A portable solution for high definition slit lamp imaging
Special for Ophthalmology Times®
Learning to use the slit lamp is not easy. I think as ophthalmologists we take this skill for granted and forget about the journey we took to master basic examination techniques. I vividly remember sitting in the clinic during my ophthalmology rotations as a medical student and wishing to see what the consultant was seeing.
When asked to look through the slit lamp, I often ended up nodding and smiling to avoid the embarrassment of admitting I had no idea what I was looking at. (The patient had probably moved his eye and what the consultant wanted me to see was no longer in the field of vision.) be careful not to get it hit in the eye by squatting uncomfortably next to the slit lamp.
I had a revelation early in my ophthalmology residency a few years ago when I witnessed the use of an anterior segment camera. Why not use this camera to teach people how to use slit lamps?
My consultants at the time seemed indifferent to this suggestion, but one of my superiors agreed with me. So when the camera was not in use (the vast majority of the time), we used it in the clinic. It helped me develop my clinical skills and I found it particularly useful in learning to examine the cornea and recognize a wide variety of pathologies.
With the consent of the patients we saw, I put together a video library to which I added my notes. Feeling vindicated and passionate about the benefits of slit lamp cameras for teaching ophthalmology, I fought for a scholarship to teach slit lamps after getting a loaner device for a few months.
Feedback from junior doctors, nursing colleagues and medical students has been overwhelmingly positive. We even managed to connect a VR headset to a beamsplitter/slit lamp camera with real-time video output to create an immersive visual experience. This configuration was presented at the American Academy of Ophthalmology meeting in 2018.
We were able to secure nearly $19,000 in funding to purchase a MediWorks digital slit lamp, and I spent just over a year using that system before I had to move to a new hospital as part of my registrar rotations in the South West of England. We made the most of the time we had and I created a YouTube channel with the support of my friends and colleagues, amassing thousands of followers. Some videos have received almost a million views.
When I upgraded to my new rotation, I was disappointed to find that, unsurprisingly, there was no slit lamp camera. The extremely complex and demanding process of applying for funding for a slit lamp camera system was too difficult to contemplate at the time.
I came across the MicroREC (Custom Surgical) optical system through an advertisement on social media. The device is mainly used to connect a smartphone to operating microscopes, to allow the user to record surgical videos on their phone. However, it can also connect to slit lamps.
I was lucky enough to have a beam splitter for a Haag-Streit BQ900 slit lamp, which allowed me to use the optical system. I first combined it with an iPhone 8 and then an iPhone 12 Pro Max, with incredible results.
Normally in a National Health Service hospital in Britain you are lucky if there is 1 slit lamp with a camera system and even luckier if an ophthalmologist can have his clinic in the room where he is located. I had a 4K slit lamp camera system that I could keep in my bag and use on any slit lamp for less than $1250! I improved the system even further by adding a diffuse illuminator that I purchased from Eye2Mobile.
Slit lamp imaging is extremely valuable and I am amazed that it is not considered a fundamental part of the eye department of hospitals. Although the diagrams in the notes are helpful, there is no doubt in my mind that a photo is much more objective and useful when combined with a clinician’s impression of the patient’s condition.
Shorter learning curves
Teaching clinical skills is much easier with the use of a slit lamp camera system: using an Apple TV device, I can “stream” a real-time, live view of my iPhone’s slit lamp on a computer screen. I successfully taught a medical student how to perform a fundus exam in just 1 afternoon, a skill that often takes weeks or even months to learn.
I was also able to teach a nurse practitioner how to competently perform Goldmann Applanation Tonometry at 2 clinics. The practitioner had sat in 1 glaucoma clinic per week for the previous 2 years trying to learn this skill, with no success.
Being able to see what the student sees allows for critical, accurate, and helpful feedback (eg, that the Myers rings are too thick or need to get closer). Indeed, the alignment at the center of the cornea, the adjustment of the tonometer, etc. are only possible when you can see what the student sees and vice versa.
With the backlog resulting from the pandemic, we need to focus on how to teach basic clinical skills to junior doctors and allied health professionals in the most immersive and effective way possible. Slit lamp camera systems or digital slit lamps are an easy fruit to learn this skill, and we have proven this in a small pilot study.2
Having an optical system that allows you to capture acts while performing them democratizes digital ophthalmic imaging, not only with regard to the slit lamp but also in terms of surgical training, for which camera systems for operating microscopes are often prohibitively expensive.
Smartphone cameras are amazing: the quality of photos and videos that can be captured from a cell phone today is astounding. The latest devices can capture video up to 8K for breathtaking quality.
In addition, with the applications provided with many ophthalmic devices, it is now possible to optimize the captured videos or photos and export or share them in various formats, including a compressed version with a small file size, which allows rapid distribution on social networks. This eliminates the need to purchase an additional camera system, and having the videos on one’s own device means they can be shared with colleagues (with patients’ permission, of course) when advice is sought. or viewed at home to hone surgical skills.
The ability to conduct remote video consultations with a slit lamp was something we found particularly beneficial during the height of the pandemic. I hope ophthalmologists will increasingly realize the importance of digital imaging in clinical ophthalmology. Maybe in the future we’ll laugh at how we used to diagram on paper notes with colored pencils while watching slit lamp videos on 8K TVs.