for screening of various ophthalmic diseases and particularly suited to resource limited settings. Thus, we assessed how best to upskill alternative healthcare cadres in SBFI and whether quality of obtained images is comparable to ophthalmologists. Ophthalmic assistants and ophthalmologists received a standardized training to SBFI (Heine iC2 combined with an iPhone 6) and 10 training examinations for capturing central retinal images. Examination time, total number of images, image alignment, usable field-of-view, and image quality (sharpness/focus, reflex artifacts, contrast/illumination) were analyzed. Thirty examiners (14 ophthalmic assistants and 16 ophthalmologists) and 14 volunteer test subjects were included. Mean examination time (1st and 10th training, respectively: 2.17 ± 1.54 and 0.56 ± 0.51 min, p < .0001), usable field-of-view (92 ± 16% and 98 ± 6.0%, p = .003) and image quality in terms of sharpness/focus (p = .002) improved by the training. Examination time was significantly shorter for ophthalmologists compared to ophthalmic assistants (10th training: 0.35 ± 0.21 and 0.79 ± 0.65 min, p = .011), but there was no significant difference in usable field-of-view and image quality. This study demonstrates the high learnability of SBFI with a relatively short training and mostly comparable results across healthcare cadres. The results will aid implementing and planning further SBFI field studies.
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Affiliation(s)
- Linus G Jansen
- Department of Ophthalmology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Payal Shah
- Sankara Academy of Vision, Sankara Eye Hospital Bangalore, Varthur Main Road Kundalahalli Gate, Bangalore, 560037, India
| | - Bettina Wabbels
- Department of Ophthalmology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Frank G Holz
- Department of Ophthalmology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Robert P Finger
- Department of Ophthalmology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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Wintergerst MWM, Jansen LG, Holz FG, Finger RP. A Novel Device for Smartphone-Based Fundus Imaging and Documentation in Clinical Practice: Comparative Image Analysis Study. JMIR Mhealth Uhealth 2020; 8:e17480. [PMID: 32723717 PMCID: PMC7424474 DOI: 10.2196/17480] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/17/2020] [Accepted: 04/10/2020] [Indexed: 01/18/2023] Open
Abstract
Background Smartphone-based fundus imaging allows for mobile and inexpensive fundus examination with the potential to revolutionize eye care, particularly in lower-resource settings. However, most smartphone-based fundus imaging adapters convey image quality not comparable to conventional fundus imaging. Objective The purpose of this study was to evaluate a novel smartphone-based fundus imaging device for documentation of a variety of retinal/vitreous pathologies in a patient sample with wide refraction and age ranges. Methods Participants’ eyes were dilated and imaged with the iC2 funduscope (HEINE Optotechnik) using an Apple iPhone 6 in single-image acquisition (image resolution of 2448 × 3264 pixels) or video mode (1248 × 1664 pixels) and a subgroup of participants was also examined by conventional fundus imaging (Zeiss VISUCAM 500). Smartphone-based image quality was compared to conventional fundus imaging in terms of sharpness (focus), reflex artifacts, contrast, and illumination on semiquantitative scales. Results A total of 47 eyes from 32 participants (age: mean 62.3, SD 19.8 years; range 7-93; spherical equivalent: mean –0.78, SD 3.21 D; range: –7.88 to +7.0 D) were included in the study. Mean (SD) visual acuity (logMAR) was 0.48 (0.66; range 0-2.3); 30% (14/47) of the eyes were pseudophakic. Image quality was sufficient in all eyes irrespective of refraction. Images acquired with conventional fundus imaging were sharper and had less reflex artifacts, and there was no significant difference in contrast and illumination (P<.001, P=.03, and P=.10, respectively). When comparing image quality at the posterior pole, the mid periphery, and the far periphery, glare increased as images were acquired from a more peripheral part of the retina. Reflex artifacts were more frequent in pseudophakic eyes. Image acquisition was also possible in children. Documentation of deep optic nerve cups in video mode conveyed a mock 3D impression. Conclusions Image quality of conventional fundus imaging was superior to that of smartphone-based fundus imaging, although this novel smartphone-based fundus imaging device achieved image quality high enough to document various fundus pathologies including only subtle findings. High-quality smartphone-based fundus imaging might represent a mobile alternative for fundus documentation in clinical practice.
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Affiliation(s)
| | - Linus G Jansen
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
| | - Frank G Holz
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
| | - Robert P Finger
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
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Abstract
This article reviews the use of the smartphone in exotic pet medicine. The mobile app is the most instinctive use of the smartphone; however, there are very limited software dedicated to the exotic pet specifically. With an adapter, the smartphone can be attached to a regular endoscope and acts as a small endoscopic unit. Additional devices, such as infrared thermography or ultrasound, can be connected to the smartphone through the micro-USB port. The medical use of the smartphone is still in its infancy in veterinary medicine but can bring several solutions to the exotic pet practitioner and improve point-of-care evaluation.
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