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Eye phone: How a TED Fellow’s new app could help restore sight to millions

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Andrew Bastawrous shares the idea behind Peek at TED2014. Photo: Ryan Lash/TED

Around 39 million people in the world are affected by blindness — 80% of which could be avoided if people had timely access to diagnosis and proper treatment. The problem is that in many developing countries, most eye care providers are in cities, while the majority of patients live in hard-to-reach rural areas. To bridge this gap, London-based opthalmologist Andrew Bastawrous created Peek — an app and adapter that turn a smartphone into a comprehensive, easy-to-use, accurate eye-exam tool. Peek makes eye tests affordable and easy to administer, bypassing the need for expensive, fragile equipment. (Watch his TED Talk, “Get your next eye exam on a smartphone.”)

Bastawrous developed and extensively road-tested Peek during a research expedition in Kenya, and has now launched an Indiegogo campaign to set up manufacturing process for the Peek Retina adapter, which allows health workers to peer into the eye and capture images for diagnosis. If successful, Peek will soon be rolled out worldwide with the help of eye NGOs. Here, he tells the TED Blog how his own childhood experiences with poverty, inequality and impaired vision led him to devote his life to restoring sight to the world.

How long has Peek been in development?

I’ve been working on it for around three years, and the team came together about two years ago. We’re now at the point where we’ve got a proven, tested prototype, and we want to make it available. We’ve had so much demand — over 4,000 eye organizations in 180 countries are asking to use it, and we want to make it available and keep the cost low. We evaluated options, and recently won the TED Mazda Rebels award. We’ve used the majority of that to fund set-up of the manufacturing pipeline to develop the adapter, and that takes us to about the halfway point.

You grew up in England. What made you want to practice in developing countries?

I was born in York, but my parents are both from Egypt, and I grew up between cultures. We spent most of our holidays in Egypt, and I always felt a little like I didn’t know where home was. When I visited Egypt, I witnessed things I didn’t see in the UK. My father’s a doctor, and he’d always visit the village where he grew up whenever we went back. He would be inundated with requests for medical attention.

It really inspired me, the way he never said no to anyone. Once a woman complained to him that she couldn’t have a child. My father, who is actually a bone doctor, did some general blood tests, and said, “Look, as far as I can see, everything’s okay.” When we went back the following year, she had a child with her — and everyone else in the region who couldn’t have babies started coming to see my dad to get it sorted out.

So I think seeing such things left me with a very deep sense of inequality. I also realized I’d had a very privileged upbringing. Within Egypt, my relatives are quite well off. But my grandma lived on the first floor, and the family that lived on the basement floor were effectively working for the apartment block. There was a kid there the same age as me, and every year we’d diverge more in terms of our opportunities. When we first met, we both just wanted to play football, but by the time we were 18, he’d had a kid, and his opportunities were very limited. Meanwhile, I had so many fantastic options for my university, career. It just seemed deeply unfair.

Peek healthcare worker examines patient in her own home. Photo: Peek

A Peek healthcare worker examines patient in her own home. Photo: Courtesy of Peek

But why eye care?

I grew up very short-sighted. I was at the bottom of my class until I was about 12, when my mum dragged me kicking and screaming to the optician’s and insisted I get some glasses. Suddenly I could suddenly see everything perfectly — and I don’t think I’ve ever forgotten that moment. So I’ve always been struck with the power of being able to have sight returned, the impact it can have. After that, I started to do well at school, and was better at sport. I looked a bit more geeky, but I was doing better in a lot of other ways.

So it had always been in my mind at medical school to go into ophthalmology. I spent my summer holidays traveling, visiting people who were doing eye care in resource-poor settings, and just really fell in love with the possibilities. There are so many people who are unnecessarily blind. Had they been living in the UK, they would have never have gotten to the point where their vision problems were anything more than a nuisance. I knew this would be how I’d spend my life.

Untreated eye disease must be a problem in many developing countries. Why did you choose to focus on Kenya?

I’d worked in various countries short term, from Uganda, Sierra Leone and Madagascar to Peru and Belize. I then got the opportunity to work at the International Center for Eye Health on a PhD program. We were to do a large trial in Kenya, for which we’d be required to take lots of expensive equipment to 100 different locations to try and work out why people were going blind. I was excited because I knew this research would result in change, as opposed to only lead to papers and publications.

The most common causes of blindness are the same everywhere in the world — with cataract the top cause. In developing countries, blindness is an issue of access to healthcare, not usually a result of weird and wonderful tropical diseases, although there are certain infectious diseases that are more prevalent in Africa.

Refractive error — simply the need for spectacles — is a major problem. We don’t even think about this in England, but had I been been born elsewhere, I’d have been classified as visually impaired. The World Health Organization classification of blindness is when you’re half the usual distance to the chart and you still can’t even see the top letter with your best eye. At that level, most people can’t function beyond basic navigation. I wear contact lenses now, and I can see perfectly. But without basic eye care, I wouldn’t have finished my education. I wouldn’t be working.

Other common conditions include diabetic retinopathy, where diabetes causes leaking of blood and fat inside the eye, and glaucoma, a disease where you slowly lose your peripheral vision. The leading cause of blindness by infectious disease is trachoma, which is on the way out. I think we’ll see that disease eradicated in the next few years.

Cataract testing outside patients home. Photo: Peek

Cataract testing outside patients home. Photo: Courtesy of Peek

What did you find in Kenya? Did you have your “aha” moment about Peek there?

The “aha” moment actually came before I moved to Kenya. While I was planning the research, I realized that it’s the kind of work that would be hard enough in England, where we have good roads and phone numbers and addresses. Where we were headed, we didn’t know where people lived, we didn’t know their names, we didn’t have road access or electricity. Yet we still had to get our team out there to find 5,000 specific people and provide them the kind assessment they’d get in a UK hospital, while hauling £100,000 worth of equipment. I thought, “This is crazy. There’s got to be a better way of doing this.”

That’s when I got the idea to harness the power of my smartphone. What if I could condense the diagnostic and mapping tools I needed into something portable and easy to use? I started to work out what was possible from what already existed, and realized I could make it work. An amazing team got together and we started building the software and hardware.

We still did have all that equipment in Kenya, so we took the opportunity to test Peek against it. We’d examine patients in their homes using Peek, and then again in the clinic. So we’re able to really compare David versus Goliath, one against the other. Doing that proved to us we had a device that really worked.

The Peek Retina adapter attaches to the lens of a smartphone, allowing examination of the lens, retina, and optic nerve. Image: Peek

The Peek Retina adapter attaches to a smartphone, allowing examination of the lens, retina and optic nerve. Image: Courtesy of Peek

What does Peek give access to?

Peek does several things. First, the phone is charged by a solar battery to make sure that there’s always a power source. The health care worker uses Peek to record the patient’s personal details, their GPS coordinates and contact details for the local village guide, who then becomes the follow-up person if we need to arrange treatment.

Once all that’s recorded, the healthcare worker uses Peek to perform all the usual eye diagnostic tests using the app. We’ve developed it so that the health worker can test in any language — you don’t need to be able to read English. If the patient’s vision is low, we can then go on to a series of other tests, including using our Peek Retina adapter, the low-cost hardware that sits over the phone and allows us to take pictures inside the eye. We use Peek Retina to examine the lens for cataract, and the back of the eye for nerve disease and retinal disease.

You said in your talk that our retinas can tell us a lot about our health. What can we learn about our well-being from looking at our eyes?

A huge amount. The nerves — the yellow circle that you see as a prominent feature on the back of the eye — is a direct extension of the brain. Certain brain diseases can be picked up by looking at patterns on the nerve. You can see glaucoma by the way the nerve changes shape. And all sorts of diseases show up within the retina, from certain cancers of the intestines, to diabetes, high blood pressure, HIV and malaria. If you go through a medical textbook for pretty much any disease, it will have some kind of eye manifestation.

Sometimes, Peek allows untrained health care personnel to find unexpected things. Once one of our health care workers, who doesn’t have a medical background, detected a retinal detachment. Typically this can only be detected by an ophthalmologist, but he picked up that something that wasn’t right. That’s the great thing with Peek — you can share that information immediately, so that a remote expert can analyze any anomalies. Part of what we’re doing is making decisions in the field. Does this person need treatment, and is it treatment that requires them to travel?

Retinal imaging on the gold standard camera against which Peek is compared. Photo: Peek

Retinal imaging on the gold standard camera against which Peek is compared. Photo: Courtesy of Peek

Once you’ve diagnosed someone, how do you get people from where they are to a clinic for further treatment?

In Kenya, many hospitals receive generous funding to treat people, and so they send their vehicle to a village to pick up patients. The problem is that only a small number of people requiring treatment will have been detected. Now, with Peek, hospitals will more efficiently locate patients that need treatment, saving on petrol and time.

Tell us about the financial model of this campaign. On Indiegogo, you’re asking people to buy one and donate it to health care organizations. Could I buy one for myself if I wanted to?

There are two models. You can either buy one for yourself because you’re a general practitioner or an optician and you would find it useful. Or you just want to help us, in which case you can buy one to be donated to a partner health care organization.

How will you decide who to roll out to first?

Right now, we’re partnered with the International Agency for the Prevention of Blindness, the umbrella organization for all eye NGOs worldwide. One of the things we need to make sure of is that if the organizations we’re giving Peek to start detecting a lot more patients requiring care, they’ll be able to provide treatment. At this stage, those are the kind of groups we want to support. And really, phones are never going to cure blindness. But if we can support the people who do, that’s how we’ll make a big impact.

Peek with solar charging rucksack. Photo: Peek

Peek with solar charging rucksack. Photo: Courtesy of Peek

Will these organizations also train the workers who go out into villages and administer the tests?

Yes. It’s been designed so that training is absolutely minimal. Normally, looking inside the eye is something that can take people weeks or months to master. But with this, everyone we’ve given it to has been able to image inside the eye on their first attempt.

Do you think Peek will be in demand outside of developing countries as well?

There is demand for it within the UK. The potential benefit is that a GP will be able to perform a more comprehensive eye assessment than they would have previously, and will better equipped to make decisions about whether to send patients on for secondary treatment.

What’s your favorite story about using Peek in the field?

There was a lady who was known as Mama Patrick who had been blind for over 20 years. She lived in a very small traditional mud hut, and her son Patrick lived in the next one across so that she could shout to him when she needed help. One of our health care workers went and examined her using Peek, and identified her being blind from cataract. We saw her in our mobile clinic the next day, which was part of the study, and we verified the diagnosis. We arranged for her to have sight restored to one eye. When people are blind in both eyes, and there are limited resources, we treat one eye first. It’s better to give sight to 10 eyes of 10 people than to 10 eyes of five people.

Using the GPS location from the Peek exam, a bus came from St. Mary’s Hospital a couple of weeks later to pick her up. When she got to the hospital, she became very agitated. It can be quite scary if you’ve been blind for a long time and you know one environment, and suddenly you’re in an alien place with different voices. They decided to give her a bit of sedation to do the operation, which took only five minutes, and she fell asleep for most of the evening. The next morning, when we came back and her patch had been removed, it was a completely different scene. She was sitting up, animated and talking to some of her old friends.

But the most powerful bit was when we took her home. She almost didn’t recognize where she lived, although it was completely unchanged in the years that she’d been blind. And there’s was a man standing outside her house, just staring at her, looking really quite concerned. It took a while, but then suddenly she said, “Is that Patrick?” “Yeah, mom, it’s me.” At that point both of them broke down crying — and then she commented on how old he now looked. Everyone else started coming out to see what the commotion was, and everyone could see that she was walking. Suddenly this lady who had been completely hidden away was now walking around and commenting on how old everyone was. And everyone started celebrating. It was really lovely.

Above, watch an introduction to Peek and its work.