Development and validation of a user-friendly smartphone imaging and telemedicine platform for remote diagnosis of anterior segment eye disease.

BACKGROUND

Cataract and anterior segment diseases are leading causes of blindness in low-resource settings. Eye camp screenings remain the primary mode of community outreach but are constrained by cost, logistics, and dependence on highly trained specialists. We designed and validated a low-cost, user-friendly smartphone-based anterior segment imaging and teleophthalmology platform to enable community health workers (CHWs) to perform diagnostic-quality eye screening.

METHODS

We designed a portable imaging device (Scout TM ) paired with an accessible Android smartphone and mobile application (InSightful) for telemedicine in low-bandwidth settings. CHWs underwent 3 hours of training on using the imaging software and hardware, then screened patients across 19 rural eye camps in South India with anterior segment images and clinical data uploaded to a cloud-based database for remote ophthalmologist (RO) review. Diagnoses and referral decisions made by ROs were compared with those of in-person eye camp ophthalmologists (ECOs). CHWs, ROs, and patients were surveyed on the platform's feasibility and acceptability.

FINDINGS: N=1093 patients underwent eye camp screening by ECOs and CHW-led smartphone screening with RO review. CHWs completed screenings in <2.5 minutes/eye and obtained diagnostic-quality images for >90% of eyes. ROs and ECOs showed 96.1% concordance for referral decisions (95% CI 94.7-97.1) and substantial agreement in diagnosis of any cataract (κ 0.77, percent agreement [PA] 89%), mature cataract (κ 0.67, PA 96%), immature cataract (κ 0.69, PA 85%), clear crystalline lens (κ 0.65, PA 89%), pseudophakia (κ 0.92, PA 97%), and moderate agreement for pterygium (κ 0.47, PA 94%). Concordance increased with image quality. CHWs, ROs, and patients reported high usability, acceptability, and net promoter scores.

INTERPRETATION: Scout TM anterior segment screening by minimally trained CHWs achieves diagnostic and referral accuracy comparable to in-person ophthalmologist examinations, supporting potential to decentralize cataract screening and expand access to eye care in low-resource settings.

FUNDING: National Eye Institute R21EY034343, National Eye Institute K23EY032988, National Eye Institute P30EY01765 (Biostatistics Core), Microsoft Innovation Acceleration Award, Johns Hopkins Center for Global Health, Stephen F Raab and Mariellen Brickley-Raab Rising Professorship in Ophthalmology, Boone Pickens Rising Professorship in Ophthalmology.