Smartphone-Based Ophthalmic Imaging Compared With Spectral-Domain Optical Coherence Tomography Assessment Of Vertical Cup-To-Disc Ratio Among Adults In Southwestern Uganda

Precis: Using optical coherence tomography (OCT) measurements as a reference standard for vertical cup-to-disc ratio (vCDR), a smartphone-based ophthalmic camera has a sensitivity of 67.7% and specificity of 96.7% to detect a vCDR>0.5. Purpose: The purpose of this study was to assess the performance of a smartphone-based ophthalmic camera system using an Apple iPhone 6S and an adapter, Paxos Scope, to obtain adequate dilated fundus photos to measure clinically useful vCDR cutoffs. Patients and Methods: Adult patients from a government tertiary level eye hospital in Southwestern Uganda were prospectively recruited from January to April 2019. All patients experienced a comprehensive eye examination, dilated posterior segment indirect ophthalmoscope imaging with the Paxos Scope, and spectral-domain OCT imaging with a Cirrus HD-OCT to measure vCDR. Patients' eyes excluded had media opacities or existing disease precluding a view of the fundus. Fundus images underwent a single masked review to assign vCDR at increments of 0.1. Descriptive statistics, parametric and chi(2) tests for significance, repeated measures correlation, kappa, receiver operating characteristics curve, and Bland-Altman were used to assess the data. Results: Among 467 (consecutive) individuals, fundus photographs acquired with the Paxos Scope demonstrated a 67.7% [95% confidence interval (CI), 63.0-72.0] sensitivity and 96.7% (95% CI, 94.2-98.3) specificity to detect a vCDR>0.5, using OCT as the reference standard. A total of 138 eyes were excluded due to poor imaging acquisition, such as dense cataract, rendering 796 eyes for analysis. The vCDR from graded Paxos Scope images and OCT correlated well with repeated measures correlation of 0.82 (95% CI, 0.77-0.86, P<0.001) and agreement, dichotomized as >0.5 or <= 0.5, was 80.9% (kappa=0.63 +/- 0.034, P<0.001). Among glaucoma and glaucoma suspects (85 eyes), the sensitivity and specificity dichotomized using vCDR>0.5 were 97.5% (95% CI, 91.3-99.7) and 80.0% (95% CI, 28.4-99.5), respectively. The area under the receiver operating characteristics curve was 0.92 (95% CI, 0.89-0.94) for all eyes and 0.98 (95% CI, 0.78-1.0) for glaucoma and glaucoma suspects. Conclusions: The Paxos Scope produced images that can be reliably used to estimate vCDR, which is closely aligned with the automated algorithm from the OCT optic disc cube scan. The low-cost, ready-to-integrate adapter, and minimal training requirements make it a viable option for population-based screening in low-resource settings.