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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 337-340

External photography – Get it right

Ophthalmic Plastic Surgery and Ocular Oncology, Centre for Sight, Hyderabad, Telangana, India

Date of Web Publication13-Apr-2022

Correspondence Address:
Santosh G Honavar
Centre for Sight, Banjara Hills, Hyderabad
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_879_22

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How to cite this article:
Honavar SG, Bansal R. External photography – Get it right. Indian J Ophthalmol Case Rep 2022;2:337-40

How to cite this URL:
Honavar SG, Bansal R. External photography – Get it right. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Oct 6];2:337-40. Available from: https://www.ijoreports.in/text.asp?2022/2/2/337/343001

Photography is an art of teleporting the past into the future.”

– Mehmet Murat Ildan

Over the last two centuries, photography has undergone an ingenious transformation from Nicéphore Niépce capturing the first ever fixed photograph of a scenery view from his balcony with the camera obscura, in 1826[1]; to the current digital world where in a blink we can have high-resolution pictures with the finest of details.

The application of photography in clinical aspects of medicine was explored in 1847 by the Scottish photographers David Octavius Hill and Robert Adamson, in Edinburgh, as they captured a calotype of a woman with a large goiter[2] [Figure 1] and the concept was successfully applied to orthopedics in the early 1850s by Hermann Wolff Berend, founder of a Berlin orthopedic clinic, and Hugh Welch Diamond, a British psychiatrist for documenting surgical success as portraiture or clinical photographs.[3],[4] The successors evolved with technology making sure that this blend of art and science is appropriately utilized for documentation in every aspect of medicine while ensuring implementation of patient privacy and anonymity.
Figure 1: Woman with a goitre by David Octavius Hill and Robert Adamson[2]

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Ophthalmic external photography is of paramount importance in baseline disease documentation, patient counselling and education, assessment of disease progression and treatment response, research and publication. Therefore, immaculate photography is essential and a perfect understanding of standardization of photography is mandatory for all ophthalmologists.

  Patient Consent and Legal Obligations Top

An informed consent for clinical photography must be obtained, which includes detailed information regarding the risks and benefits; intended use of photographs; maintaining privacy and confidentiality; distribution and storage of data; use on social media and standardization of photographs to streamline the outcomes and care. Teven et al.[5] have proposed the principles of ethical considerations in clinical photography i.e., beneficence, non-maleficence, patient autonomy and justice to ensure complete co-operation from the patient's end with a detailed understanding of their rights and maintaining anonymity in the due course.[6]

  Digitalization is Convenience Top

Digitalization has revolutionized the concept of photography ensuring easier documentation; faster retrieval and transfer of data; economical and safe storage; appropriate application in tele-ophthalmology and accurate comparative assessment.[7] An ophthalmologist must have a user friendly, genuine and licensed software for editing and storing data and for appropriate categorization of pictures in terms of either patients (as per medical records) or diseases (as per International Classification of Diseases – ICD coding).

  Parameters for Standardization Top

Serial documentation for accurate comparison demands a standardization of protocols to be kept in mind while taking the photographs.

Photography room

It is advisable for the ophthalmologists to have a dedicated room/area with appropriate dimensions and illumination for the purpose of photography. The dimensions of the room must be adequate enough to maintain a required distance between the photographer and the patient. If possible, it is recommended to ensure that data storage, editing, and back-up system is done in the same room preferably by a designated trained ophthalmic/medical photographer. It is necessary for the photographer to have a clear understanding of the diseases, areas of interest and purpose of documentation.

Camera and Illumination

A myriad of cameras is now available ranging from single lens reflex (SLR) to point-and-shoot. Although an SLR camera is the gold-standard, ophthalmologists are recommended to choose a camera as per their budget, requirements, photographer's ability and purpose of documentation while maintaining high quality.[8] Expenditure on cameras and appropriate lenses should be considered as an investment. Persichetti et al.[9] have enumerated the ideal recommendations for a basic setup[6] and have accurately described the need for optimally illuminating the area of interest. It is preferable to provide adjustable flash lights in terms of height and intensity while maintaining image stabilization and minimalizing shadowing, or use a diffuse ring flash.

Preparation of area of interest

The photographer must make sure that the area of interest is well exposed and cleaned of blood, discharge or staining and patient's hair is tidy. It is advisable to clear off make-up, jewellery, accessories like earphones and hearing aids.[8],[9] This not only provides clear and symmetrical comparative pictures but also presentable images in academic settings.

Position of patient

Anatomical positions are recommended for documentation of images whenever possible. This helps in serial photography of diseases that require frequent follow-up and monitoring of post-operative outcomes [Figure 2] or disease progression and regression. The patients must sit upright and the picture must be clicked in standard mode as well as with high-magnification covering the area of interest.
Figure 2: (a) High-magnification pre-operative image of a patient with adult-onset capillary hemangioma and (b) Post-operative comparative images displaying the excellent surgical outcome

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Distance from patient

The distance between the background and the patient must be kept at 1 foot to avoid shadow formation (which can also be minimalized by provision of adequate illumination strategy) and spatial distortion. The distance between the patient and photographer must be at least 2 feet while taking standard and 1 foot while taking high-magnification pictures keeping safety guidelines in mind.


A non-reflective, monochromatic background of neutral colours must be chosen, preferably white, grey and blue. A green background can be chosen for taking videos and in case the ophthalmologists intend to add visual-effects.


Tripods and reflectors are not only convenient while clicking images, but also help in taking pictures and videos with minimal shake and increased stabilization. It is advisable for the photographers to always use efficient and high-quality batteries.

Data editing

Various softwares are available for photo-editing and storage.[6] It is a good practice to invest well in licensed softwares. Photographer must keep all the images in a standard format as per the ophthalmologist's requirements with minimal image manipulations. In the current times of plagiarism, it is advocated to use a water-mark on the pictures while publishing on social media.

Data storage and back-up

A major disadvantage of digitalization is loss of data due to malware and viruses. It is imperative for the photographers to have sufficient storage for periodic back-up. The photographer is advised to create high-quality images in formats like JPEG (Joint Photographic Experts Group) or TIFF (Tag Image File Format) with a standard resolution of 300 dpi (dots per inch). DICOM (Digital Imaging and Communications in Medicine) viewer software must be in the photographer's system to be able to open and view the radiological images. Cloud storage is expensive but is practical for easy access without fear of accidental damage to storage devices. It is also a good practice to keep back-up cameras, light bulbs, batteries and storage devices for contingencies.

Recommended views in ophthalmology

Complete coverage of the area of interest is inescapable. It is required to take multiple views from different angles to highlight the area and the disease from a distance as well as to click close-up images.[9] Positioning is relative to the conventional Frankfurt plane (a plane passing through the inferior margin of the left orbit and the upper margin of each ear canal or external auditory meatus, also called as the auriculo-orbital plane). The following standard views are recommended:

  1. Frontal view [Figure 3]a: With the patient looking in primary gaze, the vertical aspect is maintained by clicking an image covering the upper limit of the head to the “jugular incisure” and the horizontal aspect is maintained by keeping the inter-tragal line aligned with the horizontal axis. Close-up images must be obtained for both the eyes individually to cover higher magnification while covering all gazes for documentation of ocular motility and ptosis. For ptosis evaluation, pictures are advisable to be taken with a clean transparent measuring scale aligned in the pupillary axis.
  2. Oblique view [Figure 3]b: With the patient's body rotated at 45 degrees, the Frankfurt plane is held horizontal, with patient looking ahead and tip of the nose aligned with the cheek outline. Images must be obtained from right as well as left.
  3. Lateral view [Figure 4]a: With the patient's body rotated at 90 degrees, the Frankfurt plane is held horizontal, with patient looking ahead and the nasal tip and chin aligned making sure that the contralateral eyebrow is not visible. Images must be obtained from right as well as left.
  4. Cephalic view (Bird's view) and Basal view (Worm's view) [Figure 4]b: These are recommended to document proptosis and enophthalmos; and must be taken symmetrically during every visit for serial documentation.
Figure 3: (a) Frontal view and (b) Oblique view for ideal external photography

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Figure 4: (a) Lateral view, high-magnification of a patient with left lower eyelid cystic lesion (b) Basal view (Worm's view) of a patient showing left eye proptosis secondary to an orbital mass i.e. cavernous hemangioma.

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  Intra-Operative Photography Top

Documentation of operative procedures is not only necessary in terms of medico-legal aspects but also for highlighting and presenting unique surgical techniques and procedures. The lighting in an operation theatre is a limitation and therefore, the photographer must adjust the camera settings to suit the exposure as per the surgeon's requirements. The photographer must ideally discuss the surgeon's needs before the procedure in order to avoid technical issues while clicking images or shooting videos at the time of surgery. The photographer must also stay clear of the operative field and position without disturbing the ongoing procedure. It is the surgeon's responsibility to provide a blood-less and clear field during documentation with minimal equipment.

  Specimen Photography Top

A clear gross documentation of specimens is recommended after removing all unnecessary adhesions and holding it in its original position as well as from different angles.

  Radiographic Photography Top

It is a good practice to store images of the high-quality scans of patients including computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography and CT (PET-CT) and X-rays, wherever applicable. The scans must be stabilized to avoid shaky images and the lights must be set to avoid reflection (preferably back-lit). While storing these images it is a good practice to eliminate patient details from the view.

  Conclusion Top

Documentation holds a very important place in a clinician's practice and the advances in technology have made standardized photography possible in an economic and efficient manner. Uniform serial documentation with or without morphing helps in showcasing medical and surgical outcomes to patients as well as fellow colleagues which helps in increasing patient compliance as they are able to witness treatment success. It is highly recommended for the ophthalmologists to consider photography as a wise investment and a priority.

A photograph has picked up a fact of life and that fact will live forever.” – Raghu Rai

  References Top

Gibson D. The father of photography. History through the lens. 2020. Available from: https://medium.com/history-through-the-lens/the-father-of-photography-17534db0da09. [Last accessed on 2022 Mar 31].  Back to cited text no. 1
McFall KJ. A critical account of the history of medical photography in the United Kingdom. IMI Fellowship Submission; 2000. yumpu.com. Available from: https://www.yumpu.com/en/document/read/38361169/a-critical-account-of-the-history-of-medical-photography-in-the-uk. [Last accessed on 2022 Mar 31].  Back to cited text no. 2
Encyclopedia of Nineteenth-Century Photography. Routledge & CRC Press. Available from: https://www.routledge.com/Encyclopedia-of-Nineteenth -Century-Photography/Hannavy/p/book/9780415972352. [Last accessed on 2022 Mar 31].  Back to cited text no. 3
Medical photography in the nineteenth century: From portraits to clinical photography-Hektoen International. Available from: https://hekint.org /2018/03/05/medical-photography-nineteenth -century-portraits-clinical-photography/. [Last accessed on 2022 Mar 31].  Back to cited text no. 4
Teven CM, Goldman JJ, Rebecca AM. Ethical considerations in clinical photography: An updated perspective. Plast Reconstr Surg 2021;147:366e–8e.  Back to cited text no. 5
Mukherjee B, Nair AG. Principles and practice of external digital photography in ophthalmology. Indian J Ophthalmol 2012;60:119–25.  Back to cited text no. 6
[PUBMED]  [Full text]  
Verma M, Raman R, Mohan RE. Application of tele-ophthalmology in remote diagnosis and management of adnexal and orbital diseases. Indian J Ophthalmol 2009;57:381–4.  Back to cited text no. 7
[PUBMED]  [Full text]  
Galdino GM, Vogel JE, Vander Kolk CA. Standardizing digital photography: It's not all in the eye of the beholder. Plast Reconstr Surg 2001;108:1334–44.  Back to cited text no. 8
Persichetti P, Simone P, Langella M, Marangi GF, Carusi C. Digital photography in plastic surgery: How to achieve reasonable standardization outside a photographic studio. Aesthetic Plast Surg 2007;31:194–200.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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