Mobile technology continues to revolutionize how physicians practice medicine, and ophthalmologists are no exception. From having access to the latest medical research at the point of care to being able to communicate at a moment's notice with physicians and colleagues around the world, we are practicing medicine in a technological age.

 

Ophthalmology, as a whole, is a gadget-centered specialty and as such each of us is used to carrying a phone, pager, digital camera and personal digital assistant to keep in communication with the clinic, document findings, access medical information and keep ourselves organized. However in recent years many of us have begun to replace these multiple devices with a "smartphone," which functions as a cellular telephone, camera, pager, PDA and notebook computer. Presently about one out of every two physicians utilizes smartphone, with estimates suggesting that about 85 percent physicians may use a smartphone by 2012. The boom is attributable to the proliferation of medical "apps" and the inherent portable nature of the content. With the plethora of e-mails a doctor receives, having a smartphone enables timely delivery and response.

Smartphones are multifunction electronic devices that can be used to perform photography and videography, Internet browsing, data sharing, listening to music and watching movies. They have been used by physicians for some time as a reference utility, but now, to the ophthalmologist, these devices are much more. Smartphones, and in particular the iPhone/Android phones, have utility in virtually every part of an ophthalmologic examination. With the functionality that we will present in this article, it appears that these devices have secured a place in the ophthalmologist's tool bag.

We believe potential functions of smartphones in ophthalmology can be divided into the following broad categories:

For the purpose of this article we will discuss various smartphone ophthalmology apps currently available. The Apple iTunes store is presently the largest application store with over 200,000 apps available. Many applications are now available on Google's Android platform, which has quickly become a large contender to Apple and by some estimates will surpass its leadership of the application market, largely due to Google's open-source policy and availability through multiple carriers.

 

Examining a patient for the first time in the emergency room or hospital setting can be a hassle, especially with the limited availability of ophthalmologic equipment in these settings. The smartphone has the potential to combine many commonly used clinical evaluation tools into one easy-to-use interface.

Figure 1. The free " Eye Handbook," developed by the authors, puts a multitude of portable tests at the user's fingertips.

No longer do you need to fumble through your overly stuffed white coat pockets to find your bent, faded near-vision card—it's there at the touch of a button on your smartphone. Forgot your color plates in the emergency room? There's no need to skip the test—there's a suitable alternative right in your pocket. While these tools may not replace office-based testing under ideal conditions, with appropriate standardization and acceptance of some testing variability, they can be especially valuable during in-patient consults and emergency room visits. Available tools are near-vision cards, color vision plates, a pupil gauge and ruler, a fluorescein light, a pen light, pediatric fixation targets, a Worth 4 dot test and accommodation targets, Amsler grids, red desaturation tests and an OKN drum simulator (See Figure 1). Several new testing tool applications for smartphones have been and are being developed. Eye Test, Eye Chart, EyeChart RandomEyes, Eye2Phone, and Fast Acuity Life are just a few examples. Our new application for the iPhone is called the "Eye Handbook" (available on iTunes —or free at http://www.eyehandbook.com). This application is one of the most comprehensive ophthalmology applications available and provides most of the above-mentioned examination tools.

 

As we all know, patient education is the process of providing verbal, visual or written material to improve patient understanding of ophthalmic diseases and disease processes. Patient education is provided usually by instruction sheets, brochures and videos about medical conditions. Pharmaceutical representatives have in the past provided these printed materials, eye models and diagrams that help with it. The Internet has changed both physician education and patient education regarding their disease process. Believe it or not, the smartphone can integrate most of these patient education tools and more in your and your patient's palm. We believe it is the most efficient, effective and environmentally friendly mode of patient education available to the physician. At present the ophthalmology patient education apps available at the iTunes store are the Eye Handbook and IKONION. With the Eye Handbook patient education material, you can e-mail the patient the required education material right from your phone, which is a great feature.

  

Figure 2. The " Eye Hanbook" includes a section on ophthalmic coding.

Smartphones can be great reference tools. Various ophthalmic text books and reference programs are available on the smartphones, like The Wills Eye Manual, Epocrates, etc. Various study flash card applications can be downloaded onto your phone, which synchronizes with Google docs and similar programs that allow the physician to make individualized on-the-go study material. An application called "Ophthalmology Clinical Medicine" provides some study flash cards on the iPhone. The Eye Handbook includes various physician reference tools like classifications and grading systems, a useful section on ophthalmic definitions, differential diagnosis, Spanish translations of commonly used ophthalmic terminology, DMV and legal blindness standards for each state as well as workups for common ocular diseases (See Figure 2). It also has a section summarizing the common ophthalmic randomized, controlled trials and their results, and links for a quick reference.

 

There are various applications on different ophthalmic calculators for glaucoma and contact lenses available at the iTunes store. Coding applications are also helpful. The Eye Handbook includes various useful utility calculators like a glaucoma risk calculator, an IOL calculator and back vertex distance calculator amongst others. There is a section on ophthalmic coding that allows the user to search various CPT and ICD codes. There is also a section on modifiers and when to use them.

Also on this list of useful office tools has to be the increasing quality of digital photography that can be captured on smartphones. Newer smartphones have camera resolution in the 8-megapixel range. This rivals the resolution found on any common digital camera, not to mention standard ophthalmic photography. In non-ideal clinical settings, such as in the emergency room, a smartphone can be used to document external photographs of the eye, slit lamp pictures of the anterior segment, fundus biomicroscopy and indirect ophthalmoscopy findings. In addition, they will display suitable images of magnetic resonance imaging and computed tomography scans directly from a liquid crystal display (LCD) computer monitor. The iPhone also has the ability to capture video.

As mobile devices continue to integrate into ophthalmology, special consideration should be given to HIPAA and patient confidentiality. While e-mails containing patient information and clinical photos can be sent securely with encryption, appropriate documentation of patient consent must be obtained. It should always be remembered that patient information must be protected and established guidelines adhered to.

In addition, there have been many applications geared toward integrating smartphones into existing EMR platforms. There will likely be continued improvement in the way that smartphones are utilized as their interfaces continue to improve.

The ophthalmic utility of smartphones will continue to evolve and improve over time. This dynamic interface has great functionality at present, and it has vast potential for future growth in the field of ophthalmology. Physicians appear to be embracing mobile technology at a faster rate than the general population, and ophthalmologists are no exception. Smart-phone applications in ophthalmology look like they will play a greater role in everyday patient care and education.