Comparison of smartphone ophthalmoscopy vs conventional direct ophthalmoscopy as a teaching tool for medical students: the COSMOS study

Abstract

Purpose: To investigate the utility of smartphone ophthalmology for medical students for learning fundoscopy compared with direct ophthalmoscopy.

Methods: After 1 hour of didactic instruction on ophthalmoscopy, second-year medical students in a small group setting were randomized to start training with the direct ophthalmoscope vs smartphone ophthalmoscope and crossed over to the other instrument through the session.

Main outcome measures: Ability to visualize the optic nerve and retinal blood vessels in an undilated pupil as well as a survey evaluating ease of use, confidence, and ability to visualize the optic nerve with the two instruments.

Results: One hundred and one medical students participated. Significantly more medical students were able to visualize the optic nerve with the smartphone ophthalmoscope vs the direct ophthalmoscope in an undilated pupil (82.3% vs 48.5%, P<0.0001). Students reported a more positive experience with the smartphone ophthalmoscope, specifically regarding ease of use (median of 4 vs 3; P<0.0001), their confidence in performing ophthalmoscopy (median of 4 vs 3; P<0.0001), and their ability to visualize features of the optic nerve (median 4 vs 3; P<0.0001). A significant number of participants preferred the smartphone ophthalmoscope over the traditional direct ophthalmoscope for learning how to identify the optic disc and for evaluating patients (78.2% and 77.2%, respectively; P<0.0001).

Conclusion: Smartphone ophthalmoscopy may serve as a useful adjunctive tool to teach direct ophthalmoscopy as well as being an alternative for examining the fundus for noneye care physicians.

Keywords: direct ophthalmoscopy; medical student education; smartphone ophthalmoscopy.

Figure 1

D-EYE ophthalmoscope. Notes: A University of California, San Diego, second-year medical student using the D-EYE ophthalmoscope to look at the optic nerve and vessels in an undilated eye. Written informed consent has been obtained for the image to be published.

Figure 2

COSMOS study design. Notes: The USCD second-year medical students were randomly trained with either the direct or smartphone ophthalmoscope. Students crossed over to the other instrument during the session. A postsurvey assessed objective as well as subjective measures. ^aParticipants who did not identify themselves as part of Group A or Group B on the administered anonymous survey were excluded from the study. Abbreviation: USCD SOM, University of California San Diego School of Medicine.

Figure 3

COSMOS study primary outcomes. Notes: Primary outcomes comparing the ability of students to visualize retinal structures using the traditional and smartphone ophthalmoscopes. Percentage of students who were able to (A) identify the optic nerve in undilated eyes (out of total n=86 and n=79 for traditional and smartphone, respectively), (B) the optic nerve in dilated eyes (out of total n=81 and n=71 for traditional and smartphone, respectively), (C) the retina vessels in undilated eyes (out of total n=86 and n=79 for traditional and smartphone, respectively), (D) and the retina vessels in dilated eyes (out of total n=81 and n=70 for traditional and smartphone, respectively). P-value calculated according to chi-squared test. ***Significant at P=0.0036, ****significant at P<0.0001; ns, not significant at P=0.2175 and P=0.6029 for retina vessels in undilated and dilated eyes, respectively.

Figure 4

COSMOS study secondary outcomes. Notes: Secondary outcomes measuring student experiences using the traditional and smartphone ophthalmoscopes looking at ratings and preferences. Histograms of student ratings for (A) ease of use, (B) confidence in performing ophthalmoscopy, (C) ability to visualize vessels, (D) and ability to visualize the optic nerve. Ratings were provided on a scale of 1 (“negative”) to 5 (“positive”). Student preferences between the traditional and digital ophthalmoscopes for (E) learning to identify the optic disc and (F) for evaluating a patient. Abbreviation: DO, direct ophthalmoscope.