Intergrader Agreement for Diabetic Retinopathy (DR) using Hand-Held Retinal Imaging

Paolo S Silva, Recivall Pascual Salongcay, Lizzie Anne Aquino, Claude Salva, Jennifer K Sun, Tunde Peto, Lloyd Paul Aiello

Research output: Contribution to journalMeeting abstractpeer-review


Purpose : To assess intergrader agreement when interpreting retinal images acquired with handheld retinal imaging devices for DR screening.

Methods : Mydriatic retinal images acquired using 3 hand-held retinal cameras [Aurora (AU), Smartscope (SS), RV700 (RV)] were compared with Early Treatment Diabetic Retinopathy Study 7-field standard photography (ETDRS photos). All handheld retinal images were independently evaluated by 2 grader-certified nonphysician staff and 1 retina specialist (RPS). The ETDRS photos were evaluated by a senior retina specialist (PSS). All graders had completed a structured certification program in DR assessment. Grading was performed using the International Classification for DR. Agreement was measured using kappa (k) statistics, multirater k across graders and sensitivity/specificity was calculated for vision threatening DR [(vtDR): severe NPDR or worse].

Results : Images from 177 eyes of 92 patients with diabetes were evaluated. Severity by ETDRS photos: no DR 40.1%, mild NPDR 19.2%, moderate 14.7%, severe 10.2%, proliferative DR 15.8%. Ungradable rate for DR was AU: 0%; SS: 4.5%; RV: 4.0%; and ETDRS: 0%. Results are presented in table 1. Multirater κ for DR severity (0.58 – 0.65) and vtDR (0.71 – 0.74) was uniform across all devices. Agreement (κ) for DR severity between ETDRS photos and graders was similar across nonphysician graders across devices (0.46 – 0.48) and highest with retina specialist evaluation across devices (0.70-0.78). Sensitivity/specificity for vtDR on ETDRS photo for nonphsician graders was over 0.95 in all devices but specificity was 0.87-0.89. Retina specialist specificity for vtDR was 0.96-0.97.

Conclusions : In assessing DR severity, substantial over-all agreement (0.58-0.74) among all graders was achieved emphasizing the benefit of a structured program of grading certification. Retinal images obtained using all 3 handheld cameras achieved the highest agreement with ETDRS photos (0.70-0.78) when evaluated by a retinal specialist. Among the nonphysician graders for all devices, sensitivity for vtDR was over 90% but specificity remained 87-89%. These findings suggest that in DR screening programs using hand-held retinal imaging, secondary grading of eyes with vtDR by more experienced graders may be necessary to minimize unnecessary referrals that would otherwise decrease the effectiveness of screening programs.
Original languageEnglish
JournalInvestigative Opthalmology and Visual Science
Issue number8
Publication statusPublished - 01 Jun 2021
EventAssociation for Research in Vision and Ophthalmology (ARVO) 2021 -
Duration: 01 May 202107 May 2021


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