## 4 Discussion
Consequently, care should be taken in diseased retinas containing areas of atrophy. In atrophic areas, the expected cone count is extremely low, and therefore signal-to-noise ratio is unfavorable. To avoid selecting ROIs in regions of atrophy, operators can utilize the SPECTRALIS(tm) multimodal imaging platform and acquire an (en-face) OCT of the corresponding retinal area in addition to the high magnification module image. A drawback of our study is the current lack of a golden standard regarding cone identification. Only a limited high magnification module training set was available to train human graders. This may be one reason why the Bland-Altman analysis revealed statistically significant differences in agreement between human graders. On the other hand, we found a good intergrader correlation, and we were able to quantify cones in a plausible manner automatically. Both graders had at least four months of experience in high magnification module imaging and achieved good to excellent intragrader and intergrader consistency. Nevertheless, the validation of our results by large image samples with test and validation sets is indispensable. In conclusion, a regular quantitative cone analysis on high magnification module images is feasible manually by human graders and reliable automatically by a filter-based algorithm. Larger datasets are needed to improve repeatability and consistency by training human graders and validating spatial and disease-related automated cone analyses. We hope that our presented methodology facilitates and encourages researchers to further improve automated cone analyses on high magnification module imaging. **Supplementary Materials:** The following are available online at [[https://www.mdpi.com/article/10.3390/app11125347/s1](https://www.mdpi.com/article/10.3390/app11125347/s1)]([https://www.mdpi.com/article/10.3390/app11125347/s1](https://www.mdpi.com/article/10.3390/app11125347/s1)). * [1]**Author Contributions:** Conceptualization, T.T. and C.B.H. ; Methodology, T.M. and T.T. ; Software, T.M. ; Validation, T.M., P.D. and T.T. ; Formal Analysis, T.M. ; Investigation, T.M. and L.v.d.Z. ; Resources, C.B.H. and T.T. Data Curation, T.M. ; Writing--Original Draft Preparation, T.M. ; Writing--Review and Editing, T.T., P.D., L.v.d.Z. and C.B.H. ; Visualization, T.M. and P.D. ; Supervision, T.T. and C.B.H. ; Project Administration, T.T. ; Funding Acquisition, P.D., T.T. and C.B.H. All authors have read and agreed to the published version of the manuscript. * [2]**Funding:** This work was supported by Stichting A.F. Deutman Oogheelkunde Researchfonds (SAF-DOR), Nijmegen, The Netherlands; Landelijke Stichting voor Blinden en Slechtzienden (LSBS), Ede, The Netherlands; Algemene Nederlandse Vereniging ter voorkoming van blindheid (ANVVB), Doorn, The Netherlands; Oogfonds, Utrecht, The Netherlands; Stichting Beheer Het Schild, Wolfheze, The Netherlands. * [3]**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of Radboudumc (protocol code 2017-3535, approval data: 28 January 2021). * [4]**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study. * [5]**Data Availability Statement:** Data are contained within the article and Supplementary Materials. * [6]**Conflicts of Interest:** The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.