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1. Km While being dragged the mosaic picture becomes transparent to make manual linking easier This way any issue due to the automatic reconstruction can be fixed manually Figure 5 5 Rotate a single acquisition Right clicking on a single picture brings up a pop up menu that allows to remove that picture from the mosaic Removed pictures are placed in a gallery on the bottom of the screen All images that were not selected for the automatic reconstruction process are also placed in this gallery They can be re inserted manually in the mosaic by double clicking them from the gallery INSTRUCTIONS FOR USE Sege Figure 5 6 Gallery of discarded acquisitions We All pictures edges are smoothed and image transitions combined in a more uniform image If you are satisfied with the final mosaic image you can print or save the diagnostic report choosing File gt Print screen capture If the mosaic has been finalized using the currently described procedure then all pictures are merged together and mosaic image is optimized for printing i e black background is turned to white Otherwise a normal screenshot is proposed ki This button finalizes mosaic creation as it merges all overlapping pictures together in a single image excluding of course all the pictures that have been placed in the discarded gallery Figure 5 Finalize mosaic Figure 5 8 Print preview 10 PRINTING The user may
2. PMS CS0 101010 108 104 O Je Figure 4 9 AE Configuration Click the PACS or PMS button to open the following windows INSTRUCTIONS FOR USE IHE Configuration AE x Title PMS Host 10 10 10 154 Port Timeout s Limit 104 DCM4CHEE Hast 10 10 10 101 Port Timeout s Limit 11112 Reset Cancel Reset Cancel Figure 4 10 PACS and PMS Configuration This window allows the user to identify the PACS system that will receive his information or the PMS system from which information may be requested In the relative fields enter e Title PACS PMS ID Host PACS PMS IP address e Port PC port to which PACS PMS is referred e Timeout s maximum waiting time before disconnecting a call e Limit for PMS configuration only identifies the maximum number of exams that may be received If the field is left blank any number of exams may be received Clock OK to save the settings as entered otherwise click Cancel Click Ping to initiate a call to the PACS PMS system Click Reset to remove PACS PMS Setting Under local you can configure the local Application Entity name and port storage parameters W Secondary Capture Auto Send Uncompressed Figure 4 11 Save Parameters The Storage Parameters allow the user to specify several data storage options Secondary capture by choosing this checkbox the secondary capture will be sent instead of the origi nal acquisition This is in fact the image that is sho
3. When done click OK After the system has automatically installed the instruments Scheimpflug camera and topographer it will start the first calibration see the next paragraph ai SS INSTRUCTIONS FOR USE The a button permits editing an existing instrument il To eliminate an instrument from the list select it and click E EE Click the EL button to calibrate the instrument For calibrating see next paragraph In the following setting you can choose whether to set a timeout in choosing the instrument 5 seconds after which the instruments live application will be launched automatically When not checked the acquisition choice screen will be shown until the user makes his choice 4 3 Groups For creating editing or deleting groups of examinations Cataloguing the examinations by homogeneous type groups for example keratoconus PRK myopia PPK hypermetrophy trauma etc is useful as a search aid Settings Keratoconus Myopic Postop Normal Pellucida Suspect K Transplantation Cancel Figure 4 5 Groups Menu Click the ooo button to insert a new group The lt button can be used to edit pre existing groups This button goes active when a group is selected for editing S 3 The ee button is instead used to delete a group It goes active when a group is selected for deletion INSTRUCTIONS FOR USE 4 4 Miscellaneous Other Clicking Other accesses the windo
4. gt gt wm Nome di rete Cobra Tipo di sicurezza Nessuna autenticazione ape v uggenmenti per la scelta Chiave di sicurezza C Nascondi caratteri Salva questa rete Avanti Annua Next configure the network s IP settings The IP Address assigned will be the router on client computers E a H INSTRUCTIONS FOR USE E possibile ottenere l assegnanone automatca delle Impostazioni IP se la rete supporta tale caratteristica In caso contrario sar necessario richiedere al amministratore di rete le impostamoni IP corrette Otter automaticamente un indirizzo IP Utizza i seguente indrizzo IP Indirizzo IP 192 168 10 10 Subnet mask 255 255 255 0 Gateway predefinito 192 168 10 10 Often indirizzo server ONS automabcamente Uira i seguenti indirizzi server DNS TCP IP Protocollo predefinito perle WAN che permette la Server DNS preferito comunicazione tra diverse neti interconnesse 5 DNS alternative Finally in order to make sure the ad hoc connection is started automatically on computer startup save the following command netsh wlan connect name Cobra In a file in automatic execution on the start menu 4 Ad hoc connections on windows XP From the network connections panel Choose the properties for the wireless connection adapter MPE 4 EE Reti disponibil f e Pai conmettersi disconnetterzi o ottenere ulteriori informazioni l a Cavo di rete
5. starting from the centre of the disk itself For each pair the AVR ratio arteriolar calibre over venular calibre is calculated after which the mean of these values is taken to obtain the final AVR SS INSTRUCTIONS FOR USE 12 GUIDE TO THE EXAMINATION 12 1 Capturing The first step consists in acquiring the image of the fundus bearing in mind two basic rules The patient s fixation point must be set so that the optic disk is located as close as possible to the centre of the image since the vascular calibre measurements are taken in a specific area of the disk itself If the optic disk is too peripheral the analysis can be run anyway but certain significant vessels may be outside the image field Figure 2 1 The image must be sharply focused the edges of the blood vessels around the disk must be clearly defined illuminated and contrasted otherwise the system may not detect them correctly even manual corrections are made more difficult if the image is incorrectly focused Important The vascular examination is available on both the Cobra 5Mpx and Cobra 2Mpx Although the Cobra 2Mpx has more than adequate resolution and image quality for the examination the level of detail is nonetheless lower than that of the higher resolution model It is therefore essential that you carefully assess the captured images to ensure that they satisfy the above criteria Figure 2 1 Fundus capture with properly centred optic disk cse Befor
6. 12 4 Confirmation and deletion of existing pairs Click on a vein artery pair to display a context menu ar Swap vein artery Figure 2 7 AV pair context menu INSTRUCTIONS FOR USE SS This menu allows you to confirm the pair if it has been judged doubtful by the system or eliminate it completely or change the classification from vein to artery or vice versa if the automatic classification is incorrect Pre calculated vessels pairs erg eet l l If several pairs are overlapping or it is difficult to select pairs kad 01 I AVr 0 66 m on the image a list of all pairs detected by the system is displayed on the right both those highlighted on the image 4 02 vd AVr 0 89 as reliable and those which are not included but available for review and manual inclusion if necessary 03 vd Avr 0 80 Touching a pair in the list with the cursor highlights it in the image The number of the pair in the list matches that of the pair on the image The shield symbol indicates the status of the pair reliable and included in the calculation green shield not reliable and excluded from the calculation but available for review and confirmation light blue shield not reliable and excluded form the calculation red shield Clicking on a pair in the list displays the context menu shown in figure 2 7 with the difference that in this case the system also displays pairs not shown on the image itself IN Figure 12 1Pair selectio
7. Cup to Disc ratio g areas defined by the user in surface and area line Pi Allows the user to type a line of text on mn LL JE 4 Deletes drawings and text overlaid on pm JI LA erer Table 1 Toolbar Buttons Summary 7 2 Menu Bar The bar at the top of the screen contains the menus shown below File Analysis Options Tools Filters Figure 7 1 Fundus Image Management Menu 7 2 1 File Menu Save screenshot as image Save a screenshot print screen in a user selected format JPEG BITMAP GIF PNG or TIFF Save image Saves the image in a user selected format JPEG BITMAP GIF PNG or TIFF Close Closes and returns to the main window Prints the screen containing the image A Preview Print Screen window is shown before printing Print Prints the screen containing the image without showing the Preview Print Screen immediate Print Allows the user to print up to 4 selected fundus images on a single page cfr Section 10 Printing A Preview window is shown before printing Print immediate Allows the user to print up to 4 selected fundus images on a single page without showing the Preview Exits the program Table 2 File Menu EA SS INSTRUCTIONS FOR USE 7 2 2 Analysis Menu CH Single image Accesses the single image display window a Full screen Accesses the full screen mode E H __ Wavelength Divider Accesses window for viewing the image at different wavelengths Compariso
8. Shows only the choroid component gt Barrier filters gt Choroid Shows only the vascular component Barrier filters b Vascular Shows only the red free component J Barrier filters gt Red free m r Shows only the nerve fiber component Barrier filters gt Nerve Fibers Table 6 Filters Menu 8 WAVELENGTH DIVISION Click the button in the Analysis menu oron the toolbar to access the wavelength divider window The window shown in Figure 8 1 displays e the original image top left To insert this filter on the single screened image click the button the infrared image top center To insert this filter on the single screened image click the C on e the red free image top right To insert this filter on the single screened image click the L button the choroid image bottom left obtained by considering only the red component To insert this filter on the single screened image click the H button the vascular image bottom center obtained by considering only the green component To insert this filter on the single screened image click the L button the image of the nerve fibers bottom right obtained by considering only the blue component 44 0 SS INSTRUCTIONS FOR USE To insert this filter on the single screened image click the E button Figure 8 1 Wavelength Division 9 SECONDARY FUNCTIONS 9 1 Comparison Click the Co button in the Analysis menu or in the toolbar to access the
9. Stabilize the image as much as possible wait until the patient is immobile and check that the light does not flicker The image must be uniformly illuminated see example image Do not move in further when the image is clear too close a proximity could generate undesired reflections Press the joystick button to capture the image The captured image will be saved in the OD right eye or OS left eye gallery depending on the eye to which the captured image refers Figure 5 4 Example of Optimal Centering ai INSTRUCTIONS FOR USE 5 2 Viewing cse The instrument performs simultaneous capture of two images of the central portion of the retina one obtained with visible spectrum illumination white light and one obtained with infrared spectrum illumination The visible light image is available in the gallery immediately after capture left click the thumbnail to display a full screen view CE Figure 5 5 Visible light Capture To view the infrared spectrum image right click the thumbnail and select Show IR from the pull down menu select Delete to delete the selected image The infrared spectrum image provides a different diagnostic picture since the infrared light penetrates the tissues to a greater degree this mode permits capturing the structure of the choroid and so facilitates diagnosis of nevi and other pathologies of the retina EI Show IR nl Delete a Figure 5 6 Gallery Menu GC 34 S
10. below or click Browse Check Next to start the installation Folder C Program Files CSO Phoenix Browse Disk Cost Install Phoenix for yourself or for anyone who uses this computer Evenone a Just me Figure 1 4 Installation directory Figure 1 5 Confirmation install Click Next to complete installation Click Close at the end of installation The following screen appears Click OK to confirm and proceed installation of a demo database Cancel in case of an upgrade ES i Proceed installation of DBPhoenix ex CADEPhoenik weng Figure 1 6 Install DB 35 Phoenix kal EW Installation Complete Phoenix has been successtully installed Chick Close to exit Please use Windows Update to check for any critical updates to the MET Framework The Phoenix icon will appear on the desktop INSTRUCTIONS FOR USE cse In case of an upgrade of the Phoenix software i e an installation of the Phoenix software on a system where an older version already was installed the following message might appear upon uninstalling the old version INSTRUCTIONS FOR USE 1 2 Upgrade Phoenix The following applications should be closed before continuing the install PSearch Service F Automatically close applications and attempt to restart them after getup is complete Do not close applications A Reboot may be required Cancel Figure 1 1
11. comparison function 9 1 1 Image Selection The capture image selection window will be displayed From this window the user may select up to six images by double clicking the gallery images Should the images to be compared belong to a different exam or patient click the W button on the Patient Management bar to access the search functions The selected images will be shown in the column on the right Click the Ok button to confirm click the Cancel button to cancel and return to the previous window INSTRUCTIONS FOR USE fei eh EE OK ananasa Pa anaa o O5 087042011 11 1 051080422011 11 1 Figure 9 1 Selecting Images for Comparison SS INSTRUCTIONS FOR USE 9 1 2 Comparison Window The selected fundus images will now be displayed in the comparison window as shown in Figure 9 2 The zoom and panning functions on the various fundus images are linked in order to permit observing all the images in the same position at the same enlargement Figure 9 2 Fundus Image Comparison 9 2 Full Screen The Analysis menu or toolbar allows the user to access the full screen view by clicking the D button In this mode the image occupie E Bi captured during a single exam The lt at constant time intervals 9 3 Stereo Imaging Overlay of Fundus Images Click the button on the Analysis menu or toolbar to access the fundus image stereo imaging overlay window The user
12. explained here is very simple and is replicable using Cobra and Sirius live acquisition Start the live acquisition and prepare the patient by exposing the upper lid and lower lid meibomian glands in any order Center the glands on screen and focus the image moving the instrument forwards or backwards or using the focus handle in case of Cobra e Take the picture using joystick button Acquired picture will be showed on screen as a thumbnail Acquire at least one image for the upper lid and one for the lower lid e When a satisfactory amount of images has been acquired exit Live acquisition SS INSTRUCTIONS FOR USE 14 2 Processing the examination Enter the meibography examination gallery and double click on the desired image to start meibomian glands evaluation The procedure is computer assisted but requires manual tracing of glands points After evaluation is completed a gland health score will be saved and will be available for further patient consulting Figure 14 1 Image capture 14 2 1 Starting evaluation These buttons start the evaluation for upper lid and lower lid respectively in the above case the lower lid evaluation is selected The same buttons can be used to delete the evaluation measure and restart Deletion is preceded by a confirmation message Deleting the measurement means that all control points displayed will be lost INSTRUCTIONS FOR USE 14 2 2 Tracing eye lid bounds Fig
13. menu may be accessed only if the patient list is not displayed If patients are displayed in the list click Clear Patient List to enable the Settings function Exits and closes the program Le hy Y Phoenix LD Are you sure you wantto exit Show this message again Figure 1 6 Confirm Exit from Program 113 INSTRUCTIONS FOR USE SS Selecting the suitable box on the Settings Other menu see Chapter 4 displays a request for confirmation of exit from program Click Yes to exit or No to continue using the program All data measured calculated and successively displayed to the user are to be considered subject to the user s full responsibility The manufacturer shall use its best endeavors in order to ensure that all the data displayed in the software is complete and accurate Ne vertheless the instrument s manufacturer bears no liability for any consequential damages and will not accept claims that result from incorrect data and successive incorrect interpre tations Data obtained from the software should always be compared and scrutinized with results of different instruments 2 PATIENTS DATABASE Surname Name Identification code Figure 2 1 Search Panel Each patient is identified by Last Name First Name and an Identification Code that is automatically generated by the program To locate a patient in the Database type the Last Name and First Name in the Patient Box or type the Identi fica
14. study contains more than 7 acquisitions the Image Selection window 9 1 1 is presented to select the desired acquisitions until the maximum allowed number is reached Mosaic wizard Aootpic Matched Matching Matching Matching i E Ss Ss Mosaic is being calculated this may take a while Figure 5 3 Progress mosaic window The above image indicates that the mosaic is being generated this process requires a certain amount of time depending on the number of acquisitions and their complexity In case the process takes too long more than a minute it can be stopped anytime by pressing the Cancel button on the window The reconstructed mosaic is then displayed on screen Three modalities are available in the mosaic window and they provide the functionalities that lead to the creation of the final mosaic image This button activates global view mode which is activated by default just after the mosaic is reconstructed as displayed in the next screenshot The mosaic is shown as a set of fixed overlapping pictures and the global image can be moved and zoomed in or out using mouse and mouse wheel Single mosaic pictures cannot be moved or rotated here GC 48 INSTRUCTIONS FOR USE Figure 5 4 Mosaic assembly 3 J This button activates manual edit mode Every single mosaic picture is now selectable circled in red and can be dragged using the left mouse button or rotated using the mouse wheel
15. the logo click the button to show the heading data entry change form Figure 10 1 Header 1 Header 2 Header 3 Address City Country IP code State Phone Cancel mn kz Figure 10 1 Company Data Click the va button to insert a logo Type the other company practice data in the empty fields shown in the window Click OK to confirm Enlarge Reduce Preview of the image Exits the Printing window cse Retinal vascular analysis consists in evaluating the calibre diameter of the veins and arteries present in the image of the ocular background with aim of calculating the mean value of the ratios of the calibres between individual pairs of adjacent blood vessels INSTRUCTIONS FOR USE 11 RETINAL VASCULAR ANALYSIS The vascularisation status of the retina and in particular the AVR Arteriolar to Venular Ratio are highly indicative of potential cardiovascular problems and are fundamental to screening examinations since they can highlight arterial restrictions which may require more detailed follow up examinations to reduce the risk of cerebral and cardiac infarction Clinical studies and statistical results are available in the following article currently considered the state of the art in this subject Wong TY Klein R Couper DJ Cooper LS Shahar E Hubbard LD Wofford MR Sharrett AR Retinal microvascular abnormalities and incident strokes the Atheros
16. 1 OV 0 38 Figure 2 3 Manual cup disk editing When editing is completed you can view the updated cup disk ratio values Figure 2 4 d rea 016 OV 038 Neate edi Figure 2 4 Manual cup disk marking When you are satisfied with the marking of the disk simply click on icon Y to launch vascular analysis N B there is no need to define the cup when running vascular analysis since it is not always identifiable on the image of the fundus The outline of the disk is the only requisite for the analysis 12 3 Automatic vascular analysis Click on icon to run the analysis automatically N B the analysis run by the system is sufficiently precise so long as the image quality is very good However even when the image is a good one it is still recommended that you carefully review each pair of vessels and manually edit the pairs as necessary adding new ones or deleting incorrectly detected ones so as to optimise the quality of the examination E ag INSTRUCTIONS FOR USE x i 3 AVR 0 777 k ssen P rf km ee aL w O3 id Aur OS bei Guarese E Figure 2 5 Main AVR measurement interface The system attempts to identify pairs of adjacent veins and arteries in the area of interest calculated in relation to the position and size of the optic disk see section 1 1 The system automatically distinguishes between veins and arteries and the calibre is calculated in the most reliable section The system ca
17. 2 Kerat INV TS Image Management Selecting Immediate Image Refresh will offer immediate access to the single acquisitions Upon examination loading as soon as a single image is loaded it will be accessible in the gallery Otherwise all images are pre loaded and then made available Instrument Management e When Show calibration shortcut is selected the main gallery will show shortcuts to the calibration procedure for both Scheimpflug camera as Topographer e Automatic ordering setting as available until now where the latest acquisitions are shown first in gallery e Manual ordering latest acquisitions are visualized first in gallery unless the operator chooses to change manually their ordering by drag n drop cse DICOM is a medical computer standard adopted by many health agencies and hospitals in all parts of the world which permits medical operators to exchange images and other information via computer systems adopting this standard INSTRUCTIONS FOR USE 4 6 DICOM Digital Imaging and Communications in Medicine Deselect the Suppress DICOM messages box to show any errors that do not interfere with image capture settings W Suppress DICOM warnings MOD_CSO Storage commitment Auto Send Uncompressed Java Home C Program Files x96 CSO Phoenix java Figure 4 8 DICOM If DICOM is instead selected the remaining menus must be used Configuration AE PPS PACS O si
18. 90000019 rev 0000 07 2014 CE 14 x Z TI O I A INSTRUCTIONS FOR USE CONTENTS 1 INSTALLATION AND START UP iii 7 1 14 Installazione PROGR anti 7 EE e e ANG narang Ga aane aa ANGEN paka a Ba an Sg a NB NG TIA 10 da TANGGANE OYE AN EE 11 UE DE EC UE 13 2 PATIENTS DATABASE salina 14 Cu Palenie LIST lla 15 e VIDI elena AA NA JEG Na gagian 16 2 3 CIMINO PANE DA WEE 16 24 ICCTA a Pateni susedka E din 16 29 Advanced DOAN E 17 2 6 Delele Paleht riga 18 3 EXAMINATIONS DATABASE ii 18 ol NUOVO INO E 18 32 edel de AE 18 3 3 Editing Examination Dalai 19 34 Delega EXAMIMANON WEEN 19 0 Ride 20 30 ele ET i 20 o Me Eeer 21 4 SET ENG D eege 23 di E ue 0 EE 23 2 SC e NET ET aaa Ba a abaan KANAN 23 di Sean 25 GA WISGCIANEGOUS OUNCE EE 26 do E E Ac on 21 4 6 DICOM Digital Imaging and Communications in Medicine n 28 di AUS o 30 CE A CR TER 30 5 09 Ge 4 Sane ee E eee ere ree ee eee ee ne eee ree eee 31 Sl GOMEN ne ea e eee ee a 32 S NV OWING BEE 34 do Sele 35 5 4 Mosaic preview mode iii 36 6 VIEWING AND MANAGEMENT OF SINGLE IMAGES iii 39 6 1 Linear Measurements EE 40 0 2 CUPI DISCRIIO EE 40 Di OR e anto 41 7 TOOLBAR AND MENUS iii 41 il Kee Me ana 41 20 0 ee 42 Figure 7 1 Fundus Image Management MENU 42 LSC AN Fie MEH rina rado E aa KAG SADE Bpa
19. Manual Local Syste Sk Program Compati This service Started Manual Local Syste Gh Protected Storage Provides pr Manual Local Syste 19 PSearch Service Provides Se Started Automatic Local Syste Sk Quality Windows Quality Win Manual Local Service Remote Access A Creates a co Manual Local Syste screenshot Note that when Phoenix is configured as having its database on a local network you might need to change the connection for these services Assign for example your current account with username and password to the service to make sure the web service enhanced service has access right to the network INSTRUCTIONS FOR USE 2 How to configure your iPad Select the wireless network available for interaction with Phoenix impostazioni Pi Uso TERZA Wi Fi x vo Bluetooth Scegli una rete v Cobra yw Dati cellulare Altro gt Non disturbare O Notifiche Richiedi accesso reti O L accesso alle reti conosciute sar automatico Se non disponibile nessuna rete Generali conosciuta dovrai selezionarne una manualmente KJ Suoni S Luminosit e sfondo KA Cornice immagine KA Privacy CD iCloud I Posta contatti calendari Note Promemoria This network by default will be configured as follows Impostazioni ba Uso in aereo Dissocia questa rete Ka Bluetooth Accesso automatico am Dati cellulare Nessuna SIM In
20. Pi Export DM CT View IF Calco Datagraph CT EasyFit E Focus E EyeLite E Assort N Raw File Cancel In the section Export it is possible to enable the data export to external applications Figure 4 14 Activation settings For a number of external applications it is possible to configure the export on the main gallery The default can be chosen from the combo box Check the reminder if you want a reminder message for exporting both eyes contemporarily to the external application 4 8 Schwind In the Schwind section the user may configure some settings solely for Schwind exports The back up folder for schwind exports and the export file name format EA SS INSTRUCTIONS FOR USE 5 CAPTURE The L Capture icon goes active when a new exam is created or when an empty exam is selected This function allows the user to select the instrument with which to capture the examination and to access the capture environment Capture Window Toolbar BUTTON SHORTCUT ICON FUNCTION Settings Opens the panel for setting general capture parameters Focus Indicator Reactivates the focusing support window if deactivated Exits the Capture window The window shown below will open Figure 5 1 Capture Window If the software is set for operation in the one shot single capture mode a message will request that the user press the joystick button t
21. S gt INSTRUCTIONS FOR USE oe Ae LA Been Figure 5 7 Infrared Capture 5 3 Settings L Image format Acquisition mode Non stop Autogaln enabled Quality Figure 5 8 General Settings E INSTRUCTIONS FOR USE SS Image format Selects the format for saving the captured images visible spectrum and IR The user may specify the quality in the case of Jpeg compression default setting Acquisition mode Selects the working mode In the One shot mode the instrument takes one shot and the image is automatically displayed on the screen After capture the instrument immediately enters the stand by mode With the instrument in stand by every time the capture software is launched the user must press the joystick button to wake the instrument In the Non stop mode the instrument does not go to standby except after the elapsed preset stand by time and images may be captured one after the other in this case the images are not displayed immediately after capture The instrument starts up automatically each time with no need to press the joystick button Autogain enabled Enables the auto gain function If activated the instrument continually adjusts image brightness for optimal values this feature facilitates centering especially in cases of patients with very small pupil diameters This function also permits the operator to view the patients face clearly before begi
22. SMY P SN label is sticked on CD or provided by your vendor PHOENIX SOFTWARE V26 Figure 1 3 Registration Screen You need to connect the database when you open the first time the software Press OK if the database has been created during the installation and Phoenix is ready to use If the database is just present press browse button and select phoenix mdb You need to connect the root cso file contents in the same database folder Open the Miscellaneous menu in the settings and check if the Image root field is complete Otherwise search the root cso that will be in the database phoenix mdb folder see 4 4 Reconfigure Database Either you have decided to change Database ora maintenance operation has taken place Database type ACCESS w Database location CADBPhoenix phoenixmdb Figure 1 4 Database connection Confirm pressing OK The main screen will open EA INSTRUCTIONS FOR USE File Figure 1 5 Main Screen of the Phoenix Program This first screen allows the user to manage the database of patients and the examinations associated with each It is made up of various sections and menus When the program is launched all the windows are empty 1 4 File Menu rivi Settings Settings Allows the user to select the software language manage groups and instruments and make other settings see Chapter 4 This
23. Service active This means the WCF service menu has been used to install the Web Service interface for Phoenix Please make sure to uninstall the service following Start Menu gt All Programs gt CSO gt Phoenix gt WCF Service gt Uninstall PSvcHost Wb cso J PDF Printer A Phoenix Ka Phoenix de Lenses WCF Service Configure PSvcHost t Install PSvcHost al Start PSvcHost Stop PSvcHost al Uninstall PSvcHost 4 Indietro After this the uninstall will correctly complete See the appendix for more information on the installation of the WCF Sercvice fof SS INSTRUCTIONS FOR USE 1 3 Phoenix Program Regarding Windows 8 users after having installed Phoenix on the Operating System Windows 8 it is neces sary to start the program with an elevated level of privilege We advise to choose the setting from properties like below ok pasi nar Tiri aga are hae ri correctly on PE Run this program in compatibility mode for Windows XP Service Pack 3 Saltin F Run in 256 colors I Run in 640 x 480 screen resolution Figure 1 2 Set the privilege level INSTRUCTIONS FOR USE SS Click the Phoenix icon on the desktop The screen shown below will appear asking the user to send an e mail contai ning the code for unlocking the software Ka Software Activation Wizard Input serial number You have 60 free trials left Input your software serial number
24. Trace gland points Highlight the glands area by left clicking on the upper glands bounds or lower bounds in case of upper eye lid meibography Every click adds a green gland point the more points are set the more accurate the gland area is It is also possible to keep the mouse button clicked then moving the mouse to draw the glands bound green points will be automatically set Avoid crossing lines or creating loops or complex paths It is not possible to create gland points outside of the red bounds a mouse click outside the red borders will result in the adding of a gland point on the nearest red bound d Delete this control point ia Delete all control points Figure 14 5 Edit points Defined points can be removed by left clicking the mouse a white cross appears on the point when the mouse passes over the point Right click on a single point pops up a context menu which allows removing the single point or all the gland points defined so far New points can also be set between existing ones in order to refine the green line shape Just move the mouse between points to obtain a preview of the new point s influence then left click to add it to the points set definitively E 69 f INSTRUCTIONS FOR USE 14 2 4 Zooming and tracing This is an advanced editing option Figure 14 6 Switch edit Zoom mode Sometimes it is necessary to zoom in the image to obtain more precision in tracing gland points While traci
25. a tions Database EA SS INSTRUCTIONS FOR USE 2 5 Advanced Search Ge Click the button to access the advanced search function Instrument v Instrument Groups Exam date dd MM yyyy Birthdate dd MM yyyy Keratoconus Accession Number Myopic Postop Identification code Normal Gender Pellucida PRK Lasik Suspect K Transplantation v Exam date dd MM yyyy 17102011 1 10 2011 E v Birthdate dd MM yyyy 17102011 1 10 2011 E Accession Number v Groups Patient s age Referring Physician s Name Caption identification code v Gender Male M Female P Patient s age v Referring Physician s Name DeNiro Robert v Caption Exam search Cancel Exam search Cancel Figure 2 4 Advanced Search For each of these categories clicking the CH button so as to check select it II visualizes the boxes for entering search criteria by gender male or female e by date of birth start and end dates of the interval to be searched by check in number a box for entering the number this field features the automatic completion function by examination date start and end dates of the interval to be searched e by patient age minimum and maximum age e by referring physician a box in which to type the physician s name by instrument a list of possible examination capture instruments for example Fundus camera kerato scope pupillographer Scheimpflug camera slit lamp biomicroscope e b
26. ame Name Birthdate dd MM yyyy Gender z Identification code P01100 0616 Ok Cancel Figure 2 2 New Patient Data Window Date of birth must be entered in the form two digits for the E two digits for the month and four digits for the year Entering an invalid datum will cause a warning icon to be displayed Entering a patient whose data are identical to those of a patient already contained in the database will likewise open a window containing a warning message The identification code is automatically entered by the system unless a different option is selected from the DICOM Settings menu See Chapter 4 4 To confirm new patient entry press the Enter key or click the OK button To cancel click Cancel Whenever a new patient is created an examination associated with that patient is also created A window for selecting the examination type then opens See New Exam below 2 1 Patients List Any new patient entered is displayed in the patients list window on the left hand side of the screen To view the list of all the patients entered click the button To empty the contents of the patients list from the main screen click the button INSTRUCTIONS FOR USE 2 2 When 2 3 cse Patient Data a patient is selected the entered data will be displayed on the main screen red rectangle Same Mana BAE Jane Doe 0000229384 0305 1967 F ima Oos UN E Figure 2 3 Patient Data Editing P
27. ana aana naen eee 73 APPENDIX A IMPORT EXPORT EXAMS 74 1 Exporting an examination iii 14 2 PRIOR UFC an examinalo DEE 15 APPENDIX5 SAFET ae 75 APPENDIX C CONFIGURE PVIEWER IPAD iiiii 76 1 How to configure PhoeniX ipa 76 2 HOW tO cConnguie your IPad EE 78 3 Create an ad hoc wireless connection iii 80 4 Ad hoc connections on windows An 82 SS INSTRUCTIONS FOR USE DISCLAIMER Each device manufactured marketed and or otherwise placed on the market directly and or indirectly by CSO is made in accordance with the provisions and regulations in force in their user manuals contain the necessary information to ensure intended use and to identify the manufacturer whilst taking into account the training experience and knowledge of its intended users This information including that contained in the accompanying manuals for our products and our technical advice whether verbal in writing or by way of demo and experiment is provided on the basis of our best knowledge However they must be considered as information without any binding effect including those with respect to any industrial property rights of third parties and do not exempt the customer from checking the current ver sions of our advice and suggestions in particular of our material safety data sheets instruction manuals and technical information and products supplied by us in order to estimate their suitability for the
28. arch Service Properties Local Computer File Action View Help es ME oealRHselreunm Sk Services Local Services Local Log on as PSearch Service Name Description Status Startup Type Log On As Local System account Ci Network Location Collects an Started Automatic Network S _ Allow service to interact with desktop Network Store Int This service Started Automatic Local Service S Offline Files The Offline Started Automatic Local Syste Stop the service Restart the service S Parental Controls This service Manual Local Service Description og SA PCreate Service Provides Cr Started Automatic Local Syste Password 200000000000000 diy For Se Peer Name Resolu Enables serv Manual Local Service Phoenix software Gh Peer Networking Enables mul Manual Local Service Confirm password 0900900090000 Gi Peer Networking I Provides ide Manual Local Service Gh Performance Logs Performance Manual Local Service Help me configure user account log on options Sk Plug and Play Enables a c Started Automatic Local Syste Gi PnP X IP Bus Enu ThePnP X Manual Local Syste A PNRP Machine Name Publication Service Manual Local Service Ga Portable Device E Enforces gr Manual Local Syste Gh Power Manages p Started Automatic Local Syste Se Print Spooler Loads files t Started Automatic Local Syste Gh Problem Reports a This service
29. atient Data To edit the patient data move the mouse pointer to the patient name and right click Select which reopens the patient data window for editing the last name first name date of birth and or gender Click OK after having made all required changes 2 4 Selecting a Patient A patient already listed in the database can be selected in a number of different ways When Type a last name and first name in the Patient Box In order to insert the last name and name correctly you must type Last Name comma First Name without spaces If the tyoed name does not correspond to any patient already present in the database press Enter to open the window for entering a new patient Click the J button and use the 1 keyboard keys to scroll the patients list or select a patient directly from the list With the Patient Box empty press Enter or double click the highlighted patient name A patient archive may be opened by clicking the button to the left of the name Type in a portion of the Last Name First Name string to display a list of patient names meeting the criteria To select a particular patient proceed as described in the previous point For instance you may display all the patients whose names begin with a given letter or who have the same last name or who have the same last name and the same first name initial etc a patient is selected the list of associated examinations opens automatically see Chapter 3 Examin
30. backup on a different medium of the one normally used e g CD ROM or DVD CSO srl bears no liability for loss of data due to improper handling of the archive All measured data calculated and interpreted and subsequently displayed to the user must be considered subject entirely to customer s responsibility CSO remembers that any data and or information arising from the use of the above software must necessarily be compared and verified with results from other devices in order to verify the exact calibration of the instruments and their proper functioning according to the specific parameters provided by the customer It should be noted more specifically that the indices of keratoconus screening provide mere indications which however are not sufficient for assessing either instrument calibration status nor the patient s clinical situation Therefore these indices are considered tools that the user can use to provide a diagnosis but cannot be con sidered themselves a diagnostic interpretation of keratoconus Therefore we recommend the user to exercise caution in evaluating these values and to correlate with other indices of screening tests and the clinical picture of the patient CSO does not assume any responsibility for damage of any kind howsoever arising and especially the application of the results of the Summary of Cataract in the software including those arising from an incorrect calculation of the IOL The user of the program must verify
31. by plausibility considerations that the proposed values do not contain gross mistakes CSO assumes no responsibility and makes no guarantee of accuracy calibration and or exact measurements provided by the Products and or software with which they operate even if provided by the CSO itself Consequently CSO will not and cannot be held responsible in any way or for any reason for any direct indirect consequential in general of image or profit loss or moreover of any kind or species whether they are persons isi INSTRUCTIONS FOR USE SS property or other equipment or products that the customer complaints as a direct or indirect consequence of the use of our products and our software SS INSTRUCTIONS FOR USE 1 INSTALLATION AND START UP 1 1 Installazione Phoenix Pass to chapter 1 3 if the Phoenix software has just been installed Insert the CD and wait for the installation procedure to start If Framework 4 0 is not installed on the PC the next screen will be displayed Accept the licensing conditions and click Accept For the following components Microsoft NET Framework 4 x86 and x64 Please read the following license agreement Press the page down key to see the rest of the agreement MICROSOFT SOFTWARE SUPPLEMENTAL LICENSE TERMS MICROSOFT NET FRAMEWORK 4 FOR MICROSOFT WINDOWS OPERATING SYSTEM View EULA for printing Do you accept the terms of the pending License Agreement Tr If you choose Dont Ac
32. cept install will close To install you must accept this agreement Figure 1 1 Accept installation of framework Wait until the component is installed Microsoft NET Framework 4 Setup GE Installation Progress Please wait while the MET Framework is being installed File security verification All fles were verified successfully Installation progress Installing MET Framework 4 Cent Profile Figure 1 2 Framework install Upon completion of the procedure outlined below or if Framework is already installed click Next to begin in stalling Phoenix EA INSTRUCTIONS FOR USE Ii Phoenis Welcome to the Phoenix Setup Wizard ke Tine robaka wall sie vou theough fhe step gared io ges Phoene on you compila WARNING Thi computer program t piotecied by copyright Lise ard nismational heater I ras ana dupitattn o detribubon of tho piogriam of ary portion ct meg en n cewere ceed Ceara Peale ari ra Bet petites ho Us aa Eed fal E vie Dep L Set 7 Figure 1 3 Phoenix install Select the file path for software installation and click Next We recommend not changing the default file path displayed 13 Phoenix Select Installation Folder Confirm Installation The installer wall install Phoenix to the following folder The installer is ready to install Phoenix on your computer To install in this folder click Next To install to a different folder enter it
33. clerosis Risk in the Communities study Lancet 2001 358 1134 1140 The new retinal analysis environment provided by the Phoenix software version 3 0 and later is dedicated exclusively to the Cobra instrument and is capable of automatically identifying the principal retinal blood vessels discriminate between arteries and veins and select the most reliable pairs for use in calculating the AVR The result of the AVR calculation is presented in an intuitive manner by using a representation of the normal statistical distribution of the value for the patient s age population The numerical value is accompanied by graphic and textual aids to comprehension of the results while the examination is assigned a reliability index which indicates the need for more detailed manual measurements following on screen prompts The following section describes the entire examination procedure starting from image capturing through marking of the optic disk and of artery vein pairs to the final evaluation of the result 11 1 Clinical AVR measurement procedure Two examination protocols have been formally established in recent years the Japanese method and the US method The US method implemented in this case consists in marking from 3 to 5 pairs of adjacent veins and arteries exiting from the optic nerve and tracing approximately parallel paths at a close distance to each other The marking area is a ring covering the area between 2 to 3 radii of the optic disk
34. dirizzo IP Non disturbare mo DHCP BootP Ki Notifiche Indirizzo IP 192 168 10 100 ke Generali Maschera sottorete 255 255 255 0 K Suoni Router 192 168 10 10 i fi Soe Luminosita e sfondo Ces lo ice immagine gj cornice 9 Domini di ricerca na Tei Proxy HTTP B iCloud A Manuale Auto Posta contatti calendari Promemoria Make sure the address is configured as static and the IP address is on the same netmask as the host computer Since typically the host computer will be configured as having address 192 168 10 10 this means that the iPad must have an address similar to 192 168 10 The host computer will be configured on your iPad as the router Following the smo button in the upper right corner of the main screen the address of the host computer and port it listens to are to be configured INSTRUCTIONS FOR USE Patient Directory The default configuration is IP 192 168 10 10 port 5100 Ost 192 168 10 10 DC INSTRUCTIONS FOR USE SS 3 Create an ad hoc wireless connection For indications on how to create an ad hoc wireless connection on Windows XP see below You can create an ad hoc wireless connection on the host computer to access through wifi the web service In order to create the adhoc connection follow these steps co nt Connetti manualmente a una rete wireless Specificare la modalit con cui si desidera aggiungere la rete a Creare manualmente un profilo di rete Consente d
35. e menu in your start menu choose Install PSvcHost The following screen might appear Choose no since your Phoenix CD already contains the framework Net 4 0 installation a ee Pg rer Ci panera Pet ee To nm up application you tect mauri inciall ana of pha slaning perdi OF D MET Fiat META armeria Tirani a i DI Weald yo keket pp dovenigadi and mua Ki TE avena ak D mae WE In the following directory you will find the setup for Microsoft Framework Net 4 0 Full 1 Available on https itunes apple com it app pviewer id57 1848602 E 7s f INSTRUCTIONS FOR USE Gr Compute Removable Disk CSO Organize Share with Bum New folder 12 71 2011 9 20 AM 1 20 2017 900 AM 1 57 2012 1 15 PM i ANARA H Type Fe fotees sea Dbe Date medadi 1 5 2012 1 18 PM A Manus De 522 M Folders ca de en ex fr ja bo pl pt BR on di old Fien gegierft Full 064 Product ZU LZ SES LT 25 AM 0 26 2012 1050 AM i D 8 3008 12 57 PM 8 3 2012 1044 AM 11 26 2012 7 58 AM 9 26 2012 10 01 AM 10 73 2012 10 58 After the framework is installed try again to install the PSvcHost The installation is a quick procedure and the following Windows Services are installed PSearch Service and PCreate Service These services are automatically started up on Computer startup The mentioned services are by default created as system account windows services See also the following SA Services PSe
36. e running the vascular examination itself the position of the disk on the fundus must be properly marked INSTRUCTIONS FOR USE 12 2 Marking the optic disk The calculation of the cup disk ratio already present in previous versions of the Phoenix software has been improved with the introduction of the AVR analysis system The position and outline of the disk and cup are detected automatically by the system and may also be measured manually for an even more precise result using a quick measurement system which marks six points as well as an advanced editing interface for unbeatable precision Automatic position detection is sufficiently precise in most cases but if the disk is not circular or one wishes to obtain a very precise cup disk ratio it is advisable nonetheless to use manual editing Ares 0 27 d OF sad n ek i OM 052 Manual edit Figure 2 2 Automatic cup disk detection Click on Manual Edit to launch the advanced cup disk editing interface On the right select the type of modification for instance left click to define the outline of the disk and right click to define the outline of the cup then trace the outlines of the cup and disk on the image Figure 2 3 INSTRUCTIONS FOR USE Select cup disc edit mode Left mouse click to edit disc Left mouse click to edit cup Left mouse click to edit disc Right mouse click to edit cup Current cup to disc ratio data A 0 16 OH 0 4
37. he first time cse INSTRUCTIONS FOR USE 14 MEIBOGRAPHY Meibography is an examination in which the health of meibomian glands is evaluated Such examination can be performed by Sirius Modi or by Cobra using the instruments IR illumination source since meibomian glands cannot be spotted using standard visible light illumination Once the IR images of meibomian glands have been acquired using the Live acquisition software they can be manually processed inside Phoenix in order to calculate the gland health score and save it for further patient evaluation Basically the glands health tends to decrease as its area becomes smaller inside the eye lid while a healthy eye presents the inside of upper and lower eye lids completely filled with meibomian glands a suffering dry eye presents a surface of eroded meibomian glands So the main idea is to calculate the ratio between the area covered with glands and the total eye lid area A low ratio determines a high probability of suffering dry eye 14 1 Acquiring meibography images Meibography images can be acquired by Sirius Modi and Cobra even though there could be some major differences in images acquired with the instruments due to the different optical engineering N B When acquiring with Sirius it is highly advisable to place a 4x Lens in front of the instrument optic otherwise the image cannot cover the whole glands area due to a reduced field of view The procedure
38. i creare un nuovo profilo di rete oppure di indiniduare una rete esistente e salvarne il profilo sul computer in uso necessano conoscere il nome SSID e la chiave di sicurezza se applicabile della rete Crea una rete ad hoc Consente di creare una rete temporanea per la condivisione di file o di una connessione Internet Annulla The new network will be created starting from the network connections on the control panel The limitations of the ad hoc network are illustrated below for instance maximum distance between client and host should be 10 meters therefore the configuration of an ad hoc wireless connection is only for demonstration purposes INSTRUCTIONS FOR USE Configurazione di una rete wireless ad hoc Una rete ad hoc talvolta denominata rete da computer a computer una rete temporanea utilizzata per la condivisione di file presentazioni o una connessione Internet tra pi computer e dispositivi computer e i dispositivi di una rete ad hoc devono trovarsi a non pi di 10 metri circa uno dall altro Se il computer connesso a una rete wireless possibile che durante la configurazione di questa rete venga disconnesso L Avanti Annulla Define the network Cobra without authentication and make sure to save the connection indicated by the checkbox as shown below onn manuaimente a una rete wi 5 Assegnare un nome alla rete e scegliere le opzioni di sicurezza
39. iminate a patient examination from the database select the examination to be deleted by right clicking lt Delete exam then clicking and confirming the deletion request warning message Warning deleting an examination also deletes all the images associated with it cse When an exam is selected the TO Refraction icon goes active Selecting the Refraction icon opens a window from which to enter the patient refraction data INSTRUCTIONS FOR USE 3 5 Refraction OD W e ph D Cyl D Ax mum 0 50 Eu 075 Eu 15 Eu 125 WW WW 127 0 77 105 I UEMA BCVA Figure 3 2 Entering Refraction Data Two labels permit opening the right eye OD or left eye OS chart If the refraction value entered is the value measured on eyeglasses and the corneal apex to lens distance is entered in the box for that purpose the system calculates the refraction at the corneal vertex Enter the values of the sphere in diopters Sph the cylinder in diopters Cyl the cylinder axis in degrees Ax and the distance to test eyeglass in mm in the relative fields If the data is incomplete the warning icon will appear If the data are correctly entered the icon will be displayed The patients natural visual acuity is entered in the UCVA Uncorrected Visual Acuity box the maximum visual acuity attainable with correction is entered in the BCVA Best Corrected Visual Acuity box The Cancel button closes the window without savi
40. intended purpose and processes The application use and processing of our products and the products manufactured by the customer on the basis of our technical advice and or maintenance activities occur outside of our control and fall therefore entirely under the customer s own responsibility for which CSO assumes no responsibility as set out below The technical results and or data resulting from handling or use of our devices must be analyzed by expe rienced professionals in various fields of application of the specific product being otherwise compromised the correct reading and analysis of data The sale of our products is governed by our General Conditions of Sale and Delivery as amended The software provided by us in conjunction with our products or otherwise made available for download on your computer or for use online are the exclusive property of CSO which disclaims any responsibility for the accuracy of the results obtained with the programs or algorithms used by the programs themselves or liability resulting from the incorrect use of the software For data security please refer to the management of Windows security It is recommended to enter a password to access the account used Before performing an upgrade of the application or the archive and or at least before any maintenance ope ration we advise to make a backup of the complete patient database It is also recommended you periodically every week at least make a
41. ion of the functions of each menu or button see 7 To use the measurement or overlay functions click the appropriate buttons on the toolbar to the left of the image INSTRUCTIONS FOR USE SS 6 1 Linear Measurements To make linear measurements click the i button on the toolbar or in the menu Measurements are made in degrees Since the retina image is enlarged by an unknown power the measurements supplied by this function are purely indicative Figure 6 2 2 Linear Measurement on the Retina 6 2 Cup to Disc Ratio Click the button on the toolbar or menu to measure the cup to disc ratio After this measurement mode is selected the user is requested to indicate three points on the disc and three points on the cup The first system calculation of the ratios to calculate the ratios between the areas Cup Disc A and between the diameters Cup Disc is based on evaluation of the circles passing through the three points That is it considers the cup and the disc as two circles and then calculates an approximate evaluation of the ratio The system will then ask if the user wants to refine the evaluation of the cup to disc ratio with advanced measurement Lio you want fo perform an advanced Cup to Disc ratio measurement Click Yes to enter an editing environment in which the cup and the disc are not considered simply as circles but as 32 endpoint polylines in this environment the user can manually adjust the cup and di
42. itions so you should not delete it unless it is clearly a bad quality image INSTRUCTIONS FOR USE Mosaic has 2 pictures Figure 1 9 Mosaic preview After exiting mosaic preview mode a summary window pops up and displays a bigger preview of the valid mosaic pictures merged together This is how the mosaic pictures will be automatically merged together later in Phoenix without any manual editing If mosaic preview is not satisfactory you can manually edit the produced mosaic for example in case of bad quality images or in presence of retina diseases anomalies that interfere with automatic mosaic reconstruction INSTRUCTIONS FOR USE This is a preview of the acquired mosaic Assemble and save the final mosaic using Phoenix Figure 1 10 Preview mosaic CS INSTRUCTIONS FOR USE 6 VIEWING AND MANAGEMENT OF SINGLE IMAGES Double click any image in the gallery to open the window for displaying and managing the single fundus images Figure 2 1 Fundus Image Management Window I ER This window displays the fundus images captured in the Live mode Click the d and buttons to scroll all the images captured during the same exam To browse the various displays available in the fundus imaging module use the options available in the menu at the top of the screen or the toolbar Depending on the position in the program some items may not be displayed and or may be disabled For a detailed descript
43. k ang ja Bg Ba 42 22 Analysis DG eege 43 PZ SOPUONSE IS EE 43 54 lege leg E E 43 leo FPES MEn E 44 8 WAVELENGTH DIVISION eege geed 44 INSTRUCTIONS FOR USE 9 SECONDARY FUNCTIONS nia 45 NEE Eet EE 45 Ol Mr Ee Ee WEE 45 91 2 COMPASS VVINGOW aaa aga a NG ina in 47 92 eo 2 DE 47 9 3 Stereo Imaging Overlay of Fundus Images 47 54 le ANG anana naa apana aaa Sa RE a a an aa eee aa Ba anaa a aaa eee an aaa Sapa 48 10 PRINTING ea 51 10 1 PAMmIng TOODA iaia SE 11 Reinalvascular analys Sis sasasi ua gat bas bak kaka ke ga ditelo iii 54 11 1 Clinical AVR measurement procedure anana anan en aane nana a nenen a nenen anana nane e rene 54 12 QUIGE TONE SXAMINAWOM E 55 24 Uri rina 55 122 NANING AMC ODNG ee 56 12 4 Confirmation and deletion of existing pairs 59 12 9 Modifying existing AV Ce 61 126 Creating New AV pairs a sasadan aa aaa d eaaa a Ba eja eran 62 13 FRG ACG CT LEE 64 14 le Zielen Eh E 66 14 1 Acquiring meibography iMages anana n anana anana eaaa anana nenen anana naa a nane e nee eee 66 14 2 Processing the examination i 67 14 2 1 Saning OVA AION E 67 142 2 IACI SVG DOUNOS oro nana aan 68 142 3 Tracing GIANG DOIN Scion nitriti 69 14 2 4 Zooming and tracing EEN 70 14 2 5 Finalizing meibography examination 71 14 3 Meibography thumbnails and gallery Drevlew aa aan anan aa aaa aaa anana nana n an
44. lect a vessel Click on the second vessel of the pair to complete and confirm the pair automatically INSTRUCTIONS FOR USE Figure 2 12 Manual selection of hot spot vessels The AV pair is created automatically using information detected previously by the system such as the vein artery classification and calibre of the vessel each hot spot already contains this information However you may wish to mark vessels which have not been detected by the system and therefore for which no hot spot exists To select such vessels simply move the cursor onto any point of the zone of interest to add a new vessel this opens the advanced manual editing dialogue section 2 5 with which you can manually position the calibre indicator Acid vessel here Figura 2 13 Aggiunta di un nuovo vaso senza utilizzo di hot spot cse If the reliability score of the examination is greater than 60 we can consider the resulting Arteriolar to Venular Ratio reliable as described in section 2 3 INSTRUCTIONS FOR USE 13 READING THE AVR RESULT The AVR value is the mean of the individual AVR s of the reliable pairs of veins and arteries The result is given in the following panel which displays automatically on the right of the screen when the examination reaches a high enough score ww AV Ratio 0 841 6 0 7 0 8 AVR 0 841 Mean AVR for patient s age 52 0 819 AVR is close to normality Figure 3 1 Result panel health
45. n Accesses the window for comparing different fundus images from the gallery mg Stereo Imaging Accesses the Stereo imaging window superimposition Mosaic Accesses the Mosaic window Table 3 Analysis Menu 7 2 3 Options Menu Displays general information about the patient and the Toggle smoothing Using interpolation smoothes out the image to eliminate the pixelating effect that appears when the image is greatly enlarged Overlay Font Allows the user to change the font character used for the overlay text Allows the user to change color of overlay text line Overlay Color for Measurement Overlay b Line Width Allows the user to change the width thickness of the overlay line Table 4 Options Menu 7 2 4 Tools Menu Allows the user to activate the zoom function with the mouse wheel and the panning function drag Measurement of distances on the retina in degrees A Draw Arrow Draws an arrow on the image Draws a rectangle on the image LJ Draw Rectangle INSTRUCTIONS FOR USE Allows the user to insert a line of text in the image B A Text Table 5 Tools Menu 7 2 5 Filters Menu Pee Allows the user to activate the zoom function with the Al camma mouse wheel and the panning function drag Returns to the default Gamma Prime me gt Barrier filters Unfiltered ES ih Shows only the IR component gt Barrier filters Infrared Image ES
46. n also run self diagnostics and assess the accuracy of its analysis each pair of vessels can be confirmed if not sufficiently reliable or modified manually or eliminated from the overall calculation as follows The light blue symbol indicates an automatically detected pair which is judged to be sufficiently Es reliable and hence included in the overall calculation AVR The yellow exclamation mark indicates an automatically detected pair which the system judges to be doubtful and which is hence not included in the overall calculation AVR Click on the pair and select whether to accept it or eliminate it from the screen as shown in section 2 4 A green check mark indicates that the pair has been reviewed and accepted manually as shown SX in section 2 4 The reliability of each pair together with the number of pairs marked on the screen contribute to the overall reliability score expressed as a percentage Manual confirmation of the pairs obviously greatly increases the final reliability score scores above 60 can be considered to be reliable Along with the numerical value a short tutorial is also available which indicates any problems and suggests how to improve the marking GC 58 INSTRUCTIONS FOR USE Analysis reliability 64 Number of marked pairs 3 Vessels are marked correctly f possible mark up to 5 pairs to complete a fully reliable examination Figure 2 6 Reliability feedback
47. n panel SS INSTRUCTIONS FOR USE 12 5 Modifying existing AV pairs In the event that the automatically calculated calibre is incorrect move the mouse over the vessel you wish to edit at the point in which their cross section is marked graphically click when the pencil tool displays which displays the advanced editing dialogue Figure 2 9 Advanced vessel editing To modify the selection of the vessel s calibre you can move rotate and change the size of the blue marker use the yellow side indicators to rotate and widen narrow the section or use the yellow central indicator to move the entire section Click on OK to confirm the selection Vessels which have been modified manually display with a green check mark and will increase the examination s reliability score Figure 2 10 Manually confirmed vein artery pair ei INSTRUCTIONS FOR USE SS 12 6 Creating new AV pairs You cannot always rely on the pairs chosen automatically by the software especially if the image is of poor quality However you can choose new pairs among those listed by the software as potential hits as described in section 2 4 Otherwise you can use the add manually mode by clicking on the icon l i at the top right Figure 2 11 Vessel hotspot in add manually mode The yellow points are hot spots i e points of the image in which the system has identified potential vessels for use in creating new pairs Click on a hot spot to se
48. ng points on a Zoomed meibography image it is no longer possible to move the zoomed image as usual since a left click on the image would produce a new gland point not a moving grip as it would in normal image viewing To by pass this behavior click and keep clicked the right mouse button an alert appears as shown in the screenshot to switch between points tracing mode and standard zoom mode which allows moving the image The same switching function can be obtained by clicking the button which appears only when image is zoomed in SS INSTRUCTIONS FOR USE 14 2 5 Finalizing meibography examination e cm Figure 14 7 Finalizing examination Once all gland points have been placed click the button to end the editing phase Healthy gland area will be drawn in green while loss area will be red Area of loss score is calculated together with a pre established degree in the meibomian scale Score and degree are printed and visible directly on the image while a detailed review of the attributed score is available in a separate window which appears on the top left corner of the main form Meibography score is automatically calculated even if the flag button is not pressed and edit mode is closed by clicking the quit button The updated image can now be printed alone or compared with other processed or unprocessed meibographies saved in pdf format etc It is possible to return to the editing mode by clicking the button
49. ng the changes To save the entered data click the OK button or press Enter 3 6 Capture The Capture icon goes active when a new exam is created or when an empty exam is selected It permits selecting the instrument with which to capture the exam and accessing the capture environment SS INSTRUCTIONS FOR USE 3 7 Image Gallery When an exam previously stored as described above is called up the Gallery window on the right hand side of the main screen will show the images relative to each exam as it is selected The images are subdivided by OD right eye and OS left eye Ar ee Example Cobra P0947809186 5 9 1973 Ap w in LL OS Example Cobra P0947809186 6 3 2011 10 32 Fundus Camera lt Add caption gt lt Add caption gt Figure 3 3 Image Gallery A type group may be defined for each eye in order to facilitate future searches y i Group Figure 3 4 Groups Click the TT button to open the pull down menu of the groups entered in the Settings Groups menu see Chapter 19 To enter the eye being examined in a yet to be defined group select lt new group gt to open a box in which to enter the name of the new group Select a group The buttons permit associating the right eye group with the left and vice versa You can filter the list of thumbnails in the gallery by selecting one of the filter elements from the dropdown menu All default choice onl
50. nning the approach to the pupil which is thus facilitated Stand by time Time out for stand by mode From stand by press the joystick button to wake the instrument 5 4 Mosaic preview mode This feature is available only on multi core processor PCs since real time mosaic building is a very time consuming process Please note that this function only enables the mosaic preview mode which purpose is to provide a real time feedback of how the acquired images are merging correctly together The final mosaic can be built later and can also be edited manually using Phoenix software as explained in 9 4 Therefore the final mosaic picture will not be available after closing the Live acquisition software only a preview of it will be available in order to understand if mosaic pieces have been captured with sufficient quality Press si start mosaic preview mode mosaic mode on label is shown on the screen top right corner This mode exits automatically when laterality is changed or manually when the toolbar button is pressed again Pictures can be acquired normally in any order although it is advisable to start from the central retina image to shorten computation time Immediately after every acquisition a background process evaluates the acquired images and a pop up window asserts whether the last acquired image merges with the previous ones If this is not the case the picture can still be merged with other future acquis
51. o start capture The previous window will be shown after the button is pressed INSTRUCTIONS FOR USE 5 1 Centering The first step in running an exam is to center the patients retina using the infrared LED Move in slowly toward the pupil which will appear as a brighter region in the image shown on the screen brightness is increased when the auto gain function is active Center this region on the screen raise or lower the instrument using the appropriate joystick knob Invite the patient to look directly and steadily at the orange fixation point generated by the instrument Once the pupil is centered continue to move in very slowly until the patient s retina becomes visible If necessary focus the image by turning the upper knob If enabled the focusing support window will provide visual feedback showing improvement worsening of the focus Turn the focus knob in the same direction as long as the lighted indicator continues to rise stop turning the moment it begins to descend Generally speaking an ascending path indicates that image focus is improving while a descending line indicates a worsening of the focus The focus indicator should nevertheless be considered significant only when the retina image is stable and correctly illuminated Focus feedback Quality feedback Figure 5 2 Focus Indicator INSTRUCTIONS FOR USE Focus feedback E Quality feedback Figura 5 3 Modalit Quality feedback
52. or conducting searches The groups list may be edited from the Settings menu see Paragraph 4 3 3 2 Selecting an Examination Once a patient has been selected click the l the Examinations Database button or press Enter or double click with the mouse to access Clicking the symbol to the left of the patient name opens the list of examinations associated with that patient The symbol becomes a Click the symbol to close the list Alternatively open the list by pressing the arrow key on the keyboard and close it by pressing the arrow key To select a previously stored examination use the mouse or scroll with the Ir keyboard arrows to highlight one examination after another and for each view the relative images in the window on the right hand side of the screen Dizi SS INSTRUCTIONS FOR USE 3 3 Editing Examination Data To edit the data for an examination select the exam right click and select the _ editexam data command Edit Exam Data Edit exam data venerd 21 marzo 2014 13455356 Referring Physician s Name Accession Number 140321134553 Identification code 30656130621 Exam Description Cancel Figure 3 1 Editing Exam Data This action opens a window in which the user may edit the date and time of the exam enter the name of a re ferring physician and add a description of the exam Click OK to confirm the changes otherwise click Cancel 3 4 Deleting an Examination To el
53. print a single image or several images selected for comparison Select Print from the File menu 7 2 1 the Preview Image Selection window will open PDF Print Cancel Figure 9 7 Selecting Images for Printing Buf INSTRUCTIONS FOR USE INSTRUCTIONS FOR USE SS Select the images to print up to 4 images by double clicking in the gallery on the right of the screen The selected images will be shown in the bottom right hand box The image s may be printed on paper Print button or converted to PDF format PDF button In the first case the PC must be connected to a printer In the second the user may choose the file destination desktop or gallery Choose fundus view 0 9 Visible light O IR light O Choroidal O Vascular O Redfree O Nerve fibre gl DI Show Cup Disc data 2 a Other printing modalities available Compare up to 4 images in one page Compare this image and its controlateral in visible and IRlight Notes Title PDF Print Cancel Click Yes or No s del Do You want to archive this report Click Yes to archive no to save to desktop SS INSTRUCTIONS FOR USE 10 1 Printing Toolbar Ss ga Refreshes the print preview image to show modifications e Permits changing the print settings ei Prints the page shown in the Preview K Displays or hides the heading if inserted and relative logo Permits changing the text of the heading and
54. s Select the language to be used by the software and click OK 4 2 Instruments Clicking the Instruments label accesses the section for managing the instruments to be used External Camera Acquisition setting Start acquisition after timeout Figure 4 2 Instruments Management 123 INSTRUCTIONS FOR USE di o V Connect all the instruments to use and press the Instruments wizard button You will see the next window with the instruments installed Instrument wizard The following procedure automatically detects the presence of instruments connected to the PC and allows the user to perform configuration and calibration Connectto the PC all the instruments which are going to be used and press the button Configure to start the procedure Detected devices SlitLamp Digital Vision Installed i Specular Microscope Capture Installed A Slitlamp W Capture os Figure 4 3 Installed instruments Press the Configure button to modify the settings You will see the Figure 4 4 2 The button permits inserting manually a new instrument for use The instruments must be inserted using the wizard Instruments Device class Model name Executable Sena 4 Cancel Figure 4 4 Inserting a New Instrument Enter the model name reported alongside the exam and an Executable File select the SCLive executable file then select the class from the pull down window shown in Figure 4 4
55. sc through many degrees and thus with great precision GC 40 SS INSTRUCTIONS FOR USE 6 3 Overlay For overlaying arrows rectangles and text on the image use ne and menu or toolbar buttons Click Kc delete the last overlay 7 TOOLBAR AND MENUS 7 1 Toolbar BUTTON SHORTCUT ICON FUNCTION Sema BH pan hen Single Image l images as single fundus images Wavelength Divider Accesses the window for displaying the images at different wavelengths Accesses the environment for Comparison comparing various fundus images from the gallery Accesses the full screen mode Full Screen F11 Accesses the stereo imaging window Stereo Imaging i superimposition Mosaic i Returns to the three color view of the Unfiltered a e Displays only the choroid component Displays only the vascular component Red free me ANAA Displays only the red free component View measurements toolbar Deletes the display image Closes the fundus image management window and returns to the gallery Scrolls back through the gallery images Displays only the nerve fiber component Scrolls forward through the gallery ima ges Enables activation of the zoom fun ction with the mouse wheel or the panning function drag Displays or hides the measurement buttons Measures distances on the retina in degrees oi 4 INSTRUCTIONS FOR USE Calculates the ratio between two circular
56. scollegato con fi sulla nati senza fi rilevata fare clic sul pulsante qui sotto Visualizza reti senza Fl Fiati peeterite La connessione automatica alle reti disponibdi verk effettuata Fimuoa Froonet Choose add under preferred networks EA INSTRUCTIONS FOR USE Connessione automatica Quando la rete viene rilevata d computer vi si connette automaticamente C Connetti anche n assenza d broadcast d sete Chagve rete wae w Stabilisci una connessione quando questa rete a distanza di rilevamento La rete iech una chiave pet le seguenti operamore Ausertcazzre d rete Aperta D gege E an lt indoe cleave levanzato II S L La hawa vene lonia atona amrearte C Rete computer a computer ad hoc punti di accesso rar non sono utkrzab STI And set the IP settings as described above
57. t Edit exam data 2 Delete exam Export Figura 8 1 Export examination You will see the editing screen of the anagrafic data to be exported Edit the data if you want and select OK It will be exported the file zcs My network Figura 8 2 File esportato 74 SS INSTRUCTIONS FOR USE 2 Importing an examination To import a previously exported file zcs you must open the archive containing the file and drag the column occupied by the patient list as shown in the next window Fie 31 Settings Info NG out Surname Name EA Identification code Lal 4 Export file amx La Example Slitlamp a3 d 0000655360 zc5 Oggetti 1 6 44 MB si EI vai 4 Risorse del computer Y Phoenix v 1 1 0 22 User Cristian Figura 8 3 Import file Wait a few seconds and the patient will appear in the list APPENDIX B SAFETY For data security please refer to the management of Windows security It is recommended to enter a password to access the account used rs INSTRUCTIONS FOR USE APPENDIX C CONFIGURE PVIEWER IPAD cse In order to use Phoenix with Pviewer follow these instructions First you will install the service host that exposes Phoenix Patient information then you will configure the iPad to discover that information through a wireless connection 1 How to configure Phoenix From the WCF Servic
58. tion Code To select a search criterion click the button alongside Last Name First Name or alongside the Identification Code To view a patient type his her Last Name First Name or Identification Code in the Patient Box As the letters or numbers are typed the pull down list will fal patients meeting the criteria If the typed characters do not yield any results a warning icon will appear The warning icon is also displayed in the case an excessive number of results is returned Once a patient is selected his ner Last Name First Name with Identification Code and date of birth will be displayed in large type in the top portion of the screen Fill Patient List Displays all the patients entered in the database Ea Empty Patient List Empties the contents of the window in which the patient list is displayed but does not delete the patients from the database D Search Permits searching patients in the database by gender date of birth check in number examination date patient age referring physician instrument or group See Paragraph 2 5 E 144 SS INSTRUCTIONS FOR USE el To enter a new patient in the database click the icon on the main screen to open a new window Enter the patient data in the window last name first name date of birth and gender Typing a Last Name First Name pair in the Patient Box automatically opens the window for entering the data for the new patient Create a new patient surn
59. turned sets a limit to the maximum number of examinations upon database queries Might be set in case of network environment to tune performance SS INSTRUCTIONS FOR USE 4 5 Layout Clicking Layout accesses the following screen Patient Management Deselecting Patient ID external option box also deselects the other two options mode and PMS and it will be possible to insert the ID code at the moment a patient is created If this option box is instead selected it will not be possible to enter the ID code manually Select one of the following two options e Modality the ID code is automatically assigned by Phoenix when a patient is created e PMS The ID code and relative personal data will be crossloaded to Phoenix from an external database The ID of the agency or institution providing the data must be entered in the field alongside the PMS item ua Note that in the latter case the di inserimento paziente e disabilitata Study Management e When Show description is selected the study description will be shown in the main patient tree INV TS 26 02 2011 vy INV TS 2 00 26 01 2010 E p 22 01 20 26 02 2011 9 16 Keratoscope e Otherwise the description will be visible in overlay meaning that when the mouse passes over the exa mination the description will be visible as a tooltip iy 26 02 2011 9 30 Schelmpfiug Camera va 26 02 2011 9 16 Keratoscope vy 26 01 2010 15 15 Keratoscope y 22 01 2008 16 4
60. ure 14 2 Define boundaries Four 4 control points must be set in order to define a very raw bound of the eye lid s area of interest Place the blue points in order to build a trapezoidal shape Exclude lid areas that are not completely reverted since they are not useful for the computation One point in the example case the left most one should be placed near the tear punctum while the opposite side points the right most ones should be placed on the end fold of the eye lid or as stated before where the eye lid is not comple tely reverted anymore All the control points that have already been set can still be canceled until the last point is set by hovering the mouse on them and left clicking when the white cross appears The bounds red lines do not need to be ve recise in this phase since they will be adjusted automatically in the next phase Figure 14 3 Adjust boundaries by moving the blue and yellow control points Use the all yellow points to adjust the red shape Try to move the points including the 4 manually set points and see how their movement affects the global shape The yellow points at the end of the yellow lines can be stretched such as to modify the curvature of the red shape The mechanism is very intuitive anyway try to approximate the eye lid shape but remember that there is no need to be too strict in this approximation M ce F SS INSTRUCTIONS FOR USE 14 2 3 Tracing gland points Figure 14 4
61. w shown below Settings Language Instruments Groups Database Image root CADBPhoenix lmages Database CADBFPhoenix phoenix mdb Backup in C ADBPhoenix Imagesicso Maximum number of backups Reminder W on application closing W on deletion N on series error W assign group Performance Max exams returned Inheritance by previous exam W groups W refraction a Cancel Figure 4 6 Other Information Menu Database Click the unlock button O to change image root and Database Image root Clicking the button in this section selects the image management file called root cso Database Using the button to select a file from the database phoenix mdb Backup in Using the button you can choose the destination folder fo backup files You can choose the maximum number of backups to perform Reminder The user may select among the following options Close application displays the message requesting confirmation to close the application e Delete displays the message requesting confirmation to delete an image from the gallery Series error this warning is given when traces of images erroneously moved to other folders or files remain in the examination in question e Assign group after performing an acquisition a reminder is presented for classification group as signment of the assigned series Performance Max exams re
62. which becomes visible after the meibography has been validated with the flag button This way the examination is always editable after re entering it in the future iat INSTRUCTIONS FOR USE Meiboscale Area of loss AT AY Figure 14 8 Meibo scale The meibo scale window in the top left corner of the screen can be expanded and then collapsed again for further re viewing of the attributed score Here 5 scale samples are available for consulting and visual comparison with the current examination image Those samples may help to understand if the whole process has been completed correctly so that the sample image reflects the health state of the processed image with a coherent area of loss score EA SS INSTRUCTIONS FOR USE 14 3 Meibography thumbnails and gallery preview OD e wb n Groep 08 k P gt IF date EC Figure 18 9 Gallery meibography acquisitions After closing the examination the image thumbnail is updated with the area of loss score and degree and areas of interest healthy vs unhealthy are drawn in different colors The gallery preview also contains all needed information so it is not strictly necessary to re open the examination for future patient evaluations et INSTRUCTIONS FOR USE APPENDIX A IMPORT EXPORT EXAMS 1 Exporting an examination Exporting an examination or a patient select with right button of the mouse on the examination and click expor
63. will be requested to select a second image of the same eye captured in such a position as to permit evaluating a disparity use the Image Selection window 9 1 1 to select When the selection is confirmed the program accesses the fundus image superimposition window in this window the user may Bob INSTRUCTIONS FOR USE enlarge or reduce the sizes of the two fundus images using the mouse wheel move the first image hold down the left mouse button and drag the image to the desired position e move the second image hold down the right mouse button and drag the image to the desired position change the relative percentages of transparency hold down the Shift key and rotate the mouse wheel 9 4 Mosaic This feature is available only on multi core processor PCs since real time mosaic building is a very time consuming process Please use the mosaic mode only if the currently selected acquisition belongs to a study containing at least one more image acquired satisfying mosaic criteria i e one central retina image followed by one or more peripheral images Otherwise starting mosaic mode may result in a long time consuming routine which obviously will not produce any result From the Analysis menu or toolbar click the button to access the Mosaic mode This mode can be accessed from any acquisition in the study then all other study acquisitions will be automatically added to the mosaic up to a total of 7 acquisitions If the
64. wn in the gallery created in a second moment after original acquisition Auto send by choosing this checkbox Phoenix will be configured to send images immediately after ai INSTRUCTIONS FOR USE SS acquisition This option is not available when secondary capture is chosen e Lossless select this box to select the type of compression used for sending in a 5 to 100 ratio in 5 steps in jpeg format Otherwise the files are sent in the original uncompressed format Note that this principal is based on a best first algorithm when images are originally acquired uncompressed all com pression options can be performed when the image is acquired lossless it can be forwarded also lossy but not uncompressed finally when the image is acquired lossy it can t be forwarded other than lossy This option is not available when secondary capture is chosen Jawa Home LAProgrammiCGo O Fhoenn ave Figure 4 12 Java Runtime Environment This parameter defining the environment required for using the functions offered by DICOM is configured at end of software installation A Cquisition setting start acquisition after timeout Figure 4 13 Choice time out 4 7 Activations In this section it is possible to upgrade the license of the software Settings sal emm PITTI out Groups Miscellaneous Lay DICOM Activations Sch dalak License Type e vi e aw dr RE EE eae ee di a Upgrade license Tt e gg n
65. y group a list of the groups created via the Settings function see Chapter 19 e by caption the caption added to a single acquisition is used as a search parameter Select the boxes that permit establishing the search criteria Click Search to display the search results ER INSTRUCTIONS FOR USE SS 2 6 Delete Patient To delete a patient name right click the patient select iesse and then confirm the deletion request warning message Warning deleting a patient also deletes all the examinations associated with that patient and the relative images 3 EXAMINATIONS DATABASE An unlimited number of examinations may be associated with each patient the examinations are defined on the basis of the instrument used and the date of creation 3 1 Nuovo esame After a new patient is created an examination will also be created Sp To create a new examination for an existing patient click the lt button If working with a single instrument the image capture mode will be automatically accessed Otherwise if at least two instruments are used the window shown below will open Select the instrument to be associated with the current examination After selection the capture mode is accessed 4 seconds until live Figure 3 1 Instrument Selection Each examination is filed by date of creation and instrument type It is also possible to attribute a pathology group Group Classifying the examinations by codified groups is useful f
66. y images only reports only movie frames only lenses or only mosaics af INSTRUCTIONS FOR USE SS Clicking an image displays a preview of the summary of the selected examination in the lower portion of the screen OD n All 1 Images Reports Frames Lenses Mosaics Figure 3 5 Filter Double clicking an image opens the processed image summary Chapter 5 Right click a gallery image and select Add caption F2 to add a brief description To eliminate an image click Delete acquisition CANC To open an image double click with the left mouse key or press Enter e Ifthe selected image is a previously processed map the topographic maps viewing environment will open e Ifthe selected image is a still to be processed Scheimpflug capture the image is first processed and the summary environment is then opened e Ifthe selected image is pupillographic the pupillography examination will open e Ifthe selected image is an image acquired with the slit lamp the image viewing environment will open SS INSTRUCTIONS FOR USE 4 SETTINGS The Settings menu may be accessed only if the Patients List is not displayed on the main screen Click the button to empty the patients list Then click Weg or open the File menu and select Settings 4 1 Language After selecting Settings the menu for setting the system language will open Deutsch English O Le Italiano Nederlands Portugues Figure 4 1 Setting
67. y patient The Gaussian curve gives the statistical distribution of AVR values over the population generated in relation to the patient s age The mean value of the distribution 0 819 in the example is the optimal value The red line is the threshold below which one can consider it possible that the patient is affected by a significant arterial restriction This threshold depends largely on the age however in general one can say that such restriction is certainly present for AVR s less than or equal to 0 60 The yellow line indicates the calculated AVR and is positioned in relation to the normal distribution Below please find an example of an examination whose result is significantly below the norm INSTRUCTIONS FOR USE QP av Ratio 0 5 9 a AVR 0 579 Mean AVR for patient s age 52 0 819 Severe arteriolar narrowing is present Figure 3 2 Result panel patient with arterial restriction Once you have obtained a satisfactory result you can quit the examination procedure the current status is saved and will be displayed when the AVR form is next opened unless you delete the current cup disk measurement and make a new one In this case the old examination no longer applies to the new position and size of the disk and a new examination procedure must be run Clicking on the icon i next to the AVR value discards all existing manual modifications and processes the image anew as if it has just been opened for t

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