We read with great interest the article by Lamirel et al1 in the July issue regarding the utility of the iPhone 3G (320 × 480 resolution; Apple Inc) for reviewing nonmydriatic color fundus photographs. The study raises important considerations for the use of mobile technology in settings where access to sophisticated photographic equipment is limited. A large proportion of the nonmydriatic camera images were inadequate for clinical use. The authors specified that of the 100 selected images, 50 were inadequate to exclude emergent pathology. This is a limitation of the quality of nonmydriatic photographs obtained in the first place using the Kowa α-D camera and not the iPhone per se. Nevertheless, the authors were able to show that there was excellent interreviewer and intraviewer agreement of image quality between the desktop computer and the iPhone display. This in itself is a validation of their rating scale and an initial indicator of agreement between iPhone displays and desktop screens. However, the inference from this study is that retinal images can be assessed in a telemedicine network with comparable accuracy on an iPhone screen, thereby facilitating rapid identification of emergent pathology. Certainly, the promising results would have been enhanced by obtaining higher-quality images to be transferred and read on the iPhone in the first place. It would be interesting to see a future study from this group comparing diagnoses made when using high-quality images. The use of smartphones as a diagnostic aid has been demonstrated in nonophthalmic specialties such as radiology. The authors make reference to an excellent study by Modi et al,2 who demonstrated a sensitivity of 80% and specificity of 97% in detecting vertebral body fractures on computed tomographic scans on an iPhone by 2 independent radiologists. More recently, Padmasekara et al3 found the iPhone 3GS camera (3.2 megapixels) to be adequate for the interpretation of distal radius fracture radiographs. This suggests that the camera and screen on previous-generation iPhones (3GS, 3.2 megapixels) can also be useful adjuncts in clinical decision making. This is particularly relevant for patients in rural and remote areas where rapid diagnosis and appropriate referral are dependent on identification of clinically important features. We agree with the authors that at present there is insufficient evidence to support the use of smartphone-based imaging for the detection of subtle features of posterior segment disease such as diabetic retinopathy. However, this is unlikely to be far away. In a recent review, Bastawrous et al4 identified a commercially available iPhone slitlamp adaptor (Keeler Apple iPhone 4 portable slitlamp imaging adaptor). Furthermore, Lord et al5 have previously described imaging of the fundus using an iPhone and an indirect lens. In the context of diabetic retinopathy screening, the UK National Screening Committee's photographic specification recommends a minimum resolution of 20 pixels per degree of retinal field imaged, at a maximum image compression of 1:12.6 Using a nonmydriatic retinal camera, Harper et al7 showed that a single, 45° image centered between the optic disc and macula was adequate to determine referable retinopathy. Given that smartphone cameras have an ever increasing image resolution, it is conceivable that in the near future smartphones may provide fundus images to facilitate early referral of patients in low-resource settings. Further validation studies of the photographic capacity of smartphones to screen for conditions such as diabetic retinopathy will enhance their role as a useful adjunct to ophthalmologic consultation. Back to top Article Information Correspondence: Dr Chakrabarti, Department of Ophthalmology, Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye and Ear Hospital, 32 Gisborne St, Level 1, East Melbourne, Victoria 3002, Australia (email@example.com). Conflict of Interest Disclosures: None reported. References 1. 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):939-94022776940PubMedGoogle ScholarCrossref 2. 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):849-85421059550PubMedGoogle Scholar 3. Padmasekara G, Nazarian D, Wall C. The reliability of mobile multimedia messaging (MMS) for decision making in distal radius fractures: an effective alternative. J Mob Technol Med. 2012;1(1):8-12Google ScholarCrossref 4. Bastawrous A, Cheeseman RC, Kumar A. iPhones for eye surgeons. Eye (Lond). 2012;26(3):343-35422399022PubMedGoogle ScholarCrossref 5. Lord RK, Shah VA, San Filippo AN, Krishna R. Novel uses of smartphones in ophthalmology. Ophthalmology. 2010;117(6):1274-1274, e320522335PubMedGoogle ScholarCrossref 6. Atan D, Foy C, Scanlon PH. Reply to “Evaluation of the effect of JPEG and JPEG2000 image compression on the detection of diabetic retinopathy.” Eye (Lond). 2008;22(3):47117992197PubMedGoogle ScholarCrossref 7. Harper CA, Livingston PM, Wood C, et al. Screening for diabetic retinopathy using a non-mydriatic retinal camera in rural Victoria. Aust N Z J Ophthalmol. 1998;26(2):117-1219630291PubMedGoogle ScholarCrossref
JAMA Ophthalmology – American Medical Association
Published: Mar 1, 2013
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