4. Eagle RC Jr. Uveal malignant melanoma. In: Eye Pathology: An Atlas and Text. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:183-186. A 5. Shields CL, Furuta M, Berman EL, et al. Choroidal nevus transformation into melanoma: analysis of 2514 consecutive cases. Arch Ophthalmol. 2009;127 (8):981-987. 6. Ferrara DC, Costa RA, Tsang S, Calucci D, Jorge R, Freund KB. Multimodal fundus imaging in Best vitelliform macular dystrophy. Graefes Arch Clin Exp Ophthalmol. 2010;248(10):1377-1386. 7. Amselem L, Pulido JS, Gunduz K, et al. Changes in fundus autofluorescence of choroidal melanomas following treatment. Eye (Lond). 2009;23(2):428-434.

Nonmydriatic Digital Ocular Fundus Photography on the iPhone 3G: The FOTO-ED Study

he widespread use of smartphones provides a unique opportunity for telemedicine. In oph- B T thalmology, smartphones are used for visual acu- ity assessments and to document examinations, particu- larly in settings like the emergency department, where the usual ophthalmic tools and photographic services are unavailable.1 However, to our knowledge, these devices have not been used for systematic, remote review of clini- cal photographs in ophthalmology as they have in radi- ology and dermatology.2,3 We performed a pilot investi- gation to compare the quality of nonmydriatic fundus photographs displayed on an iPhone 3G (Apple Inc) vs a desktop computer.

Methods. Three hundred fifty patients with headache,

focal neurologic deficit, visual changes, or diastolic blood C D pressure 120 mm Hg or higher were prospectively en- rolled during the Fundus Photography vs Ophthalmos- copy Trial Outcomes in the Emergency Department (FOTO-ED) study.4,5 Nonstereoscopic, nonmydriatic, single-field photographs of the ocular fundus were ob- tained using the Kowa ␣-D camera. All photographs were stored as JPEG lossy compression images (resolution, Figure. Comparison of a nonmydriatic fundus photograph on a computer 2528ϫ1936 pixels; compression ratio, 1:5). Photo- monitor vs an iPhone 3G (Apple Inc). A, A 19-inch computer liquid crystal display (HP W1907; Hewlett-Packard Development Company, LP; resolution, graphs were graded for general quality by 2 neuro- 1440ϫ900; pixels per inch, 89.1; brightness, 300 cd/m2) displaying a ophthalmologists (C.L. and B.B.B.) on a computer moni- nonmydriatic fundus photograph. B, An iPhone 3G (resolution, 320ϫ480; tor (Figure) using a previously validated 5-point scale.6 pixels per inch, 164.6; brightness, 480 cd/m2) displaying the same nonmydriatic fundus photograph. C, Screenshot taken from the iPhone 3G Six weeks after initial review on the computer display, while displaying the photograph at the actual size and resolution of the 100 photographs were chosen by a pseudorandom se- screen. D, Screenshot taken from the iPhone 3G while displaying the quence and graded on an iPhone 3G (Figure) by both photograph zoomed in on the device at the actual size and resolution of the neuro-ophthalmologists. Zoom level could be adjusted screen. on both devices. Photographs were transferred to the iPhone via the wired interface without modification. One out abnormalities. The 2 reviewers had excellent inter- year later, 1 neuro-ophthalmologist (C.L.) regraded the reviewer and intrareviewer agreement on either the same 100 photographs on the iPhone. desktop computer or the iPhone display without evi- Agreement was assessed by quadratic (Fleiss-Cohen) dence of systematic differences (␬=0.93-0.97; 95% CI, weighted ␬. Systematic differences in ratings were as- 0.68-1.00; ␹2 Յ 4.3; P Ն .19) (eTable 1, http://www sessed by the Bishop, Fienberg, and Holland modifica- .archophthalmol.com). The agreements for the same re- tion of the McNemar ␹2 test. P values were Bonferroni viewer on the desktop computer vs the iPhone were also corrected. excellent (␬=0.82-0.91; 95% CI, 0.56-1.00). Both re- viewers tended to rate an image’s quality on the iPhone Results. The quality ratings on the computer display for as superior to that same image viewed on the computer the 100 randomly selected photographs were the follow- display (␹2=36.4-43.1; PϽ.001) (eTable 1 and eTable 2). ing: 31 photographs, grade 1 (inadequate for any diag- nostic purpose); 19 photographs, grade 2; 13 photo- Comment. We expected equal- or lower-quality ratings graphs, grade 3; 16 photographs, grade 4; and 21 for photographs displayed on the iPhone compared with photographs, grade 5 (ideal quality). There was no dif- the desktop computer, but instead we found that review- ference in quality ratings of photographs with vs with- ers assigned higher ratings on average for photographs

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 displayed on the iPhone. Because the magnitude of this sis, or interpretation of data; or in the preparation, re- difference was similar for both reviewers and no bias in view, or approval of the manuscript. the other ratings was observed, we believe this occurred Online-Only Material: The eTables are available at http: because the advantages of the iPhone’s display (eg, higher //www.archophthalmol.com. dot pitch and brightness) outweighed its disadvantages 1. Lord RK, Shah VA, San Filippo AN, Krishna R. Novel uses of smartphones in (eg, lower resolution and smaller screen area). The fac- ophthalmology. Ophthalmology. 2010;117(6):1274-1274.e3. tors contributing to this difference warrant additional in- 2. Modi J, Sharma P, Earl A, Simpson M, Mitchell JR, Goyal M. iPhone-based vestigation. It also remains to be seen whether relevant teleradiology for the diagnosis of acute cervico-dorsal spine trauma. CanJNeu- rol Sci. 2010;37(6):849-854. abnormalities found on the computer display would also 3. Ebner C, Wurm EM, Binder B, et al. Mobile teledermatology: a feasibility study be found on the iPhone display under routine condi- of 58 subjects using mobile phones. J Telemed Telecare. 2008;14(1):2-7. 4. Bruce BB, Lamirel C, Wright DW, et al. Nonmydriatic ocular fundus photog- tions. This was not studied directly because currently no raphy in the emergency department. N Engl J Med. 2011;364(4):387-389. iPhone software exists to transfer and review a large num- 5. Bruce BB, Lamirel C, Biousse V, et al. Feasibility of nonmydriatic ocular fun- ber of photographs grouped by patient. However, our re- dus photography in the emergency department: phase I of the FOTO-ED study. Acad Emerg Med. 2011;18(9):928-933. sults support the iPhone’s display as a potential compo- 6. Lamirel C, Bruce BB, Wright DW, Delaney KP, Newman NJ, Biousse V. Qual- nent in a telemedicine network. We are not suggesting ity of nonmydriatic digital fundus photography obtained by nurse practition- using the iPhone to screen for subtle conditions (eg, dia- ers in the emergency department: the FOTO-ED study. Ophthalmology. 2012; 119(3):617-624. betic retinopathy) or as a replacement for in-person oph- thalmologic consultation. Rather, we believe the iPhone, and similar devices, in combination with nonmydriatic photography can complement ophthalmologic consul- Intravitreal Daptomycin in a Case tations in settings such as the emergency department4,5 of Bilateral Endogenous Endophthalmitis by allowing for rapid and remote identification of obvi- ous conditions affecting the posterior pole such as pap- acterial endophthalmitis is a devastating intra- illedema and malignant hypertension. ocular infection that, in its most severe form, can B result in complete loss of vision in the affected Ce´dric Lamirel, MD eye. In patients with endogenous bacterial endophthal- Beau B. Bruce, MD, MS mitis, 69% have a final visual acuity worse than count- David W. Wright, MD ing fingers.1 Visual outcomes are directly related to the Nancy J. Newman, MD infecting bacteria, with eyes infected with coagulase- Vale´rie Biousse, MD negative Staphylococcus faring much better than those infected with Staphylococcus aureus, Streptococcus, and Author Affiliations: Departments of Ophthalmology (Drs gram-negative organisms.2 With the emergence of drug- Lamirel, Bruce, Newman, and Biousse), Neurology (Drs resistant bacteria, increasing the arsenal of safe and ef- Bruce, Newman, and Biousse), Emergency Medicine (Dr fective antibiotics for treatment is of particular impor- Wright), and Neurological Surgery (Dr Newman), Emory tance. We report a case of bilateral endogenous University, Atlanta, Georgia. methicillin-resistant S aureus endophthalmitis treated suc- Correspondence: Dr Newman, Department of Ophthal- cessfully with intravitreal injections of daptomycin. mology, Emory Eye Center, Emory University, 1365-B Clifton Rd NE, Atlanta, GA 30322 (ophtnjn@emory Report of a Case. A 69-year-old previously well woman .edu). who was retired, married, and caregiver to her chroni- Author Contributions: All authors had full access to all cally ill husband was taken to the emergency depart- of the data in the study and take responsibility for the in- ment by her daughter with an acute onset of confusion, tegrity of the data and the accuracy of the data analysis. disorientation, and generalized malaise. Her medical his- Financial Disclosure: None reported. tory included a remote history of angina, intermittent pleu- Funding/Support: This study was supported in part by risy, a total abdominal hysterectomy with bilateral sal- a departmental grant (Department of Ophthalmology) pingo-oophorectomy, and cataract surgery in the left eye. from Research to Prevent Blindness and core grant P30- Her only medication was estrogen replacement. There was EY06360 (Department of Ophthalmology). Dr Lamirel no illicit drug use, recent dental work, or indwelling ve- is supported by Institut Servier, Fondation Planiol, and nous catheter. The patient was admitted to the hospital the Philippe Foundation. Dr Bruce is supported by grants for workup of altered mental status and eventually found KL2-RR025009 and UL1-RR025008 from the US Public to have bacterial endocarditis with methicillin-resistant Health Service and K23-EY019341 from the National Eye S aureus. The bacterial isolate had an intermediate resis- Institute, by the Knights Templar Eye Foundation, and tance to vancomycin hydrochloride (minimum inhibi- by the American Academy of Neurology Practice Re- tory concentration, 4-8 µg/mL). Magnetic resonance search Fellowship. Dr Wright is supported by grant KL2- imaging of the brain showed multiple bilateral acute is- RR025009 from the US Public Health Service. Dr New- chemic changes, and echocardiography revealed mitral man is a recipient of the Lew R. Wasserman Merit Award valve endocarditis. from Research to Prevent Blindness. Dr Biousse is sup- The ophthalmology service was consulted for evalu- ported by grant UL1-RR025008 from the US Public Health ation of the patient’s blurred vision. At initial examina- Service. tion, the patient’s visual acuity was at least counting fin- Role of the Sponsors: The sponsors had no role in the gers OU and intraocular pressures were normal. Findings design or conduct of the study; in the collection, analy- on anterior segment examination at the bedside were nor-

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