GREiF - Graphical Documentation of Retinal Findings Using a Standardized Digital Symbol Library

Abstract

Aim: To develop a software package that improves standardized clinical documentation of retinal findings. In clinical routine retinal findings are usually documented with sketchy free-hand drawings and supplementary handwritten remarks. Documentation features of common ophthalmologic software products include only simple sketching functions, which are limited to change location, size or colour of graphical primitives (e. g. ovals, rectangles, lines, textboxes . . .). As a result a feasible creation of standardized graphical documentations in retinal imaging is almost impossible. Methods: We developed a java-based software tool that features quick and intuitive generation of fundus schemes, which can be printed as findings sheet or digitally archived. Particularly for clinical ophthalmologists we created a set of standardized symbols, which can be digitally rendered for graphical documentation. All symbols were integrated into a graphics library and separated in specific categories: "Preoperative", "Postoperative", "Angiomas and tumours", "Retinopathy of the premature". The required symbol can be chosen from the library and is simply modelled on the retina scheme by placing anchor points with mouse clicks. Results: Practicability of existing features for graphical documentation of retinal findings is not sufficient, because free-hand drawings are too time-consuming and besides share the risk of false interpretation due to individual handwritings. In contrast to free-hand sketching our software tool not only applies a faster way of graphical creation but additionally improves medical documentation using a standardized symbol library, which also is specifically categorized. Conclusions: Graphical symbols for retinal documentation have found universal acceptance in ophthalmologists for a long time but still the practical use is not efficient in clinical routine. This report shows how the adequate use of software technology can contribute to documentation quality and clinical practice.