Low-Cost, Smartphone-Based Specular Imaging and Automated Analysis of the Corneal Endothelium

PURPOSE: Specular and confocal microscopes are important tools to monitor the health of the corneal endothelium (CE), but their high costs significantly limit accessibility in low-resource environments. We developed and validated a low-cost, fully automated method to quantitatively evaluate the CE using smartphone-based specular microscopy. METHODS: A OnePlus 7 Pro smartphone attached to a Topcon SL-D701 slit-lamp was used to image the central corneal endothelium of 30 eyes using the specular reflection technique. A novel on-device image processing algorithm automatically computed endothelial cell density (ECD), percentage of hexagonal cells (HEX), and coefficient of variation (CV) values. These values were compared with the ECD, HEX, and CV generated by a Tomey EM-4000 specular microscope used to image the same set of eyes. RESULTS: No significant differences were found in ECD (2799 ± 156 cells/mm(2) vs. 2779 ± 166 cells/mm(2); P = 0.28) and HEX (52 ± 6% vs. 53 ± 6%; P = 0.50) computed by smartphone-based specular imaging and specular microscope, respectively. A statistically significant difference in CV (34 ± 3% vs. 30 ± 3%; P < 0.01) was found between the two methods. The concordance achieved between the smartphone-based method and the Tomey specular microscope is very similar to the concordance between two specular microscopes reported in the literature. CONCLUSIONS: Smartphone-based specular imaging and automated analysis is a low-cost method to quantitatively evaluate the CE with accuracy comparable to the clinical standard. TRANSLATIONAL RELEVANCE: This tool can be used to screen the CE in low-resource regions and prompt investigation of suspected corneal endotheliopathies.