Evaluating the Diagnostic Accuracy of a Portable, Motorized, and Remotely Controlled Slit Lamp Imaging Adaptor Prototype for Head-Mounted Displays.

Purpose: The purpose of this study was to validate the performance of a portable and remotely controlled slit lamp imaging adaptor. Methods: Twenty patients with anterior eye segment conditions participated in a randomized masked clinical trial. Imaging was performed using a Haag-Streit AG, BX 900 slit lamp biomicroscope and a new slit lamp prototype. Three ophthalmologists independently reviewed masked and randomized 2D images from both instruments and conducted physical eye examinations based on these images. Inter- and intra-grader reliability were assessed using kappa statistics, and sensitivity and specificity were determined with reference to the clinical eye examinations performed during the patients' visits. Results: The sensitivity and specificity of the evaluations with the prototype were 47.8% and 64.1%. Similarly, the evaluations from the conventional system obtained a sensitivity and specificity of 49.5% and 66.2%. The differences in the sensitivity and specificity between imaging modalities were not statistically significant (P > 0.05). The intra-grader reliability showed moderate to substantial agreement between the systems (κ = 0.522-0.708). The inter-grader reliability also indicated moderate agreement for the evaluations with the conventional system (κ = 0.552) and the prototype (κ = 0.474). Conclusions: This study presents a new prototype that exhibits diagnostic accuracy on par with conventional slit lamps and moderate reliability. Further studies with larger sample sizes are required to characterize the prototype's performance. However, its remote functionality and accessibility suggest the potential to extend eye care. Translational Relevance: The development of portable and remotely controlled eye imaging systems will enhance teleophthalmology services and broaden access to eye care at the primary care level.

A method for teaching depth of corneal lesions using a portable slit lamp (biomicroscope).

A novel, simple, and inexpensive model for teaching depth of lesions within the cornea using slit lamp biomicroscopy to veterinary students, ophthalmology residents, and general clinicians with access to a slit lamp biomicroscope is described. Using common laboratory items, this method can be created in any clinic and can be used to teach and quiz students through independent study with objective self-testing achieved.

Protocolo Clínico e Diretrizes Terapêuticas da Degeneração Macular Relacionada à Idade (forma neovascular) / Clinical Protocol and Therapeutic Guidelines of macular degeneration related to age (neovascular form)

CONTEXTO: Os PCDT são documentos que visam garantir o melhor cuidado de saúde diante do contexto brasileiro e dos recursos disponíveis no SUS. Podem ser utilizados como materiais educativos aos profissionais de saúde, auxílio administrativo aos gestores, regulamentação da conduta assistencial perante o Poder Judiciário e explicitação de direitos aos usuários do SUS. Os PCDT são os documentos oficiais do SUS que estabelecem critérios para o diagnóstico de uma doença ou agravo à saúde; tratamento preconizado, com os medicamentos e demais produtos apropriados, quando couber; posologias recomendadas; mecanismos de controle clínico; e acompanhamento e verificação dos resultados terapêuticos a serem seguidos pelos gestores do SUS. Os PCDT devem incluir recomendações de condutas, medicamentos ou produtos para as diferentes fases evolutivas da doença ou do agravo à saúde de que se tratam, bem como aqueles indicados em casos de perda de eficácia e de surgimento de intolerância ou reação adversa relevante,

Building the barricade-DIY slit lamp breath shield.

Ophthalmologists were concerned about the risk of SARS-COV-2 transmission via droplets given the close proximity to the patient during slit lamp examination. There is a need to design a simple, low-cost, waterproof breath shield to minimise risk of infection.Dimensions of the Haag-Streit slit lamp (model BM 900) were recorded to guide accurate design of the breath shield. A questionnaire was circulated among slit lamp users on their perceived risk and concern about SARS-CoV-2 transmission and their perception of how effective different designs of breath shields would be at protecting them from an infection. A number of breath shield prototypes were designed and trialled. Plan, Do, Study, Act (PDSA) cycles were used to improve the design. Materials used to create the breath shields included transparent A3 laminating pouches and laminator, two sheets of A4 paper, scissors, hole punch and a ruler. The breath shield was designed to fit over the objective lens on the slit lamp after temporarily removing the standard, manufacturer-provided breath shield, before replacing it. The breath shields were cleaned after every patient with alcohol wipes and removed for deep cleaning with hand soap and water after each session. We used a proof of concept experiment using fluorescein instilled spray to test the effectiveness of each breath shield at preventing droplet transmission to the slit lamp user.Following four PDSA cycles, a breath shield that is user-friendly, easy to clean was produced. The percentage of confidence that the final design would be effective at preventing droplet transmission increased from 5.6% to 80%.Implementation of a low cost, simple to make, transparent, waterproof breath shield together with other forms of person protective equipment (PPE) creates a safe working environment for clinicians and patients. This intervention can be readily replicated and modified for other slit lamp models.

Assessment of the conjunctival microcirculation in adult patients with cyanotic congenital heart disease compared to healthy controls.

PURPOSE: Congenital heart disease (CHD) is the most common live birth defect and a proportion of these patients have chronic hypoxia. Chronic hypoxia leads to secondary erythrocytosis resulting in microvascular dysfunction and increased thrombosis risk. The conjunctival microcirculation is easily accessible for imaging and quantitative assessment. It has not previously been studied in adult CHD patients with cyanosis (CCHD). METHODS: We assessed the conjunctival microcirculation and compared CCHD patients and matched healthy controls to determine if there were differences in measured microcirculatory parameters. We acquired images using an iPhone 6s and slit-lamp biomicroscope. Parameters measured included diameter, axial velocity, wall shear rate and blood volume flow. The axial velocity was estimated by applying the 1D + T continuous wavelet transform (CWT). Results are for all vessels as they were not sub-classified into arterioles or venules. RESULTS: 11 CCHD patients and 14 healthy controls were recruited to the study. CCHD patients were markedly more hypoxic compared to the healthy controls (84% vs 98%, p = 0.001). A total of 736 vessels (292 vs 444) were suitable for analysis. Mean microvessel diameter (D) did not significantly differ between the CCHD patients and controls (20.4 ± 2.7 µm vs 20.2 ± 2.6 µm, p = 0.86). Axial velocity (Va) was lower in the CCHD patients (0.47 ± 0.06 mm/s vs 0.53 ± 0.05 mm/s, p = 0.03). Blood volume flow (Q) was lower for CCHD patients (121 ± 30pl/s vs 145 ± 50pl/s, p = 0.65) with the greatest differences observed in vessels >22 µm diameter (216 ± 121pl/s vs 258 ± 154pl/s, p = 0.001). Wall shear rate (WSR) was significantly lower for the CCHD group (153 ± 27 s-1 vs 174 ± 22 s-1, p = 0.04). CONCLUSIONS: This iPhone and slit-lamp combination assessment of conjunctival vessels found lower axial velocity, wall shear rate and in the largest vessel group, lower blood volume flow in chronically hypoxic patients with congenital heart disease. With further study this assessment method may have utility in the evaluation of patients with chronic hypoxia.

Renal cell carcinoma choroidal metastasis recorded by smartphone with interface eyepiece adapter mounted on slit lamp: A case report.

RATIONALE: Ocular metastasis of renal cell carcinoma (RCC) is rare, and mainly located on the choroid. We report a choroidal metastasis from RCC, which was recorded by a smartphone with an interface eyepiece adapter mounted on a slit lamp. PATIENT CONCERNS: A 45-year-old female presented with 1-month history of painless occlusion of the vision field on the left eye, who had undergone right nephrectomy for RCC 19 months ago. DIAGNOSES: A smooth, hemispherical and brown protrusion was found behind the pupil nasally. An enhanced computed tomography scan of the orbit showed a slightly high-density hemispherical nodule involving the nasal portions of the left eyeball, the enhancement of the lesion was obvious and homogeneous. A metastatic choroidal space-occupying lesion from RCC was highly suspected according to the clinical and radiological findings. INTERVENTIONS: The patient was advised to undergo further treatment, such as radiotherapy. OUTCOMES: The images of choroid metastasis were recorded by the smartphone with the interface eyepiece adapter mounted on the slit lamp handily. CONCLUSIONS: The smartphone with an interface eyepiece adapter mounted on the slit lamp can be widely used to record the precious images in the clinic in a timely manner.

Association of Anterior Uveitis With Acute Zika Virus Infection in Adults.

Importance: Acute anterior uveitis has been reported to be associated with Zika virus (ZIKV) infection in case reports and retrospective studies based on systemic clinical signs of ZIKV and positive serologic tests. Objective: To describe the ophthalmic findings associated with systemic ZIKV infection during the 2016 ZIKV outbreak in Guadeloupe in the French West Indies. Design, Setting, and Participants: This cohort study assessed adult patients with red eye and virologic or serologic confirmation of acute ZIKV infection who were admitted to the Pointe-à-Pitre University Hospital from January 1, 2016, to January 1, 2017, for a systematic ophthalmologic examination. All patients with anterior uveitis also underwent a complete uveitis workup to rule out other causes of uveitis. Patients were excluded from the study if they had active uveitis and a history of uveitis or positive serology for other infectious diseases including dengue fever virus and chikungunya virus. Data were analyzed from January 1, 2016, to January 1, 2017. Exposures: Patients with confirmed ZIKV infection underwent full ophthalmic examination at study inception and 3, 6, and 12 months. Main Outcomes and Measures: Description of the presenting ocular characteristics, management, and outcome. Results: Of 62 total patients with a red eye, 32 (51.6%) had no uveitis (mean [SD] age, 27.8 [3.7] years; 26 women [81.3%]) and 30 (48.4%) had anterior uveitis (mean [SD] age, 27.5 [3.8] years; 26 women [86.7%]), which was bilateral in all cases. Acute anterior uveitis was nongranulomatous and without synechiae, exhibiting mild anterior chamber reaction with small keratic precipitates. Ocular hypertension occurred in 25 patients (83.3%) with uveitis at presentation and persisted in 15 patients (50%) at 1 year despite antiglaucoma therapy and control of uveitis. Uveitis responded to topical steroids in all cases. Intraocular pressure was within normal limits for all patients without uveitis throughout the follow-up period. Conclusions and Relevance: Anterior uveitis was present in almost half of patients with a red eye and acute systemic ZIKV infection; the uveitis was usually bilateral and often associated with increased intraocular pressure. These results suggest that ophthalmic evaluation should be performed in patients with red eye and acute ZIKV infection to potentially detect and manage hypertensive anterior uveitis.

Tolerance to Light of Patients Suffering From Infectious Keratitis.

PURPOSE: With very photophobic patients, the advantages of red or near infrared light to develop new ophthalmology imaging devices seem obvious: no or little glare, possibility of long signal integration, no phototoxicity, and lesser autofluorescence of ocular tissues. Nevertheless, in this range, the shortest possible wavelength facilitates signal detection. The aim of this study was, thus, to determine the maximal irradiance tolerated with 6 wavelengths: 2 red, 2 far red, and 1 near infrared lights to determine the shortest wavelength well tolerated by patients, in comparison with the standard cobalt blue light of ophthalmology slitlamp. METHODS: An interventional, monocentric, single-group assignment study was conducted on 30 eyes of 30 patients with infectious keratitis. Thanks to a customized machine, the photophobic eye was exposed to the 6 lights with increasing intensity. The patients switched off the light when the discomfort was too elevated. The maximal cumulative irradiance possible at 482, 650, 675, 700, 750, and 800 nm were 171, 689, 759, 862, 920, and 889 mW/cm, respectively. RESULTS: The maximal cumulative irradiance tolerated by patients increased significantly with wavelength (P < 0.001), but the difference was not significant between each increment: red at 675 nm gave a significantly higher cumulative irradiance than blue at 482 nm; red at 700 nm did not provide significant gain compared with 675 nm; and far red at 750 nm still provided additional gain compared with 700 nm, but no significant gain was observed between 750 and 800 nm. The shortest wavelengths were stopped more quickly, and more than 50% of patients reached the maximum irradiance delivered by the source at 750 and 800 nm. CONCLUSIONS: We demonstrate that a light source at 750 and 800 nm can be used for ophthalmic imaging with good tolerance in photophobic patients. CLINICAL TRIAL REGISTRATION: NCT03586505.

Safe Slit-lamp Shield: Maintaining a balance between ergonomics and safety.

Since the emergence of COVID pandemic, health workers have been facing major challenges every day. Ophthalmology practice has encountered countless modifications in the practice pattern not to jeopardize patient care and at the same time maintain all safety measures to reduce transmission. One such modification we made was the Safe Slit-Lamp Shield (SSS) which has been found to be extremely protective in differentiation to other available shield. Although SSS has a larger surface area when compared to already available shields, it won't compromise the comfort of the clinician at the same time gives satisfactory protection.

Efficacy of Slit Lamp Breath Shields.

Purpose: To evaluate the efficacy of slit lamp breath shields to prevent droplet spray from a simulated sneeze. Design: Experimental study to test the effectiveness of personal protective equipment. Methods: The nozzle of a spray gun was adjusted to angularly disperse a mist of colored dye that approximated a patient sneezing on a dimensionally accurate cardboard slit lamp model. The designs of 6 commercially available breath shields and 1 breath shield repurposed from a plastic container lid were tested. Each breath shield was sprayed in a standardized fashion 3 times, and the amount of overspray was compared to spray with no shield and quantified. The surface area that was sprayed was calculated using a commercially available software with color range function. The average percentage of overspray of each breath shield was computed in comparison to the control. Results: The breath shields ranged in surface area from 116 to 924 cm2, and the amount of overspray varied from 54% to virtually none. Larger breath shields offered better protection than smaller ones. Breath shields attached to the objective lens arm were better barriers than those of comparable size hung by the oculars. A repurposed plastic lid breath shield, 513 cm2, was slightly curved toward the examiner's face and allowed only 2% overspray. The largest breath shield (924 cm2) hung near the oculars and prevented essentially all overspray. Conclusions: The performance of different designs of breath shields was variable. Even high-functioning shields should be used in conjunction with personal protective equipment including masks, goggles, and gloves and handwashing. Ideally patients should also wear a face mask during all slit lamp examinations.

Commercial Slit Lamp Anterior Segment Photography versus Digital Compact Camera Mounted on a Standard Slit Lamp with an Adapter.

PURPOSE: To compare slit lamp mounted anterior segment cameras (SLCs) versus digital compact camera (DCC) with slit-lamp adaptor when used by an inexperienced technician. METHODS: In this cross sectional study, where posterior capsule opacification (PCO) was used as a comparator, patients were consented for one photograph with SLC and two with DCC (DCC1 and DCC2), with a slit lamp adaptor. An inexperienced clinic technician, who took all the photographs and masked the images, recruited one eye of each patient. Images were graded for PCO using EPCO 2000 software by two independent masked graders. Repeatability between DCC1 and DCC2, and limits-of-agreement between SLC and DCC1 mounted on slit-lamp with an adaptor were assessed. Coefficient-of-repeatability and Bland-Altmann plots were analyzed. RESULTS: Seventy-two patients (eyes) were recruited in the study. First 9 patients (eyes) were excluded due to unsatisfactory image quality from both the systems. Mean evaluation of posterior capsule opacification (EPCO) score for SLC was 2.28 (95% CI: 2.09-2.45), for DCC1 was 2.28 (95% CI: 2.11-2.45), and for the DCC2 was 2.11 (95% CI: 2.11-2.45). There was no significant difference in EPCO scores between SLC vs. DCC1 (p = 0.98) and between DCC1 and DCC2 (p = 0.97). Coefficient of repeatability between DCC images was 0.42, and the coefficient of repeatability between DCC and SLC was 0.58. CONCLUSIONS: DCC on slit lamp with an adaptor is comparable to a SLC. There is an initial learning curve, which is similar for both for an inexperienced person. This opens up the possibility for low cost anterior segment imaging in the clinical, research, and teaching settings.

Microvascular abnormalities in dry eye patients.

This study was conducted to evaluate conjunctival blood flow velocities and microvascular network density in patients with dry eye disease (DED). Twenty-five patients with DED and 25 healthy controls were recruited. The microvasculature and microcirculation of the temporal bulbar conjunctiva of the right eyes were assessed using a functional slit-lamp biomicroscope. Vascular variables included blood flow velocity (BFV), blood flow rate (BFR), microvascular network density and vessel diameter. A fractal analysis was performed using the box counting method to measure the fractal dimension (Dbox) representing the vessel density. The bulbar BFV was 0.59 ±â€¯0.09 mm/s in the DED group and 0.47 ±â€¯0.12 in the control group (P < 0.001). BFR was 169.5 ±â€¯1.8 in the DED group compared to the control group (107.2 ±â€¯49.6) (P < 0.001). Dbox was higher in DED patients (1.65 ±â€¯0.04) than controls (1.60 ±â€¯0.07, P < 0.05). Moreover, the vessel diameter was larger in the DED group (21.8 ±â€¯1.8 µm) compared with controls (17.9 ±â€¯2.2 µm, P < 0.001). Dbox was positively related with ocular surface disease index (OSDI) in patients with DED (r = 0.54, P = 0.008). Microvascular alterations were found in the bulbar conjunctiva of DED patients, including increased blood flow velocity, higher vessel density and larger vessel diameter.

Inter-visit variability of conjunctival microvascular hemodynamic measurements in healthy and diabetic retinopathy subjects.

Conjunctival microcirculation imaging provides a non-invasive means for detecting hemodynamic alterations due to systemic and ocular diseases. However, reliable longitudinal monitoring of hemodynamic changes due to disease progression requires establishment of measurement variability over time. The purpose of the current study was to determine inter-visit variability of conjunctival microvascular hemodynamic measurements in non-diabetic control (NC, N = 7) and diabetic retinopathy (DR, N = 10) subjects. Conjunctival microvascular imaging was performed during 2 visits, which were 17 ±â€¯12 weeks apart. Images were analyzed to determine vessel diameter (D), axial blood velocity (V), blood flow (Q), wall shear rate (WSR) and wall shear stress (WSS). The inter-visit variability was determined based on mean inter-visit differences. In NC, inter-visit variability of D, V, Q, WSR and WSS were 0.2 ±â€¯0.5 µm, -0.01 ±â€¯0.16 mm/s, -8 ±â€¯46 pl/s, -3 ±â€¯46 s-1 and -0.01 ±â€¯0.10 dyne/cm2, respectively. Inter-visit variability of D, V, Q, WSR and WSS were beyond the normal 95% confidence limits in 60%, 20%, 40%, 20% and 20% of DR subjects, respectively. The variability of hemodynamic measurements over time was established in non-diabetic subjects, suggestive of the potential of the method for detecting longitudinal changes due to progression of DR.