The Problem
As Ophthalmologists, we come across countless interesting fundus cases in our daily practice which we want to capture but do not have the equipment to do so. The reason being not able to take the fundus camera to a patient who is bedridden, at camps or for ROP screening. Although there are handheld fundus cameras in the market, they are expensive and not everyone can afford them especially the post-graduate students. This was exactly what I went through when I used to see patients in ICU and camps/ rural health centers or while seeing my colleagues go through a tedious process of shifting the patient to take fundus photographs.
The Idea
I have always been passionate about photography and when I joined as a post-graduate in ophthalmology, it extended to capturing various fundus pathologies I encountered in the OPD. I had started taking fundus photographs using my smartphone and a 20D lens but taking a decent photograph with the patient rolling his eyes everywhere was quite a task. What I needed was something which would structurally support and hold both the smartphone and the 20D lens together in place. It so happened that one day in the OPD I saw an intern playing with an empty hand sanitizer bottle trying to shoot it into the wastebasket. At first glance it did not strike me but later I thought to myself that it might actually be the one thing which I was looking for and then started the endeavor.
The product and the journey
The sanitizer bottle was a 20 cm long cylinder, which was the perfect distance between the phone and the lens. The next step was to fit the lens into the bottle and I really did not know how to do that. I had to think a lot of different ways to fit it, but most of the techniques involved using sticky tapes or glue which would have made the equipment clumsy and ruined the 20D lens and I was very particular not to get even a scratch on the lens. Days passed by and I still had nothing on it, also nearing was my exam on the topic – Glaucoma. I was reading about trabeculectomy and the rectangular scleral flaps created in the surgery. That’s when it hit me that I had seen so many scleral flaps being made in trabeculectomies, why not use the same technique for the device to fit the 20D lens!!! I started measuring the lens and the bottle to find out the best length and breadth of the flap which would hold the lens. It was actually a strenuous process, cutting the plastic bottle with an 11.no surgical blade and also getting my fingers cut now and then during the process. Although a few days and multiple iterations later, I had perfected the flaps into which the lens snuggly fit. The 20 D lens was kept at the base of the bottle and an outer circular outline was marked. An inner circular outline was drawn such that it was 0.6 cm less than the diameter of the outer outline. The circles drawn were then divided into four quadrants (a, b, c, d). The outer circular outline area of panels a and c and the inner circular outline area of panels b and d was cut continuously which gave rise to flap like structures at area b and d. The flaps were folded inwards and the 20D lens was inserted into the circular hole made at the base of the bottle in a rotational manner. Attaching the smartphone to the bottle was an easy job which required just a smartphone cover and cyanoacrylate glue. The other alternative was to use a smartphone adapter which is easily available on the Amazon app. The lens, the bottle and the phone were aligned in a straight axis such that the lens rim fit exactly within the smartphone display. All I had to do now was to switch on the flash (video mode) and start taking beautiful fundus photographs anytime, anywhere without spending a single penny.
The Technique
This procedure was performed on dilated eyes. The flashlight used in the smartphone was strong enough to obtain clear fundus images. It is advisable to practice the procedure on model eyes or on peers before attempting on any patient as it has a small learning curve. Patient cooperation is a must to get good fundus photographs The patient was explained about the procedure and that it involves shining bright light for a minute or two into the eye. The pupil was dilated using 1% tropicamide with 2.5% phenylephrine, one drop each 2–3 minutes apart for 15–20 minutes until it became dilated. The retinal photographs can be taken in both siting and lying down positions. The patient was asked to look at a target finger with the other eye. The smartphone was set on video mode with the flash kept on in the continuous mode. The 20D lens in fit exactly to the smartphone screen using the zoom option. The room was darkened and the T3 Retcam was placed 3–5 cm away from the dilated eye. The device was supported with the index finger, whereas the middle and the ring finger were used to keep the patient’s eye open. The device was aimed at the pupil to find out the retinal glow and the retinal image was recorded in the smartphone. While recording, the device was moved to focus and get an image free of artifacts. The device was aligned in different angles to take peripheral photographs. The device can also be coupled with scleral indentation though practice is required. Once a satisfactory image was achieved, the patient was asked to lie back and relax. The image recorded was laterally reversed and vertically inverted hence any movement while attempting to align was noticed to be in the opposite direction of the image and could be addressed by recording it with the smartphone placed upside down. There are also innumerable applications such as the HopeScope and Ullmann Indirect, in play store and app store for Android and iOS respectively which help in editing these photos and also allows to adjust the flashlight intensity, focus, exposure, helps invert the images, and also stores name and diagnosis for future reference and follow‐up.
Traits of an innovator
Lateral thinking, persistence and motivation from parents, peers and mentors are all that was needed. No person is too young or old to innovate. It’s just about looking at things a bit differently rather than accepting them as they are.
Roadblocks along the way
The first roadblock was making the flaps to fit the lens into the bottle which was a bit of a challenge. Everything else just fell into place. Getting inputs from my peers helped me a lot in my journey. Each one had something new to add to the device, though something minor but made a huge difference. One instance I can give was adding a matte black chart paper inside the bottle which actually helped reduce the glare and light reflection from the bottle surface. My colleagues were fascinated by the end result – The Trash To Treasure Retcam, a name given by the same intern who was playing with the bottle. They were also very keen to learn how to make it and use it for themselves. We then started using it in OPD, camps, ICU, in our rural health center to document findings and eventually even trained a few anxious interns on how to use it. That’s when I figured out maybe it was time that every post- graduate knew about such a device, not just to take fundus photographs for documentation, but also to learn from the picture they capture, clear doubts with superiors and educate patients about the disease they have, because as I see it patients are convinced more when we show them exactly what they have and what could happen if timely intervention is not taken – as is said, a picture is worth a thousand words.
The second roadblock was creating awareness on how to make and use such a device in ophthalmology among post-graduates and ophthalmologists. The best way to address such a situation was through publishing it in a reputed journal. That’s when I started writing for the Indian Journal of Ophthalmology (IJO). Writing my first article was again a difficult process. There were times I thought of giving up but my mentors had my back, they encouraged and helped me throughout the process. I guess that’s where mentoring comes into play, motivating us when we get low and getting us back on track. Also, I would like to thank the IJO for giving me the opportunity to take the T3 Retcam to ophthalmologists in every corner of the country and also taking the extra leap in projecting the importance of innovation and its impact in ophthalmology.
By,
Dr. Prithvi Chandrakanth,
Aravind Eye Hospital,
Coimbatore