Alex Walsh

　　Doheny Eye Institute U.S.A

　　Background:We believe that diagnostic technologies exist today that can decrease the cost, increase the efficiency and improve the quality of ophthalmic care around the world. The purpose of this talk is to introduce concepts that may address the growing disparity between numbers of ophthalmologists and numbers of patients due to global epidemics of eye disease, an aging population, and economic uncertainty.

　　The Foundation:One possible solution to the widening disparity between numbers of physicians and numbers of patients could be a simple, inexpensive, automated, patient-operated binocular device containing bilateral optical coherence tomography imaging systems. We feel that a binocular design would be preferable to typical chinrest/headrest ophthalmic device designs since binoculars are relatively ubiquitous, would allow both eyes to be evaluated simultaneously, provide added functionality beyond monocular instruments, can be operated by the patient without the need for a photographer and because they have many fewer components and should be cheaper to manufacture than conventional ophthalmic instruments. This device is still in the concept stage and has not been built or tested. Nevertheless, since it enables four ideas that could have a broad impact on the field of Ophthalmology, we feel that it is important to encourage discussions in this area even at this early stage.

　　Concept 1: Next Generation Biomicroscopy

　　Despite being a cornerstone of modern ophthalmology, slit lamp biomicroscopic examinations are time-consuming, subjective, undocumented, qualitative and difficult to reproduce. Optical coherence tomography (OCT), on the other hand, is fast, non-invasive, objective, documented, reproducible, and can be quantified. Since OCT is uniquely capable, and often superior, at providing magnified, cross-sectional views of transparent tissues in the eye, we feel that Fourier domain OCT images of the entire central axis of the eye, so-called OCT biomicroscopy, may be the next generation of biomicroscopy.

　　Concept 2: Ophthalmic Testing Center

　　Software-driven instruments, like multi-functional telephones, present new opportunities for cost reduction and workflow efficiency. An OCT-based ophthalmic testing center has the unique ability to track a subject's foveal depression or preferred area of fixation, and use their direction of gaze and attention as an input for OCT-based functional testing. Furthermore, binocular devices that receive inputs from both eyes can perform novel analyses, such as automated, quantitative pupillometry and measurements of strabismus.

　　An OCT-based ophthalmic testing center has the potential to perform many or all of the functions of the following diagnostic tests: visual acuity testing, autorefraction, static perimetry, kinetic perimetry, confrontation visual fields, ocular alignment and motility testing, pupillometry, corneal topography, corneal pachymetry, gonioscopy, slit-lamp biomicroscopy, color vision assessments, amsler grid testing, reading speed assessments, contrast sensitivity testing, stereoacuity testing, suppression testing, exophthalmometry, and optical coherence tomography. Since these tests can be self-administered using a binocular device, this instrument could reduce the number of employees required to administer these exams, could collect all data for the physician before they see the patient, could provide a list of diagnoses to consider, and could allow the doctor to order follow-up examinations that can be performed outside of the hospital.

　　Concept 3: Electronic Patient Encounters

　　A single OCT-based, binocular instrument may be capable of performing a comprehensive ophthalmic evaluation in a remote location via patient-administered biomicroscopy and functional or structural diagnostic tests. This could enable electronic, comprehensive consultations between patients and physicians. Online consultations may be more convenient and efficient for select patients who would no longer need to take off time from work for an office visit, would no longer need to travel back and forth to the clinic, and would no longer need to spend time with dilated pupils waiting to be seen by a specialist. Online consultations could also be more efficient for clinicians who may be able to conduct more of these consultations per day, at their own convenience, and without the need for the expensive facilities and staff required to conduct office hours. In addition, for chronic diseases, self-administered eye exams could be used to monitor patients more closely for conditions such as diabetic retinopathy, age-related macular degeneration or glaucoma.

　　Concept 4: Automated Comprehensive Screening

　　Arguably, the greatest impact that an automated, self-administered, comprehensive eye examination system could have would be in screening for eye diseases around the world. The principle difference between this approach and the methods described previously is that the screening instrument would provide immediate, point-of-care risk assessments directly to the user and could recommend ophthalmologists and the appropriate timeline for evaluation for any high risk areas identified. All assessments on this device would be automated at the point of care so that an Internet connection would not be required for operation of this device to facilitate distribution to rural areas and decrease costs.

　　The common binocular design chosen for this instrument should a) make it easy to understand and operate, b) save time by scanning both eyes at the same time, and c) enable scanning of eyes with decreased acuity when fixation is intact in the fellow eye. OCT may be a good modality for screening since it works well through undilated pupils, is sensitive for the detection of subtle problems like macular edema, and is noninvasive and comfortable. The sensitivity and specificity of Fourier Domain OCT for the detection of various diseases in the eye has yet to be determined, although studies are underway currently.