Background Visual impairment from diabetic retinopathy (DR) is an increasing global public health concern, which is preventable with screening and early treatment. Digital retinal imaging has become a preferred choice as it enables higher coverage of screening. The aim of this review is to evaluate how different characteristics of the DR screening (DRS) test impacts on diagnostic test accuracy (DTA), and its relevance to a low-income setting. Methods We conducted a systematic literature search to identify clinic-based studies on DRS using digital retinal imaging of people with DM (PwDM). Summary estimates of different sub groups were calculated using DTA values weighted according to the sample size. The DTA of each screening method was derived after exclusion of ungradable images and considering eye as the unit of analysis. The meta-analysis included studies which measured DTA of detecting any level of DR. We also examined the effect on detection from using different combinations of retinal fields, pupil status, index test graders and setting. Results 6646 titles and abstracts were retrieved, and data extracted from 122 potentially eligible full reports. Twenty-six studies were included in the review and 21 studies, mostly from high income settings (18/21, 85.7%), were included in the meta-analysis. The highest sensitivity was observed in mydriatic >2 field strategy (92%, 95% CI 90-94%). The highest specificity was observed in >2 field methods (94%, 95% CI 93-96%) where mydriasis did not affect specificity. Overall, there was no difference in sensitivity between non-mydriatic and mydriatic methods (86%, 95% CI 85-87) after exclusion of ungradable images. The highest DTA (sensitivity 90%, 95% CI 88-91%; specificity 95%, 95% CI 94-96%) was observed when screening was delivered at secondary/tertiary level clinics. Conclusions Non-mydriatic 2-field strategy could be a more pragmatic approach in starting DRS programs for facility based PwDM in low-income settings, with dilatation of pupils of those who have ungradable images. There was insufficient evidence in primary studies to draw firm conclusions on how graders’ background influences DTA. Conducting more context specific DRS validation studies in low-income and non-ophthalmic settings can be recommended.