To assess the utility of a universal smartphone attachment to capture images of the anterior segment of the eye, we conducted a retrospective analysis of 344 images captured using a smartphone by the patients to identify factors affecting image quality, such as lack of perspective, lack of focus, improper illumination, and resolution. Based on this analysis, a universal smartphone attachment named GrabiTMLite and a protocol for anterior segment imaging were designed and validated in the first prospective arm of 60 patients. These images were then compared with the same eyes imaged on the gold standard slit-lamp photography. In the second prospective arm, nine patients were trained to use the GrabiTM Lite with the imaging protocol, and the images were assessed for utility in arriving at a diagnosis. A total of 178 images were analyzed using a questionnaire by masked observers. The images were evaluated based on their quality and suitability in clinical decision-making, risk stratification for triage for referral to a tertiary eye care centre. The quality of 344 images captured by patients using only their smartphone was rated as good 24 (7%), average 209 (60.8%), and poor in 111 (32.2%). Of these, 55 (16%) images were deemed suitable for clinical decision-making, and 224 (65.6%) images were adequate for risk stratification. Lack of perspective, focus, illumination, and resolution were seen in 167 (51.2%), 284 (87.1%), 226 (69.3%), and 126 (38.7%) images, respectively. These metrics improved in the next iteration of 178 images captured by patients using Grabi Lite + imaging protocol to good 103 (57%), average 58 (32.6%), and bad 17 (19.6%) (p < .001 using chi-square test). Images deemed suitable for clinical decision-making, and risk stratification for triage also improved to 80 (45%), 158 (88.8%) (p < .001 using chi-square test), respectively. Adherence to protocol was seen in 98 (55.5%) images, of which all were suitable for risk stratification, while of these images, 66 (67.3%) were eligible for clinical decision making. In comparison with slit-lamp photography, out of 120 responses by masked observers to images captured by GrabiTM Lite with the imaging protocol, 63 (52.85%) were suitable for clinical decision-making, and 68 (57%) were graded to be between 70 and 99% of the quality of the slit lamp photographs. The GrabiTM lite with imaging protocol training is an effective tool to improve anterior segment imaging, potentially allowing smartphone use for teleconsultations. This device may serve as a universal solution for all smartphones with the patient as the user and is of value in the future of tele-ophthalmology.
Keywords: Anterior segment imaging; Ophthalmic imaging with a smartphone; Smartphone attachment; Smartphone imaging.