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The site is secure. This study is to test the feasibility of using trans-pars-planar illumination for ultra-wide field pediatric fundus photography.
Fundus examination of the peripheral retina is essential for clinical management of pediatric eye diseases. However, current pediatric fundus cameras with traditional trans-pupillary illumination provide a limited field of view FOV , making it difficult to access the peripheral retina adequately for a comprehensive assessment of eye conditions.
Here, we report the first demonstration of trans-pars-planar illumination in ultra-wide field pediatric fundus photography. For proof-of-concept validation, all off-the-shelf optical components were selected to construct a lab prototype pediatric camera PedCam. A low-cost, easy-to-use ultra-wide field PedCam provides a unique opportunity to foster affordable telemedicine in rural and underserved areas. Pediatric eye diseases such as retinopathy of prematurity ROP and retinoblastoma can affect both the central and peripheral retina.
Therefore, wide field fundus examination is essential for screening, diagnosis and treatment evaluation of pediatric eye diseases [ 1 , 2 ]. ROP is a public health problem worldwide [ 3 , 4 ]. Globally, at least 50, children are blinded because of ROP each year [ 7 ]. Prompt screening and early diagnosis are essential steps to prevent visual impairment and blindness due to ROP [ 8 ]. If it could be diagnosed promptly, most of ROP caused visual losses are preventable.
Laser photocoagulation and intravitreal injection of vascular endothelial growth factor VEGF antibodies have been approved for ROP treatment [ 5 ].
However, routine ROP screening is challenging, particularly in underserved areas and developing countries, where the access to both expensive instruments and skilled ophthalmologists is limited [ 9 ].
ROP is caused by abnormal development of retinal blood vessels in premature infants. In a healthy gestation period, retinal vascular development starts from the center of the retina, continues during pregnancy and reaches the peripheral retina after the birth. Preterm birth may disrupt the normal vascularization process, predominantly in the peripheral retina [ 7 ].
Therefore, wide field fundus examination is needed to evaluate vascular abnormality of the peripheral retina. The current gold standard for ROP screening is conventional binocular indirect ophthalmoscopy BIO with scleral depression [ 10 — 12 ], which is a time-consuming procedure that is painful for the patient and stressful for the ophthalmologist. It is technically difficult to construct wide field fundus imagers, due to the complexity of illumination and imaging mechanisms. Trans-pupillary illumination allows limited FOV in a snapshot image because only the central part of the pupil can be used for collecting image light; while the periphery area of the pupil has to be used for delivering illumination light [ 16 ].
Based on the Gullstrand-Principle of fundus photography [ 17 ], the observation and illumination light beams have to be separated from each other. Otherwise, trans-pupillary illumination may cause severe light reflections from the cornea and crystalline lens, which can be multiple orders of magnitude higher than the useful signal from the retina. Sophisticated optical design and delicate system construction increase the instrument complexity and cost of the pediatric fundus camera.
With the limited FOV, it is time-consuming for clinical examination of the retina, and technically difficult to access zone III for a comprehensive ROP management [ 18 ]. By combing two or more laser wavelengths, color fundus SLO photography is practical.
However, sophisticated scanning device has to be involved, compared to traditional snapshot fundus cameras. The pars plana is a smooth, posterior part of the ciliary body. The pars plana lacks muscle, blood vessels and pigmentation [ 20 ]. Therefore, it is more transparent than other scleral areas, making it an alternative location for delivering light into the eye [ 21 — 23 ].
Trans-scleral illumination has been successfully demonstrated for retinal imaging of adult eyes [ 24 , 25 ]. However, the previous effort for exploring trans-scleral illumination in pediatric fundus imaging failed [ 26 ]. However, the dimension of the pars plana is closely correlated with postconceptional age in pediatric patients. The mean pars plana width in full-term infants is between 1. Therefore, careful control of the illumination spot size and accurate identification of the pars plana location are essential factors to optimize trans-pars-planar illumination in pediatric fundus photography.
All off-the-shelf optical components were selected to construct the handheld PedCam for proof-of-concept validation Fig. The trans-pars-planar illuminator in Fig. The contact OL consists of two elements, a meniscus lens and a condensing lens. The removable design of the contact OL in the prototype PedCam enables easily sterilization of the meniscus lens contacting to the eye.
The contact OL produces an aerial retinal image in front of the relay optics Fig. The relay optics consists of three lenses, i. For capturing images presented in the article, the aperture of the camera lens was set to F1. A Optical layout of the prototype PedCam. All off-the-shelf optical components were used for this prototype. B Photographic illustration of the prototype PedCam for fundus imaging.
C Light spectrum, normalized intensity of the light source and ISO aphacic photochemical hazard weighting function. E The relay optics in Fig. This study was approved by the Institutional Review Board of the University of Illinois at Chicago and was in compliance with the ethical standards stated in the Declaration of Helsinki. Two patients with ROP and one patient with previously diagnosed retinoblastoma were used for functional validation of the PedCam with trans-pars-planar illumination.
As shown in Fig. Topical tetracaine 0. General anesthesia was also used for the retinoblastoma patient as part of a routine exam under anesthesia. An eye speculum was used to keep the eyelids open during the recording. All images were captured by pediatric ophthalmologists using the PedCam with trans-pars-planar illumination.
During image focusing adjustment, live video images were streamed to the computer for continuous monitoring Visualization 1. Image focusing was performed manually by rotating the focusing ring on the camera lens.
Slightly moving the illuminator back and forth from the limbus, the optimal illumination location, i. For imaging the central retina, the illuminator was placed on the temporal sclera. For reaching the ora serrata region, the imaging probe was slightly tilted from the axis and the illuminator was placed on the opposite side of the ora serrata.
ISO is the standard guidance for assessing light safety of ophthalmic devices. Although there is no special requirement for pediatric patients, conservative estimation was carefully used to ensure the safety of newborns. For light safety, both photochemical and thermal hazards of the retina were quantitatively evaluated. It is known that the photochemical hazard to biological tissues is primarily related to the blue light absorption Fig. Therefore, a nm LED was selected as the light source to minimize the photochemical hazard risk to the retina.
The weighted irradiance in Fig. For the 7 mW maximum light power, the weighted power was 0. For conservative estimation of the worst case, assuming all light directly reaches to the retina behind the illuminated sclera area, the illuminated retinal area was estimated as 5. Therefore, there was no thermal hazard concern. Figure 2 A and Fig. Figure 2 B illustrates a schematic diagram of the eye, showing the locations of the pars plana, ora serrata, peripheral retina and equator of the globe.
By delivering the trans-pars-planar illumination light from the temporal Fig. B Schematic diagram of the eye showing the location of the pars plana, ora serrata, peripheral retina, and equator of the globe. C Schematic diagram of the left ocular fundus, illustrating retinal zones for ROP classification.
D Representative fundus images captured with the prototype PedCam from the left eye of a patient with plus disease, zone II stage 2 ROP in the nasal region and zone II stage 3 ROP in the temporal region, with trans-pars-planar illumination light delivered from the temporal D1 and nasal D2 sides, respectively.
In addition to the ROP imaging in Fig. Retinoblastoma is the most common primary malignant intraocular tumor in children and can be life threatening without prompt medical intervention [ 37 ].
Figure 3 shows representative images of the patient under topical and general anesthesia. A treated retinoblastoma lesion surrounded by photocoagulation scars was observed in Fig. Figure 3 A shows the fundus image captured with the prototype PedCam. By slightly tilting the imaging system relative to the visual axis of the eye, the ora serrata and pars plana region were unambiguously observed in the superior temporal quadrant Fig.
Fundus images of a patient previously diagnosed with retinoblastoma. A Central view of the fundus captured with the prototype PedCam2 in Fig. Treated retinoblastoma lesion surrounded by photocoagulation scars was observed below the optic disc. B Vortex vessels, ora serrata and pars plana were observed by slightly tilting the axis of the imaging system for peripheral imaging.
C Fundus image of the same eye captured by clinical Retcam. In summary, we demonstrated the feasibility of using trans-pars-planar illumination for ultra-wide field fundus photography. To the best of our knowledge, this is the first successful demonstration of using contact-mode trans-pars-planar illumination in pediatric fundus photography. Contact-free trans-pars-planar illumination has been demonstrated for wide field fundus photography in adult patients [ 23 ].
Contact-free imaging requires careful cooperation of the patients for retinal alignment and focusing, because poor fixation and eye movement may significantly affect the image quality [ 38 ]. Therefore, the contact-free modality is not practical for uncooperative pediatric patients, particularly newborns.
Contact-mode imaging is required for pediatric patients to minimize the effect of eye movements on retinal imaging [ 39 ].
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