diagnosis and management are improved …bcninnova.com/uploads/brochure_2013_06_12_eng429.pdf ·...
TRANSCRIPT
> The easiest way to measure strabismus:
Objective, accurate and documented
Helps you to diagnose and improve your
treatments
Allows you to track the evolution of your
patients
Relieves you and assure your correct practices
> The most powerful research tool in ocular
motility that allows to measure:
How much is the ocular deviation (between
both eyes)
What is the behavior of the pupils
How are oscillating the eyes,
And if the eye is in torsion and how much.
> Detecting the pupil and scanning the iris we
can measure:
Ocular deviation at any point in space
(horizontal + vertical + torsional).
Ductions, versions and vergences. Saccadic
and following movements.
Cover test. Uncover test. Alternate test.
Automatic Hess test (9 Gaze Points).
Concomitant and paralytic strabismus.
Measure the field of ocular motility.
Bielchowsky Test.
Nystagmus.
Pupillary dynamics (pupillography).
Accommodation-convergence reflex.
And soon, eyelid dynamics and visual
therapy.
Motility and centering of ocular prosthesis.
DIAGNOSIS AND MANAGEMENT ARE IMPROVED THANKS TO BETTER AND OBJECTIVE MEASUREMENTS
This means GAZELAB
Both eyes uncovered
Glasses concept 9 gaze positions test
0,6±0,9 0,5±0,9 0,3±0,9 0,2±0,9 0,3±0,9 0,3±0,9
0,4±0,9 0,3±0,9 0,0±0,9 0,1±0,9 0,6±0,9 -0,2±0,9
-0,3±0,9 0,1±0,9 0,3±0,9 0,3±0,9 0,5±0,9 0,3±0,9
Horizontal Vertical
Strabismus can be diagnosed in children and
adults using digital videocameras mounted on
standard trial frames.
The 9 gaze positions test helps to measure with
objectivity and accuracy the ocular motility
disorders. These better measurements are a quicker
improvement in diagnostic support, surgical planning
and monitoring.
Display results in a normal patient (bottom)
The patient is required to look a laser test projected in the wall in each of the 9 gaze
positions. The exam is performed under 3 different manners:
both eyes uncovered,
right eye covered (left eye fixing)
left eye covered (right eye fixing).
The computer process simultaneously the horizontal and vertical data of each point, as
well as torsional measured in degrees. The resultant reports show the images of both
eyes for each point analysed.
In addition to the 9 gaze positions, the device allows you to pass other tests like
Bielchowsky test, papillary dynamics, nystagmography, etc.
> Less than 400g
> Quicker than 2 minutes
ADVANTAGES:
Effective - increases accuracy and
diagnostic measurement capability.
As a consequence, improves the
surgical success rate and facilitates
post-surgery monitoring.
Flexible - allows to explore many
of the eye positions.
Documented - generate
documentary evidence appended to
the clinical history.
Pre-programmable - with scan
patterns defined by the specialist.
Easy to use - provides the
possibility to delegate scanning
tasks to physician assistants.
Versatile - allows the
implementation of other features
related to ocular motility.
Videoculograph (VOG) with laser projection
system, integral with the patient's head, that
allows to measure and accurately diagnose
complex deviations of gaze in all directions.
Why Gazelab?
Provides you the ability to analyze every muscle independently.
Allows to improve surgical success rate.
Controls the gaze of the patient with the projection system and explores concrete
positions.
Measurement independent of the Explorer.
Pattern Projection, Gaze Position & the Recording all together in the same reference
This medical device is equipped with two
cameras with infrared vision, that allows
recording eye movements with great
precision, and with a laser projector able to
projects at any point in space.
Components:
1. Laser projector
2. Cameras with infrared vision
The device includes an ad hoc computer with
the necessary applications preinstalled.
Glasses concept
1
2
If the eye moves, how is it that none of the
medical devices that can be currently find in an
ophthalmologist clinic measures the dynamic
of the eyes? This was the question posed by
Dr. Joan Prat Bartomeu when the idea of
developing a measurement technique that
could accurately capture and measure ocular
biomechanics came up.
Most of already existing ophthalmological
devices explore parts of the eye (anatomical
structures) from a static point of view. For
example, through the slit lamp you can
observe the anterior segment of the eye;
Same historic considerations in digitalization of ocular movements.
The first eye-trakers made around 20 years ago were used specially for research and
marketing applications. They were able to know where the eyes were looking at. Neither her
constructive concept nor software applications were designed for clinical use.
Ophthalmologist remember the eye-traker implemented in Excimer Laser; the laser was
blocked when the eye loss the green spot because of its movement.
The videonistagmographer (VNG) measured the eye movements in patients with
nystagmus. Some otolaryngologists use this device for study of vertigo during the last
decade. Only a few ophthalmologist used it for diagnosis of any sort of nystagmus. The
problem were that VNG took measurements in millimeters and not in degrees or prism
diopters.
The videoculography (VOG) is, on the other hand, a system that measure the ocular
deviations in cases of strabismus or extraocular muscle palsies. It consists in analyze eye
movements using a monitored image by computer. Two previous European devices weren’t
useful for clinical purposes but good in research.
Videopupillography (VPG) is nowadays into the research centers, used by a few
neurophthalmologist or neurologist. Its records the pupillary light reactions with accuracy in
cases affected of optic nerve or cerebral diseases.
the ophthalmoscope does the same with the ocular fundus; or the OCT (Optical Coherence
Tomography) that shows cuts of the retina and choroid. For all of them the patient must be
still.
In any case, it is impossible to measure the movements with actual ophthalmic devices:
- Is possible to have an ocular motility field? We have a campimeter that give us a visual
field! Is possible to study the behaviour of a concrete extraocular muscle?
- In which accuracy can be measured a nystagmus?
- Which are the changes during the light pupillary reflex? Is important the velocity of
contraction and dilatation?
- Perhaps could by useful to known the blinking parameters in a facial palsy or other
disorders.
A little bit of history about Videoculography
Dots Coordinates Horizontal Dif. Vertical Dif.
1 0,30 -15.9 -1.9
2 0,20 -16.2 -0.2
3 0,10 -16.4 -0.4
4 0,0 -15.8 2.2
REPORT: Right Exotropy
In the pictures above, it can be observed that the left eye followed correctly the vertical pattern,
while the right eye maintains a steady drift towards the right.
At each coordinate it can be observed the deviation of the right eye compared to the red cross (0,0).
Right Left
Basic Concepts of reliable VOG
The gaze is the result of 2 main movements done by eye and head. So, the VOG must
be attached to the head to avoid the register of head movements. The device should
be only mounted as a helmet, on the head, any other system can avoid the head
movements during the digital recording.
If you want to know were the eyes are looking at you have to fix a project system in
the same head mounted device. Then you could move a test projected in a wall in
your desired way. Cameras record the eyes when move following the test. A computer
vision software take measurements during all the procedure.
¿What can you digitalize with a VOG?
You can digitalize the primary position and the main 9 positions of the gaze at a
exactly known point in coordinate axis. And perhaps more important, you can as well
register the behavior of the eyes in the specific ocular action muscles, all 6 plus 6
muscles. This is the best way to interpret the paper of every muscle in ocular motility
disorder.
Exam method
1: Primary position without or with and cover test
2: Horizontal movements (0, -40º and +40º)
3: Superior movements (up to -23º, 0 and +23º)*
4: Inferior movements (down to-23º, 0 and +23º)
5: Bielchowsky test (torsions 15º,30º,and 45º)
Strabismus: exotropy
REPORT: Left Esotropy + Left Hypertropy
On the eye’s pictures it is observed the right eye is looking straight to the dot, while the left eye deviates
to the left. An increasing hypertrophy appears in the left eye.
At dot number 5 (eyes looking at coordinate 10,0) the left eye deviation towards the right is horizontal=19.5° and vertical=-9.4°. For dot number 8 (eyes looking at coordinate 40,0) the left eye deviation towards the right is horizontal=9° and vertical=-20.5°.
Right Left
Dots Coordi-nates
Horizontal Dif.
Vertical Dif.
1 -40,0 5.2 -4.1
2 -30,0 6.1 -3.9
3 -20,0 10.3 -4.6
4 -10,0 16.6 -7.5
5 10,0 19.5 -9.4
6 20,0 19.4 -12.1
7 30,0 14.9 -17.0
8 40,0 9.0 -20.5
Results presentation
The computer process the horizontal, vertical and torsional data of every point
registered during and after the exam.
At the end, the reports show all the registered data in several formats that can be saved
in any digital support:
1: Serial key photogram.
2: Graphic representation.
3: Data collection in a table.
“Now ophthalmologist can work in strabismus on scientific data base, then can
develop and improve its practice”
- Schneider E, Villgrattner T, Vockeroth J, Bartl K, Kohlbecher S, Bardins S,Ulbrich H, Brandt T. EyeSeeCam: an eye movement-driven head camera for the examination of natural visual exploration. Ann N Y Acad Sci. 2009;1164:461-7. - Laria C, Gamio S, Alió JL, Miranda M. Difficult vertical diplopia studied by video-oculography in aphakia after contactlens use. A case report. Binocul Vis Strabismus Q. 2006;21(4):223-30. - Becker R, Krzizok TH, Wassill H. Use of preoperative assessment of positionally induced cyclotorsion: a videoculographic study. Br J Ophthalmol. 2004;88(3):417-21. - Schworm HD, Ygge J, Pansell T, Lennerstrand G. Assessment of ocular counterroll during head tilt using binocular video oculography. Invest Ophthalmol Vis Sci. 2002;43(3):662-7.
Strabismus: esotropy with hypertropy
REPORT
Left Esotropy + Left Hypertrophy
Alternate Fixation
The eye fixation to vertical pattern
changes according to the point
examined.
For pattern dot number 2 (coordinate
0,20) the fixating eye is the left, while
the right eye looks inward. The visual
difference between right and left eye is
horizontal=23.1° and vertical=-2.9°.
For pattern dot number 5, the fixating
eye is the right one, while the left eye
looks inward. Visual deviation of the
r ight eye towards the left is
horizontal=17.7° and vertical=-10.6°.
Dots Coordinates Horizontal Dif. Vertical Dif.
1 0,40 21.7 -7.9
2 0,20 23.1 -2.9
3 0,10 23.8 -12.2
4 0,0 23.7 -15.3
5 0,-10 17.7 -10.6
6 0,-30 14.0 6.5
7 0,-40 17.4 -11.9
Right Left
Gazelab detects the ocular fixation too. So, cover-uncover test as well as alternate cover
can be performed with any problem here. Heterophories were detected as easy as
heterotropies.
However, head tilt and compensatory ocular torsions are not related with ocular fixation.
The device uses a sophisticated algorithm (complete iris images detection) that allows to
measure with total accuracy the torsions of the eyeball during head movements.
Strabismus: alternant esotropy
The blue graph presents the rapid
response of the right pupil diameter over time, as a result of two flashes of light. The red graph shows identical
response in the left.
- Wilhelm H, Peters T, Lüdtke H, Wilhelm B. The prevalence of relative afferent pupillary defects in normal subjects. J Neuroophthalmol. 2007 Dec;27(4):263-7. - Kardon R, Anderson SC, Damarjian TG, Grace EM, Stone E, Kawasaki A. Chromatic pupil responses: preferential activation of the melanopsin-mediated versus outer photoreceptor-mediated pupil light reflex. Ophthalmology. 2009 Aug;116(8):1564-73. - Kankipati L, Girkin CA, Gamlin PD. Post-illumination pupil response in subjects without ocular disease. Invest Ophthalmol Vis Sci. 2010 May;51(5):2764-9. - Kardon R, Anderson SC, Damarjian TG, Grace EM, Stone E, Kawasaki A. Chromatic pupillometry in patients with retinitis pigmentosa. Ophthalmology. 2011 Feb;118(2):376-81. - Kankipati L, Girkin CA, Gamlin PD. The post-illumination pupil response is reduced in glaucoma patients. Invest Ophthalmol Vis Sci. 2011 Apr 8;52(5):2287-92. - Feigl B, Zele AJ, Fader SM, Howes AN, Hughes CE, Jones KA, Jones R. The post-illumination pupil response of melanopsin-expressing intrinsically photosensitive retinal ganglion cells in diabetes. Acta Ophthalmol. 2012 May;90(3):e230-4. - Ishikawa H, Onodera A, Asakawa K, Nakadomari S, Shimizu K. Effects of selective-wavelength block filters on pupillary light reflex under red and blue light stimuli. Jpn J Ophthalmol. 2012 Mar;56(2):181-6.
Light pupillary reflex (LPR) is usually observed directly by the eye of the
ophthalmologist. He hasn’t accurate data about the diameter and even less about speed
movements.
Gazelab study the LPR recording 2 diameters and the surface of the papillary space over
time of both eyes. Ocular movements don’t affect the results. The device analyzes static
and dynamic parameters as:
Initial and final pupil diameter under a concrete light stimulus
Speed of contraction and dilatation.
On the graphics in the top you can see the normal LPR after a 2 seconds stimulus with a
direct ophthalmoscope at maximum power. First, a fast contraction of about 0,5 seconds
until de maximum miosis. After the light is retired the pupil does a slow dilatation until its
original diameter during 30 seconds approximately.
You can change the light stimulus in several parameters according your convenience:
intensity, exposition time, repeated time and even color. Ganglion cells specialized in LPR
have a maximum response to the blue (similar to cobalt blue).
Same authors have investigated the pupil behavior in patients with glaucoma, diabetes,
Parkinson disease, retinal dystrophies and other ocular or brain diseases. They use the
Pupil Dynamics
- Kingma H. Clinical testing of the statolith-ocular reflex. ORL J Otorhinolaryngol Relat Spec. 1997;59(4):198-208. - Négrevergne M, Ribeiro S, Moraes CL, Maunsell R, Morata GC, Darrouzet V. [Video-nystagmography and vibration test in the diagnosis of vestibular schwannoma. Review of 100 cases]. Rev Laryngol Otol Rhinol (Bord). 2003;124(2):91-7. - Pérez P, Llorente JL, Gómez JR, Del Campo A, López A, Suárez C. Functional significance of peripheral head-shaking nystagmus. Laryngoscope. 2004;114(6):1078-84. - Hong SK, Koo JW, Kim JS, Park MH. Implication of vibration induced nystagmus in Meniere's disease. Acta Otolaryngol Suppl. 2007;(558):128-31. - Juhola M, Aalto H, Jutila T, Hirvonen TP. Signal analysis of three-dimensional nystagmus for otoneurological investigations. Ann Biomed Eng. 2011;39(3):973-82.
When registering nystagmus the Gazelab needn’t be calibrated because of its measured in millimeters and not in degrees in horizontal and vertical movements. However, in torsional movements the device calculated in degrees directly.
First we have to define the basic parameters of the nystagmus in the graphics:
Torticolis (head tilt is registered continuously by Gazelab)
Plane of oscillation: vertical, horizontal, oblique and torsional
Amplitude (in millimeters or degrees in the torsions)
Frequency: oscillations per minute or per second (Hertz)
Direction (phase velocity: pendular, jerk or irregular)
The test must be performed under different conditions: unilateral occlusion, bilateral occlusion or
darkness and in different gaze positions (on the right, on the left, upwards and downwards) Otolaryngologist have been using the VNG for the diagnosis of equilibrium disorders during the last decade performing several test (caloric, head position…).
Saccadic movement and Nystagmus
REPORT: Irregular nystagmus RED=RE Horizontal; BLUE=RE Vertical Register of a complex irregular nystagmus in
primary gaze position displaying in the three planes of oscillation: - Vertical and horizontal in millimeters: 4 mm
oscillation in horizontal movement and no oscillation in vertical movement.
Measurement of Ocular Torsions
- “Counter-roll” (classical knowledge) Kushner BJ, Kraft SE, Vrabec M. Ocular torsional movements in humans with normal and abnormal ocular motility--Part I: Objective measurements. J Pediatr Ophthalmol Strabismus. 1984;21(5):172-7. Kushner BJ. Ocular torsional movements in humans with normal and abnormal ocular motility: Part II--Subjective observations. J Pediatr Ophthalmol Strabismus. 1986;23(1):4-11. - Not movement at all Jampel RS, Shi DX. The absence of so-called compensatory ocular countertorsion: the response of the eyes to head tilt. Arch Ophthalmol. 2002 Oct;120(10):1331-40. - Some movement (13-22%) Schworm HD, Ygge J, Pansell T, Lennerstrand G. Assessment of ocular counterroll during head tilt using binocular video oculography. Invest Ophthalmol Vis Sci. 2002 Mar;43(3):662-7.
GazeLab is able to measure torsions in the paracentral region. The system scans the IRIS
detecting the “characteristics points” and tracking them through the video to determine the
exact rotation in every moment of the test. Rotations module can be used to:
Nystagmus: torsional movements are calculated in degrees directly with no need to
calibrate.
Bielchowsky test (torsions 15º,30º,and 45º): head tilt is registered by GazeLab. Iris
scanning in a head mounted device allows to measure with total accuracy the torsions of the
eyeball during head movements.
9 gaze positions test: the computer process the torsional data of every point registered.
Torsional measurements are possible if the point projected in the wall is below 10 degrees.
Ocular Prosthesis
GazeLab provides several advantages in order to improve the prosthesis quality:
Analyze motility field in all space points,
centering precision,
what are the motility limits,
and look for synchronization between both eyes.
So the adaptation of the prosthesis can be evaluated before having the right one.
GazeLab performs 3 different tests in order to analyze the movement and the right location of
the prosthesis:
1
1
2 3
4
GazeLab allows you to measure the
difference between the horizontal and
vertical movement of the healthy eye and
the prosthesis:
Movement limit,
and Speed.
The quality of the prosthesis adjustement is not enough
now. Then, it is easy to be recognised that the patient
wears a prosthesis, due to lack of centering precision: 5
degrees. So it is below the esthetics expectations.
Gazelab allows you to line up better the prosthesis with
the healthy eye. It increases accuracy thanks to the one
degree precision it gives. Then esthetic requirements are
covered.
GazeLab allows to measure the
deviation between the prosthesis and
the healthy eye in each point analyzed
as the same way as it is done in the
strabismus module. 3
2
1
4
> Saccade movements:
> Centering
> Following
bcninnova is a technology start-up founded in 2008 in Barcelona.
Our mission: Assist Ophthalmologists developing, manufacturing and commercializing new
“diagnosis support devices” that measures the Ocular Motility using computer vision
technologies and other engineering disciplines.
Parc de Recerca UAB
Edificio EUREKA — Campus Universitat
Autònoma de Barcelona (UAB)
08193 Bellaterra (Cerdanyola del Vallès)
Barcelona — España
www.bcninnova.com
T: +34 93 586 8964
M: +34 61 952 5610 From 09:00 to 20:00 GMT+1
CECOT Recognition to business progress - Category "The Value of Entrepreneurship"
In the picture (left to right): Pere Navarro, Terrassa Mayor; Artur Mas, President of Generalitat de Cataluña; Oriol Prat, General Manager Bcn Innova; Antoni Abad, President of CECOT
Our guiding principles:
We develop technology for the health of the Man-
kind.
We make Top Quality Devices in adjusted Costs.
We are a researcher company.
We are an efficient company.
Business is not only.