title: A comparative evaluation of digital imaging, retinal photography and optometrist examination in screening for diabetic retinopathy.
abstract: OBJECTIVE
  To compare the respective performances of digital retinal imaging, fundus photography and slit-lamp biomicroscopy performed by trained optometrists, in screening for diabetic retinopathy. To assess the potential contribution of automated digital image analysis to a screening programme.
  
  
  METHODS
  A group of 586 patients recruited from a diabetic clinic underwent three or four mydriatic screening methods for retinal examination. The respective performances of digital imaging (n=586; graded manually), colour slides (n=586; graded manually), and slit-lamp examination by specially trained optometrists (n=485), were evaluated against a reference standard of slit-lamp biomicroscopy by ophthalmologists with a special interest in medical retina. The performance of automated grading of the digital images by computer was also assessed.
  
  
  RESULTS
  Slit-lamp examination by optometrists for referable diabetic retinopathy achieved a sensitivity of 73% (52-88) and a specificity of 90% (87-93). Using two-field imaging, manual grading of red-free digital images achieved a sensitivity of 93% (82-98) and a specificity of 87% (84-90), and for colour slides, a sensitivity of 96% (87-100) and a specificity of 89% (86-91). Almost identical results were achieved for both methods with single macular field imaging. Digital imaging had a lower technical failure rate (4.4% of patients) than colour slide photography (11.9%). Applying an automated grading protocol to the digital images detected any retinopathy, with a sensitivity of 83% (77-89) and a specificity of 71% (66-75) and diabetic macular oedema with a sensitivity of 76% (53-92) and a specificity of 85% (82-88).
  
  
  CONCLUSIONS
  Both manual grading methods produced similar results whether using a one- or two-field protocol. Technical failures rates, and hence need for recall, were lower with digital imaging. One-field grading of fundus photographs appeared to be as effective as two-field. The optometrists achieved the lowest sensitivities but reported no technical failures. Automated grading of retinal images can improve efficiency of resource utilization in diabetic retinopathy screening.
authors.affiliation: Department of Ophthalmology, The Eye Clinic, Aberdeen Royal Infirmary, Grampian University Hospitals NHS Trust, Aberdeen, UK. j.olson@arh.grampian.scot.nhs.uk
authors.forename: J A
authors.initials: JA
authors.lastname: Olson
authors.forename: F M
authors.initials: FM
authors.lastname: Strachan
authors.forename: J H
authors.initials: JH
authors.lastname: Hipwell
authors.forename: K A
authors.initials: KA
authors.lastname: Goatman
authors.forename: K C
authors.initials: KC
authors.lastname: McHardy
authors.forename: J V
authors.initials: JV
authors.lastname: Forrester
authors.forename: P F
authors.initials: PF
authors.lastname: Sharp
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003930:Diabetic Retinopathy / Q000175:diagnosis*; D003941:Diagnostic Techniques, Ophthalmological; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods*; D008875:Middle Aged; D009907:Optometry / Q000379:methods; D010781:Photography / Q000379:methods*; D012680:Sensitivity and Specificity