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T. Das et al.
ness [12]. Given its portability, ease of use, and
non-requirement of local anesthesia, a rebound
tonometer is also useful for monitoring IOP in
children and mass screening for glaucoma.
35.5 External Eye Examination
The external eye structures include the eyelids,
tissues surrounding the eyes, conjunctiva, and
lacrimal apparatus. A pocket ashlight is usually
sufcient to conduct an external eye
examination.
Technique: One looks for asymmetry of the
eyes, prominence of one/both eyes, improper closure of the eyelids, eye alignment and ocular
motility and any unusual eyeball movements, the
health of lid margins (mucus or pus discharge,
scales, or lumps), conjunctiva of both lids (upper
lid conjunctiva can only be observed by everting
the upper lid), lacrimal apparatus (tearing, discharge on pressure over the lacrimal sac), or any
other eye defects, such as anophthalmia, microphthalmia, coloboma, or any mass lesions during an
external examination of the eye.
Clinical Application: Many systemic diseases
manifest in the eyes. Metabolic disorders such as
hyperthyroidism cause changes in the tissues surrounding the eye, thereby altering their appearance and functionality. Changes in the autonomic
nervous system alter the position of the eyelids.
While abnormal lipids may be deposited on the
lids, abnormal heavy metal deposits may be seen
in a specic ring near the edge of the cornea.
Abnormalities of the lacrimal system may produce either tearing or dry eyes. Rheumatoid
arthritis or collagen diseases may decrease tear
and mucus production, causing dry eyes. There
could also be localized bacterial, viral, or fungal
infections of the lids, conjunctiva, and cornea.
35.6 Visual Field
Visual eld testing is integral to diagnosing glaucoma and a few neuro-ophthalmic conditions. It is
also used for follow-ups and monitoring of these
conditions. Standard automated perimetry (SAP)
is the current gold standard of visual eld testing.
This technique quantitatively assesses an individual’s visual function across the eld of vision. It
determines sensitivity thresholds (ST) at specic
retinotopic locations to measure the visual eld.
However, it is not without limitations. In addition
to its cost, SAP acquisition takes around 6–8min
for each eye, during which the patient is required
to maintain high levels of concentration [13].
Such long acquisition times, combined with the
slight forward-leaning position of the subject, can
be uncomfortable and taxing. Some of these limitations can be overcome by using portable alternatives. One such modality is the head-mounted
device (HMD) system. The HMD, along with its
accompanying tablet PC and handheld controller,
has the advantage of being low cost, having a
shorter testing time (under 3 min for each eye),
being portable (can be used in an examination
chair), and a having more exible options than the
traditional method of visual eld testing. The
HMD can also perform 10–2, 24–2, and 30–2
visual elds in addition to contour stereo testing
[14]. The Order of Magnitude (OM) is an HMD
device described below.
35.6.1 Order ofMagnitude
Order of Magnitude is a virtual reality-based
perimetry device.
Technology: The OM allows static automated
perimetry using a customized supra-thresholding
algorithm. The test is very similar to a conventional perimetry test using a Humphry Field
Analyzer (HFA) machine, where patients respond
using a clicker. The test is done in two steps:
determining the fovea threshold and visual eld
testing. (Fig.35.7).
Technique: The fovea thresholding uses a
staircase testing method and nalizes the threshold after two reversals. The visual eld testing
uses a standard 24–2 test grid with 54 testing
points (each point is 6° apart). The reliability of
the test can be monitored using xation losses
and false positives, which are tested during the
visual eld testing. The device uses Heijl-Krakau
blind spot tracking to check for xation losses.
While the OM tests for false positives by giving a
blank or no stimulus and checks for a click
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Fig. 35.7 (a) The OM visual eld showing superior alti-
tudinal eld defect. (b) VR-based OM visual eld analyzer device. (c) A patient wearing the headset and the
response, it does not check for false-negative
responses as the testing algorithm takes the best
two-of-three responses for a light stimulus level.
Clinical application: On comparing a customdesigned VR perimeter with a conventional
visual eld-testing device (Octopus 900; HaagStreit, Bern, Switzerland), the VR perimeter
slightly underestimated the visual eld defects in
glaucoma subjects (1.4dB). However, there was
no signicant bias with respect to eccentricity or
subject age [14]. The OM can be used reliably to
detect visual eld defects caused by glaucoma
and other neuro-ophthalmic conditions [15, 16].
35.7 Examination oftheAnterior
Segment
A detailed examination of the anterior segment is
best performed with a slit lamp. A slit lamp is a
stereoscopic biomicroscope that emits a focused
beam of light with variable height, width, and
examiner pairing the device to the smartphone. (d)
Fixation target. (e) High decibel stimulus
angle. It allows three-dimensional visualization
and measurement of the ne anatomy of the
adnexa and anterior segment of the eye. It is a
mainstay of the comprehensive eye examination.
Documenting slit lamp images can help in furthering patient care. Typically, a slit lamp is a tabletop
device housed in an eye clinic with large spaces.
The new portable slit lamps are as versatile as the
tabletop ones but less expensive. This has largely
benetted teleophthalmology and home care. A
description of a modular portable slit lamp and
anterior segment imaging device follows.
35.7.1 HOLDEN ™ (Modular Slit Lamp
withApplanation is
aHandheld Slit Lamp)
Technology: This compact and adaptable handheld
ophthalmic device operates with a smartphone. It
consists of multiple modules, such as anterior segment imaging with slit functionality, tonometry
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Fig. 35.8 Left: modular slit lamp; Middle: slit module; Right: tonometer module
T. Das et al.
based on the Goldmann applanation mechanism,
and corneal topography, among others. (Fig.35.8)
These modules can be effortlessly interchanged
using high-power neodymium magnets, facilitating
seamless, and comprehensive eye examinations.
The slit module width is 0.2mm, and the tonometry module incorporates the standard applanation
bi-prism technique. Additionally, the device offers
a corneal topography module capable of generating
axial and tangential heat maps.
Technique: Modular slit lamp is held against
the forehead (Fig.35.8, middle panel) for anterior segment examination, IOP measurement,
and corneal topography as an optional
attachment.
Clinical Application: The modular slit lamp
has the advantage of storing the images while
performing the anterior segment examination.
This handheld device can also be used in people
in a supine position. It is useful for home care,
teleophthalmology, and primary and secondary
care level centers.
35.7.2 Grabi ™ is aDevice toImage
theAnterior Segment
oftheEye
Technology: Smartphones have powerful cameras for general photography. But the variability
in their features and lack of appropriate tuning
makes them unsuitable for macro-ophthalmic
photography. Grabi images the anterior segment
of the eye, mainly the conjunctiva and cornea. It
can be operated directly by the patients, irrespective of the kind of smartphone they possess
(Fig.35.9). The Grabi has specically designed
hardware and a specically congured app. The
app ne-tunes the native smartphone camera and
ashes by adjusting the magnication, illumination, and focus to get a good-quality image of the
cornea, limbus, iris, and lens.
Technique: The spacer device is mounted on
the smartphone, as shown in the gure by the
user (patient’s relative or caretaker), in such a
way that it does not obstruct the camera lenses
and ts snugly. The distal end of the spacer
should touch the forehead of the patient; this acts
to provide mechanical support to stabilize the
hand and smartphone and also align the camera at
a set distance from the eye of the patient. The app
is then engaged so that the user aligns the cornea
and iris within the center of the screen. To help in
this process, a simple white circular graticule
appears on the screen as a guide, assisting the
users in aligning the cornea and iris within it and
tapping on the screen to capture the image. The
process is simplied and user-friendly because
the user is trained to obtain images of the patient’s
eye on their smartphone camera. This simplies
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Fig. 35.9 Upper panel: left-Grabilite™ device; Upper
right: Grabi app must be paired to the smartphone. Lower
panel: Left and Middle: the guide must be xed to the
the learning curve, and users can acquire good
anterior segment images.
Clinical Application: These images are sent to
the consulting clinician via the teleconsultation
forehead above the eyebrow. Right: the dotted circle
shows the area of interest for photography
platform, which helps manage the follow-ups and
medications more effectively. These images are
also stored in the cloud. Further applications
include utilizing AI, deep learning algorithms,
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Fig. 35.10 Left Panel (a) shows the segmented diagram
of the key elements of the custom-designed dynamic
pupillometer. (b and c) Light stimulation channel used in
the 488 Pupil+ device. (d) Plots the spectral power distribution as a function of the wavelength of the LED used in
the device for stimulating the pupillary light reex. (e)
The device in use and the LCD screen- based user interface for initiating the test; observing the progress of the
test in real-time
and computer vision to improve the quality of the
images, helping patients obtain better images,
and identifying the at-risk signs to be agged for
further medical or surgical intervention.
35.7.3.1 Pupil-Lite (Device
forAssessing thePupil)
Technology: The device uses image processing to
acquire the raw diameter of the pupil and then
runs through the algorithm in the cloud to esti-
35.7.3 Pupil
mate the pupillary parameters. It uses an edge
identication algorithm. (Fig.35.10).
Examination of the pupil is important to monitor
the health of the eye. Testing for relative afferent
pupillary defect (RAPD) is an important test. The
RAPD grading can be automated using the concept of the swinging ashlight test, and the pupil
response can be quantied to reduce subjectivity
and test variability.
Technique: The device is held up to the
patient’s face, and the patient is instructed to look
into it like they would look into a pair of binoculars. The device is connected to a computer that
displays live video feeds from the two cameras.
When the device is in place, the person administering the test clicks on the center of each pupil.
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This allows the image processing algorithm to
use edge identication techniques to identify the
pupil diameter for each frame. The rest runs at a
speed of 30 frames per second. Once the test
begins, the cameras start recording.
Clinical applications: [17] (1) Grading of
RAPD; (2) monitoring the pupil size before and
after any intervention, including neurological
interventions; (3) documenting pupil size and
shape.
35.8 Fundus
Classically, fundus examination is done by a
handheld direct or head-worn indirect ophthalmoscope. While pupil dilatation may not be necessary for fundus examination with a direct
ophthalmoscope, it is nearly always required for
indirect ophthalmoscopy. However, one should
remember that an undilated eye exam is not
complete.
35.8.1 Direct Ophthalmoscope
Technology: The direct ophthalmoscope
(Fig.35.11) contains a handle with a battery and
a head. The head contains a bulb, a set of apertures for the light source, and a set of lenses. The
light source is bright enough to evaluate the
pupil. A cobalt blue lter is often built into the
instrument for use with uorescein staining of
the cornea. The direct ophthalmoscope provides
a monocular, non-stereoscopic, narrow eld of
view, but it is magnied. Light from a bulb is
reected at right angles and projected as a spot
through the patient’s pupil to illuminate the retina. The illuminated retina is seen directly by the
examiner.
Technique: Using mydriatics for direct ophthalmoscopy is generally unnecessary, but a weak
mydriatic agent (0.5% or 1% tropicamide or
2.5% phenylephrine) is a good choice when
required. The patient must sit in a comfortable
position so that his/her head is at the level of the
examiner. A dim light helps. The patient then
xes his/her gaze on an object across the room
without looking directly at the light. When the
patient is comfortable, the examiner should start
at a distance of at least arm’s length. The examiner looks through the hole in the ophthalmoscope and approaches the patient’s eye gradually
until the red reex of the retina is visible. Once
the retina is in good focus, it is critical to then
maintain this axis of alignment. The −3 to −4 D
lens on the ophthalmoscope usually generates a
comfortable view of the fundus. The examiner’s
left eye is examined by the patient’s left eye,
standing on the patient’s left side, and vice versa.
Usually, removing the examiner’s eyeglasses is
unnecessary, but one must remove the patient’s
Fig. 35.11 Direct ophthalmoscope. Left: optics; Right: the device. (Source: Ismael Cordero. Copyright 2016, used
under the Creative Common Attribution 2.0 license) [18]
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glasses (no need to remove contact lenses, if
any).
Clinical Application: Even in undilated eyes,
examination with the direct ophthalmoscope can
give useful information on the clarity of the ocular media and refractive error. A diminished red
reex or irregularities might result from cloudy
media (e.g., corneal or lens opacities, blood in the
vitreous) and unusual/high refractive errors. The
direct ophthalmoscope evaluates the optic nerve
head, retinal vessels, and macula.
35.8.2 Indirect Ophthalmoscope
The (binocular) indirect ophthalmoscope is worn
on the examiner’s head, and it is sometimes
attached to spectacles for fundus examination. It
produces a stereoscopic image of the fundus.
Technology: The viewing system of the instrument (Fig. 35.12) consists of a pair of lowpowered convex lenses. This design affords the
examiner a stereoscopic view of the virtual image.
The lens condenses light from the illumination
system towards the patient’s pupil. Light reected
from the retina passes back through the lens, creating a real, horizontal, and laterally inverted
image of the fundus between the lens and the
examiner. A+20 D lens is the standard lens for
general examination offering 3× magnication
and approximately 45° elds of view. A+30 D
lens is sometimes used for small children and/or
in eyes with small pupils; it provides 2× magnication and approximately 65° elds of view.
Technique: In a dark room, the examiner orientates his/her head so that light from the internal
light source is directed into the patient’s eye. The
examiner then holds a positive-powered condensing lens from the patient’s eye at its focal length.
(Fig.35.12) The patient’s pupils must be dilated
for retinal examination using an indirect ophthalmoscope. The patient is asked to look straight up
at the ceiling if supine or over the examiner’s
shoulder if seated. The condensing lens is grasped
with the index nger and thumb. The examiner
uses one or more of the spare ngers of the same
hand to brace against the patient’s forehead to
steady the lens. The right eye is examined by
holding the lens in the right hand, with the examiner standing on the patient’s right side, and vice
versa. The other hand is used for scleral indentation as and when required. Typically, the extreme
periphery is examined rst, working towards the
equator along the 12 o’clock meridian. Having
examined the entire retina from the equator to the
ora serrata in each quadrant, the procedure is
completed by examining the posterior pole.
When seeking to sweep the view across the retina
(e.g., from the extreme periphery to the equator),
it is vital to maintain a direct line between the
observation system, the center of the condensing
lens, and the patient’s pupil, referred to as the
“common axis principle.”
Clinical Applications: The indirect ophthalmoscope is exceptionally valuable for detecting
retinal detachments, retinal holes, and retinal
tears. The comparison of indirect and direct ophthalmoscopy is shown in Table35.4.
Fig. 35.12 Indirect ophthalmoscope. (Source: Ismael Cordero. Copyright 2016, used under the Creative Common
Attribution 2.0 license) [19]
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Table. 35.4 Comparison between indirect and direct ophthalmoscopy
Parameter Indirect Ophthalmoscopy Direct Ophthalmoscopy
Condensing lens Required Not required
Examining distance Arm’s length As close to the patient as possible
Field of view (diameter) 20D—45°; 30D—65° Small (approximately 10°)
Magnication 20D—3x; 30D—2x Approximately 15x
Structures viewed Peripheral retina seen Only the central retina seen
Brightness More Less
Stereopsis Binocular—Superior stereopsis Uniocular—Non-stereoscopic
Image of fundus Inverted and virtual image Erect and real image
Scleral indentation Easily achieved Difcult
Retina anterior to the equator More easily seen Can be seen with difculty
Visibility in hazy media Better Poor
485
35.8.3 Integrating
Teleophthalmology
withHome Eye Care
Technology is increasingly important to reach
the last mile in eye care [20]. In addition to
improving accessibility, it also reduces the cost
of care [21]. To reach the unreached and meet
the 2030 sustainable development goals, the
World Health Organization has suggested adopting an integrated, people-centered eye care
(IPEC) model that caters to eye care from primary to tertiary levels [22]. Vision centers are
part of one such model adopted in India that provides in-person services to around 50,000 people
in remote rural and tribal regions [23]. Using
newer technology, these vision centers can connect to secondary and tertiary care, and one
could expand teleophthalmology from the vision
center to home care [24].
Another method is the use of mobile services
for home eye care. All devices used in home
care are lightweight and portable. These are
packed in a box, and typically one allied ophthalmic personnel trained explicitly for home
care drives a two-wheeler carrying the box.
(Fig.35.13) Mobile home eye care generally is
a hybrid teleophthalmology asynchronous/synchronous model. In this model, a eld team visits the individual’s home, records vision,
performs refraction, measures intraocular pressure, obtains high-resolution anterior and posterior segment images, and uploads these to the
electronic medical record in the examination
site (possibly cloud-based). This facilitates the
ophthalmologist’s video consult in real-time
(synchronous) or at a pre-decided time (asynchronous) to treat the patients. Medical prescriptions reach the individual electronically,
and the patients are invited to visit xed eye care
facilities for investigations and/or surgery as
needed.
The advantages of integrating home eye care
with xed eye care centers include:
• Suited for individuals of vulnerable age
groups (extremes of age) and those who are
sick and/or homebound. Following the tests at
home, the individuals can be referred for specic investigations to xed eye care facilities
where these could be fast-tracked for comfort
and convenience.
• Reduce the number of visits for those suffering from chronic eye conditions like glaucoma, uveitis, and diabetic retinopathy.
• Avoids over-crowding at xed-capacity eye
care facilities.
• Continuity of care is maintained as data points
recorded at the home visit get integrated into
the individual’s medical record.
• Scalability: Home eye care (synchronous or
asynchronous) is offered within 10–20km
of the fixed eye care centers. Integration
with eye care at the district, state, or
national level can ensure that eye care is
delivered at the last mile across the region
and reach all those who cannot reach a
hospital.
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Fig. 35.13 (a) Electric scooter with a box containing the
ophthalmic devices used in home eye care. (b) The devices
inside the box; (c) fundus photography; (d) slit lamp
examination and imaging. (Images “c” and “d” are reproduced after signed written consent
could be too old to reach the eye care facility inde-
35.9 Conclusion
pendently due to low/no family support. In these
instances, teleophthalmology and home eye care
There are two compelling reasons for the increasing use of teleophthalmology. These are population growth and population aging. The Global
would be useful. Although technology has now
made this more accessible and safer than before, it
is only the beginning to reach the last mile.
Burden of Disease has estimated that nearly onefourth (2.2 of 8 billion) of the world population
needs eye care for distance and/or near vision
[25]. Thus, one would expect more people to need
ophthalmologists for their eye care. However,
there are insufcient human resources for health
to meet this demand [26]. In ve decades (1970–
2022), the global mean age has increased from 20
to over 30 years [27]. Most eye diseases that
require medical/surgical attention beyond a pair
of spectacles occur in the elderly, and approxi-
Acknowledgments Kartikesh Anche, Rahul Negi, Amir
Ali, Vineet Joshi, and all members of Center for
Technology Innovation, LVPEI, Hyderabad, India.
Funding Hyderabad Eye Research Foundation,
Hyderabad, India.
Disclosure KN: Employee of Remidio Innovative
Solutions Pvt Ltd, Bangalore, India.
Others: None.
mately 10% of the world population is 65years or
older [27]. Thus, an increasing number of older
adults will need eye care. However, many of them
do not have timely access to eye care either
because of other ailments such as multimorbidity
and/or multi- disability (in one elderly residential
care study in India, these were 37.6% and 23.6%,
respectively [28]). In addition, these older adults
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