IEEE TRANSACTIONS ON INSTRUMENTATION AND MEASUREMENT, VOL. 67, NO.
5, MAY 2018
Virtual Instrumentation System With Real-Time
Visual Feedback and Needle Position Warning
Suitable for Ophthalmic Anesthesia Training
Nimal J. Kumar , Boby George, Member, IEEE, and Mohanasankar Sivaprakasam
Abstract— In this paper, the design and development of a
novel mannequin-based ophthalmic anesthetic training system
with two cameras integrated into it to provide a real-time visual
feedback to the trainee is presented. The system developed
uses anatomically accurate 3-D printed ocular structures and
a novel feature for ophthalmic training system where the trainee
is able to see the needle and ocular structures on a monitor
in real time during the training. Other new features of the
system include a virtual instrument, which has been developed
to acquire the images, process, and automatically capture the
required information from the images from the cameras. The
system is developed in such a way that when a trainee practices
using the proposed system, it detects and tracks the needle tip
position automatically using an appropriate algorithm. Then, the
position of the needle is used to trace the path of the needle,
and the system warns if the needle enters locations within the
orbital cavity that are classified as unsafe. The entire training
session as observed by the two wisely positioned cameras can be
recorded; the same can be reviewed by an expert anesthetist
at any point of time to give the feedback. The trainee with
information provided by the training system and the feedback
provided by the expert instructor helps him/her to improve and
perform safer regional ophthalmic blocks. The system developed
was tested at a pilot study, which comprised of 21 trainees and
20 consultant ophthalmic anesthetists to validate its utility.
Index Terms— Anesthesia training, camera-based tracking,
object detection, object position warning, real-time visual feed-
back, virtual instrumentation.
I. I NTRODUCTION
R EGIONAL ophthalmic anesthesia or regional blocks are
a common procedure, practiced in several parts of the
world, preceding the ophthalmic surgeries, such as cataract
surgeries, vitro-retinal surgeries, and so on. Regional oph-
thalmic needle blocks, commonly referred to as needle blocks,
are classified as peribulbar (needle outside the ocular muscle
cone) and retrobulbar (needle inside the ocular muscle cone),
this procedure requires a syringe with suitable anesthetic to
be introduced into the orbital cavity to achieve akinesia,
which is the impairment of voluntary motor control of a
Manuscript received July 2, 2017; revised November 18, 2017; accepted
November 20, 2017. Date of publication January 24, 2018; date of current
version April 5, 2018. The Associate Editor coordinating the review process
was Dr. Huang-Chen Lee. (Corresponding author: Nimal J. Kumar.)
The authors are with the Department of Electrical Engineering, IIT Madras,
Chennai 600036, India (e-mail: ee14d403@ee.iitm.ac.in).
Color versions of one or more of the figures in this paper are available
online at http://ieeexplore.ieee.org.
Digital Object Identifier 10.1109/TIM.2018.2790679
0018-9456 © 2018 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission.
See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
1111
muscle. This procedure carries its own risks. For example,
improper injection, wrong entry sites, and improper angulation
of the needle can cause various complications arising from
puncturing the vital ocular muscles, perforation or penetration
of the eye ball, or brain stem anesthesia wherein the anesthetic
agent is introduced into the optic nerve causing irreparable
damage to the patients [1]. It is vital for the trainee anesthetists
to undergo proper training to comprehend and interpret the
intricacies involved in the procedure. Ophthalmic anesthetists,
due to the lack of proper training modules occasionally train
on animals or human cadavers. Thus, there was a need for a
system through which the trainees can train and gain compre-
hensive knowledge of the procedure and evaluate their skill
level. Such a system must provide an anatomically accurate
analog of the human ocular anatomy and provide a repeatable
means to educate and evaluate the trainee. A couple of years
ago, an ophthalmic anesthesia simulation system (OASiS) [2]
was developed. OASiS uses capacitive sensors to sense the
position of the needle within the ocular anatomy and provides
indicators to alert the trainee about the proximity of the needle
to the major ocular muscles and the globe itself.
The OASiS system uses a capacitive sensory system to find
the position of the needle within the orbital cavity; this requires
scrupulous conductive painting of the ocular structures and
delicate electrical connections, which arises a complication in
the assemblage, the cost of manufacturing, and maintenance
of the system. In addition, the OASiS system has constraints
with the syringe that can be used. The syringe in the system is
encompassed as a part of the system; therefore, the trainee has
little flexibility in substituting the syringes as it is warranted in
certain newer ocular procedures. The system has also had some
innate limitations with the detection of the needle position and
also has very heavy constraints on the advancement of the
system to include more anatomical and pathological conditions
of the human eye [2], as the inclusion of every new ocular
structure would add one additional sensory element, moreover
as the human ocular anatomy is complex and with structures
placed at close proximities, thereby increasing the complexity
of the sensory requirement of the OASiS system.
This paper proposes a mannequin-based ophthalmic anes-
thetic training system with an anatomically accurate human
eye integrated with two cameras; such a system with this pre-
liminary idea has been presented by the authors recently [3].
Such a system can be improved with automated needle
1112 IEEE TRANSACTIONS ON INSTRUMENTATION AND MEASUREMENT, VOL. 67, NO. 5, MAY 2018
Fig. 1. (a) Ocular anatomy of the eye [5]. (i) Trochlea. (ii) Levator palpebrae
superioris. (iii) Frontal bone. (iv) Superior oblique. (v) Superior rectus.
(vi) Optic nerve. (vii) Lateral rectus. (ix) Inferior rectus. (x) Maxilla.
(xi) Inferior oblique. (b) Zonal distinctions of an eye.
tracking, warning indication, erroneous procedural warning,
and session recording. This system would replace the sensory
elements present in the OASiS system with cameras as the
primary sensory element [4], with the necessity of the sensory
requirements mitigated, inclusion of more ocular structures can
be executed quite easily by replacing the 3-D printed ocular
globe to simulate varied pathological conditions such irregular
globe orbit relations, as no electrical connections are present at
the globe. The complications arising from the manufacturing
and assemblage of this proposed system would be far less
complicated as compared with the previous system.
Regional ophthalmic needle block procedures often involve
a primary injection performed on the lateral side followed by a
supplementary injection on the medial side to achieve akinesia,
which is the complete inhibition of the motor muscles [3], [7].
The human eye anatomy, shown in Fig. 1(a), is separated
into four different quadrants: superior, inferior, lateral, and
medial [3], as shown in Fig. 1(b). The common needle block
performed on the medial side is the superior-medial block, and
the lateral-medial 1/3rd 2/3rd is used as a guide for the lateral
block [3], [7]. These procedures in recent studies have shown
that it carries significant risks, and there are contemporary
procedures based on safer zones in the ocular anatomy.
Real-time visual feedback is the main aspect of the proposed
mannequin-based system with a real-time view of the regional
ophthalmic blocks [3]. The visual feedback can significantly
increase the trainee’s perspective and help the trainee to
acquire the necessary skills to safely administer the anesthetic
agent.
Such a system capable of providing real-time visual feed-
back of the orbital spaces in two different quadrants of the eye,
namely the inferiolateral quadrant and the medial quadrant, can
provide an extensive understanding of the ocular anatomy and
the regional ophthalmic block procedure. In addition, it will
enhance the learning experience of the trainee as it helps
in easily visualizing the needle within the human eye orbit,
the free spaces available within the orbital cavities which
constitute the safe zones for the ophthalmic blocks. The linear
(2-D) path is traced by the needle, angulation of the needle
within the orbit, and so on.
Angulation of the needle is one of the paramount concern
of ophthalmic anesthetists as wrong angulation of the needle
can force the needle to enter into more vital regions of the
human eye even if the initial entry of the needle was at the
proper site [6], [7]. Therefore, there is a need for such a system
wherein the trainee can get a real-time visual feedback during
the anesthesia training. A system with a visual feedback can
comprehensively prove the limitations of the older procedures
and validate the contemporary procedures.
II. M ANNEQUIN -BASED R EAL -T IME V IEW S YSTEM
A 3-D rendered image of the proposed system is shown
in Fig. 2(a) with its various components and their placements.
To facilitate the display of the real-time view, a virtual instru-
ment (VI) was developed using the NI LabVIEW interface,
this is displayed on a personal computer (PC) or laptop which
is used as both interface and control to the system. Fig. 2(b)
shows the developed system with the interface. The developed
system uses two cameras positioned at strategic points to
visualize two of the major areas which are predominantly
utilized while performing the ophthalmic regional blocks.
A block diagram representing this whole system developed
is shown in Fig. 3.
The developed prototype mannequin-based ophthalmic
anesthesia training with real-time view consists of a man-
nequin which replicates human facial anatomy its features
were cast using Oomoo 30 by Smooth-On using a model of a
typical human face. This mannequin face is integrated with
an anatomically accurate ocular model of the human right
eye, the 3-D model was designed, and a 3-D rendering of
the image was obtained from Autodesk 3DS Max, 2016, to
accurately replicate the ocular anatomy of a normal human
adult. The ocular anatomy of the mannequin consists of three
separate 3-D printed parts: the globe, the upper orbit, and the
lower orbit. This ocular anatomy model and the mannequin
face constitute the human face setup of the model. This face
setup is assembled on an aluminum holder which consists of
a top sheet and a bottom box. The top sheet has a rectangular
cavity drilled and the mannequin face integrated with the 3-D
printed ocular model sits within this cavity protruding inward
into the bottom box. A support sheet of fiber reinforced plastic
is attached perpendicularly to the inside of the top sheet below
the protruding mannequin. To improve the tactile feel and to
represent the closeness to model to a human, an overlaying
skin made with different layers of Dragon Skin by Smooth-
On with varied shore thickness is used to mimic the tactile
feel of the normal human skin. Such approaches to replicate
human features and provide haptic and tactile feedbacks to the
trainee have been previously used [2].
KUMAR et al.: VIRTUAL INSTRUMENTATION SYSTEM WITH REAL-TIME VISUAL FEEDBACK AND NEEDLE POSITION WARNING
Fig. 2. (a) Rendered image of showing the various components of the proposed system. (b) Photograph of the developed system with the real-time feedback
displayed on the interface.
Fig. 3. Block diagram of the real-time view system developed.
The cameras that were employed were selected based on
certain design criterions notably as follows. First, the camera
must have an adjustable depth of field with a suitable viewing
angle greater than 80°, as the camera has to focus objects
at near distances (≈2.5 cm), depth of field is considered as
the most important criterion for choosing the camera, and the
regions of the ocular anatomy that have to be focused require
a short focal length (near distance focus) to be able to focus on
all the ocular objects and the needle present in the regions that
are of interest. The chosen cameras must have the ability to
focus a region at near distance and also possess a wide depth of
field to focus on the entire region of interest (ROI). Therefore,
the depth of field criterion is the primary consideration for
choosing the camera. Second, the camera packaging must be
small to fit within an allocated space (5 cm × 5 cm × 4 cm).
Third, the camera should be economical. The frames per
second (frames/s) of the procured video is not treated as
a very vital requirement, as the anesthetist is trained for
slow and patient entry and exit of the needle, typically an
anesthetist takes 2–3 min to perform a single injection. The
orbital distance traversed by the needle during this time can
be a maximum of 20 mm, thereby warranting a minimum rate
of 6 frames/s. Satisfying these aforesaid criterions, the analog
high-definition camera model number SKU VZGR1394 which
has a 0.3 Mpixel sensor and a focus adjustable front lens with
a viewing angle of 100° has been used. It produces an output
video with a resolution of 720 × 576 pixels at 30 frames/s
through an analog Radio Corporation of America (RCA)
video interface. However, the same system can be developed
by employing a digital camera with equivalent specifications
1113
can be employed. Two of the above-mentioned cameras are
employed in the system. This resulting system gives a res-
olution of approximately 200 μm. The tested resolution of
the system is 197.86 μm. The standard 23G needle which is
predominantly used for the regional ophthalmic blocks has
a diameter (wall to wall) of 489 μm; the resolution this
system provides is more than sufficient. To effectively switch
between the outputs of the two cameras, they are multiplexed
through a video multiplexer: CD4053 by Texas Instruments,
a 3-channel 1:2 DeMux/Mux IC, was used. The control logic
for the multiplexer was provided through a data acquisition
system (DAS) (NI MyDaq), which can be directly controlled
through the developed VI. The DAS provides the digital
selection line for the multiplexer and also supplies the ±5 V
necessary for the CD4053 IC.
The multiplexed single video output from the mannequin
system developed uses an analog RCA video interface. How-
ever, for cogent processing and displaying the visuals, convert-
ing the interface to USB is preferred as it is more pertinent
in PCs. This conversion was enabled using a single channel
EasyCap video converter, which uses the USB TV 007 IC.
To provide adequate illumination and enhance the visual
perspective of the regions assessed by the cameras, an array of
20 white LEDs with a power rating of 0.55 W was used. The
cameras require +12 V supply which can provide a minimum
current of 20 mA. The array of LEDs and the cameras within
the system are powered by a dc +12 V power supply.
The visual interface is realized through a VI developed using
NI LabVIEW [8] and NI Vision Acquisition Software (NIVAS)
running on a PC. Such type of VI-based monitoring has
been used widely for monitoring the conditions of physical
elements and biomedical-based systems [2], [9]. Although
virtual simulators-based training models for various medical
procedures are already available [10], the method of training
proposed, with the combination of a physical training module
and VI-based systems, can extensively improve the teaching
and training of medical procedures and create a promising
environment to develop further such systems.
III. P OSITIONING OF THE C AMERAS
The visual feedback must be able to visualize the areas of
interest to properly train the trainee. Such a system must be
1114
Fig. 4. (a) Pictorial view of the injection zones in the superiomedial quadrant.
S—superiomedial block and M—medial block. (b) Pictorial view of the
injection zones in inferiolateral quadrant. L1—lateral junctional block and
L2-lateral-medial 2/3-1/3rd block.
able to visually show the trainee the dangers, such as wrong
entry sites, improper angulation of the needle, and real-time
location of the needle within the needle cavity. Such a system
should also be able to point out the safe zones which previous
existing system was unable to show.
Anatomically accurate ocular parts can be designed and
3-D printed; however, the 3-D modeled ocular structures have
to be modified specifically so as to enable the camera to
visualize within the orbital cavity. To comprehensively decide
the regions which have to be concentrated, the predominant
regions of the human ocular anatomy where the regional anes-
thesia blocks are performed were studied. Regional ophthalmic
anesthesia generally requires two injections, the primary and
secondary injections. The two zones that are used for injection
sites are present in the inferiolateral and superiomedial zones.
The inferiolateral quadrant of the human eye is used for the
primary injections for the peribulbar needle blocks or for a
single injection in the retrobulbar blocks. The superiomedial
quadrant is used for supplementary or secondary injections.
Fig. 4(a) shows the injection zones present in the superior-
medial quadrant of the human eye and Fig. 4(b) shows the
injection zones present in the inferiomedial quadrant.
A. Medial View
The medial view has to mainly concentrate on highlighting
the regions marked as S and M in Fig. 4(a). The region
highlighted in red and marked as S refers to the injection zone
used for the superiomedial block, this block is considered high
risk as this zone is vascular in nature [3], [7].
The region highlighted in green and marked M refers
to the injection zone used for the medial block, which is
considered far safer [3], [7]. The camera must be placed in
a strategic location to highlight these two regions. A system
with visual feedback can also highlight certain risks [11] in
certain procedures such as the superior-medial block, which
were previously undemonstrable. Fig. 5 represents an image
with a tentative camera position to highlight these two regions.
B. Lateral (Inferiolateral) View
Fig. 4(b) represents the posterior of the human eye. This
quadrant of the human eye is used for the primary injections.
IEEE TRANSACTIONS ON INSTRUMENTATION AND MEASUREMENT, VOL. 67, NO. 5, MAY 2018
Fig. 5. Camera placement for medial ROI.
Fig. 6. Camera placement for lateral ROI.
The injection zones in this quadrant are highlighted as L1 (red)
and L2 (green), where L1 represents the injection used for the
lateral-medial 2/3rd-1/3rd guide; this block, however, carries
greater risks according to recent studies, and improper injec-
tions can cause damage to the ocular muscles especially the
inferior oblique muscle which can lead to complications, such
as squint. Lateral junctional block, represented as L2 (green)
in Fig. 4(b), is considered as a safer alternative [3], [11]. The
camera must be placed at a location which can concentrate
these two particular injection zones and the ocular structures
in the vicinity.
Fig. 6 shows a tentative position at the posterior of the
human eye to highlight the injection zones for the lateral
quadrant of the human eye.
C. Realization of the Lateral and Medial Views
As mentioned earlier, it is very important to place cameras
in strategic locations to adequately visualize all the major
ocular structures present within the aforementioned injection
ocular zones. To satisfy certain requirements arising out of
the medial regional block procedures, and the inability to
visualize both the quadrants using a single camera, it was
decided to utilize two cameras each dedicated to the individual
quadrants. The camera dedicated for the inferiolateral (lateral)
quadrant is placed close to the lateral junctional wall, an
anatomical feature present in the orbit where the frontal and
the zygomatic walls meet [11]; Fig. 7(a) shows the camera
placement position for the lateral and the medial cameras.
Further adjustment, such as minor viewing angle adjustments,
is performed experimentally to encompass all the ocular struc-
tures and the injection zones. The camera dedicated to the
superior-medial (medial) zone is placed parallel to the lateral
KUMAR et al.: VIRTUAL INSTRUMENTATION SYSTEM WITH REAL-TIME VISUAL FEEDBACK AND NEEDLE POSITION WARNING 1115

Fig. 7. Diagrams illustrated in various views associated with the placement of the cameras (a) front view, (b) side view (right), and (c) side view (left). The
corresponding regions viewed by the cameras are indicated using the green conical structures.

camera; the camera is tilted at an angle of 23° toward the

ocular model, the medial camera position is shown in Fig. 7(a)
in a 3-D rectangular plot with axis legend to indicate the
rotation of the axis. Fig. 7(b) and (c) shows the right-side
view and the left-side view of the camera position plane,
respectively.

D. Modified Ocular Anatomy

The 3-D printed ocular anatomy analog has three parts: an
upper orbit, the lower orbit, the globe, and the rear glass pane.
To meet the necessary requirements, the ocular model needs
certain modifications. The medial view requires modifications
to the upper orbit; to facilitate the camera to visualize the
superior-medial quadrant, the predominately flat medial wall Fig. 8. Mannequin with integrated ocular structures.
is replaced with a pane of glass. Since, the medial wall is
mainly flat, the changes made does not alter the anatomy of
the model [12], [13]. The lateral view requires the camera to
be placed underneath the ocular model. Hence, a rear pane
of glass measuring 4 × 4 cm with a thickness of 3 mm is
placed. The globe is anchored onto the center of the rear glass
panel using molding cement. The modified upper orbit and
the lower orbit now encompass the globe and are attached
to each other and to the rear glass panel. The movement of
the eye is restricted and only vertical movement (∼3 mm)
is allowed; movement of gaze is completely arrested. In an
actual procedure, the patients are counseled not to shift their
gaze [1], [7]; however, slight vertical movements are some- Fig. 9. Assembly of the cameras and the modified ocular structures viewed
times required to create space between the globe and the floor from bottom of the system shown in Fig. 2(a).
of the orbit. This movement, however, does not compare with
free movement of a normal eyeball. Therefore, any relative These structures are at the periphery of the injection zones
motion between the eyeball and the camera is negligible. present within this quadrant.
Fig. 8 shows the mannequin that has been integrated with The medial view realized by the camera placed within the
modified ocular anatomy model; Fig. 9 displays the modified system is shown in Fig. 11. As in the previous figure, it is
anatomical analog and the actual placement of the cameras as shown in monochrome to show the medial visual feedback
viewed from bottom of the system, as shown in Fig. 2(a). in a better manner. This view shows the two injection zones,
The lateral view obtained by the camera placed within present within the medial quadrant, and the ocular structures
the system is shown in Fig. 10. The figure is shown in that are within these injection sites. The visualization of the
monochrome to show a better lateral visual feedback. The ocular structures and the areas required for regional blocks
realized lateral view shows the two injection zones and also will provide a means to comprehensively educate about the
the ocular structures which include the ocular muscles: lateral regional ophthalmic blocks and provide pertinent knowledge
rectus, inferior rectus, inferior oblique, and the optic nerve. about the ocular anatomy as well [13].
1116 IEEE TRANSACTIONS ON INSTRUMENTATION AND MEASUREMENT, VOL. 67, NO. 5, MAY 2018
Fig. 10. Lateral view displayed on the VI.
Fig. 11. Medial view displayed on the VI.
IV. V IRTUAL I NSTRUMENTATION
An VI interface was developed in an NI LabVIEW environ-
ment to acquire and display the visuals seen by the cameras.
The system must be equipped with both NIVAS and NI IMAQ
drivers. This interface has controls to switch between the
lateral and medial views. Besides displaying the video on
the front view of the VI, an inline video processing is used
for the needle position detection [3]. Detecting the needle tip
within the orbital is vital [4]; an image-based object tracking
method is utilized to detect the position of the needle within
the orbital spaces. The needle tip is detected from the images
showing the ocular structures and the orbital spaces in certain
ROIs which include the injection zones in both the lateral and
the medial views; the ROI should also include regions close
to the major ocular structures, such as the globe and ocular
muscles in both views. The needle detection approaches use an
image-based object tracking which uses edge detection. The
edge detection is done by comparing the brightness, contrast,
and differences in the gradient between the surroundings and
the object. To enhance the contrast differences and remove
noise from the images, each frame of the acquired video is
converted from an RGB image to an 8-bit grayscale image to
enhance the contrast differences. The image is then processed
with an auto-median grayscale morphology filter [3], [14].
A local average smoothening filter is employed in the next
stage to bring gradual smoothness to the image and to remove
unexpected blemishes. The penultimate process before the
image goes through the pattern matching algorithm is a set of
two 3-kernel custom convolution filters. Kernel filters are used
for various purposes and their effect can vary depending on
the convolution matrix chosen [14]. Here, the two convolution
filters [15] were chosen as to sharpen the areas within the
Fig. 12. (a) Image of a lateral view after the predetection stage. (b) Image
after edge detection (green) with needle template shown in inset.
ROI and define the edges more clearly, the kernel matrices are
chosen with respect to this particular type of image and light
source provided. The first filter has a kernel matrix K 1 , which
is customized from the generalized sharpening matrix [16].
The second filter has a kernel matrix K 2 , which is a
customized from the generalized edge detection [16]. This pre-
processing of the image emphasizes the ROIs and smoothens
the surroundings. The image is now processed by the edge-
based geometric pattern matching algorithm, using a general-
ized matching algorithm-based on Hough transform [16]–[18].
The edge-based geometric pattern matching VI uses preset
template image of the object, which we would like to locate
within the image. Using the image-template editor of the NI
vision assistant, a suitable template of the needle tip was
created using one of the previously acquired images [3]. The
template image is then looked up by the Hough geometric
pattern matching algorithm to find a match within a threshold
score of 800 for the lateral view and a score of 750 on the
medial view [19]. The camera placement for the medial view
is slightly angular and has dim lighting to avoid shadows and
reflections to the camera; therefore, a lower threshold has
to be used [3]. An image showing the preprocessed image
before edge detection is shown in Fig. 12(a). Fig. 12(b) shows
the same image after being processed by the edge detection
algorithm, the brightness of this figure is intentionally reduced
to visualize the detected edges better.
The edges present within the images that match the needle
template with a match score higher than the set threshold are
considered as a positive needle detection. The ROI is manually
selected and stored (once) for both the views to correctly select
the area of search. This was incorporated into an NI vision
assistant script [3]. In addition, the VI also has a video logging
feature which is used to record a particular session, the video
logging, however, records only the video output of the two
cameras. The entire VI front view can be recorded through the
Microsoft game recorder in compatible computers, a shortcut
to start and stop the recording is provided within the VI itself.
In addition to the needle detection, the VI is also integrated
with an automated warning system, this warning system is
capable of delivering indications to the trainees if there are
some procedural mistakes during the procedure. A flowchart
detailing the subsequent steps involved in the needle detection
and warning methodology is shown in Fig. 13.
KUMAR et al.: VIRTUAL INSTRUMENTATION SYSTEM WITH REAL-TIME VISUAL FEEDBACK AND NEEDLE POSITION WARNING
Fig. 13. Flowchart of the needle detection and warning approaches.
V. AUTOMATED WARNING A PPROACHES
To assess and evaluate the trainee, it is vital that the
developed system is equipped with a provision where in
the position of the needle within the orbital cavity can be
ascertained and feedback provided to the trainee to improve
the training experience. The position of the needle tip can be
utilized to give warnings to the trainees about the placement of
the needle within the ocular cavity and about the proximity of
the needle to various ocular structures. Such a system can also
provide the participant with information about improper prac-
tices or routines, if any, that he/she might have followed in the
training accidentally. The proposed system is equipped with an
automated scheme to detect the tip of the needle, as mentioned
earlier, from the images acquired from the videos produced by
the cameras. The position of the needle is now used to locate
the injection zone and a feedback is presented to the trainee.
Generally, these warnings can be classified into three different
types: muscle proximity, procedural warning, and angulation
warning. Muscle proximity warning is generated when the
needle tip approaches an ocular muscle. A procedural warning
is given to the trainee if unsafe procedures or if the needle is
detected within a region that is deemed as unsafe. Angulation
warning is a specific warning given if the needle which was
present in a safe zone or location upon entry but the needle tip
is angulated toward ocular structures, the orbit, or toward an
1117
Fig. 14. Lateral view after applying canny edge detection algorithm.
unsafe region. Unlike the proximity warning, in the angulation,
the needle tip may not be in proximity to an ocular structure.
Wrong angulation can be dangerous during delivery of the
anesthetics and can cause undue pain to the patient. The
warnings are delivered to the trainee by LED indicators placed
on the front view of the VI. There are no physical indicators
present on the actual mannequin. This was done so as to
keep the trainee focused on the procedure and to keep the
training scenario as real as possible; during an actual operation
procedure, there are no such guidance or interruptions. The
feedback to the trainee is given after the trainee finishes the
procedure using the video session review, and the mannequin
now can be utilized as a teaching module where the instructor
can explain the errors and the safer alternatives. The system is
also capable of tracing the 2-D path traversed by the needle,
this feature can show a visual representation to the trainee
if there are any unwanted motion of the needle and the
angulation of the needle tip with respect to the site of injection.
The position of the needle is now employed to find the
proximity of it to the major ocular structures and provide
warnings about procedure undertaken by the trainee. Visual
feedback already provides enough information about the nee-
dle’s position, therefore guidance and warnings about the
procedure are deemed appropriate. As a preprocess, a single
image from the camera without the presence of the needle is
taken and processed using a canny edge detection matrix.
Fig. 14 shows the lateral view processed through a canny
edge detection algorithm. In the lateral view, only the inferior
oblique muscle is concentrated on, this muscle is hemispher-
ical in nature and forms the boundary for both the injection
zones, whereas both the lateral and the inferior rectus muscles
are fairly linear in nature and can be reached only by following
an incorrect procedure.
The geometry of the inferior oblique muscle is convex.
To process it easily, this muscle can be divided into a piecewise
linear function by choosing five consecutive points from the
edge coordinates obtained from the preprocessed edge detec-
tion. The muscle can now be represented by four individual
linear lines, each represented by two-point line equations as
represented in (1). IO1 , IO2 , IO3 , and IO4 represented by
(2)–(5) can be used to represent the inferior oblique muscle.
The lateral view can now be divided into quadrants or zones
1118 IEEE TRANSACTIONS ON INSTRUMENTATION AND MEASUREMENT, VOL. 67, NO. 5, MAY 2018
Fig. 15. Lateral view with detection zones marked.
Fig. 16. Medial view with detection zones marked.
based on these individual lines representing the ocular muscle,
as shown in Fig. 15. The solid lines represent the boundary
condition for the respective zone. The LR1 represents the
boundary for the lateral rectus muscle; this boundary is more
than sufficient for the lateral rectus muscle, considering that
the image is 2-D and the only possible way to reach the muscle
is by angulating the needle upward.
The line IO4 will serve as the boundary condition for the
inferior rectus muscle, as again the only possible way to reach
this muscle is improper angulation.
The injection zone, L1, can now be represented by IO3 and
IO4 , and L2 is represented by LR1, IO1 , and IO2 . Since there
is a physical barrier (orbital wall), there is no need to specify a
bounding coordinate on the y-axis, and the x-coordinate zone
separation is more than adequate
a X + bY + C (1)
IO1 : 0.0379X + Y −463 (2)
IO2 : 0.817X + Y −755 (3)
IO3 : 1.52X + Y −1077 (4)
IO4 : 3.92X + Y −2233. (5)
The medial automated warning is fairly straightforward
as one procedure is completely under disrepute, only the
medial block is considered as the safe procedure. Three edges,
MR1 , MR2 , and MR3 , are enough to adequately represent the
injection regions of the medial view. Fig. 16 shows the zone
separation in the medial view of the system. The flowchart
displayed in Fig. 13 details the steps involved in the automated
warning approach.
A. Muscle Proximity Warning
Muscle proximity warning is displayed to the trainee with
a green (safe) or red LED (unsafe) highlight on the front view
of the VI. The unsafe warning is given to the trainee if the
needle tip is detected within the proximity of an ocular muscle.
The distance d is calculated from the located needle position to
the nearest muscle boundary lines (demarked zones) using (6),
a and b are line coefficients selected based on which zone the
needle is present. The needle position is represented as x needle
and yneedle [20], [21].
The distance is the calculated distance d of the needle
tip from the ocular muscle boundary. This distance is now
compared with a threshold value of ten pixels which is
approximately about 2 mm if d is lesser than or equal to
the threshold value. In the lateral view, the boundaries of the
muscle include IO1 , IO2 , IO3 , and IO4 (inferior oblique and
inferior rectus) and LR1 (lateral rectus). In the medial view,
MR2 (medial rectus) is the only muscle boundary [20], [21]
|ax needle + byneedle + C|
d= √ . (6)
a 2 + b2
B. Angulation Warning
Angulation warning is given to the trainee when an angu-
lation of the needle tip is detected; angulation of the needle
occurs when the needle tip forms an angle (minimum of 4.5°)
with respect to the entry site. This type of error can be
dangerous because even though the entry site of the needle was
safe due to angulation, the needle tip may be present in the
unsafe zone or even be in proximity to an ocular structure. The
system, however, is not capable of locating the injection site as
it can track only the tip of the needle, and since the image is
2-D, calculating the angle of the needle is difficult. Therefore,
an approach was devised for the angulation warning; in the
lateral view, the zone in which the needle is initially present
is taken into consideration. A reasonable assumption is that if
the needle tip leaves the zone of entry, there is an angulation of
the needle tip (this can detect a minimum of approximately 3°).
In the lateral view, if the needle enters the region bound
by IO2 after which the needle tip enters the region bound
by IO1 or IO3 , and if the needle tip crosses LR1 (lateral
rectus muscle) in L2 or IO4 (inferior rectus muscle) in L1,
irrespective of the muscle proximity, an angulation warning
is given to the trainee. In the medial view, angulation is
detected using the boundaries MR1 and MR3 , if the needle
is detected within zone M and if needle tip crosses MR1 or
MR3 , an angulation warning is given [21]. The angulation
and the muscle proximities are superseded by the procedural
warning in the discredited S zone. The angulation warning,
however, can detect only considerable changes in angulation
for minor angulation and changes in the position of the needle,
the needle path trace can be utilized. Fig. 17 shows the
front view of the VI during an improper procedure where the
needle is in proximity to lateral rectus muscle and improper
angulation was also observed; therefore, the system has given
both the muscle proximity and the angulation warning. Both
the muscle proximity and angulation warning are given a
similar notification as the muscle proximity green or red
KUMAR et al.: VIRTUAL INSTRUMENTATION SYSTEM WITH REAL-TIME VISUAL FEEDBACK AND NEEDLE POSITION WARNING
Fig. 17. Front view of the VI displaying muscle proximity and angulation
warning during a procedure.
Fig. 18. Front view of the VI displaying procedural warning during a
procedure.
LED notification for safe and unsafe angulations, respectively,
on the front view of the VI.
C. Procedural Warning
The procedural warning is notified on the front view of
the VI, using a LED notification and string message of the
attempted procedure. A green LED is given for safe procedure
and red for an incorrect procedure. The attempted procedure
can be ascertained by comparing the position of the needle
with the boundaries of each zone. This type of warning is
given to the trainee if the system detects the needle within
the injection zones that are deemed as unsafe—L1 zone
bounded by IO3 and IO4 in the lateral view and the S zone
in the medial view. In the medial view for the prudent use
of computational power, the check was performed to verify
whether the needle was present within the safer M zone.
The procedural warning is triggered, if the needle is detected
within L1 in the lateral view and any region outside zone
M in the medial view. Fig. 18 shows a procedural warning
displayed on the front view when the superior-medial (S zone)
procedure was attempted. In the S zone, as this procedure is
not recommended in the medial quadrant [7] view, both the
muscle proximity and angulation warning are superseded by
the procedural warning.
D. Needle Path Tracing
The VI is also equipped with a needle position tracer both
in the lateral and medial views, wherein the path followed by
1119
the needle is traced on screen. This was done to encourage
an environment where the instructors can create objective
geometric line patterns for each procedure, thereby forming
a template which the trainee can retrace and learn. This
particular feature can also be used to visualize angulation
because the angulation cannot be quantified in the 2-D real-
time video. The last ten (maximum) located positions of the
needle are stored in a buffer, and a linear (2-D) line is plotted
with two points chosen in succession from the available points
for the trainee to explore the path traced by the needle for
abrupt motions of the needle or angulation of the tip.
The maximum number of points, in this case ten, is deemed
sufficient, as there is no intentional swift motion of the needle
within the orbital cavity, and the procedure is performed
patiently (2–3 min/ injection); therefore, the velocity is consid-
erably slow and the distance traversed by the needle is less than
2 cm and can be at the maximum 2.5 cm (extreme cases). Since
the system provides a resolution of approximately 200 μm,
the path traced by the needle is dependent on the velocity,
depth of penetration of the needle, and the angle of entry of the
needle [16] but considering the typical velocity of the needle
is approximately about 8 mm/min and the needle location is
not refreshed unless the needle position shows a five pixels
change from the previously known position. Considering the
moderate velocity, the refresh rate, and the needle path can
now display the trajectory and the angulation of the needle.
The trajectory, however, has a limitation if the entry angle
of the needle remains constant throughout the procedure and
since the image is 2-D, the depth of the needle cannot be
perceived in which cases the path is represented by closely
placed points. The needle trace is updated in real time with
every fifth frame (166 ms) of the video utilizing the present
location of the needle, provided the change in position of the
needle is above the threshold of five pixels. The needle path
trace is displayed as an overlay on the video displayed on
the front view of the VI. This can be used to illustrate that
there was no angulation during the procedure. This feature can
be used to educate the trainee by pointing out the geometric
path used for each procedure and help to visualize angulation.
Fig. 19 shows a needle block procedure where the needle upon
entry was angulated upward, the plotted line utilizes seven
points and the thickness of the displayed line is one pixel.
VI. E XPERIMENTAL VALIDATION
A. Needle Detection
To verify the accuracy and efficacy of the needle detection
approach, the VI developed was tested [3] using 180 images
in L1 and L2 zones, in the lateral view, and S and M zones
in the medial view; the medial view’s ROI is concentrated on
a small area as it has fewer anatomical injection sites, which
are located close together [22].
The angulation of the needle is more of a concern in
the medial quadrant and considering that the numbers of
anatomical injection sites are fewer than the lateral [5], [22]
since the needle can be injected only at certain sites, the needle
cannot be present outside these areas, and the image set
consists of angulated needle tips from these injection sites.
1120 IEEE TRANSACTIONS ON INSTRUMENTATION AND MEASUREMENT, VOL. 67, NO. 5, MAY 2018
TABLE I
E XPERIMENTAL V ERIFICATION OF THE P ERFORMANCE OF THE N EEDLE D ETECTION A PPROACH
Fig. 19. Front view of the VI displaying needle path in the lateral view with
the previous needle location represented as green circles.
All the images were recorded using the prototype mannequin
system with ocular structures and cameras. To completely
assess the scheme, images contained the needle in various
positions within the ROI were employed.
The set also contained images with no needle present
(30 in each zone) to detect any false detection. The image
sequence was run in the VI developed, with needle detection
methodology. The results obtained from the test are presented
in Table I.
The results as displayed in Table I infers that in the lateral
view, the methodology performs very well. There were no
false detections in the ROI in the L1, L2, M, and S zones.
The test results show 99.4% accuracy in detecting the needle
within the L1 zone, and 98.8% accuracy in detecting the
needle within the L2 zone. There were three no-detection
cases; however, since the needle in these false detections
lies within the L2 zone and away from the major ocular
structures, the errors are of less impact. The M zone view
reported 100% accuracy in the detection of the needle. The
S zone reported an accuracy of 95.4%. The relatively reduced
accuracy for this zone is mainly due to the ambient light
and the camera limitations, such as resolution. The anatomy
and camera viewing angle makes it difficult for this region
to be completely illuminated by the ambient light without
causing reflections or shadows in the resultant image. If the
needle is present in these areas, it is difficult for the algorithm
to identify the needle edges; however, this relative reduction
in illumination does not affect the ability of the trainee to
visualize the needle. Images with needles in these regions were
used to assess the efficiency of the detection algorithm and
are uncommon in general procedures. Cameras with higher
resolution and low-light capabilities (greater aperture size) can
be employed to detect the needles within these areas to achieve
a better accuracy.
B. Automated Warning
The automated warning system uses the needle position
information to warn the trainee about improper procedures and
ocular structure proximity warnings, to validate the algorithm
positional trials were conducted where the needle is present
in various positions in the orbital cavity in regions of both
in the safe and unsafe injection zones in the lateral and the
medial views. The 150 validation trials were conducted in
the lateral quadrant with 50 trials allocated for the demarked
boundaries (IO1 , IO2 , IO3 , IO4 , and LR1). The angulation
warning was tested using ten trials (LR1) and proximity to
the muscle was tested with ten trials (IO1 , IO2 ). The medial
quadrant was tested with 150 validation trials, 30 validation
trials for the demarked boundary (MR1, MR2, and MR3),
and the needle used for this particular block is shorter than
the needle used for the lateral block only the angulation of
the needle was considered and 60 trials are reserved for the
unsafe regions of the medial zone. Ten trials per boundary
were deemed appropriate considering that the needle position
detection has been extensively tested. All the procedural and
angulation warning systems were simultaneously tested when
each boundary was tested. Proximity was tested by bringing
the needle closer to the muscle at each boundary line till
the needle touched the muscle. Angulation and proximity
were verified in the L1, L2, and M zones as the S zone
procedure is no longer recommended [7], it was not necessary
to monitor the angulation and proximity in this zone. In the
angulation testing, the needle was injected perpendicular at
first and slowly angulated toward neighboring zones and the
ocular structures, since there are no quantifiable means for the
angulation, this was verified with visual and haptic feedbacks.
For procedural warnings, needle blocks were performed in
L1 and S zones. The results are displayed in Table II. The
angulation warning is 99% accurate; the only instance where it
failed was when the angulation of the tip of the needle crosses
the muscle, this type of practice is extremely uncommon;
100% accuracy was recorded for the proximity warning and
KUMAR et al.: VIRTUAL INSTRUMENTATION SYSTEM WITH REAL-TIME VISUAL FEEDBACK AND NEEDLE POSITION WARNING
TABLE II
E XPERIMENTAL V ERIFICATION OF THE AUTOMATED WARNING S YSTEM
98.1% for the procedure warning. The two trials of an unsafe
procedure which was not detected by the system at the medial
position again is an extreme case, with uncommon angulation.
C. Needle Path Tracing
To test the validity of the needle path tracing, the needle
path tracing was designed as a way to visualize the angulation
experimental trials were performed with the system using a
needle which was measured and was marked at every 5 mm
using a marker. This marking was done to have the perspective
of the length of the needle present within the orbital space.
This distance can be used to evaluate the angulation by
comparing the length (number of pixels) of the traced line and
the distance traveled by the needle. The needle was then used
to perform a needle block, using the typical needle injection
sites. The trials were conducted with needle entering to a
depth of 10 mm (two markings on the needle) perpendicular
to the top aluminum holder and the angle was incremented
till 10° toward the orbital wall. This value of the angle is
measured using a protractor on the syringe present outside on
the aluminum top sheet, and the measured angle is with respect
to this top sheet as there are no means to physically measure
the angle of the needle within the irregularly shaped orbital
wall, now the pixel count of the line is noted. The angulation of
the needle can be calculated using the length of the path trace
line L p (number of pixels in the line × 0.2 mm) and the depth
of penetration of the needle L d (10 mm). In this manual test
with a known depth of penetration of the needle, the angulation
θ can now be calculated as shown in the following:
 
−1 Lp
θ = 90 − cos . (7)
LN
In the lateral view, a total of 15 injection points were
chosen spread across the two injection zones. The medial was
validated using 15 injection points all in the M zone as the
S zone is completely disreputed, and a procedural warning is
presented; even if this procedure is attempted, the tracing of
the needle path is not required for this quadrant, only as the
procedure itself is considered unsafe; monitoring the needle
path is not required. The location of the needle position at rare
instances can change with a maximum of two pixels, this is due
to the needle position detection algorithm, which can show a
1121
minor change in the location of the needle when every frame is
refreshed in the video, even without any increment in needle
position. From the 30 trials conducted, for 28 trials (93.3%
of the trials), the calculated value of θ was comparable and
acceptable with a worst case error of 1.5% to the initial angle
of 10°. The two trials in the lateral gave an erroneous value due
to the difference in the location of the needle position. Besides
such occasions the path traced by the system is acceptable
and can be used to visualize angulation, however, the system
cannot quantify the angulation using this method as there is
no method to ascertain the depth of penetration from a 2-D
video. This method to quantify that the angulation can only
be done manually was performed to validate dependence of
the needle path trace to the angulation of the needle, thereby
giving a visual guide for angulation.
D. Pilot Study
To evaluate the usefulness of the system in an actual
environment of typical usage and to test the efficacy and
design of the visual feedback, the porotype was taken for
a pilot study at the hospital, Sankara Nethralaya, Chennai,
India. A total of 41 participants which included 21 trainee
doctors and 20 consultants participated and were asked to
give their feedback about the system. The participants were
asked to perform their routine blocks during which the visual
feedback was not visible to the participant. At the end of
their routine procedure, an experienced instructor would use
the recorded session to point the errors in the performed
procedures if any. The instructor then utilizes the visual
feedback to explain the shortfalls of the unsafe procedures
and demonstrate the safer procedures and the participants
were allowed to practice the safer techniques using the visual
feedback. A questionnaire containing 11 questions concerning
the visual feedback and if the participants found realized
medial and lateral views were positioned suitably to visualize
the relevant ocular anatomy were given to the trainee at the end
of the session, through which they provided feedback on the
helpfulness of the visual feedback system, the likeness of the
system to human ocular anatomy and viability of the system
for ophthalmic anesthesia training; 95% of the participants
agreed that the lateral and medial views were positioned to
understand the ocular anatomy and the procedure better. All
1122 IEEE TRANSACTIONS ON INSTRUMENTATION AND MEASUREMENT, VOL. 67, NO. 5, MAY 2018
TABLE III
C OMPARISON B ETWEEN OAS I S AND THE P ROPOSED S YSTEM
the 41 participants agreed that such a system with visual
feedback would help them learn the ocular procedures and
help perform safer blocks, thereby validating the viability of
the system as a repeatable tool for learning and practicing
ophthalmic regional blocks. All the participants were new to
such a system of training, and they were not trained earlier in
the OASiS system [2], reported earlier which does not have a
real-time view.
VII. D ISCUSSION
The important factors of the developed prototype system
and that of the previous system have been compared and
presented in Table III. The intention to develop the proposed
system was to develop a way to integrate more ocular anatomy,
the previous system needs a dedicated sensory element for
every ocular structure, and therefore, the main motivation was
to develop the proposed system with the basic abilities of
the previous system, such as needle position detection and
warning systems without the sensory requirements. Utilizing
cameras as the sensory instruments replace the individual
sensing requirements. Since there are no sensory requirements
for the ocular model in the proposed system, a 3-D ocular
model simulating pathological conditions, such as irregular
eye and globe relation, can be replaced at the instructors
wish to emulate various cases. The basic features, such as
needle position tracking and the warning, were achieved using
object tracking methods. The proposed system has similar
functionalities and is relatively simple compared with the
previous approach. The proposed system also utilizes visual
feedback to improve the training. The ability to replace the
syringes is another advantage as certain newer procedures
require a different needle and syringe. However, this ability to
replace the syringe is at cost of replacing the capability of the
system to detect the injection rate of the needle. This detection
system requires external magnets and a special piston and
needle arrangement, which would feel artificial and restricts
the trainee’s freedom. The rate of injection is generally not a
very vital requirement since the volume of the anesthetic is
always monitored and rate of injection is generally practiced
without any aid by all medical professional and clinical
laboratory experts. If the instructor or examiner wishes to
validate the injection rate of a trainee a modified syringe
setup as used in [2] can be utilized. A broader approach is
being explored to measure the rate of injection without being
invasive of the procedural requirements. Scoring the session
which was present in the previous system has been replaced
with video session review; the system was primarily intended
as the teaching and training modules, where procedures can
be demonstrated by an experienced instructor, thereby the
instructor can grade the trainee by virtue of a session recording
of the procedure rather than the score of the procedure. The
proposed system also has features that the help the trainee
visualize angulation of the needle, the angulation warning
was introduced to provide angulation feedback. The needle
path trace provides visualization of the angulation and needle
tip movement and can also provide a geometric template for
certain procedures. There were no such provisions to provide
feedback on the angulation. Training modules can provide
knowledge and provide a necessary means to hone one’s
skillset; however, the training systems have their own limi-
tations. An in-surgery assistance system capable of assisting
actual surgical procedures can provide prompt approaches to
the procedure and warnings but the intraocular anatomy is
difficult to monitor in real time during surgery. Developing
such a system would be a proposition for further research.
VIII. C ONCLUSION
Development and evaluation of an intelligent mannequin-
based ophthalmic anesthesia training system capable of
providing visual feedback on a VI with the ability to present
procedural warnings and needle path tracing is presented in
this paper. The system developed uses anatomically accurate
3-D printed ocular structures, a silicone skin layer and two
cameras to continuously capture the images of the ocular
structure and needle, during a training session. The system
provides the real-time view of the structures and needle in
the display. It detects the position of the needle, using an
appropriate algorithm, and tracks and displays the path of the
needle. This information is then used to detect the errors, such
as improper injection procedures, the proximity of the needle
to ocular structure, and angulation of the needle made by the
trainee. The progress made by the trainee can also be assessed
using the session record feature of the system presented in
this paper. Experimental validation of the needle detection
methodology [3] was performed considering requirements
of the proposed system with 180 images for the individual
injection zones L1, L2, M, and S. The results show that
the system developed accurately detected the needle position
with an accuracy of 99.4% in L1 zone and 98.8% in L2 zone
KUMAR et al.: VIRTUAL INSTRUMENTATION SYSTEM WITH REAL-TIME VISUAL FEEDBACK AND NEEDLE POSITION WARNING
in the lateral view and 100% in M zone and 95.4% in the
medial view. The automated warning scheme was tested using
300 validation trials to prove the efficacy of the warning
system, the system performed with an accuracy of 99%,
100%, and 98.1% for angulation, proximity, and unsafe
procedure warning, respectively. The system was intended
as an alternate repeatable means for teaching and training
of the ocular anesthesia procedures. The system can be used
by trainee anesthetists to learn ocular anatomy and regional
anesthesia procedures and perfect their skill for performing
ocular needle blocks before they can perform them on patients
during surgery. The responses from the 41 participants of the
pilot study with the proposed system unanimously concur
that such a system can perform as viable means for the
trainee doctors to the learn ocular anatomy, ocular regional
anesthesia procedures, and will function as an aid to learn
and practice safer ocular anesthetic procedures. Such an idea
for ophthalmic anesthesia is novel and not present in any
typical contemporary ophthalmic training equipment.
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Nimal J. Kumar was born in Chennai, India, in
1991. He received the B.Tech. degree in electronics
and communications engineering from SRM
University, Chennai, in 2014. He is currently
pursuing the M.S. and Ph.D. degrees with IIT
Madras, Chennai.
He is currently a Research Scholar with IIT
Madras. His current research interests include
camera-based instrumentation and bio-medical
instrumentation for ophthalmic practices.
Boby George (M’07) was born in Kannur, India, in
1977. He received the M.Tech. and Ph.D. degrees
in electrical engineering from IIT Madras, Chennai,
India, in 2003 and 2007, respectively.
He was a Post-Doctoral Fellow with the Institute
of Electrical Measurement and Measurement Sig-
nal Processing, Technical University of Graz, Graz,
Austria, from 2007 to 2010. He joined the faculty
of the Department of Electrical Engineering, IIT
Madras, in 2010, where he is currently an Associate
Professor. His current research interests include mea-
surements, sensors, and instrumentation for industrial applications.
Dr. George is serving as one of the associate editors for the IEEE S ENSORS
J OURNAL.
Mohanasankar Sivaprakasam is currently a Fac-
ulty Member of electrical engineering with IIT
Madras, Chennai, India, and the Director of the
Healthcare Technology Innovation Centre (HTIC),
a Research and Development Centre of IIT Madras.
After the Ph.D. and post-doctoral research in U.S.
in implantable medical devices for eight years,
he returned to India with a goal of developing
affordable medical technologies. Since 2009, he has
successfully built an ecosystem of technologists,
clinicians, and industry, culminating in setting up of
HTIC in 2011. He has authored over 80 peer-reviewed publications in journals
and conferences.