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

BackgroundCataract 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. MethodsWe designed a portable imaging device (ScoutTM) 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 platforms feasibility and acceptability. FindingsN=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 ({kappa} 0.77, percent agreement [PA] 89%), mature cataract ({kappa} 0.67, PA 96%), immature cataract ({kappa} 0.69, PA 85%), clear crystalline lens ({kappa} 0.65, PA 89%), pseudophakia ({kappa} 0.92, PA 97%), and moderate agreement for pterygium ({kappa} 0.47, PA 94%). Concordance increased with image quality. CHWs, ROs, and patients reported high usability, acceptability, and net promoter scores. InterpretationScoutTM 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. FundingNational 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