**1. Introduction**

The difficulties of sustaining care in hospitals are forcing health economies to deliver health care closer to the home in the community. The increased use of Vasoactive Endothelial Growth Factor (VEGF) antagonists to treat patients with wet age related macular degeneration has exponentially increased the need for additional clinic and treatment capacity. New National Institute of Clinical Excellence (NICE) guidelines for glaucoma (2009) have increased the number of referrals into secondary care. This chapter will explore how additional capacity may be created using digital imaging transfer techniques, to allow patients to be seen in virtual clinics, which may be located in either primary or secondary care.

The learning goal of this chapter is better understanding of novel ophthalmic technology for retinal disease management and glaucoma assessment deployed in the digital health environ‐ ment. This is a topic of considerable significance in retinal care given the explosion of relevant clinical imaging technology and the huge burden of certain retinal disease (age related macular degeneration, retinal vein occlusion and diabetic retinopathy) on National Health Service (NHS) services and which is set to expand even more with further new and welcome treat‐ ments for these conditions. It is also of importance in view of the increased glaucoma referrals into secondary care in the light of recent NICE guidance, increasing the need for more advanced imaging techniques in the diagnosis and investigation of these patients. Glaucoma patients are now more commonly undergoing Optical Coherence Tomography (OCT) scanning of the optic disc, or advanced disc imaging for follow up purposes and diagnosis.

Smarter ways of working, using new technology, are required to cope with this clinical need and organisational burden. The need includes better use of IT infrastructure; innovation in primary care to secondary care referral management and enhanced productivity in secondary care. The development of "Virtual Clinics" using this technology will be discussed.

© 2013 Dragnev et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 Dragnev et al.; licensee InTech. This is a paper distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Some clinical IT/imaging driven solutions to such challenges will be explored in this and with emphasis on retinal/glaucoma care pathways and treatment of eye emergencies.

lished with slit lamp videos after telephone input of history. Urgent corneal conditions such as microbial keratitis, herpetic eye disease, etc can be initially managed urgently via elinks of photographs and videos. Images of optic discs can help in the diagnosis of papilloedema in an emergency setting. Images may now be transmitted to pads, phones and blackberry devices,

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5

The initial cost of investing in tele-ophthalmology in an emergency department is returned favourably by the savings in on call hours. This strategy is being employed at various rural centres across Australia, Wales and Canada. In Australia, most rural emergency departments

It has been shown to be feasible to apply satellite based tele-ophthalmology for making a presumptive diagnosis and planning further management of adnexal and orbital diseases based on live interaction and digital still images of the patients taken by a digital video slit lamp in rural areas of Tamil Nadu as demonstrated by Verma et al (2009). It has been demon‐ strated to be reliable in the assessment of ocular trauma as researched by Simon et al (2003).

In Sweden and Australia, General Practitioners have used these digital slit lamps in rural settings to gain experience in management of primary care emergencies and are supervised in the removal of corneal foreign bodies by the technology as shown by Hall et al (2005). A general ophthalmologist, Camara et al (2000) has used teleophthalmology to link up with an orbital

Nurse Practitioners can be well trained to take anterior segment photographs on the slit lamp. (Kulshrestha MK, Williams C, Lewis D, Axford A (2010) A pilot trial of tele-ophthalmology

Smart phones have been used in ophthalmology emergency departments to document visual acuity and examination findings. They have been used in dermatology and radiology to transfer images, but there is limited published use documented for image transfer in ophthal‐ mology. The Foto-Ed Study by Lamirel et al (2012) compared the quality of images of nonmydriatic fundus images on a phone vs a computer screen, showing no loss of resolution of

Smart phones, such as the iphone, therefore present a unique opportunity for a role in teleophthalmology. They have a high resolution "retinal" screen with 326dpi resolution located between two glossy panels of aluminosilicate glass (the same glass used in the windshields of helicopters and high speed trains). It has 78% of the pixels of a larger tablet or pad in a far smaller screen size. The resolution is therefore optimised to the way the human

We therefore explored the use of the smart phone to take photos of the digitally captured image and transfer these to the Consultant Ophthalmologist in charge of the Tywyn Eye Clinic in

Smart phone technology has already been used in emergencies in the Norway's Arctic Svalbard archipelago where British students were recently attacked by a polar bear (www.myfox8.com/

now have tele links with one on call ophthalmologist covering several areas at once.

so diagnosis and treatment may be made remotely.

surgeon to assist in the removal of a lateral orbital tumour.

services in North Wales. J Telemed Telecare;16:196-197).

eye sees things at the normal distance from the eyes.

North Wales through MMS smart phone text.

the image.

Tele ophthalmology is a visual specialty with a long history. Therefore, the development of image and video transmission through a telephone line makes it possible to transfer ophthal‐ mologic images over long distances. Li H (1999) reported a modern application in the late 1980s: NASA developed a real time transmission system of retinal images acquired using a portable video funduscope. Shimmra et. al (1998) used a conventional telephone system to transmit slit lamp images of the eye and evaluate the feasibility of real-time video and audio transmission. Yoshida A (1998) used video conferencing systems to transmit full-motion colour images between a university and hospital.

Using those early systems, an expert remote presenter who is trained in the use of the oph‐ thalmic peripherals, hardware, and software can capture still and moving images of the eyes can transmit them to ophthalmologists. The current status of teleophthalmology applications has been limited to specific purposes such as doctor-to-doctor consultation, research and clinical trial collaboration, and distance learning for medical professionals. The purpose of this chapter is to demonstrate how refinement of this technology has successfully led to the clinical application of teleophthalmology systems for the benefit of patients.

Barsela and Glovinsky examined the feasibility of a low-bandwidth, Internet-based teleophthalmology system for consultation in an ophthalmic emergency room. Forty-nine patients were seen in the eye casualty by a resident and ocular images were taken using a slit-lamp connected to a video camera and transmitted to a senior ophthalmologist by email. A telephone was used for real-time audio communication of each case. Each case was re-examined by the same senior ophthalmologist the following day. Each case was assigned a feasibility score (0-100%), which was defined as the contribution made by the transmitted images in presenting clinical details which could not have been described verbally.

High feasibility scores from 85 to 90% were found for the following images: ocular surface, anterior chamber, anterior chamber angle, pupils, lens, optic nerve and macula. Images of vitreous and peripheral retina received low feasibility scores (mean score 65%). There was 100% agreement between the diagnosis made during consultation and the examination made by the consultant ophthalmologist later on. This illustrates the feasibility of teleophthalmoo‐ gy consultations in the emergency room. It has also proven to overcome the barriers and improve quality, access and affordability in eye care in South India, (John S et al 2012) in teleophthalmology mobile units in the community, a topic which will be discussed in more detail in section 3.

#### **1.1. Eye care using wireless smart phone technology**

Tele-ophthalmology is taking an increasing role in the provision of primary emergency services. Digital images, slit lamp video conferencing and transfer of fundus images allow the provision of substantial clinical care. Most urgent ophthalmic diagnosis may be made and treatment prescribed remotely. Decisions to transfer patients urgently can also be made. For instance the difference between acute iritis and acute angle closure glaucoma can be estab‐ lished with slit lamp videos after telephone input of history. Urgent corneal conditions such as microbial keratitis, herpetic eye disease, etc can be initially managed urgently via elinks of photographs and videos. Images of optic discs can help in the diagnosis of papilloedema in an emergency setting. Images may now be transmitted to pads, phones and blackberry devices, so diagnosis and treatment may be made remotely.

Some clinical IT/imaging driven solutions to such challenges will be explored in this and with

Tele ophthalmology is a visual specialty with a long history. Therefore, the development of image and video transmission through a telephone line makes it possible to transfer ophthal‐ mologic images over long distances. Li H (1999) reported a modern application in the late 1980s: NASA developed a real time transmission system of retinal images acquired using a portable video funduscope. Shimmra et. al (1998) used a conventional telephone system to transmit slit lamp images of the eye and evaluate the feasibility of real-time video and audio transmission. Yoshida A (1998) used video conferencing systems to transmit full-motion colour

Using those early systems, an expert remote presenter who is trained in the use of the oph‐ thalmic peripherals, hardware, and software can capture still and moving images of the eyes can transmit them to ophthalmologists. The current status of teleophthalmology applications has been limited to specific purposes such as doctor-to-doctor consultation, research and clinical trial collaboration, and distance learning for medical professionals. The purpose of this chapter is to demonstrate how refinement of this technology has successfully led to the clinical

Barsela and Glovinsky examined the feasibility of a low-bandwidth, Internet-based teleophthalmology system for consultation in an ophthalmic emergency room. Forty-nine patients were seen in the eye casualty by a resident and ocular images were taken using a slit-lamp connected to a video camera and transmitted to a senior ophthalmologist by email. A telephone was used for real-time audio communication of each case. Each case was re-examined by the same senior ophthalmologist the following day. Each case was assigned a feasibility score (0-100%), which was defined as the contribution made by the transmitted images in presenting

High feasibility scores from 85 to 90% were found for the following images: ocular surface, anterior chamber, anterior chamber angle, pupils, lens, optic nerve and macula. Images of vitreous and peripheral retina received low feasibility scores (mean score 65%). There was 100% agreement between the diagnosis made during consultation and the examination made by the consultant ophthalmologist later on. This illustrates the feasibility of teleophthalmoo‐ gy consultations in the emergency room. It has also proven to overcome the barriers and improve quality, access and affordability in eye care in South India, (John S et al 2012) in teleophthalmology mobile units in the community, a topic which will be discussed in more

Tele-ophthalmology is taking an increasing role in the provision of primary emergency services. Digital images, slit lamp video conferencing and transfer of fundus images allow the provision of substantial clinical care. Most urgent ophthalmic diagnosis may be made and treatment prescribed remotely. Decisions to transfer patients urgently can also be made. For instance the difference between acute iritis and acute angle closure glaucoma can be estab‐

emphasis on retinal/glaucoma care pathways and treatment of eye emergencies.

application of teleophthalmology systems for the benefit of patients.

clinical details which could not have been described verbally.

**1.1. Eye care using wireless smart phone technology**

detail in section 3.

images between a university and hospital.

4 Telemedicine

The initial cost of investing in tele-ophthalmology in an emergency department is returned favourably by the savings in on call hours. This strategy is being employed at various rural centres across Australia, Wales and Canada. In Australia, most rural emergency departments now have tele links with one on call ophthalmologist covering several areas at once.

It has been shown to be feasible to apply satellite based tele-ophthalmology for making a presumptive diagnosis and planning further management of adnexal and orbital diseases based on live interaction and digital still images of the patients taken by a digital video slit lamp in rural areas of Tamil Nadu as demonstrated by Verma et al (2009). It has been demon‐ strated to be reliable in the assessment of ocular trauma as researched by Simon et al (2003).

In Sweden and Australia, General Practitioners have used these digital slit lamps in rural settings to gain experience in management of primary care emergencies and are supervised in the removal of corneal foreign bodies by the technology as shown by Hall et al (2005). A general ophthalmologist, Camara et al (2000) has used teleophthalmology to link up with an orbital surgeon to assist in the removal of a lateral orbital tumour.

Nurse Practitioners can be well trained to take anterior segment photographs on the slit lamp. (Kulshrestha MK, Williams C, Lewis D, Axford A (2010) A pilot trial of tele-ophthalmology services in North Wales. J Telemed Telecare;16:196-197).

Smart phones have been used in ophthalmology emergency departments to document visual acuity and examination findings. They have been used in dermatology and radiology to transfer images, but there is limited published use documented for image transfer in ophthal‐ mology. The Foto-Ed Study by Lamirel et al (2012) compared the quality of images of nonmydriatic fundus images on a phone vs a computer screen, showing no loss of resolution of the image.

Smart phones, such as the iphone, therefore present a unique opportunity for a role in teleophthalmology. They have a high resolution "retinal" screen with 326dpi resolution located between two glossy panels of aluminosilicate glass (the same glass used in the windshields of helicopters and high speed trains). It has 78% of the pixels of a larger tablet or pad in a far smaller screen size. The resolution is therefore optimised to the way the human eye sees things at the normal distance from the eyes.

We therefore explored the use of the smart phone to take photos of the digitally captured image and transfer these to the Consultant Ophthalmologist in charge of the Tywyn Eye Clinic in North Wales through MMS smart phone text.

Smart phone technology has already been used in emergencies in the Norway's Arctic Svalbard archipelago where British students were recently attacked by a polar bear (www.myfox8.com/ news/wghp-story-deadly-polar-bear-attack-norway). Images were sent through a phone to University Hospital Tromsoe for immediate advice on first aid to be obtained.

The Trust Telemedicine Board and the Caldicott Guardian were consulted to discuss in detail issues in regard to transfer of images through smart phones to a Consultant Ophthalmologist

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A pilot in the use of smart phone technology to transfer digital images was discussed in the Telemedicine Board. The Caldicott Guardian stated that in an emergency transfer of an image for an expert opinion could be justified on clinical need. None of the anterior segment photos would show an identifiable face, and no patient identifiable information would be on the image. After the emergency decision and treatment were carried out the images were to be

Patients presenting to casualty with an eye emergency which the Nurse Practitioner on call deemed to need a Consultant opinion were asked and given the option of transfer to Swansea or for an image of the anterior segment of the eye to be sent to the Consultant Ophthalmologist

The experience/success of the pilot was to be fed back to the Telemedicine group for further

Over a 12 month period from September 2011– August 2012, there were 12 eye casualties who needed assessment by digital transfer of images through the smart phone to the Consultant.

These patients were then assessed in Tywyn clinic at an appropriate time interval, the diagnosis

We used smart phone technology to transfer a digital image taken on a slit lamp of the anterior segment of the eye to a Consultant Ophthalmologist to gain an instant, rapid opinion on diagnosis. This reduced unnecessary travelling down to Swansea, with a total of 84 hours or 2800 miles saved over 12 months for patients and hospital transport. Twelve patients had their eye findings correctly diagnosed through the smart phone image by an expert and appropriate

This had allowed eye emergencies to be seen in Tywyn, despite changes in the on call ar‐ rangements. Patients can still gain an expert opinion through use of digital photography, and gain rapid treatment by instruction to a trained Nurse Practitioner. This has been useful for patients who present with anterior segment disorders of the eye, but is not as useful for disorders of the posterior segment of the eye. These patients would need assessment of their

deleted from the Smart phones by the Nurse Practitioner and the Consultant.

The Consultant gave help on history/investigation/diagnosis and treatment

confirmed and the outcome on symptoms/visual acuities assessed.

treatment was given rapidly with excellent visual outcomes in all cases

symptoms and are referred for urgent assessment in the local clinic.

to obtain an expert opinion and avoid hospital transfer

*1.2.3. Strategy for change*

in charge of the Tywyn Eye Clinic.

*1.2.4. Measurement of improvement*

discussion/improvements.

*1.2.5. Effects of changes*

We used smart phone technology to transfer a digital image taken on a slit lamp of the anterior segment of the eye in rural North Wales to a Consultant Ophthalmologist in the local District General Hospital, over 1 hour away by ambulance transfer to gain an instant, rapid opinion on diagnosis. This reduced unnecessary travelling down to Swansea, over 3.5 hours away. Eye Emergencies have been shown to be treated in rural areas by Nurse Practitioners obtaining advice directly from a Consultant Ophthalmologist through high resolution images of the eye seen on a smart phone.

Larger pads and tablets may also be used to send macular Optical coherence tomography images to a Consultant Ophthalmologist wirelessly using appropriate apps to carry out Virtual Clinics, run by Nurse Practitioners or Opticians, so that treatment decisions may be made remotely if the ophthalmologist is working many miles away from the rural centre.

#### **1.2. Smart phone images used for diagnosis and treatment of eye emergencies in rural North Wales**

#### *1.2.1. Brief outline of problem*

Tywyn, Gywnedd, North Wales at the Tywyn War Memorial Cottage Hospital, is a rural outreach clinic in the Betsi Cadwaladr University Health board. One hundred and twenty four eye emergencies are seen at this unit by Nurse Practitioners in casualty per year. Twenty four of these emergencies have needed referral per year to a Consultant Ophthalmologist on call at Bronglais Hospital, Aberystwyth for assessment. Bronglais Hospital is in the neighbouring Hywel Dda Health Board.

Nurse Practitioners have already undergone training in use of the Topcon SL D7 slit lamp to take photos of the anterior segment of the eye and send these images to Bronglais casualty for assessment through a Polycom Telemedicine monitor

Last year, Consultant Ophthalmologists in Hywel Dda Health Board were taken out of the on call rota and no longer carried out on call duties. Nurse Practitioners in Tywyn would therefore have to send eye emergencies to Swansea for assessment, which is 3 hours away.

The Nurse Practitioner is well trained to take anterior segment photographs on the slit lamp. We therefore explored the use of the smart phone to take photos of the digitally captured image and transfer these to the Consultant Ophthalmologist in charge of the Tywyn Eye Clinic through MMS texting.

#### *1.2.2. Assessment of problem and analysis of its causes*

Twenty four patients with eye emergencies would need to be transferred to Swansea per year, involving 144 hours of travelling time per year or 1526 kg of CO2 pollution per year, to gain a Consultant Ophthalmologist opinion.

The Trust Telemedicine Board and the Caldicott Guardian were consulted to discuss in detail issues in regard to transfer of images through smart phones to a Consultant Ophthalmologist to obtain an expert opinion and avoid hospital transfer

### *1.2.3. Strategy for change*

news/wghp-story-deadly-polar-bear-attack-norway). Images were sent through a phone to

We used smart phone technology to transfer a digital image taken on a slit lamp of the anterior segment of the eye in rural North Wales to a Consultant Ophthalmologist in the local District General Hospital, over 1 hour away by ambulance transfer to gain an instant, rapid opinion on diagnosis. This reduced unnecessary travelling down to Swansea, over 3.5 hours away. Eye Emergencies have been shown to be treated in rural areas by Nurse Practitioners obtaining advice directly from a Consultant Ophthalmologist through high resolution images of the eye

Larger pads and tablets may also be used to send macular Optical coherence tomography images to a Consultant Ophthalmologist wirelessly using appropriate apps to carry out Virtual Clinics, run by Nurse Practitioners or Opticians, so that treatment decisions may be made

**1.2. Smart phone images used for diagnosis and treatment of eye emergencies in rural North**

Tywyn, Gywnedd, North Wales at the Tywyn War Memorial Cottage Hospital, is a rural outreach clinic in the Betsi Cadwaladr University Health board. One hundred and twenty four eye emergencies are seen at this unit by Nurse Practitioners in casualty per year. Twenty four of these emergencies have needed referral per year to a Consultant Ophthalmologist on call at Bronglais Hospital, Aberystwyth for assessment. Bronglais Hospital is in the neighbouring

Nurse Practitioners have already undergone training in use of the Topcon SL D7 slit lamp to take photos of the anterior segment of the eye and send these images to Bronglais casualty for

Last year, Consultant Ophthalmologists in Hywel Dda Health Board were taken out of the on call rota and no longer carried out on call duties. Nurse Practitioners in Tywyn would therefore

The Nurse Practitioner is well trained to take anterior segment photographs on the slit lamp. We therefore explored the use of the smart phone to take photos of the digitally captured image and transfer these to the Consultant Ophthalmologist in charge of the Tywyn Eye Clinic

Twenty four patients with eye emergencies would need to be transferred to Swansea per year, involving 144 hours of travelling time per year or 1526 kg of CO2 pollution per year, to gain a

have to send eye emergencies to Swansea for assessment, which is 3 hours away.

remotely if the ophthalmologist is working many miles away from the rural centre.

University Hospital Tromsoe for immediate advice on first aid to be obtained.

seen on a smart phone.

*1.2.1. Brief outline of problem*

Hywel Dda Health Board.

through MMS texting.

assessment through a Polycom Telemedicine monitor

*1.2.2. Assessment of problem and analysis of its causes*

Consultant Ophthalmologist opinion.

**Wales**

6 Telemedicine

A pilot in the use of smart phone technology to transfer digital images was discussed in the Telemedicine Board. The Caldicott Guardian stated that in an emergency transfer of an image for an expert opinion could be justified on clinical need. None of the anterior segment photos would show an identifiable face, and no patient identifiable information would be on the image. After the emergency decision and treatment were carried out the images were to be deleted from the Smart phones by the Nurse Practitioner and the Consultant.

Patients presenting to casualty with an eye emergency which the Nurse Practitioner on call deemed to need a Consultant opinion were asked and given the option of transfer to Swansea or for an image of the anterior segment of the eye to be sent to the Consultant Ophthalmologist in charge of the Tywyn Eye Clinic.

The experience/success of the pilot was to be fed back to the Telemedicine group for further discussion/improvements.

#### *1.2.4. Measurement of improvement*

Over a 12 month period from September 2011– August 2012, there were 12 eye casualties who needed assessment by digital transfer of images through the smart phone to the Consultant. The Consultant gave help on history/investigation/diagnosis and treatment

These patients were then assessed in Tywyn clinic at an appropriate time interval, the diagnosis confirmed and the outcome on symptoms/visual acuities assessed.

#### *1.2.5. Effects of changes*

We used smart phone technology to transfer a digital image taken on a slit lamp of the anterior segment of the eye to a Consultant Ophthalmologist to gain an instant, rapid opinion on diagnosis. This reduced unnecessary travelling down to Swansea, with a total of 84 hours or 2800 miles saved over 12 months for patients and hospital transport. Twelve patients had their eye findings correctly diagnosed through the smart phone image by an expert and appropriate treatment was given rapidly with excellent visual outcomes in all cases

This had allowed eye emergencies to be seen in Tywyn, despite changes in the on call ar‐ rangements. Patients can still gain an expert opinion through use of digital photography, and gain rapid treatment by instruction to a trained Nurse Practitioner. This has been useful for patients who present with anterior segment disorders of the eye, but is not as useful for disorders of the posterior segment of the eye. These patients would need assessment of their symptoms and are referred for urgent assessment in the local clinic.

The main problem encountered in the change was the issue of confidentiality. The Caldicott Guardian deemed that the clinical need was greater in these instances, and once the decision was made, the images were to be deleted form both Smart phones

increased rate of falls. This costs either the health authorities and/ or the patients for organising and supplying this transport. More CO2 gases are released in the atmosphere from the

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9

The solution for all these issues is to deliver healthcare closer to the home in the community. This can be achieved with community based OCT machines, together with (non- ) mydriatic fundus cameras. In areas with not very dense population or in countries, where the purchase of enough equipment is an issue, this equipment can be integrated into special mobile vans. Mobile vans can visit different areas with a pre- determined schedule, and are the topic of

The information obtained with this equipment is sufficient for a trained ophthalmologist to assign appropriate treatment or follow up, using modern telemedicine equipment, even if he or she is thousands of miles away. This allows remote diagnosis and management of patients. Glaucoma is a chronic disease, in which in the majority of cases lifetime follow up is required. This puts a large strain on the ophthalmology clinics. For most of the patients with stable

Trained opticians or nurses can check visual acuity, IOP ( Goldman application ), perform visual acuity test, nerve fibre layer scans (OCT, GDX, HRT ) and record fundus photos with a (non)- mydriatic camera. All these tests can be done in the community and after that the information can be digitally transferred to a regional ophthalmology centre, where it can be interpreted by ophthalmologists. In this way patients are not going to have travel long distances. The ophthalmologists will be able to increase the capacity of their clinics. They will have all the required information for changing treatment and assigning follow up appoint‐ ments. Prioritisation of patients who need to be seen for a face to face consultation can be made

In the UK there are currently 2.3 ophthalmologists per 100 000 population, as described by Kulshrestha and Kelly (2011). This is the lowest pro rata than any other European Union country (www.uems.net). In the UK, optometrists play an important role in managing patients with eye complaints. Most of the patients seen in the Hospital Eye Service (HES) are referred by them either directly or through the patient's general practitioner (GP) (Bell and O'Brien 1997). For example more than 90 % of all suspected cases of primary open angle glaucoma are referred to the HES by optometrists according to Harrison and Wild et al (1988). The National Health Service (NHS) hospitals in the United Kingdom are a part of the public system. Optometry practices are private and have a dual role: they carry sight tests and dispense

The Hospital Eye Services (HES) in the UK are usually overloaded with patients and have waiting times of several months for new patients. There are also waiting times for follow up appointments. This means that for many patients allocated 6 months follow up appointments, the appointment may be delayed by a number of months. This is called slippage, and slippage has increased in recent years due to the introduction of new NICE guidance for glaucoma,

spectacles and contact lenses. The sight tests are reimbursed by the NHS.

increased pollution.

from the information.

**2.1. Optometry and teleophthalmology**

discussion of the next section in this chapter.

glaucoma follow up in a virtual clinic is possible.

#### *1.2.6. Lessons Learnt*

Smart Phone technology has been shown to be useful in the assessment and treatment of eye emergencies. All patients showed improvements in visual acuity ranging from 1 line to 7 lines, and complete resolution of symptoms due to prompt diagnosis and therapy.

A Consultant opinion was gained quickly in all 12 cases. The costs of patient and hospital transport were saved. There is a role for the use of smart tablets in digital image transfer to provide a larger image, and these could also be used for transfer of retinal optical coherence tomography images in a macular clinic. There is the potential for use of smart phone images in dermatological emergencies

Eye Emergencies can be effectively treated in rural areas by Nurse Practitioners obtaining advice directly from a Consultant through high resolution images of the eye seen on a smart phone.

#### **1.3. Smart phone adapters for slit lamps**

It is possible to take slit lamp photos by placing the lens of a smart phone against the slit lamp lens; however, the use of an adapter will allows higher quality photographs. This may help to facilitate teleophthalmology for nurse practitioners and optometrists in the primary care setting.

The Keeler Portable Slit Lamp iPhone 4 image adapter has been reported to be compatible with the Haag-Streit 900 BM (older series) and Topcon SL-3F slit lamps. The adapter is not com‐ patible with Topcon SL-D7, Mentor. When using the Keeler adapter, a moderate amount of force has to be applied to attach the adapter to most Haag-Streit slit lamp oculars (the diameter of my slit lamp's ocular is 30 mm and it requires a moderate amount of force to attach).
