SURVEY OF OPHTHALMOLOGY VOLUME 24. SUPPL l MAY-JUNE 1980

APPENDIX D - FUNDUS PHOTOGRAPHY PROTOCOL

I. PRELIMINARY PROCEDURE

A. Dilation of the Patient’s Eye The subject’s eyes must have complete

cycloplegia in order to hold the image of the fundus at a fixed level during the focusing of the camera and the exposure of the film . The pupil must be dilated to as much as 8 m m diameter . . . especially for stereo photo- graphs. The examining doctor will have done this prior to sending a patient to you for fun- dus photography. IF PUPIL IS NOT SUFFICIENTLY DILATED, ASK THE NURSE TO INSTILL ADDITIONAL MYDRIATIC DROPS AND LET THE SUBJECT RETURN TO THE WAITING ROOM FOR AN ADDITIONAL 10 M INUTES. If after this period the eyes are not sufficiently dilated, or the ocular media is not sufficiently clear to obtain good photographs, attempt the fundus photographs in spite of these difficulties. Make a note of this on the Photographer Work-Sheet. (Fig. D.l) B. Camera Preparation

1. Remove plastic dust cover from fundus camera; take off objective lens cap. 2. Prepare fundus camera as follows:

a. Adjust eyepiece setting for individual operator’s eye. Each photographer will check his eyepiece setting via an actual photographic film test being used in Boston University Department of Ophthalmology prior to starting with the Framingham Study. b. The #7 aperture of the illuminating diaphragm is to be used. Never use any but the #7 illumination aperture since

other apertures introduce artifacts, even the oval ones which were especially designed not to. c. Set the optical compensator knob (top of camera) to the “0” diopter set- ting; the position of the lever axis is 90 degrees. d. Set the spherical correction lens knob to the red marking (-16/+ 17 diopter). This is the normal range for the nonemmetropic eye. Obviously, if this setting is not suitable for the eye you are photographing, you will have to select another setting. e. The stereo base for stereo separator is set always at 2.5 m m . f. Check the objective lens for dust, fingerprints, etc. (See section G). g. Place camera in position for pho- tographing the right eye. A set procedure of doing the right eye first and then the left eye must be es- tablished. The films can be easily iden- tified by this procedure. h. Place fixation target on the left side of camera.

3. Prepare camera body, i.e., check the following:

a. Shutter speed (l/30 sec.). [Prior to October 29, 1973 l/60 second was used.] b. Strobe synchronization setting (FX). c. Synchronization cord inserted d. Motor drive cord inserted. e. Load camera body with Koda- chrome 2 and take up film to the #O position. [Prior to October 29, 1973 Ektachrome-X was used with process-

570

FRAMINGHAM EYE STUDY s71

ing done by the Department of Oph- thalmology, Boston University School of Medicine.] f. There are eight penlight batteries in the cordless power pat. Should you have a camera failure because of batteries, a spare set may be found in the refrigerator. Otherwise a new set will be installed every 4 months.

4. Prepare the power supply units as follows:

a. Turn master power switch to the ON position. b. Set the viewing intensity knob to #2. c. Set the electronic flash intensity knob at #l. d. Switch on the stereo separator power supply unit.

C. Plug in electrical cord for overhead red fluorescent light.

II. PHOTOGRAPHIC REQUEST FORM A. Duplicate forms will be filled out by the appointment clerk and submitted to the

photographer. B. Information to be noted on the form by the photographer are:

1. Roll number. 2. Exposure numbers as pertaining to the exposures of the right eye (OD) or the left eye (OS).

Example: x06197; OD 1-4; OS 5-8 3. Photographer’s signature. 4. Record any comments about conditions that might influence the quality of the photographs, e.g., about patient’s coopera- tion, pupillary dilation, cornea, lens, or vitreous opacities, etc.

C. Film can and film number obtained from roll of number labels. Paste one part on film can and other part on film cartridge.

III. PATIENT PHOTOGRAPHY A. Adjusting patient for photography

1. Seat patient at the fundus camera table and adjust the camera to his seating height. 2. Have patient place his chin solidly down on the chin rest, close his teeth, and

BUM2 Framingham Ophthalmic Study

Photographer Work-Sheet

Patient's Name Number

Photographs to be taken

External

Specify:

Cataract suspect (include lens)

10 percent sample

Diabetic retinopathy suspect

Glaucoma or senile macular degeneration suspect

FIG. D.l. Photographer's work sheet

572 Surv Ophthalmol 24 (suppl) May-June 1980 LEIBOWITZ ET AL

place his forehead firmly against the forehead rest. The chin rest can be ad- justed for the length of each patient’s head. 3. Tell the subject of his role in the photography-that to take good photographs, especially stereo photo- graphs, he must remain exactly in one position until the exposures have been made.

B. Fi lm labeling 1. Use the spherical correction lens on the red marking (- 16/i- 17). 2. Photograph roll number of film can at start of each roll of film . 3. Photograph patient’s name, date of birth, and Framingham number prior to actual patient photographs - from the Request Form. Be sure that this informa- tion is sharply focused to avoid un- necessary rechecking.

C. Turn off the overhead room light . . . the red fluorescent light will give you ample room illumination to see camera controls. D. Coarse adjustment of camera to patient’s eye: While looking around the camera, bring the bright exit pupil of the fundus camera to coincide with the patient’s pupil by operating the vertical adjustment knob and the control level accordingly. If necessary, move the fun- dus camera on the table laterally in its ledge; the position of the illumination pupil is now observed directly on the patient’s eye through the camera eyepiece. E. Fine adjustment of camera to patient’s eye: Look through the camera eyepiece and correct the adjustments made in paragraph D until reflexes and stray light are no longer visible, and the brightness is evenly dis- tributed on the fundus.

F. Align fundus image to view desired: Ask patient to look at fixation light with left eye only (right eye for left eye photography) and move light until proper view is achieved. G. Focusing

1. Focusing will be carried out by means of the focusing knob and not by use of the control lever. The required fundus image is correctly focused if it appears sharp. 2. If the focusing range is not sufficient, the appropriate correction lens must be in- serted.

H. Use of the stereo separator (Stereo base: 2.5 mm): Move the right side of stereo separator lens forward for first stereo view (right hand), and left side of lens forward for second view (left hand). I. Exposure procedures

1. Group 1 patients (cataract, glaucoma, or senile macular degeneration suspects): Two complete stereo exposures respec- tively for the macula and the disc - OU - starting first with the disc and then macula of the RIGHT eye followed by the disc then macula of the left eye. 2. Group 2 patients (diabetic retinopathy suspects): Seven stereo views diabetic sur- vey as per the “Collaborative Diabetic Retinopathy Study” starting with the RIGHT eye in the numerical sequence pic- tured in Figure D.2. (Diabetic Retinopathy Study Coordinating Center, Diabetic Retinopathy Study: Manual of Operations. Baltimore, 1972). 3. Group 3patients (10% sample patients): Seven stereo views as per the “Col- laborative Diabetic Retinopathy Study” starting with the RIGHT eye in the numer- ical sequence pictured in Fig. D.2.

FIG. D.2. Sequence fundus photographs

of the seven

FRAMINGHAM EYE STUDY 573

J. The Assistant 1. If needed, the nurse will be available to hold the eyelids of those patients who are unable to keep their eyelids open wide ensough for good photography. The lids can prevent some of the illumination from reaching the fundus, and, in some positions, they can reflect light irregularly to “fog” the image. Sometimes a deep pool of tears along the lower lid margin must be pulled away from the photo- graphic area of the pupil. 2. If no one is available to assist with the patient, attempt to use one hand to hold the lids open while operating the camera with the other hand.

It must be remembered at all times that all. the subjects in this study are volunteers and most are elderly. They must be treated with care and consideration. When it is not possible to take stereo photographs try to take single views. But if the photography causes an individual undue discomfort, it is better to discontinue the procedure for that subject than to cause him to be unhappy about the study. Be sure to give a short ex- pl.anation of the problem on the Request Form.

IV. FILM MAILING PROCEDURE A. Eixposed film should be placed back into its film can and put into a Kodak self- addressed and stamped Prepaid Processing Mailer. B. To help identify the film, please write the roll number on the return label of the prepaid mailer. C. It is the individual photographer’s respon- sibility to mail exposed films. There is a mail box located at the corner of Evergreen Street. Please do not carry the films around with you until you happen to think of mailing them.

V. SORTING AND SLIDE LABELING PROCEDURE

The processed films will be returned from Eastman Kodak (Fairlawn, N.J. plant) to the Department of Ophthalmology, Boston University Medical Center, Photography Section. A. Sorting

1. The films will be sorted and separated by patient into groups of right eye (OD) and left eye (OS). 2. The sorted groups will be stamped on

the right-hand side of the cardboard mount at mid-center with the OD stamp or OS stamp (whichever applies). 3. The slides will be checked to determine the right-hand and left-hand stereo slide of the stereo pairs and respectively stamped with the stereo R or stereo L stamp on the left-hand side of the 2X2 cardboard mount. 4. Letter-sized envelopes (3%” X 6%“): This envelope will be rubber-stamped and the appropriate information filled in as ob- tained from the Photographic Request Form. Information needed will be patient’s name, date-of-birth, and Framingham #. Other information to be written on the envelope will be date of photography, photographer’s name, and photographer’s comments. 5. The right and left eye groups of slides will then be respectively enclosed with a rubber band and placed into the envelope.

B. Labeling 1. The patient’s name will be the first line typed on a white label (M” X 1%“) #43- 533. The second line typed will be the patient’s date of birth. The label will be applied to the bottom of the front side of the cardboard mount. 2. Another label, referred to as the “FRAMINGHAM BU STUDY” label, (W’ X l%“, pre-printed) is to have the patient’s Framingham number typed below the pre-printed words “Framingham BU Study.” This label is to be applied to the front top of the cardboard mount.

VI. SLIDE FILING A. All slides are to be inserted into a clear plastic 8%” X 11” (20 pocket) slide page. B. Slides will be mounted as follows:

1. Grout 1. Stereo views will be mounted in their ‘cardboard mounts with the right eye views on the left-hand side of page, and left eye views on the right-hand side of the page, enabling the viewer to see the photographs as though he were looking at the patient. Disc views will be mounted on top and the macula underneath, one page per patient as diagrammed in Fig. D.3. 2. Group 2. Slides will be mounted in their respective order as pictured in Fig. D.2 of this protocol. Mount the slides of one eye per page. Begin at the top left of the page and continue down the left side, and then

574 Surv Ophthalmol 24 (suppl) May-June 1980 LEIBOWITZ ET AL

2 Fields (Both OD and OS on Same Page)

7 Fields (OD and OS on Separate Pages)

Disc mi “,U,;W;iOr

Temporal1 OF / y 1 / 1

Inferior OD OD Temporal L R

I I I I I

FIG. D.3. Fundus slide mounting sequence

the top right and down the right side, start- ing with field number one and continuing through number seven as shown in Fig. D.3. 3. Group 3. The same procedure as for Diabetic Survey views.

C. The slides will then be returned by the Boston University photography department to Framingham for reading and storage.

VII. CAMERA MAINTENANCE A. The lenses of the Fundus Camera are never to be cleaned with lens tissue, lens cleaners, or other solutions unless absolutely necessary.

1. A can of compressed air will be available for blowing dust off objectives. It is recommended that this be done prior to each clinic session. 2. If it becomes necessary to clean the lens with more than air, a can of cleaner is provided. 3. Periodically, the Chief Photographer will clean the lenses using the Boston University lens maintenance method. This consists of using a weighted turntable and ether on a cotton swab:

B. Changing Illumination Lamp Carefully remove the lampholder, located

at the top right side of the Fundus Camera

under the spherical correction lens. The lamp can then be removed by gently pressing it down, gently turning it slightly to the left, and withdrawing it.

To insert the new lamp, its base is pressed into the corresponding non-interchangeable mount, and then turned to the right until it engages. The lampholder is then returned to the side of the Fundus Camera. The two white dots at housing and lampholder must lie op- posite each other. C. Changing the Electronic Flash Tube

IMPORTANT: SWITCH OFF POWER SUPPLY UNIT - DISCONNECT FROM MAIN WALL OUTLET,

1. Remove two red-lacquered screws and drop flash unit downward. 2. Unscrew flash tube retaining ring. Be careful to hold the flash tube in place by its prongs while unscrewing retaining ring. 3. Slide flash tube downward from its housing.

D. Replacing Flash Tube 1. Simply slide the new tube into the flash tube housing and gently turn the tube until the alignment pin engages into its proper slot in the tube socket. 2. Screw the retaining ring back in, fixing the flashtube in place. 3. The flash unit is returned to its respec- tive place and the red lacquered screws returned to their holes and tightened.