THE APP WILL SEE YOU NOW

In the space of a decade, the mobile phone, with an estimated 6.8 billion mobile subscriptions worldwide, equivalent to 96 per cent of the world population, has become arguably the fastest-spreading technology in human history.

Medicine in general, and ophthalmology in particular, have lagged behind retail and business services in embracing mobile phone applications, with regulatory and data security concerns partly to blame for the slow uptake.

But that picture is changing rapidly. For Apple’s popular iPhone and iPad, there are currently more than 60 ophthalmology-related applications available for download in the iTunes store, and more are coming on stream all the time. Many of these apps are now also available for download on other smartphone platforms such as Android, Symbian and Windows Phone.

The applications cover a broad range of clinical and educational use, many free, some with a nominal fee and the most expensive for an eye-popping $550. Some apps such as the Eye Handbook seek to offer a one-stop diagnostic and reference tool for ophthalmologists, while a large number of individual testing or screening apps are available for visual acuity, visual field, contrast sensitivity, toric IOL calculations, glaucoma screening and much more.

Reference and educational apps are also in plentiful supply, giving ophthalmologists instant access to texts such as the Atlas of Ophthalmology or Clinical and Experimental Ophthalmology. More than 3,000 surgical videos can also be consulted on a smartphone via the popular EyeTube application.

Critical mass

“I think we are now reaching a certain critical mass in mobile health applications,” believes Ken Lord MD, a vitreoretinal specialist at Retina Associates of Southern Utah, US, and co-developer of the Eye Handbook, which has logged over one million downloads and more than 25,000 registered users.

“More people are spending time on mobile devices now than at any other period because the functionality has got so much better,” he added.

While younger ophthalmologists have unsurprisingly been the early adopters of mobile technology, their more seasoned colleagues are now following suit in ever-increasing numbers, said Dr Lord.

“There was initially the generation gap but we are definitely seeing more experienced ophthalmologists now catching the bandwagon. Some of these user interfaces for these newer devices are just so intuitive, you don’t need to be particularly tech-savvy to navigate on them and be able to pull out the information you need,” he said.

Much of the momentum behind the uptake in mobile apps is also coming from patients, points out Stephen H Sinclair MD, a retinal specialist in private practice in Media, Pennsylvania, US, who developed the iVFQ app, a quality-of-life, visual function questionnaire based on the National Eye Institute VFQ 25 and intended for use with patients having moderate vision loss associated with ocular disease.

“There is a desire on the part of patients to have more control over their health, with more and more patients proactively asking what they can do to improve their health. We are also seeing huge marketing behind this trend with companies like Microsoft and Google realising that the next big wave of Internet devices are probably going to be 24/7 health monitoring devices. It is really just beginning,” he said.

Dr Sinclair said that the development of the iVFQ app was partly borne out of his own frustration at seeing patients only after retinal disease had already taken hold.

“We usually do not see patients in our offices until they have significant vision loss, most often in the second eye, and by then it is late down the course of the disease process. Unfortunately patients do not come to us prophylactically as they do with their dentist. As physicians we are frustrated because we are seeing things far too late to have significant vision impact even in spite of all the drugs that we give,” he said.

Visual function

The disparity between patients’ scores on traditional visual acuity charts and their real-life experience prompted Dr Sinclair to find a better way of measuring their visual function.

“Very commonly I would see that the measurement on the eye chart did not parallel with what the patients were telling me. The eye chart is the oldest thing in continuous use in medicine today, and it fails every single time. My app enables clinicians to evaluate the effect of clinical treatments and rehabilitative programmes on their patient’s vision in real-world conditions,” he said.

The desire to repurpose tried-and-trusted clinical tests for mobile devices and, if possible, make them better, was also what inspired Christophe Huber MD, a retired ophthalmologist in Zurich, Switzerland, to develop his own Contrast Vision app for the iPad.

While testing patients it became clear to Dr Huber and his co-workers that not only could a type of modulation transfer function be measured and stored, but that they had in the process created a practical low-vision test (App Store “Contrast Vision” 9.9$).

“Measuring visual acuity during the course and treatment of macular pathology is frustrating because of the few large test figures available. With the contrast vision test used in 30cm the range of visible test figures was increased. Testing not only size but also contrast made the function of eyes with a maculopathy accessible to quantitative testing,” he said.

Dr Huber said that the app may be particularly useful to monitor the efficacy of anti-VEGF treatment for AMD patients.

Even without downloading a specific application, most smartphones already have the capability to make life easier for the busy ophthalmologist thanks to the device’s built-in camera, says Allon Barsam FRCOphth, a consultant ophthalmic surgeon in the UK.

“A standard photo application on any smartphone allows you to take very good quality slit lamp photographs of the anterior segment,” he said. “I use the iPhone camera regularly as a way of monitoring disease progress in the clinic or to help explain particular pathologies to my patients. A dedicated slit lamp camera can be expensive and technically difficult to master, whereas the iPhone gives ophthalmologists a quick and efficient way of documenting and recording what is happening with a patient’s eye,” he added.

Colour vision test

Dr Barsam also uses other apps such as the Eye Handbook and Snellen, a free app that includes an Ishihara colour vision test.

“I use it for testing distance, intermediate and near vision. It is especially useful in between operating on patients if the patient is having their eyes done close together where there is not sufficient gap to warrant or justify a clinic appointment,” he said.

Photography is not just confined to the anterior segment. For retinal imaging, researchers at the Massachusetts Eye and Ear Hospital recently developed a simple technique of fundus photography using an iPhone, an imaging app called Filmic Pro and a 20 D lens with or without a Koeppe lens.

Apps may also play an important role in helping ophthalmologists deal with ever-increasing patient numbers as populations grow older and existing services are stretched to breaking point.

“We are already using texting and emails to confirm and follow up surgeries because so many of our patients are now online with their phones and can respond instantly,” said Renato Neves MD, director of the Eye Care Eye Hospital, Sao Paulo, Brazil, and creator of the Eye2Phone app, a collection of commonly used eye tests in one application.

Dr Neves said that his app, which sells for $0.99, has now reached over 50,000 downloads from all parts of the world.

“This was achieved despite the fact that I could not find a sponsor for my app because large companies were not aware of the reach and importance of this application. It is also difficult and expensive to continually upgrade the app for new software versions,” he said.

Customised apps

Despite these obstacles, Dr Neves believes that more ophthalmologists will switch to using customised apps for more efficient patient management and follow-up.

“We are sure to see growth in everything that connects patients to clinics and enables them to administer tests off-site such as macular and glaucoma screening using secure applications,” he said.

One such application already gaining traction in the market is AppVisit, which uses the power of mobile devices to connect doctors and their patients for virtual “visits” using a secure communications platform.

Its co-developer, Harvey A Fishman MD, PhD, an ophthalmologist in private practice in Palo Alto, California, thinks that the demand for such applications is sure to increase as ophthalmologists seek to make more efficient use of their time and resources.

“I think there is no question that the number of patients is going to far exceed the capacity of ophthalmologists to take care of them in the near future. Furthermore, the amount of money that it is going to cost to take care of patients in an office setting is going to be prohibitive. As the United States healthcare system moves towards an increasing number of Accountable Care Organizations (ACOs) spending will shift from physical capital (eg, buildings) to more efficient technology. This trend will only intensify in the coming years,” he said.

Dr Fishman emphasised that AppVisit is not a replacement for one-on-one consultations, but rather a way for practitioners to manage their existing patients more efficiently.

“What the app does is provide the opportunity to triage much more effectively and to treat many of the routine, low-level cases that simply don’t need to be seen in person every time. Patients can take a visual acuity test, use an Amsler grid (for macular degeneration and other detection), snap a picture of their eye and send all that information along with exam questions via AppVisit. If the patient has blepharitis or conjunctivitis and has been seen regularly from month to month, the app enables the doctor to monitor their progress, prescribe or alter treatment and, if necessary, call them in for an office consultation,” he said.

To those who raise concerns about such virtual consultations, Dr Fishman points out that worldwide, there are an estimated one billion phone calls per year (200 million in the US alone) already involve clinicians or nurse practitioners conducting medicine on the phone.

Ken Lord: dr.kenlord@gmail.com

Stephen Sinclair:
ssinclair@stephensinclairmd.com

Christophe Huber:
huber.christophe@gmail.com

Allon Barsam: abarsam@hotmail.com

Renato Neves: renatoneves1@gmail.com

Harvey A Fishman:
drfishman@fishmanvision.com