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ALL INDIA OPHTHALMOLOGICAL SOCIETY

ISSN : 0301-4738

Vol 67, Issue 06, June 2019

IJOIndian Journal ofOphthalmology

Open access at

http://www.ijo.in

Indian Journal of Op

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© 2019 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

Original Article

Smartphone guided wide-field imaging for retinopathy of prematurity in neonatal intensive care unit – a Smart ROP (SROP) initiative

Anubhav Goyal, Mahesh Gopalakrishnan, Giridhar Anantharaman, Dhileesh P Chandrashekharan, Thomas Thachil, Ashish Sharma1

Purpose:   To suggest a low cost, non-contact smartphone-based screening system in retinopathyof prematurity (ROP), and to illustrate its potential clinical application  as a potential future tool forteleophthalmology. Methods: Neonatal intensive care unit (NICU)-based bedside ROP screeningdone between January 2018 andMay 2018. Documentation of ROP was done by using a smartphoneand +40D, +28D, or +20D indirect non-contact condensing lenses. By using the coaxial light source ofthephone, this systemworksas an indirectophthalmoscope that creates adigital imageof the fundus.With smartphone-based camera we extracted high-quality still images extracted from the video clip.Results:Totalof228eyesof114infantsscreenedforROPbetweenJanuary2018andMay2018.Incidenceof totalROPwas 23.68%,out ofwhich incidenceof type 1ROPwas 8.77%.After initial screeningwithindirect ophthalmoscope, we uesd  smartphone imaging to document ROP in 28 eyes out of 55 eyeshavingROP.Image qualitywasgoodin89.28%eyes.Fieldofviewvaryfrom46°,53°,and90°with+20D,+28D, and+40D indirect condensing lenses, respectively,whichgives excellent images forbedsideROPdocumentation.Conclusion:Thedescribedtechniqueofsmartphonefundusphotographyisalightweight,cost-effective, user friendly, high-quality wide-field fundus photographs for  bedside documentationofROP inNICUsusing readily available instruments that are handy andportable with simple power sources.Smartphoneshasthepotentialtobeoperatedwithonlyonehand. Itcanalsobeusedasafuturetelescreeningdevice.

Key words:Condensinglens-Smartphone-MIIRetCam(CSM)deviceassembly,neonatalintensivecareunit,retinopathy of prematurity

DepartmentofVitreo-Retina,GiridharEye Institute,Cochin,Kerala,1DepartmentofRetina,LotusEyeHospitalandInstitute,Coimbatore,TamilNadu,India

Correspondence to:Dr.AnubhavGoyal,Giridhar Eye Institute,PonnethTempleRoad,Kadavanthra,Cochi-682020,Kerala,India.E-mail:dranubhavgoyal@gmail.com

Manuscriptreceived:02.08.18;Revisionaccepted: 06.01.19

Retinopathy of prematurity (ROP) is a leading cause ofchildhoodblindnessworldwide. In India, the incidenceofROP is increasingbecauseof expandingneonatal care andimprovedneonatal survival rate. The incidenceofROP inIndiaisreportedbetween38and51.9%inlow-birth-weightinfants.[1]AccordingtoearlytreatmentforROPearlydetectionand prompt treatment can reduce unfavorable outcomessecondarilytotype1high-riskprethresholdROP.[2] In present study,earlydetection, imageacquisition,andinterpretationaredonebyanexperiencedophthalmologist.

The current gold standardmethod forROP screeningrequires indirect ophthalmoscopewith the condensinglens.[3]Nowadays,digitalfundusphotographyisusedinROPscreeningtofacilitateconsultationindifficultcasesandalsocontribute tomedicolegalaffairs.However, it isnoteasy totakeafundusphotographofanewbornwithoutprofessionalequipment such as theRetCam system,[4]which is costlyandunaffordable inmost of the localmedical healthcaresystems.Theeaseofuse,portability, and cost-effectivenessof smartphone fundoscopy can share the advantages of

telemedicine,eithertodocumentthefundusstatusortoconsultan experienced senior ophthalmologists and alsohelps inmedicolegalaffairs.[5]Besides,thelightsourceofsmartphonesissafeforhumaneyes.Retinalirradiancefromsmartphonesislessthanthatfromanindirectophthalmoscope.[6]

Thesmartphonehasbecomethebasicnecessity intoday’sworld.Withadvanced technologyandeaseofhandling forcapturingimagessmartphonesarecommonlyusedastheclinicalimagingdeviceinophthalmology.[7]Modernsmartphonecameraisalreadyequippedwithahigh-qualityopticalsystemandacoaxiallightsource,whichcanbeusedtocapturehigh-qualityretinalimages.Variousapplicationsanddevicesareavailableforsmartphonecamerasthatnotonlyincreasestheimagequalityoffundoscopy,butalsocost-effectiveandgiveeaseofhandlingwhilecapturingROPimages.[3,8]Inthisstudyweusedcondensinglenswithsmartphoneattachedtocost-effective,handy,mobile,non-contactdevice to capturewide-fieldandgoodbedsidefundusimagesofROPinfantsinanIndianpopulation.

Cite this article as: Goyal A, Gopalakrishnan M, Anantharaman G, Chandrashekharan DP, Thachil T, Sharma A. Smartphone guided wide-field imaging for retinopathy of prematurity in neonatal intensive care unit – a Smart ROP (SROP) initiative. Indian J Ophthalmol 2019;67:840-5.

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June2019 841Goyal, et al.: Wide field smartphone ROP initiative

MethodsItisanobservationalstudy. Bedsidefundusimagesofpreterminfants initially screenedwith indirect ophthalmoscopeand diagnosed having ROPwere captured in neonatalintensive care unit (NICU) between January 2018 toMay2018.Allinfantswereawakeduringfundusexaminationandsmartphone imaging.Pupilswere welldilatedusing 0.4%tropicamide+2.5%phenylephrineeyedropsthreetimestillfulldilatationoccurredandonly2%proparacainedropsastopicalanesthesiawas administered for applying apediatricwirespeculumandperforminggloberotation.Onenurseassistedin holding infant’s head stable.

Imageswere capturedwith a smartphone, iPhone 5S(Apple Inc., Cupertino,CA,USA)   and either 20D, 28D,or 40D lens (VolkOptical Inc.,Mentor,OH,USA). 20D,28D, and 40D lenses give a field of viewof 46°, 53°, and90°,respectively.[3]Since, it isan initialexperiencewetriedcapturing images fromall threedefined lenses randomly.Condensinglensandasmartphone(iPhone5S)underoriginalcamera settings isused to recordavideo,with a constant,coaxial inbuilt light source and capturing snapshotsoutofthe videohelpus indocumentingROP.  MIIRetCam (aninventionused for capturing adult fundus byDr.AshishSharma),[9]wasusedtoholdlensandsmartphoneatafixedworkingdistance[Fig.1].Alternately,aself-designeddeviceconsistingof40mmdiameterwideand15cmlongpolyvinylchloride (PVC)pipepaintedmattblack from inside (blacktube), smartphone attached at one endwith the help ofuniversalmobile holder available online and condensinglens stabilizedonother endof tubewith thehelpofblackelectricalinsulationtape,canbeusedtocapturesamequalityimages [Fig.2].Theautofocuscapabilityofsmartphonecameramaintainstheimagequalitytoperformindirectfundoscopy.Thepupilshouldbefullydilatedtoreducelightreflections.Condensinglens-smartphone-MIIRetCam/blacktubedeviceassembly(CSD)wasturnedtodifferentanglestoimageretinalperiphery.CSDassemblywasalignedinastraightaxisataparticulardistance,stabilizedwithinfants foreheadsupportbyonehandandanotherhandcanbeusedoccasionallytorotatetheglobewithpediatricwirevectis,forbetterperiphery

visualization. It isa singleexaminer techniquewithout theneedofanyassistantduringimagecapture.Singledevicecanholdallthelensesdescribedwithanadditionallensholder.Ophthalmologistholds“lensholdingcuff”ofCSDassemblytotakeretinaimages.

Thelensshouldbecleanwithoutanydustparticlesonit.Otherwise,itmaymisleadtheautofocusofthephonecamera.Theeyelidswerewidelyopenedbytheuseofpediatricwirespeculumandpupil shouldbe  fullydilated in aminimalilluminated room tominimize glare during fundoscopy,with thenursemonitoring the infantduring the courseofexamination.Hazyvitreousandvasculosalentiswereotherreasonswhichhamperedgoodquality image acquisition.Theinfant’scorneashouldbekeptmoistwithsteriledistilledwater. Through a clearmedium, the iPhone camera canautomatically focuson the retina.The recordingwasdonebyuniversally available inbuilt videomodeof smartphoneforapproximately1mindurationandthevideowaskeptonduring thewhole examination.Videomode automaticallyfocuses to give clear imaging. If the light reflection is toosevere,thelightintensitycanbereducedbycoveringtheflashwitha layerofmicropore tape (3M,St.Paul,MN,USA).[10] Once recordingwas completed, still imageswere capturedfromthevideosequencebytakingascreenshot(bypressingandholdinghomeand sleep/wakebutton simultaneously).Videosweretakenat30fpsat1080presolution,with1mincapture fileswere 150–200MB in size. Screenshotswere1–2MBatmaximumresolution.However,wefoundthatthesefiles couldbe compressedon transmission through securee-mail/WhatsApp softwaredown to approximately 100KBandstillbeadequate forclinicaluse.   Imagescapturedandreadbya single examiningophthalmologist. These imageswere also transferred for explaining to (ophthalmologist andneonatologists) elsewhere by internet-guided inbuiltsoftwares in smartphone, customizing telemedicine inROPscreening.Examineravoidedimagingininfantswithphysicalbarriers around the eye, such as the obstructivemodes ofventilatorysupport,poorlydilatingpupil,andeyeswithhazymedias,allofwhichmayaffectimagequality.

Figure 1: Technique of Smart retinopathy of prematurity (ROP) and field of view from different condensing lenses – (a) showing technique to hold condensing lens‑smartphone‑MIIRetCam (CSM) device assembly while ROP screening, (b) shows field of view of 30° from +20D lens, (c) field of view of 55° from +28D lens, (d) field of view of 90° from +40D lens, (e) showing technique to rotate the globe with pediatric wire vectis to visualize retinal periphery

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Figure 2: Make It Yourself (MIY) assembly and technique of Smart retinopathy of prematurity (ROP) and field of view through 40D condensing lenses – (a) showing MIY device assembly, (b) technique to hold condensing lens‑smartphone‑black tube (MIY) assembly while ROP screening, (c) shows field of view from +40D lens, (d) stage 3 ridge and avascular retina, (e) plus disease with dilated and tortuous vessels, (f) fresh laser marks, (g) scars marks after laser treatment

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842 Indian Journal of Ophthalmology Volume67Issue6

Single ophthalmologist (AG) trained inROP screeningcapturedallimages.ImagequalitywasgradedasgoodandpoorbasedonabilityofgradertodeterminethedilatationandtortuosityofvesselsorpresenceofdifferentstagesofROPintheimages.“Good”wasdefinedasanimageinwhichtherewasa clearviewofopticnerveandvessels and thegradercouldeasilydiscernthedilatationandtortuosityofvesselsorpresenceofvariousROPstageswithorwithoutglareartifact,whichensuredaccuratediagnosis,and“poor”imageinwhichthegraderwasunabletoclearlyvisualizeanddeterminethecharacteristicsoftheretinaorvessels,andthusunabletomakecorrectdiagnosis.

Telemedicinerefers to theuseof telecommunicationandinformation technologies toprovide clinicalhealthcareat adistance.Itinvolvescapturingandtransportingpatientdataforsubsequentinterpretationbyaremoteexpert.Simultaneously,withthehelpoftheserecordedROPimagesparentswerealsoeducatedabouttheimportanceofROPscreening.

Table 1 highlights the comparisonofdifferent imagingmodalitiesusedforfundoscopyininfantswithROP.

ResultsAtotalof228eyesof114preterminfantswereinitiallyscreenedwithindirectophthalmoscopeforROPinNICUsof17referralhospitals inKochi,Kerala between January 2018 andMay2018.Allinfants<1750gbirthweightand<34weeksgestationalagewere screenedaccording to theNationalNeonatologyForum (NNF) Clinical Practise Guidelines.[11] ROP was observedin54eyeswithanincidenceof 23.6%outofwhichtype1high-riskprethresholdROPwasseenin20eyeswithanincidenceof8.7%.Smartphone-basedfundoscopywasusedtodocumentROPin28outof54eyesdiagnosedasROP.Imagequalitywas“good” in25outof 28 (89.2%)eyesundergonesmartphone imaging.Three eyes showingpoorvessel andretinaldifferentiationweregradedas“bad”.Sixeyeswithzone1ROPweredocumentedwithoutglobe contactor rotation.Glareandartifactswereseenin20outofthese28eyes(71.4%)butdidnothamperinimageclarityinmostoftheeyes.Usingdifferentcondensinglensesvaryingfrom+20D,+28D,and+40Dgiveusvisualizationwithafieldofviewof46°,53°,and90,°respectively.Fig.1showingthetechniqueofSmartROPimagecapture (video 1) and comparisonofvarious images takenfromdifferent condensing lenses.Workingdistance frominfant’seyetocondensinglensmeasuredwasapproximately5inches,3inches,and1.5incheswith+20D,+28D,and+40Dlens, respectively.Weobservedcomparatively smallfieldofviewwith+20Dlensandmorechancesofperipherallensedgeglarewith +40D condensing lens.Wide-fieldvisualizationand peripheralretinalfundoscopytilloraserratawaspossibleineyesimagedwith+28Dor+40Dlens(video2,video3).Variouspresentations of ROP are seen in Fig.3.Fig.4Ashowsfundusimagesofzone1ROPbeforeandafteranti-vascularendothelialgrowth (VEGF) injectionand rescue laser treatment.Fig. 4Bshows retinal imagesofaggressiveposteriorROP (APROP)beforeandafterlasermonotherapy.

DiscussionUse of smartphone to capture retinal images has severaladvantageswith small learning curve. First, a smartphonehas an almost coaxial, constant, andpowerful light source

thatcandirectlyilluminatetheretinaandeasytophotograph.Second,thesmartphonecameracanadjustautomaticallyboth,exposuretimeandfocusontheretina.Third,fundoscopywithasmartphoneisaninexpensive,easy,non-contact,andportable waytorecordtheretinalconditionofpatientswithROP.Fourth,the smartphone andMIIRetCamor blackPVC tubebeinga lightweightgadget, the CSDassembly canbe supportedwithasinglehandtocaptureretinapictures,thusnoneedofmultiplecostlygadgetsoradditionalassistantstoholdandcarrythem.ThisisprobablythebestandtheonlywayforasingleophthalmologistwhohastovisitmultipleNICUsetupsonthesamedaytoachievegooddocumentation.Wehavefoundthatgooddocumentationgreatlyimprovesthecommunicationwiththeparentsconcernedandtherebyensuresbettercomplianceintreatmentandfollow-up.Fifth,easyavailabilityandquickdatatransferfacilitymakeitusefulandeffectivetelescreeningtool to share anddiscussROPeven in remoteplaces.Useof+28Dand+40Dinadditionto+20Dcondensinglenseshaveanadvantageofwide-fieldvisualizationofretina.Itcanalsohelp invisualization till farperipherywithoutmuchscleraldepression.AlthoughthequalityofthepictureisnotequivalenttothosetakenbyprofessionalequipmentlikeRetCam,thecostperformancehasmorevalueindevelopingcountrieslikeIndia.Inaddition,availabilityofasmartphoneinlocalandremotehospitalsorrelativelypoormedicalhealthcareenvironmentsiseasynowadays.Thistechniqueisalsohelpfulingeneralpatientconsultationbyexperiencedophthalmologists,andtheeaseofsharingimagesmakessmartphonefundoscopyanextremelyusefultechniqueforROPscreeningandtelemedicine.[10]

StabilizingCSDdeviceassembly inonehandandusingotherhandforeyeballrotationand/orscleradepressioneaseustocaptureretinalperipheryimagesequivalenttoprofessionalwidefield fundus imagingsystems.According toLin et al.,directionoflightandlensshouldbemanuallyadjustedforgoodrecordingbutourdevice assembly facilitates automaticallyadjustedcoaxialimagewithminimumeffort.[10]Onanaverage,thetimetakenbyanexperiencedophthalmologistforafullexaminationundertopicalanesthesiaisapproximately1min,whichisslightlylongerthanthatrequiredbyaprofessionalwide-field retinal imaging system. Still, cost-affectivity,portability,easeofhandling,andtelescreeningfacilitymakessmartphone imaging more useful than any other imaging modality.

ROP imaging from KIDROPdiffers fromSmartROP invarious aspects. Firstly,KIDROP composedof 3–4 trainedophthalmic staff, RetCam shuttle, and a laptop equippedwithadditionalspecialsoftwaretorecordROPimageswhichareassessedbyophthalmologist elsewhere.[12]While, SmartROPneeds single-trainedperson (mainlyophthalmologist)andamobile lightweightdevice tohold smartphoneandcondensinglensusinginbuiltvideosettingsofphonetorecordROP.Probeweightofcontactimagingdeviceslike3netraneois 310gand thatofRetCamshuttle is stillheavier exertingunduepressureovereyeballduringexamination,especiallyin thehandsof beginners and trainees. Smartphone-basedfundus camerahave reasonablygoodfield of viewof 53°with +28D and 90°with +40D condensing lens,which isnotwideas3netraneo(120°),[12]RetCam(130°),[13] or Optos imagingsystem(200°).[3,14]RetCamand3netraneocanthroughexcessivepressureon the eye affect the accuratediagnosisofplusdisease, aproblem thatwouldnotbeexpectedofa

June2019 843Goyal, et al.: Wide field smartphone ROP initiative

non-contactsystem.[14]Non-contacttechniqueusedintheSmartROPthoughhaslesserfieldofviewascomparedtopreviouslymentioned techniques but has ease of portability and theamountofpressureexertedonglobeispracticallynegligible.Moreover,costofMIIRetCamdevice,inadditiontocondensinglenseasilyavailableinclinicandpersonalsmartphone,isfarless thanthepriceof3netraneo,RetCamshuttle,orOptosfunduscamera.Usingblacktubewithuniversalsmartphoneholderfurthermakesitaffordableevenforbeginners.SmartROPscreeningispossiblewithallthesmartphonesavailableinmarket.

Smartphone-based fundus camerawas able to obtain“good” images of the retinawithwide enough field ofviewandsufficientqualitytogradethepresenceofROPin89.28%eyesofscreenedprematureinfants.Wefoundgoodquality image in 89.28% eyes captured forROPwhich iscomparablewith90–99%goodqualityimageseeninPictornon-contact camera,[15] RetCam,[13,16] 3 netra neo,[12] and

Optosdualwavelengthscanning laserophthalmoscope.[14] Itisanticipatedthatnewersmartphone-basedcameraswithbetterimageacquisitionwillaidinincreasingthispercentageevenfurther.

Smartphonefundoscopyhascertainlimitations.LimitationofMIIRetCamorblacktubeisthelearningcurveinvolvedandpoorimagequalitywhileusing20Dlens.Thenursingassistantneedstoholdtheheadandpupilhastobewelldilated.Lightemittedbytheflashismuchstronganddivergentthanthelightsourceofbinocularindirectophthalmoscopeorprofessionalwide-fieldimagingsystems.Asofnowthetechnology isusedmainlyfordocumentationofROPininfantsalreadydiagnosedafterROPscreeningbyindirectophthalmoscopy.Therearesomeonlineavailableapplicationswhichhavetheadvantageofmultiple inbuilt lightcontroloptions.Coveringtheflashwithtapecanbeanalternatewaytoreducelightintensity.[17] ItisaninitialexperiencewiththisnoveltechniqueofmobilesmartphoneROPimaging,stabilizing,andcapturingimages

Table 1: Comparison of different imaging modalities for retinopathy of prematurity imaging

Imaging modality Field of view

Setting for use

Staffing requirement

Advantages Disadvantages

SROP cameraCondensing lens• +20D• +28D• +40D(attached with MIIRETCAM device)

46 degree53 degree90 degree

• Special care baby unit

• Outpatient department

• Theatre

• Ophthalmologist• Nursing staff to

hold baby and monitor vital signs.

• Non‑contact based• Portable• Wide field of view• Cost effective• Able to image till ora

serrata through sclera depression

• High‑resolution images

• Only colour imaging available

NIDEK Camera[3] 30 degree • Special care baby unit

• Outpatient department

• Theatre

•Ophthalmologist • Non‑contact based• Portable

• Low resolution images• Narrow field of view• Only colour imaging available• Unable to image till ora serrata

Video indirect ophthalmoscopy[3]

53 degrees(28D lens)46 degrees(20D lens)

• Special care baby unit

• Outpatient department

• Theatre

• Ophthalmologist• Nursing staff

to monitor vital signs

• Non‑contact based• Portable• Cost effective• Able to image till ora

serrata through scleral indentation

• Low resolution images• Only colour imaging available

3Netra Neo widefield camera[13]

120 degrees

• Special care baby unit

• Outpatient department

• Theatre

• Ophthalmologist• Nursing staff

to monitor vital signs

• Portable• Wide fundal field of view• Fast image acquisition

• Contact based• Heavy weight camera• Unable to image out to ora serrata• Costly

RetCam Widefield camera[14,15]

130 degrees

• Special care baby unit

• Outpatient department

• Theatre

• Ophthalmologist• Nursing staff

to monitor vital signs

• Portable• Wide fundal field of view• Fast image acquisition• Colour and fluorescein

angiographic imaging available

• Contact based• Heavy weight camera• Sedation or general anaesthesia

essential only for high quality angiograms

• Unable to image out to ora serrata• Costly

Optos ultrawidefield camera[17]

200 degrees

• Outpatient department

•Ophthalmologist• Nursing staff tomonitor vital signs• Ophthalmicphotographer

• Non‑contact based• Fast image acquisition• High resolution images• Widel field of view• Colour and

angiographic imaging available

• No sedation required

• Non‑portable• Unable to image out to ora serrata• Costly• Ophthalmic photographer

needed for image capture

844 Indian Journal of Ophthalmology Volume67Issue6

Figure 3: Various retinopathy of prematurity (ROP) presentations – (a) glare due to mid‑dilated pupil, (b) wide‑field view of a normal retina, (c) plus disease with ridge (arrow) in zone 1, (d) laser marks (arrow), (e) aggressive posterior ROP in zone 1, (f) demarcation between vascular and avascular retina (arrow), (g) ridge (arrow) in zone 2, (h) stage 3 fibrovascular proliferation in zone 2 (arrow), (i) dilated tortuous vessels in all four quadrants s/o plus disease, (j) laser scar marks in periphery, (k) skip area between normal retina and laser marks (arrow), (l) ora serrata nicely seen with scleral depression

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Figure 4: (A) Case of zone 1 retinopathy of prematurity (ROP) showing (a) plus disease with ridge (arrow) in the right eye, (b) zone 1 with ridge (arrow) in the left eye, (c) complete resolution of plus disease and ridge after anti‑vascular endothelial growth (VEGF) injection in the left eye, (d) recurrence of ridge (arrow) after 4 weeks of anti‑VEGF injection, (e) shows rescue laser treatment marks (arrow) anterior to ridge in the left eye. (B) Case of aggressive posterior ROP (APROP) showing (a) plus disease in zone 1, (b) demarcation between vascular and avascular retina (arrowheads) at zone 1 edge, (c) laser marks, (d) complete regression of plus disease, (e) laser scar marks (arrow) in retinal periphery

BA

June2019 845Goyal, et al.: Wide field smartphone ROP initiative

randomizedtrial.EarlyTreatmentforRetinopathyofPrematurityCooperativeGroup.ArchOphthalmol2003;121:1684-96.

3. Fung TH, Smith LM, Patel CK. Contemporary imaging ofretinopathyofprematurity.Infant2014;10:143-6.

4. EllsAL,HolmesJM,AstleWF,WilliamsG,LeskeDA,FieldenM,et al.Telemedicineapproachtoscreeningforsevereretinopathyofprematurity:Apilotstudy.Ophthalmology2003;110:2113-7.

5. BastawrousA. Smartphone fundoscopy. Ophthalmology2012;119:432-3.

6. KimDY,Delori F,Mukai S. Smartphonephotography safety.Ophthalmology2012;119:2200-1.

7. LordRK, ShahVA,SanFilippoAN,KrishnaR.Novelusesofsmartphonesinohthalmology.Ophthalmology2010;117:1274.

8. MaamariRN,Keenan JD,FletcherDA,MargolisTP.Amobilephone-basedretinalcameraforportablewidefieldimaging.BrJOphthalmol2014;98:438-41.

9. SharmaA,SubramaniamSD,RamachandranKI,LakshmikanthanC,Krishna S, Sundaramoorthy SK. Smartphone-based funduscameradevice(MIIRetCam)andtechniquewithabilitytoimageperipheralretina.EurJOphthalmol2016;26:142-4.

10. LinSJ,YangCM,YehPT,ChangHoT.Smartphonefundoscopyfor retinopathy of prematurity. Taiwan J Ophthalmol2014;4:82-5.

11. PejaverRK,VinekarA,BilagiA.NationalNeonatologyForum’sEvidenceBasedClinicalPracticeGuidelines2010.RetinopathyofPrematurity(NNFIndia,Guidelines)[cited2015Jun29];Availablefrom:http://www.ontop-in.org/ontop-pen/Week-12-13/ROPNNFGuidelines.pdf.[Lastaccessedon2015Jun15].

12. VinekarA,GilbertC,DograM,KurianM,ShaineshG,ShettyB,et al.TheKIDROPmodelofcombiningstrategiesforprovidingretinopathyofprematurity screening inunderservedareas inIndiausingwide-field imaging, tele-medicine, non-physiciangraders and smart phone reporting. Indian J Ophthalmol2014;62:41-9.

13. ChiangMF,WangL,BusuiocM,DuYE,ChanP,KaneSA,et al. Telemedical retinopathy of prematurity diagnosis:Accuracy,reliability,andimagequality.ArchOphthalmol2007;125:1531-8.

14. PatelCK,FungTHM,MuqitMMK,MordantDJ,BrettJ,SmithL,et al.UltrawidefieldimagingofretinopathyofprematurityusingtheOptos dualwavelength scanning laser ophthalmoscope.Eye(Lond)2013;27:589-96.

15. SasipanGP,DavidKW,SharonFF.Retinalimaginginprematureinfants using the Pictor noncontact digital camera. JAAPOS2014;18:321-6.

16. ThanosA,YonekawaY,TodorichB,MoshfeghiD,TreseMT.Screeningand treatmentsusing telemedicine in retinopathyofprematurity.EyeBrain2016;8:147-51.

17. HaddockLJ,KimDY,MukaiS. Simple, inexpensive techniqueforhigh-qualitysmartphonefundusphotographyinhumanandanimaleyes.JOphthalmol2013;2013.doi:10.1155/2013/518479.

withonlysinglehand.Presenceofincreasedworkingeyetolensdistanceandcomparativelysmallfieldofviewwith+20Dlens suggest +28Dand +40D lens aspreferred condensinglenses for initial experience inwide-field ROP imaging.Presenceof a single examiner for capturing and accessingROP imageswarrantsmorestudies to test imageaccuracy.Thestrengthofthisstudyisusingsinglehandforstabilizingmobilesmartphoneovertheinfant’seye,useofnon-contacttechnique, utilizing second hand of same examiner forvisualizingretinalperiphery,andwithouttheuseofbulkyandcostlyimagingcameras,wewereabletocapturewide-fieldfundus images forROPscreeninganddocumentation.Ourinitialexperienceusingportable,highdatastoragecapacity,cost-effectivemobilesmartphonecansuggest thatamobilephone-based retinal camera canplay an important role ininfantswithROP.

A portablehand-heldsmartphonecanobtainfundoscopyofgoodquality.Condensinglens-Smartphone-MIIRetCamdeviceassemblyislightweight,non-contact,portabletechnologywithacoaxiallightsourceforfundoscopy.SmartphonefundoscopycanservesasaneffectiveeducationaltoolforeducatingNICUstaffandparentswhichmayhelpwith compliance. It alsoprovides reliable, defensiblemedicolegal documentation.Smartphone-based fundoscopy can be used to visualizefundus till ora serrata.Digital fundusphotographs canbesentimmediatelyandconvenientlythroughtheWhatsAppore-mails.Fornon-institutionalpractiseandsinglepractitionerscostandportabilityoftheinstrumentremainsamajorissue.Thistechniqueisrelativelyeasytomasterandcost-effective,and above all, with proper training of observers, thistechniquehasapotentialadvantageofexpandingsmartphonefundoscopyfortelemedicineindevelopingcountrylikeIndiawhere cost andavailability is a considerableproblem.OurinitialexperiencewithSROPcanhelpanyonewhowishestoperform a ROP imaging and make appropriate diagnosis in a cost-effectivemanner.

Financial support and sponsorshipNil.

Conflicts of interestTherearenoconflictsofinterest.

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SciJMedVisResFoun2015;XXXIII:93-6.2. Revisedindicationsfortreatmentofretinopathyofprematurity:

Results of early treatment of retinopathy of prematurity