Arclight: a pocket ophthalmoscope for the 21st centuryBMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6637 (Published 14 December 2016) Cite this as: BMJ 2016;355:i6637
- Andrew Blaikie, senior lecturer1,
- John Sandford-Smith, emeritus consultant ophthalmologist2,
- Sahib Y Tuteja, third year medical student1,
- Christopher D Williams, senior lecturer3,
- Christopher O’Callaghan, professor of respiratory and paediatric medicine4
- 1University of St Andrews School of Medicine, St Andrews KY16 9TF, UK
- 2Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK
- 3Department of Health Sciences, University of Leicester, Leicester, LE1 7RH, UK
- 4UCL Institute of Child Health, University College London, London, WC1E 6BT, UK
- Correspondence to: A Blaikie
“Wow, it really works!”—rural health worker, Malawi, 2016
“Less is more”—Peter Behrens, Architect, 1868-1940
Around 285 million people in the world are estimated to be visually impaired,1 and 360 million hearing impaired,2 with the majority of cases considered preventable or treatable if diagnosed promptly. Ophthalmoscopes and otoscopes are typically designed for wealthy countries and are complex, heavy, and expensive; their basic designs have remained relatively unchanged for over 100 years.3 Very few practitioners in low and middle income countries have these essential tools. If they do, they are typically hand-me-downs that don’t work because they need parts that are hard to find or expensive, such as bulbs and batteries.4 The vast majority of cases of vision and hearing impairment, however, are found in these countries with least access to diagnostic tools. The Lancet Commission has recommended greater focus on frugal technologies designed for the needs of low and middle income countries.4
Frugal inspiration from The BMJ at Christmas
In 2000 the Christmas issue of The BMJ contained an article describing a cheap, homemade ophthalmoscope.5 This inspired the Arclight; a prototype pocket sized (110 mm×26 mm×9 mm, weight 18 g) ophthalmoscope, otoscope, and loupe powered by a slim rechargeable lithium battery that is charged by an integrated solar panel and illuminated by a patented LED light source (figs 1 and 2⇓).
The Fred Hollows Foundation offered seed development funding to develop the prototype into a device ready for market. The simplified design has considerably lower production costs, and the Arclight is now available to low income users through the standard list of the International Agency for Prevention of Blindness at a fraction of the cost of traditional devices.6 Several thousand devices have been distributed to countries around the world, including Malawi, Ethiopia, Kenya, Tanzania, Rwanda, Ghana, Fiji, Indonesia, and the Solomon Islands, enabling healthcare workers to perform comprehensive eye and ear examinations for the first time.
The Arclight is tailored to the conditions and needs of low resource settings7 so that it can be used to identify the most common causes of vision and hearing loss. Although it is still in the early stages of evaluation, preliminary studies from Scotland, Malawi, and Tanzania indicate that the device is more effective than traditional tools for teaching ophthalmoscopy8 9 and is just as accurate for screening for signs of diabetic retinopathy and glaucoma.7 10 Studies for other conditions requiring a “red reflex” examination, such as congenital cataract and retinoblastoma, which if diagnosed late can lead to poor visual outcomes and even death, are currently under way. Consequently Sense International is using the Arclight in a large screening programme of infants aged 0-3 years in Kenya and Uganda.11 The loupe of the device is being used by the Fred Hollows Foundation in Ethiopia to screen for trachoma for the prevention of blindness that is estimated to affect over three million people worldwide.12 13 The otoscope has also been used in Malawi to identify and treat middle ear disease and cerumen impaction as part of a hearing impairment prevention programme.14
Feedback from formal training with users in Malawi identified several barriers to care, including the need for access to relevant training material and local referral guidelines.7 The next iteration of the Arclight contains a memory chip loaded with a multimedia training programme accessible through a smartphone app.15 The Arclight can also acquire digital images for remote interpretation and for training purposes by clipping to a mobile phone camera (fig 3⇓).
The development of this device has created a piece of disruptive technology that has the potential to transform care in low and middle income countries. It all started with a paper in the millennial Christmas issue of The BMJ. So please keep reading the festive issue of the journal; you never know what ideas might light up.
Competing interests: We have read and understood the BMJ policy on competing interests and declare the following interests: JSS had his travel paid for by Arclight Medical to attend the IAPB conference in Hyderabad in 2012. AB is seconded to the University of St Andrews from NHS Fife. The University owns a social enterprise subsidiary company, for which AB acts as an unpaid adviser, which sells the Arclight to users in the UK with all profits being used to fund distribution and education exercises of the device in low income countries via the Global Health Implementation team at the University of St Andrews.
In memory of Sandy Holt-Wilson.
Provenance: Not commissioned; externally peer reviewed.