Original Article

Smartphone applications in ophthalmology: A quantitative analysis

Lokeshwari Aruljyothi, Anuja Janakiraman, B Malligarjun, Balasundaram Manohar Babu

Purpose: There is limited information in literature about the scope and usability of Smartphone Access this article online
Applications (Apps) in ophthalmology. Eye care professionals are therefore skeptical about the benefits of Website:
smartphone Apps and are reluctant to adopt it in their day to day practice. The purpose of this study was to www.ijo.in
provide an updated overview of all Apps exclusive to ophthalmology. Methods: This study was a quantitative DOI:
analysis of Smartphone Apps exclusively designed for ophthalmic care. The Apple iPhone and Google play 10.4103/ijo.IJO_1480_20
store were searched for eye care themed Apps. Any App related to eye treatment and management such as PMID:
*****
visual acuity screening, eye education, calculators, eBooks, Low Vision Aids were included in the study.
Data on the purpose of the Apps, target end‑users, validation, App usage, user ratings, and App developer Quick Response Code:
qualifications were documented. Results: As of March 2020, a total of 131 Apps exclusively dedicated for eye
care were identified. 53% (69/131) were available in iPhones, 44% (58/131) in Android smartphones, and 3%
in both. 32% (41/131) Apps were designed for visual acuity (VA) screening, 13% (17/131) for eye relaxation
exercises, 12% (15/131) for professional education, and the remaining for Apps detecting color blindness,
low vision aids, and assistance and patient education. Among the 131 Apps, 6 (4.5%) Apps are claimed by
the developers as validated. Conclusion: This study unveils a wide range of smartphone Apps exclusive
to ophthalmology and suggests guidelines to choose an appropriate App. The study also highlights the
importance of interdisciplinary collaboration in the design, development, and validation of such Apps.

Key words: Apps in Ophthalmology, eye care apps, ophthalmic apps, smartphone applications

Mobile‑based technology is likely to be the future of the benefits of these Apps and may be reluctant to adopt it in
telemedicine. Outreach activities would be centered around their day to day practice. Additionally, there an increasing
the home than it is now.[1‑3] Visual acuity (VA) and visual number of ophthalmic Apps dedicated to general public
field screening Apps available in the App market are capable and non‑eyecare professionals.[8‑18] Therefore, it is also the
of detecting visual degradation even before they present to responsibility of HCPs to guide patients to choose a suitable
a healthcare professional (HCP). Apps could also make the App. The purpose of this study was to provide an updated
patient feel more engaged and improve their compliance with overview of all Apps exclusive to ophthalmology available in
treatment. In this regard, smartphone Applications (Apps) are the market as of March 2020. In addition, the study explores
capable of improving disease outcomes. the current trend in the usability and validation of these Apps.
Globally, there is an increasing trend in the usage of Methods
smartphones. In 2010, the ASCRS (American Society of Cataract
and Refractive Surgeons) survey showed that approximately This study was a quantitative analysis of Smartphone
83% of members use smartphones to accomplish their Applications exclusively designed for ophthalmic care.
professional responsibilities.[4] It was predicted that by 2022,
Search methods: The Apple iPhone and Google play store
36% of mobile phone users in India would use a smartphone.[5]
were searched from Jan 2020 to March 2020 for eye care themed
Therefore, widespread use of smartphones could enhance
Apps. Keywords such as “eye”, “vision”, “vision screening”
the potential of mhealth in early diagnosis and treatment of
“visual acuity”, “sight”, “ophthalmology” and “optics” were
ophthalmic diseases. Several Apps were released in the last
used. Apps were also manually searched semantically by
decade. However, ophthalmologists still find it difficult to
tracking similar Apps, developers, and healthcare products.
adopt a good App into their day to day practice.[6]
All the Apps were manually analyzed by a single researcher
It has been over a decade since Apps were designed and data was collected from the App description provided by
exclusively for the ophthalmic purpose. Since then several its developers in the App store.
studies have showed the potential scope of Apps in the near
Inclusion criteria: Any App intended to perform preliminary
future.[1‑5] Many studies have given a qualitative analysis of
ophthalmic assessments such as visual acuity screening,
randomly selected Apps.[4,6,7] Little is discussed about the
validity and usability of these Apps. HCPs are skeptical about
This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
Department of Ophthalmology, Cataract and Cornea Services, Aravind
the identical terms.
Eye Hospital, Salem, Tamil Nadu, India
Correspondence to: Dr. Lokeshwari Aruljyothi, #1‑D, ARRS Majestic For reprints contact: [email protected]
Apartments, Suramangalam Main Road, Salem ‑ 636 005, Tamil Nadu,
India. E‑mail: [email protected] Cite this article as: Aruljyothi L, Janakiraman A, Malligarjun B, Babu BM.
Received: 16-May-2020 Revision: 09-Jul-2020 Smartphone applications in ophthalmology: A quantitative analysis. Indian J
Ophthalmol 2021;69:548-53.
Accepted: 29-Aug-2020 Published: 17-Feb-2021

© 2021 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

March 2021 Aruljyothi, et al.: Apps in Ophthalmology 549

color vision screening, and support management such as eye who do not have any professional training in ophthalmology
education, calculators, eBooks, LVAs were included in the study. but could have obtained part‑time training in using a particular
App. For example, Portable Eye Examination Kit (PEEK) Acuity
Exclusion criteria: General medical and non‑English App can be used by either community outreach workers or
Apps (translation unavailable) were excluded. Apps such individuals for self‑ assessment of visual acuity. Most of the
as eye chart remotes, blue light filters, eye protectors, eye Color blindness testing Apps are designed for self‑assessment
video games, eye color changers, eye product advertisements of color vision by taxi and truck drivers. Eight % (11/131) of the
were also excluded from the study. General healthcare Apps Apps are dedicated for both ECPs and non‑ECPs.
that could be used in ophthalmology but not exclusively to
ophthalmology such as torchlight, camera, voice recorders, Distribution of Apps as per Operating system and util-
and voice to text dictation Apps were also excluded. Apps ity [Figs. 1 and 2]
that require specialized equipment such as slit lamp adaptors 53% (69/131) of the Apps were available on iPhones, 44% (58/131)
as add‑ons were also excluded. in android smartphones, and 3% in both. 32% (42/131) were
Data collection and Analysis: Data collection included year designed for Visual Acuity (VA) screening alone. Of the 42 Apps
of publication, the purpose of App, target audience, whether designed for VA screening, 7 Apps, additionally included other
the App was available for free or not, estimated number comprehensive eye exam tests also and 5 Apps were designed
of downloads, average user ratings, reports on validation, exclusively for near vision to detect Age‑Related Macular
and documented involvement of qualified professionals. Degeneration (AMD) and Diabetic Retinopathy (DR). 4 Apps
A descriptive quantitative analysis was conducted and depicted documented VA measurement statistics also.
as pie charts, bar, and line diagrams. 13% (17/131) of Apps were designed for eye relaxation
exercises. About 12% (15/131) of the Apps were dedicated to
Results professional education. These include eBooks, videos, and
Our initial search identified more than 700 Apps (both android emergency manuals. Nine % (12/131) designed for eyecare
and iPhone) with eye care themed search terms. As of March decision support such as Intra Ocular Lens (IOL) power and
2020, 259 Apps were selected after applying the inclusion and Contact Lens (CL) calculators. Apps detecting color blindness,
exclusion criteria mentioned in the methodology. Following Low Vision Aids& Assistance, and Patient education includes
this, 131 Apps were selected by the researcher to be relevant 8%, 8%, and 4% each respectively.
exclusively for ophthalmic practice after removing general Availability
healthcare Apps and Apps that require specialized equipment. 76% (100/131) of the Apps are available for free. About
Target audience 22% (30/131) need a monthly or annual payment ranging from
5‑22 $ per month. Of the 30 Apps that required a payment, 23
32% (42/131) of the Apps were designed exclusively for Eye
belonged to iPhone, 5 to Android phones and 2 in both. In about
Care Professionals (ECP), that is, ophthalmologists and
2% of Apps, developers provide a free trial of about 2 weeks.
optometrists. 60% (78/131) of the Apps were developed for
non‑Eye Care Professionals (non‑ECPs). Non‑ECPs include The 10‑year trend of Apps [Fig. 3]
eye‑care health workers, and HCPs who may not be eyecare About 4 Apps dedicated to ophthalmology were first published
professionals, community healthcare outreach workers, in 2009. Since then the scope of Apps on ophthalmology has
volunteers, or the general public. In short non‑ECPs are those

Figure 2: Distribution of Apps as per Operating System and Utility.

Orange bars indicate iPhone and Blue bars indicate android operating
Figure 1: Distribution of Apps as per Utility system
550 Indian Journal of Ophthalmology Volume 69 Issue 3

expanded from vision screening to data collection, amblyopia by the International Centre for Eye Health, Department
treatment, and low vision assistance. In 2018, 23 Apps were of Clinical Research in London. The same team compared
released for public use and further 19 were added in 2019. test–retest variability (TRV) and measurement time, with
that of the Snellen and ETDRS‑based tumbling E Log MAR
Download rates chart in private clinics and rural houses in Kenya. The study
Download history was readily available in android phones. concluded that the PEEK Acuity smartphone test is capable
45/131 Apps (34%) were downloaded over 10,000 times. Of these of accurate and repeatable acuity measurements in either set
3 Apps, Eye Exam App, Eye Care Plus App and Eye Test App, in the elderly population.[8] Few other studies, including a
crossed 1 million downloads. All the three Apps were dedicated cluster randomized controlled Kenya, found that the App is an
for general public. Of the 42 Apps developed exclusively for efficient tool for school screening purposes also.[9‑12] The App
ECPs, three Apps crossed 100 thousand downloads. These was showed promising results when used by non‑ophthalmic
include the Eye Hand Book (EHB), Color Blindness Test : Eye staff in emergency department.[13] Similarly, PEEK App was
Color Vision App and Daltonism Test: Color Blindness Test App. also tested amidst the Chinese and Australian population
Reviewer rating revealing promising results.[14]
13 Apps had more than 500 reviewers. all of which were Kay ISight Test Professional App
designed for non‑ECPs. The Eye test App, designed for general
This App measures near and distant visual acuity by using the
public, received largest number of reviewers’ ratings. Of the
LogMAR chart. It provides various distances from 33 cm to 6
42 Apps designed for ECPs, 30 Apps had less than 50 review
m, depending on which the size of the chart could be altered.
rating. The App with maximum reviewer rating is Smart
Kay’s picture optotypes are used for young children and those
optometry App. The App had 50,000 downloads, of which 680
reviewers had rated the App. with a learning disability. The App has undergone a couple
of validation tests in the UK and is suggested to be a reliable
Validation tool to assess vision in pre‑school children.[15,16] Another study
Four % (6/131) Apps are claimed by the developers to have concluded that LogMAR crowded Kay picture test is a useful
undergone some validation tests. 28% (37/131) of these Apps tool in clinical practice.[17,18]
claim to have involved an ECP in the making of the App. Three
Community Eye Care App
Apps were designed by ECPs without developer involvement.
About 10 Apps were endorsed by ECPs and healthcare The App provides free online and offline access to
institutions. My Vision Tracker (mVT) is the first ophthalmic peer‑reviewed articles in community eye health. The App
App to be FDA approved in 2014. The features of these Apps aims to improve standardization and enable easy access to eye
are tabulated in Table 1. care knowledge for all categories of eye care beginning from
ophthalmology, optometry, eye nursing, and eye care delivery.
PEEK Acuity App The App is supported by several well‑known NGOs such as
PEEK Acuity App has undergone several validation tests the Conrad Hilton Foundation, Sightsavers, Orbis, and Seva
under different circumstances. Peek acuity App was developed Foundation.[19,20]

Figure 3: MindMap of Scope of Smartphone Applications in Eye Care

March 2021 Aruljyothi, et al.: Apps in Ophthalmology 551

Table 1: Validated/Endorsed Apps with their Features

Name of APP Operating System Target Audience Purpose Cost of the App
PEEK Acuity Android Mixed Users VA screening free
Kay iSight Test Professional iPhone ECP VA screening in children free
Community Eye Android+iPhone ECP ECP education free
Eye Hand Book Android ECP Multi‑purpose free
Smart Optometry ‑ Eye Tests for Professionals Android+iPhone ECP VA screening free
My Vision Tracker (mVT) iPhone ARMD and DR Patients Home vision screening 8.95$/month

Table 2: Author’s Picks: Some interesting Apps (not yet validated)

Name of APP Operating Purpose Interesting Features
System
Exclusively For ECPs
Eye Emergency Manual Android e‑Book + Clinical Decision Quick and simple guide to manage eye emergencies
support (CDS)
Eye Grader Android e‑Book + (CDS) Instant access to all Grading scales
Optiexpert™ Android CDS for Contact lens (CL) Calculators for Toric and multifocal CL prescription
prescription
ViaOpta Simulator Android Patient Education Simulates vision loss in different diseases
Eye Pro iPhone CDS Toric IOL power Calculator
VA Converter iPhone CDS Auto calculates VA in different scales
Astigmaster iPhone CDS Surgery Induced Astigmatism Calculator
Eye Diagnosis Android Data Collection Support visualization and organization of eye photos by
name, date and laterality.
For General public
Eye Exam Pro Android Home vision Screening Also provides VA measurement statistics like history,
charts and trends (one time cost Rs. 183 per download)
Eyeque Insight iPhone Patient Education Patented technology
Lazy Eye Exercises Android Amblyopia Management Send reminders and treats amblyopia via games
Magnifying Glass with Light iPhone LVA Digital magnifier
Sullivan+ Android LVA Magnifier + uses Artificial Intelligence (AI) to recognize
Text, face and images
Be My Eyes iPhone LVA + LVAssistance Also connects to support groups
Eye‑D iPhone LVA + LVA Assistance AI, both aid and assistance, available Indian language also
Color Blind Eye Exam Test iPhone Color Blindness Screening Self‑screening by truck drivers and taxi cab drivers

Eye Hand Book (EHB) App mVT (My Vision Track) App
EHB is both a diagnostic and treatment reference App. EHB mVT App can easily convert the Apple smartphones into a
serves as a one‑stop‑shop for multiple needs of ophthalmic medical device that can track the progression of vision damaging
practice. It offers a dozen features to both ophthalmologists diseases such as age‑related macular degeneration and diabetic
and eye care workers such as educational videos (for both retinopathy. Patient test data are automatically uploaded to a
patients and professionals), calculators, testing tools, practice Physician’s Portal where licensed eye‑care professionals can
efficiency tools, coding tools, journal portals, treatment monitor all patient test results. It has been validated as a remote
reference manuals, discussion boards, etc. The EHB is one of monitoring tool at home to track treatment effects and to detect
the most popular Apps amidst ECPs with over half a million disease condition changes.[24] Alleye is another App which also
downloads and 25 thousand active users.[21] Several studies FDA approved for monitoring maculopathy. Both are available
have mentioned and endorsed the use of EHB.[7,22] in iPhone bd cost about 9 $/month.[25]
Smart Optometry‑ Eye Tests for Professionals App Professional Education and Decision Support Apps
This App incorporates various vision screening tests including 26 out of 131 (20%) Apps were dedicated to ophthalmic
color vision, near vision, amblyopia, Worth four dot test, education and decision support in the form of calculators.
Hirschberg, Amsler grid, etc. The App is available in 11 None of the Apps were validated by any HCP groups. Three
languages in both android and iPhone. Developers of the were endorsed, all of which were designed by institutions.
App claim it to be fast, easy to use with results that are A majority of HCPs did not provide any reviewer rating. The
accurate, reliable, and clinically validated. It is one of the most maximum reviewer participation was 121 for Ophthalmology
downloaded App by healthcare professionals with over 50,000 and Optometry Guide App which had a download rate of
downloads.[23] 10000. Eye‑hand Book (EHB) is one of the most popular eyecare
552 Indian Journal of Ophthalmology Volume 69 Issue 3

educational App with maximum of 1 million downloads. The Download rates and reviewer rating provide information
App has an average reviewer rating of 3.8 stars in Android about the readiness of the ECPs to use the Apps. Download
phones and four stars in iPhone. rates are an indirect indication of awareness of end‑users
about the existence of an App and an opportunity to try
Eye Exercise And Training Plan Apps using the APP. Despite hundreds of Apps created, the usage
13% of the Apps are dedicated to general public for eye of Apps in day to day practice as seen by download rates is
exercises and eye training plans. All these Apps are available for very low, especially among HCPs. One of the main reasons
free. But, they are yet to be validated or endorsed. Eye Exercises for this is the lack of awareness among HCPs regarding the
& Eye Training Plans ‑ Eye Care Plus App contains more than benefits of Apps. Many others are confused about choosing
50 exercises, 12 eye tests to track vision improvement and a the right App. HCPs are also doubtful about the reliability
training calendar. The App has over two million downloads of such Apps.[2,6] Reviewer rating is one of the ways to judge
with a reviewer rating of 4.6 among 27000 reviews. the usability of an App. The quality of an App is measured
in terms of ratings provided. Poor review ratings may be
Apps as Low Vision Aids (LVA) and Low Vision attributed to a lack of validity tests and usability tests on
Assistance (LVAsst) these Apps. So far only 2 Apps has been FDA approved in
About 10 Apps (8%) are dedicated to LVA and LVAsst, 5 ophthalmic practice.[24,25]
in each [Table 2]. All are available in iPhone alone and none
have been validated. The App “BE My Eyes” functions based This study elaborates on the scope of mHealth Applications
on Audi‑Visual interaction between visually impaired and a in ophthalmology and provides an updated version of its
global community of volunteers who provide remote assistance uses [Table 2]. It identifies lacunae in designing, validating,
via a live video. Although not validated, the App has received and adoption of mhealth in day to day practice. Most of the
several awards such as 2020 Dubai Expo Global Innovator, 2018 Apps were developed without professional ophthalmologist or
Winner of Google Play Awards ‑ Best Accessibility Experience a professional App designer. The study reveals opportunities
and 2018 Winner of AbilityNet Accessibility Award at the Tech4 to HCPs and institutions in promoting mHealth. It unfolds
Good Awards.[26,27] reasons ECPs’ reluctance to choose and adopt Apps such as
lack of validation, endorsement, or peer review. This is further
Discussion enhanced by poor participation from ECPs in the making,
reviewing, validation, and endorsement of Apps.
Purpose of the study is to give a comprehensive overview
of all Apps currently available, their uses in eye care and The study could not provide a qualitative analysis of each
their complex interconnections. Apps exclusive to eye care App as describing and evaluating each App is a study by
were first released in 2009. By 2013, around 340 Apps were itself. However, the authors plan to conduct and recommend
released in both Android and iPhone using eye care themed evaluation of individual Apps in the future. The study has
concepts.[28] Few studies have been published in literature excluded general Apps that could also be used in ophthalmic
regarding Apps exclusive to ophthalmology.[6,7,22,23,29,30] Attempts practice as it is beyond the scope of this paper. Apps designed
were made to broadly categorize the Apps based on user for LVA and LV Assistance, amblyopia management, eyedrops
needs and qualitatively describe selected Apps in ophthalmic reminders, vision simulators etc., are a domain by themselves
practice from a clinicians’ perspective. A study by Akkara and that needs special attention.
Kuriakose has qualitatively analyzed smartphone applications The researchers recommend active participation from
specifically for LVA. [30] Two studies have quantitatively individuals (ECPs and general public) by sharing their
analyzed smartphone Apps in ophthalmology.[6,13] The first experience with the App via review ratings and comments.
comprehensive quantitative analysis of Apps in ophthalmology Current validation methods are inadequate as it needs
was published in 2015. This study identified about 182 Apps validation of scientific concepts used in the App and usability
from the iPhone alone.[6] The second was focused on using such factors. Healthcare institutions must promote strong
Apps in emergency conditions.[13] interdisciplinary collaboration between eye care professionals
This study portrays in‑depth quantitative analysis of all and software developers in the designing, validation, and
Apps currently designed exclusively for ophthalmic practice. updating of an App. Frequent workshops could educate and
train ECPs to adopt mhealth technology into their routine
Several search words resembling ophthalmological themes
practice. The study also aims to provide guidelines to ECPs
but not intended for healthcare purposes were excluded from
to choose the apt App and encourage them to evaluate the
the study to avoid cluttering. The 131 Apps thus identified in
usability of Apps. A well trained ECP can, in turn, educate
the study were categorized into 10 categories based on their
patients, stay connected, and suggest suitable Apps that could
scope of practice in ophthalmology. Each category is further
empower patients in managing their disease condition or even
divided into subcategories based on its intended use. Every
diagnose it in their neighborhood.
App understudy was designed to cater one or more application
each of which are interrelated to each other. Apps like EHB Concerning professional educational Apps such as EHB and
caters a wide variety of ECP needs beginning from vison Eye Emergency Manual App, institutions, and/or individuals
screening tools, IOL power calculators, and educative materials could endorse and make suggestions. Like research papers,
to support evidence based decision making. Therefore the Apps dedicated to professional use must also be peer‑reviewed.
authors have designed a MindMap instead of a multilevel list Further studies are needed to understand the readiness and
or table to illustrate complex interrelations via linking arrows concerns of ECPs in adopting mhealth.
between various categories and sub categories [Fig. 4].
The study also adds light to the feasibility and reliability of
Conclusion
using such Apps including cost, validity tests, and download rates. Our study unveils a wide range of smartphone Apps exclusive
The study exposes the fact that less than a quarter of the Apps to ophthalmology. Guidelines to choose an appropriate App
exclusively designed for Eye care involves an ECP in the design. are suggested. We also emphasize on the importance of
March 2021 Aruljyothi, et al.: Apps in Ophthalmology 553

interdisciplinary collaboration in the design, development, Clin Exp Ophthalmol 2016;254:1175‑80.

and validation of such Apps. 14. Han X, Scheetz J, Keel S, Liao C, Liu C, Jiang Y, et al. Development
and validation of a smartphone‑based visual acuity test (vision at
Financial support and sponsorship home). Transl Vis Sci Technol 2019;8:27.
Nil. 15. Dawkins A, Bjerre A. Do the near computerised and
non‑computerised crowded Kay picture tests produce the same
Conflicts of interest measure of visual acuity? Br Ir Orthopt J 2016;13:22‑8.
There are no conflicts of interest. 16. Kay HA. New method of assessing visual acuity with pictures. Br
J Ophthalmol 1983;67:131‑3.
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Commentary: An app a day keeps the us in our profession. We should also be aware of apps that can
be useful to our patients.
eye doctor busy
Eye Doctors are iDoctors
We are all familiar with smartphones and the power of their
Ophthalmology is often at the cutting edge of technology.
apps. Often, we hear the phrase “there’s an app for that”, which
There has always been a steady stream of innovations, from
makes our old gadgets obsolete. Common objects replaced by
ophthalmic innovators worldwide.[1] Many of the frugal
apps include flashlight, watch, alarm, stopwatch, reminder,
phonebook, camera, calendar, calculator, and many more. innovations have been helped by easy availability of affordable
Apps are so powerful that recently, we have seen the Indian but powerful smartphones and they are often made by
government ban several apps that risk national security. ophthalmologists themselves.[2] The accompanying article[3]
Properly designed apps have great potential to convert your quantitatively studies the apps available in the Apple App
smartphone into a useful and specialized multi‑tool. We, as Store and Google Play Store, to identify the various types of
ophthalmologists, should know the various apps that can help apps designed for ophthalmic care. They also note that most