title: Clinical Validation of a Smartphone-Based Adapter for Optic Disc Imaging in Kenya.
abstract: OBJECTIVE
  Visualization and interpretation of the optic nerve and retina are essential parts of most physical examinations.
  
  
  OBJECTIVE
  To design and validate a smartphone-based retinal adapter enabling image capture and remote grading of the retina.
  
  
  METHODS
  This validation study compared the grading of optic nerves from smartphone images with those of a digital retinal camera. Both image sets were independently graded at Moorfields Eye Hospital Reading Centre. Nested within the 6-year follow-up (January 7, 2013, to March 12, 2014) of the Nakuru Eye Disease Cohort in Kenya, 1460 adults (2920 eyes) 55 years and older were recruited consecutively from the study. A subset of 100 optic disc images from both methods were further used to validate a grading app for the optic nerves. Data analysis was performed April 7 to April 12, 2015.
  
  
  METHODS
  Vertical cup-disc ratio for each test was compared in terms of agreement (Bland-Altman and weighted κ) and test-retest variability.
  
  
  RESULTS
  A total of 2152 optic nerve images were available from both methods (also 371 from the reference camera but not the smartphone, 170 from the smartphone but not the reference camera, and 227 from neither the reference camera nor the smartphone). Bland-Altman analysis revealed a mean difference of 0.02 (95% CI, -0.21 to 0.17) and a weighted κ coefficient of 0.69 (excellent agreement). The grades of an experienced retinal photographer were compared with those of a lay photographer (no health care experience before the study), and no observable difference in image acquisition quality was found.
  
  
  CONCLUSIONS
  Nonclinical photographers using the low-cost smartphone adapter were able to acquire optic nerve images at a standard that enabled independent remote grading of the images comparable to those acquired using a desktop retinal camera operated by an ophthalmic assistant. The potential for task shifting and the detection of avoidable causes of blindness in the most at-risk communities makes this an attractive public health intervention.
authors.affiliation: International Centre for Eye Health, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Andrew
authors.initials: A
authors.lastname: Bastawrous
authors.affiliation: Department of Biomedical Engineering, University of Strathclyde, Glasgow, United Kingdom.
authors.forename: Mario Ettore
authors.initials: ME
authors.lastname: Giardini
authors.affiliation: Department of Biomedical Engineering, University of Strathclyde, Glasgow, United Kingdom.
authors.forename: Nigel M
authors.initials: NM
authors.lastname: Bolster
authors.affiliation: National Institute for Health Research, Biomedical Research Centre, University College London Institute of Ophthalmology, Moorfields Eye Hospital National Health Service Foundation Trust, London, United Kingdom.
authors.forename: Tunde
authors.initials: T
authors.lastname: Peto
authors.affiliation: National Institute for Health Research, Biomedical Research Centre, University College London Institute of Ophthalmology, Moorfields Eye Hospital National Health Service Foundation Trust, London, United Kingdom.
authors.forename: Nisha
authors.initials: N
authors.lastname: Shah
authors.affiliation: Glasgow Centre for Ophthalmic Research, National Health Service Greater Glasgow and Clyde, Gartnavel General Hospital, Glasgow, United Kingdom.
authors.forename: Iain A T
authors.initials: IA
authors.lastname: Livingstone
authors.affiliation: International Centre for Eye Health, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom5Medical Research Council Tropical Epidemiology Group, Faculty of Epid.
authors.forename: Helen A
authors.initials: HA
authors.lastname: Weiss
authors.affiliation: Division of Optometry and Visual Science, School of Health Science, City University London, London, United Kingdom.
authors.forename: Sen
authors.initials: S
authors.lastname: Hu
authors.affiliation: International Centre for Eye Health, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom7Kitale and Zonal Eye Surgery, Kitale Hospital, North Rift, Kenya Nort.
authors.forename: Hillary
authors.initials: H
authors.lastname: Rono
authors.affiliation: International Centre for Eye Health, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom8International Centre for Evidence in Disability, London School of Hyg.
authors.forename: Hannah
authors.initials: H
authors.lastname: Kuper
authors.affiliation: International Centre for Eye Health, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom3National Institute for Health Research, Biomedical Research Centre, U.
authors.forename: Matthew
authors.initials: M
authors.lastname: Burton
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003941:Diagnostic Techniques, Ophthalmological / Q000295:instrumentation*; D005260:Female; D006801:Humans; D007630:Kenya; D008297:Male; D008875:Middle Aged; D009184:Mydriatics / Q000008:administration & dosage; D015588:Observer Variation; D009898:Optic Disk / Q000473:pathology*; D009901:Optic Nerve Diseases / Q000175:diagnosis*; D010781:Photography / Q000295:instrumentation*; D011680:Pupil / Q000187:drug effects; D012016:Reference Values; D015203:Reproducibility of Results; D000068997:Smartphone / Q000295:instrumentation*
chemical_list: D009184:Mydriatics