Residents versus experts in interpreting standard Scheimpflug imaging for the diagnosis of keratoconus

PurposeTo evaluate the diagnostic performance of final-year ophthalmology residents in classifying keratoconus using standard Scheimpflug corneal tomography and to compare their accuracy to that of experienced corneal specialists.DesignProspective, investigator-initiated, multicenter observational study.MethodsFive final-year residents assessed 1,239 anonymized Pentacam HR (Oculus GmbH, Germany) quad-map outputs, categorized as normal, suspect keratoconus, or keratoconus, previously obtained from 620 pediatric patients in a prior population-based imaging study. Two corneal experts independently established the reference standard. Residents rated their diagnostic confidence using Likert scales. Agreement was quantified using Cohen's kappa (κ) and Fleiss's κ.ResultsResident-to-expert agreement ranged from Cohen's κ = 0.031 to 0.324 (slight to fair). Overall inter-rater reliability across all raters was slight, Fleiss's κ = 0.088. Four residents rated their diagnostic skill as neutral; one rated it as poor. Self-assessed competence relative to peers was rated as neutral by three residents and good by two.ConclusionsFinal-year ophthalmology residents showed limited agreement with expert graders when interpreting Scheimpflug images. The alignment between self-assessed confidence and measured diagnostic performance highlights a potential educational gap in image-based diagnosis of ectatic corneal disease. These findings support the need for competency-based curricular enhancements, including image interpretation benchmarks, expert-guided calibration sessions, and simulation-based learning modules, aiming to improve diagnostic accuracy and support earlier detection of keratoconus. Further multicenter studies are needed to validate these results and guide national and international training strategies.