There’s an app for that...


Smartphones are now commonplace across the world. How are they helping with eye conditions, at home and abroad? Radhika Holmström reports.

“The beauty of doing things on a phone is that they are potentially very powerful computers and cameras,” says Dr Andrew Bastawrous of the London School of Hygiene and Tropical Medicine. “It’s very mobile, and the quality of the phones just keeps on going up.”

Over the past few years, smartphones have become part of everyday life for people across the globe. So it’s not surprising that smartphone apps are also being used in a wide variety of health contexts.

Apps in the mainstream

At a very general level, there are apps that monitor health and wellbeing, like the myfitnesspal and sleep apps, which track the user’s habits and give them the information they need to make changes. Others are used as a health or wellbeing aid, like the mindfulness meditation apps from Headspace, the ‘happyplace’ app  developed by the Mental Health Foundation and the University of Bristol, or the Sleepstation app.

The next step up from this are apps that enable people to check their symptoms and/or give themselves some kind of diagnosis, including the free NHS Health and Symptom Checkers app.

Among these, there are also a number of apps that cover sight and sight loss. For instance, one of the major high street optician chains has an ‘eye check app’ with ‘four easy-to-use eye checks’, covering visual acuity, astigmatism, focus and colour, with more questions at the end ‘to help further assess the health of your eyes’. Obviously, the main aim is to drive users in-store to pay for an eye test – but that itself is arguably extremely valuable.

Then there are apps which focus on a specific condition, like Eye Screen, which aims to give an assessment of age-related macular degeneration (AMD).

These apps vary, hugely, in the way that they have been designed and put to use. Are they useful? One potential problem is that they fuel what’s been popularly termed ‘cyberchondria’ – the habit of constantly referring symptoms for an online diagnosis, especially if people turn from the app to the internet browser on their smartphone.

The studies so far suggest – unsurprisingly – that ‘consulting Dr Google’ can be pretty unhelpful, especially if this is just used to fuel fears without actually doing anything about it; but on the other hand, practitioners point out that apps can conversely be very useful. “There are lots available out there to download to different devices; and if one of them picks up that, for example, the user’s visual acuity is below par and that encourages a visit to the optometrist, that’s a positive to me,” says Dr Fiona Rowe of the University of Liverpool, who’s also the chief investigator of the VISION trial. The trial explores the visual rehabilitation of patients who lose either the left or right half of the visual field in both eyes (homonymous hemianopia) following a stroke.

Apps as medical aids

Probably the next step, for patients, are the apps for people who already have a diagnosed condition, like one that people with diabetes can use to monitor their blood glucose levels. Moorfields Eye Hospital in London, for example, has a glaucoma app, developed with the International Glaucoma Association, which shows patients how their glaucoma will worsen over time if it’s not monitored properly. "You name the condition, we get the apps to match up with your phone," says US cardiologist Dr Eric Topol.

Rowe’s take on this is: “Self-monitoring is useful if it’s been advised and directed by the eye care team. For example, those with AMD can monitor changes in their central vision and get an early appointment if they detect a change. When I did interviews with stroke survivors last year, many (regardless of age) used apps and various gadgets and were very positive about how they had helped. Many were free or very inexpensive, too. And on top of this, there are some fascinating apps to help people adapt to sight loss, like ones that work with global positioning systems to help someone navigate unfamiliar areas. I’ve noticed that many of the larger ophthalmology conferences provide sessions purely on using this kind of technology for low vision services.” 

Certainly recent research outside the field of sight loss supports her opinion. A study from the George Institute of Global Health presented at the World Heart Federation’s congress in May 2014 looked at ‘e-health strategies’ in Australia, and specifically at how web and mobile apps can potentially reduce the risk of cardiovascular disease. Nor is this restricted to the better-off countries, because smartphones are becoming commonplace worldwide. Alongside the George Institute presentation, Dr Dhruv Kazi of the University of California, reported on a study exploring different ways of using apps with poor, often illiterate, heart patients in Bangalore – and found that with some modification (often to address people’s problems with literacy and/or numeracy) there was considerable enthusiasm for the idea.

Apps for practitioners

Increasingly, medical practitioners themselves are using apps in different ways, from the BMJ’s ‘Differential Diagnosis’ app onwards. Ophthalmology is now catching up in this area; in fact the European Society of Ophthalmology website has an entire section dedicated to ‘the use of smartphones in everyday ophthalmology practice’, starting with the Eye Handbook app which is produced in collaboration with the American Academy of Ophthalmology.

The Auckland Eye Manual app, produced with the help of 14 New Zealand eye surgeons, aims to be a similar ‘comprehensive ophthalmic diagnostic resource’, but targeted more at GPs and other health professionals (including optometrists). “GPs don’t have the specialised examination equipment available to ophthalmologists, so diagnosis can be more difficult for them, particularly if the condition is uncommon,” creator Dr Sue Ormonde points out.  

In addition, as Bastawrous says, smartphones also have the potential not just to act as a resource but as a diagnostic tool – and a tool that can be used in places where the usual ones aren’t to hand.

Indeed, researchers at the University of Cambridge have recently (March 2014) reported that they have developed a new app ‘which turns any smartphone into a portable medical diagnostic device’. It does this by producing an accurate reading of ‘colorimetric’ tests of bodily fluids. Usually, the strips that change colour to indicate the fluid’s makeup have to be assessed using specialised laboratory equipment. The new app uses the phone’s camera and an algorithm to analyse the data instead. The researchers hope it has the potential to be used in the developing world to combat diseases including HIV, tuberculosis and malaria. They are now planning to use it in clinical test at Addenbrooke’s Hospital in Cambridge.

App acclaim

Finally, there’s the app that Bastawrous and colleagues (including ophthalmologists, developers and engineers) have developed. PEEK (portable eye examination kit) has already scooped the digital category of the Design Museum’s 2014 designs of the year.

It’s a mobile app, along with clip-on hardware, that converts a smartphone into an eye examination and diagnostic suite which can run a series of different eye tests to diagnose a lot of different eye conditions.

It requires fairly minimal training, and patients can either be diagnosed automatically or by sending digital images to experts in other places (including across the world). 

Bastawrous explains the background. “We are tackling conditions which are caused, above all, by poverty. The patients who are the most difficult to reach are the ones tend to be most in need of care – they’re the ones furthest from treatment options, and least aware that there are treatments in the first place. Our primary market is people in settings where access to hospitals is difficult.

"This isn’t designed for home use, though – it still needs a level of understanding and minimal training which can be delivered through the app itself.  It’s not a replacement for eye doctors either; it’s a way of connecting people who are usually beyond the end of the road with clinicians.”

“Being digital helps it do things that we couldn’t do before,” explains designer Kim Colin, who was one of the museum judges. “ It’s a portable optician – the camera can look at your eyes, the flash from the camera can hit the back of your eye and get a picture, you can use it as an eye test sight card, and you can then send the results to wherever you want in the world. It also feels like it can scale; you can get the kit to millions of people really quickly in one go - another advantage of digital.

"PEEK is enabling teachers in schools to test the eyes of kids without having to go to an optician and that feels like a really good use of digital technology.”

The PEEK app, concludes jury chair Ekow Eshun, “uses high design and high technology for a really fundamental purpose, which is ideally to make people’s lives better”.

It’s a high bar for other apps to reach, but one that shows just how much this portable, pocket-sized affordable technology really can achieve.

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