Anterior segment photography isn't a
glamorous tool. But it is an excellent complement to contact lens and
anterior segment care and management. It's something that you can and
perhaps should apply to most if not all of your patients.
Figure 1. Fluorescein staining showing an
ocular surface problem.
Figure 2. A photograph that illustrates the
fit of a GPlens.
What's better than written notes or drawings?
What says a thousand words in an instant? It's the photograph. With one
quick look, you can tell that the eye in Figure 1 has an ocular surface
problem, or what kind of fit a GP lens has in Figure 2.
A photograph is valuable because of the
amount of information that an image can hold. When you read a patient's
chart a year later, do you still understand its meaning? You may make
detailed notes and even drawings, but even if these notes are understandable
to you, they may not be clear to others.
Now look at those same notes with an
accompanying photograph. Why can't all charts be so easy to read?
Here I'll explain how you can get started
with anterior segment photography.
Choosing Your Camera
Is anterior segment photography expensive or
difficult? It doesn't have to be. It's as simple as using a digital
point-and-shoot camera. Sure, you can spend thousands of dollars more, but
you don't have to. I use a five-year-old 3.34 mega pixel camera to take
full-head pictures. I see many trauma patients from the emergency room, and
it's great to be able to photo document facial as well as periocular
injuries or pathology.
It wasn't too long ago that film ruled the
world of photography. Film still offers better color fidelity and sharpness.
But what we lose in those two attributes with digital photography we gain in
convenience. It's heartening to know that you have a good image while the
patient is still in the office rather than worrying about whether you got a
usable image while waiting for the film to return from the laboratory.
Consumer digital cameras are capable of
taking clinically useful photographs of the upper face, lids and globe. Such
pictures are ideal for establishing landmarks like right and left eyes or
I photographed the patient in Figure 3 using the camera and its built-in
flash at a distance of 2 feet with the lens set at a slight telephoto effect
(to increase camera-to-subject distance).
Figure 3. Patient was photographed with just the
camera and its built-in flash at a distance of 2 feet
and the lens set at a slight telephoto effect.
Figure 4. Photo can depict a frames position
on a face, and may serve as a rationale for
pediatric contact lens wear.
Today's consumer-style digital cameras may
not have interchangeable lenses. Don't worry. You won't miss this feature
because most digital cameras come with modest zoom lenses that work for most
situations, if not for all. Fixed lens cameras also tend to be smaller. In
fact, they're small enough to fit into a jacket or clinic coat pocket. Small
also means that the camera is always nearby. Many a good photographic
opportunity has been lost because a larger camera is usually stored away
from arm's reach or is too bothersome to find and retrieve.
You've also heard about the mega pixel (MP).
This is the feature that most buyers and users pay the most attention to.
The inevitable question is how many mega pixels are enough. The good news is
that even 3.0 MP is sufficient for most eye needs. Think of 8 MP or 10 MP
only when you're trying to print a large poster.
Most of the photographs I take are with a
3.34 MP fixed lens point-and-shoot camera. It has a macro capability and
on-board flash for most full face photos, or of the forehead and eyes. For
even closer shots of the eye itself, I added a front-threaded LED ring
light. The ring light illuminates the eye better because at distances closer
than 6 inches, an off-axis (of the camera lens) on-board flash cannot shed
enough light. An on-axis light source (one that is positioned nearer to the
camera lens) can (Figure 5).).
Figure 5. This photo of a subconjunctival
hemorrhage was taken with an on-axis light
The Right Light
When I see something interesting on the
cornea, conjunctiva, irides or crystalline lenses, I use the camera with the
slit lamp. I either hold my camera against the stationary ocular of the slit
lamp or replace the ocular with an adapter tube and slide both the adapter
and the camera into the space previously occupied by the ocular (Figure
6). The former approach is a bit more tricky because I have to line up
the entrance pupil of the camera lens to the exit pupil of the ocular to
ensure a full field image. With either approach, you often need a
cooperative patient and sometimes a third helping hand (Figure
Taking great pictures of the eye isn't
difficult or complicated. The critical success factors are appropriate
lighting and a steady hand. In a full-face picture, the camera's own flash
will usually freeze the minute movements that are inevitable. Some camera
flashes, though, may highlight lightly complexioned faces too much, thus
washing out the details of the face.
Sometimes the flash can wash out a
particularly congested or hyperemic bulbar conjunctiva. It's dismaying to
see how red an eye looks in the office, but it only looks one-third as red
in the image. If this happens, stepping back a foot or more might reduce
this reflection. Sometimes a bright room light will further enhance the
light of the picture.
|Figure 6. Lens tube adapter for
7. This image of an amiadurone swirl was taken
using a camera with the slit lamp.
On a slit lamp, the illumination is more
complicated. The brighter the light, the faster the shutter speed, which
means that camera movement is minimized. But if there's too much light,
corneal reflections and patient discomfort are more likely to occur. Use too
little light and the picture becomes fuzzy because of camera shake or
patient eye movements. A good picture deserves a balance of all of these
Sometimes it's not the amount of light that
matters but the quality of the light. Some slit lamp camera vendors offer
fiber optic fill in illumination. By highlighting the surrounding tissues,
the picture may actually be easier to see.
A Practical Approach
Let's get back to the practical. Following is
a quick step-by-step approach to help you incorporate photography into your
Have the camera ready and nearby. I hate to
fumble for a camera especially if a patient is a bit anxious already. It
also conveys confidence that you've done this before.
Sometimes, I take an overall head shot to
get a frame of reference for the more magnified image. Or, I'll photograph
some part of the medical record to ensure that I can match the image with
the patient's chart later. Some practitioners even write down the exposure
numbers and reference them with a patient name.
Determine the value expected of the photo.
Is it a general photograph or is it positioned for risk management? Expect
to handle either differently. The former requires fewer images and the
latter more. I routinely take photos of a corneal foreign body and rust ring
both before and after debridement, one to three days after initial treatment
and at the time of discharge.
Particular to contact lenses is the
relative appearance of the lens in situ prior to any vital stains or
examination. What makes this valuable is the potential for patient
education. Seeing this before any doctor intervention can be helpful toward
If you're using this photographic image
within the office and it's part of the examination procedure, then you don't
necessarily need a model release. If you want to use the photograph but have
no informative or identifying information on the image, then again, no
specific model release is needed.
Once I've finished examining patients and
taking photographs for the day, I remove the memory card and insert it into
a memory card reader on my desktop computer. I have also transferred files
between the camera and the computer using a special data cable. Either works
well. Doing this daily translates to better characterization or sorting of
I tend to back up my images by leaving them
on the memory card and buying new cards as they fill up. I also have the
images stored on a desktop computer, which is also backed up.
A word of caution about memory cards.
They're not completely trouble free. If you happen to turn on the camera and
then open the battery compartment and disconnect the battery, you will
likely lose all the images on that memory card. This is a permanent error.
My use of photography during the course of a
clinical day is mainly driven by curiosity, patient education and the goal
of better patient care. All of these factors must somehow work together to
minimize interference of the workflow of a clinical encounter. This isn't
always possible! If photography ever does become a disruption in your
practice, you must decide whether the value of the photo supersedes
workflow. That isn't necessarily easy to determine either. Yet, I think the
treating practitioner is the final arbiter as to what's appropriate.
Reimbursement for Photographs
Now you're probably thinking, can I ever get
paid for taking these photographs? This depends on the reason for the
If a photograph is for patient education,
then it's not likely to be billable to a medical plan. When it is billable,
John Rumpakis, OD, of Lake Oswego, Oregon, an authority on third-party
billing for optometrists, advises that photography can be reimbursable if
the photograph is a medical necessity.
Dr. Rumpakis asks each practitioner to
consider the relevance of the photograph to treatment and whether without
it, the outcome would have been different.
Clearly, though, most practitioners such as
myself like taking anterior segment photographs for better patient
For contact lens practitioners, it's an
excellent way to demonstrate a particular risk factor. For instance, I would
use a photograph to show the location of a particular corneal foreign body.
In this form, I would bill the photo directly to the patient. Dr. Rumpakis
advises also that this charge should be equal to what you charge a medical
Improved Patient Management
Photography of the anterior segment can go a
long way in helping your patients better understand their contact lenses,
the nature of their care and the potential for complications.
Photography is more than just showing the
condition. The value of photography is in its ability to present a
tremendous amount of information to someone in a short span of time.
Patients understand and remember more from a
picture than what we say. What someone may partially remember in words he
will remember indelibly by imagery. Photography can even level the playing
field with other practices that may offer services in other areas.
Optometrist Michael Murphy's Swansea, Illinois, practice is less than a year
old, and his use of anterior segment photography has definitely been a
In summary, you can incorporate anterior
segment photography into your practice simply and easily. You can do it
quite frugally and yet yield valuable and relevant results, leading to
better patient management.
For those who find photography rewarding and
interesting, an investment in a more comprehensive system will only add
value to your present practice.