title: Digital versus film Fundus photography for research grading of diabetic retinopathy severity.
abstract: OBJECTIVE
  To assess agreement between digital and film photography for research classification of diabetic retinopathy severity.
  
  
  METHODS
  Digital and film photographs from a 152-eye cohort with a full spectrum of Early Treatment Diabetic Retinopathy Study (ETDRS) severity levels were assessed for repeatability of grading within each image medium and for agreement on ETDRS discrete severity levels, ascending severity thresholds, and presence or absence of diabetic retinopathy index lesions, between digital and 35-mm slides (film). Digital photographs were color balanced to match film.
  
  
  RESULTS
  There was substantial agreement (κ = 0.61, κ(w) [linear weighted] = 0.87) in classification of ETDRS diabetic retinopathy severity levels between digital images and film. Marginal homogeneity analyses found no significant difference in frequency distributions on the severity scale (P = 0.21, Bhapkar test). The κ results ranged from 0.72 to 0.95 for presence or absence of eight ascending diabetic retinopathy severity thresholds. Repeatability of grading between readers viewing digital images was equal to or better than that obtained with film (pair-wise interreader κ for digital images ranged from 0.47 to 0.57 and for film from 0.43 to 0.57. The κ results for identifying diabetic retinopathy lesions ranged from moderate to almost perfect. Moderate agreement of intraretinal microvascular abnormalities and venous beading between digital images and film accounted for slightly lower concordance for severity thresholds ≥47 and for slightly lower interreader agreement within digital and film images at severity thresholds ≥43 and ≥47.
  
  
  CONCLUSIONS
  Under controlled circumstances, digital photography can equal the reliability of 35-mm slides for research classification of ETDRS severity level.
authors.affiliation: School of Biomedical Informatics, University of Texas Health Science Center, Houston, Texas, USA. hlimed@mac.com
authors.forename: Helen K
authors.initials: HK
authors.lastname: Li
authors.forename: Larry D
authors.initials: LD
authors.lastname: Hubbard
authors.forename: Ronald P
authors.initials: RP
authors.lastname: Danis
authors.forename: Adol
authors.initials: A
authors.lastname: Esquivel
authors.forename: Jose F
authors.initials: JF
authors.lastname: Florez-Arango
authors.forename: Nicola J
authors.initials: NJ
authors.lastname: Ferrier
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Krupinski
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003922:Diabetes Mellitus, Type 1 / Q000150:complications; D003924:Diabetes Mellitus, Type 2 / Q000150:complications; D003930:Diabetic Retinopathy / Q000145:classification*; D003941:Diagnostic Techniques, Ophthalmological; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D010781:Photography / Q000379:methods*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D012815:Signal Processing, Computer-Assisted