title: Is screening with digital imaging using one retinal view adequate?
abstract: OBJECTIVE
  To compare the detection of diabetic retinopathy from digital images with slit-lamp biomicroscopy, and to determine whether British Diabetic Association (BDA) screening criteria are attained (>80% sensitivity, >95% specificity, &<5% technical failure).
  
  
  METHODS
  Diabetics referred for screening were studied in a prospective fashion. A single 45 degrees fundus image was obtained using the nonmydriatic digital camera. Each patient subsequently underwent slit-lamp biomicroscopy and diabetic retinopathy grading by a consultant ophthalmologist. Diabetic retinopathy and maculopathy was graded according to the Early Treatment of Diabetic Retinopathy Study.
  
  
  RESULTS
  A total of 145 patients (288 eyes) were identified for screening. Of these, 26% of eyes had diabetic retinopathy, and eight eyes (3%) had sight-threatening diabetic retinopathy requiring treatment. The sensitivity for detection of any diabetic retinopathy was 38% and the specificity 95%. There was a 4% technical failure rate. There were 42/288 false negatives and 10/288 false positives. Of the 42 false negatives, 18 represented diabetic maculopathy, 20 represented peripheral diabetic retinopathy and four eyes had both macular and peripheral changes. Three eyes in the false-negative group (1% of total eyes) had sight-threatening retinopathy. There was good concordance between the two consultants (79% agreement on slit-lamp biomicroscopy and 84% on digital image interpretation).
  
  
  CONCLUSIONS
  The specificity value and technical failure rate compare favourably with BDA guidelines. The low sensitivity for detection of any retinopathy reflects failure to detect minimal maculopathy and retinopathy outside the 45 degrees image. This could be improved by an additional nasal image and careful evaluation of macular images with a low threshold for slit-lamp biomicroscopy if image quality is poor.
authors.affiliation: Department of Ophthalmology, Hinchingbrooke Hospital, Hinchingbrooke Park, Huntingdon, Cambridgeshire, UK. helen.herbert@ntlworld.com
authors.forename: H M
authors.initials: HM
authors.lastname: Herbert
authors.forename: K
authors.initials: K
authors.lastname: Jordan
authors.forename: D W
authors.initials: DW
authors.lastname: Flanagan
mesh_terms: D003930:Diabetic Retinopathy / Q000175:diagnosis*; D005188:False Negative Reactions; D005189:False Positive Reactions; D006801:Humans; D008403:Mass Screening / Q000379:methods*; D010781:Photography / Q000379:methods*; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012680:Sensitivity and Specificity