title: Grading fluorescein angiograms in malarial retinopathy.
abstract: BACKGROUND
  Malarial retinopathy is an important finding in Plasmodium falciparum cerebral malaria, since it strengthens diagnostic accuracy, predicts clinical outcome and appears to parallel cerebral disease processes. Several angiographic features of malarial retinopathy have been described, but observations in different populations can only be reliably compared if consistent methodology is used to capture and grade retinal images. Currently no grading scheme exists for fluorescein angiographic features of malarial retinopathy.
  
  
  METHODS
  A grading scheme for fluorescein angiographic images was devised based on consensus opinion of clinicians and researchers experienced in malarial retinopathy in children and adults. Dual grading were performed with adjudication of admission fluorescein images from a large cohort of children with cerebral malaria.
  
  
  RESULTS
  A grading scheme is described and standard images are provided to facilitate future grading studies. Inter-grader agreement was >70 % for most variables. Intravascular filling defects are difficult to grade and tended to have lower inter-grader agreement (>57 %) compared to other features.
  
  
  CONCLUSIONS
  This grading scheme provides a consistent way to describe retinal vascular damage in paediatric cerebral malaria, and can facilitate comparisons of angiographic features of malarial retinopathy between different patient groups, and analysis against clinical outcomes. Inter-grader agreement is reasonable for the majority of angiographic signs. Dual grading with expert adjudication should be used to maximize accuracy.
authors.affiliation: Department of Eye and Vision Science, University of Liverpool, Liverpool, UK. ian.maccormick@gmail.com.|Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi. ian.maccormick@gmail.com.|Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK. ian.maccormick@gmail.com.
authors.forename: Ian J C
authors.initials: IJ
authors.lastname: MacCormick
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. richardmaude@gmail.com.|Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK. richardmaude@gmail.com.|College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK. richardmaude@gmail.com.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Maude
authors.affiliation: Department of Eye and Vision Science, University of Liverpool, Liverpool, UK. N.Beare@liverpool.ac.uk.|St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK. N.Beare@liverpool.ac.uk.
authors.forename: Nicholas A V
authors.initials: NA
authors.lastname: Beare
authors.affiliation: Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK. shyamanga@aol.com.|Department of Ophthalmology, University of Edinburgh, Edinburgh, UK. shyamanga@aol.com.|Princess Alexandra Eye Pavilion, Edinburgh, UK. shyamanga@aol.com.
authors.forename: Shyamanga
authors.initials: S
authors.lastname: Borooah
authors.affiliation: School of Medicine, University of St Andrews, St Andrews, UK. simonglover@doctors.org.uk.
authors.forename: Simon
authors.initials: S
authors.lastname: Glover
authors.affiliation: Liverpool Ophthalmic Reading Centre, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK. David.Parry@rlbuht.nhs.uk.
authors.forename: David
authors.initials: D
authors.lastname: Parry
authors.affiliation: Liverpool Ophthalmic Reading Centre, St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK. Sophie.Leach@rlbuht.nhs.uk.
authors.forename: Sophie
authors.initials: S
authors.lastname: Leach
authors.affiliation: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi. mmolyneux999@gmail.com.|Liverpool School of Tropical Medicine, Liverpool, UK. mmolyneux999@gmail.com.
authors.forename: Malcolm E
authors.initials: ME
authors.lastname: Molyneux
authors.affiliation: Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK. Baljean.Dhillon@ed.ac.uk.|Department of Ophthalmology, University of Edinburgh, Edinburgh, UK. Baljean.Dhillon@ed.ac.uk.|Princess Alexandra Eye Pavilion, Edinburgh, UK. Baljean.Dhillon@ed.ac.uk.
authors.forename: Baljean
authors.initials: B
authors.lastname: Dhillon
authors.affiliation: Kilimanjaro Centre for Community Ophthalmology, Cape Town, South Africa. slewallen@kcco.net.
authors.forename: Susan
authors.initials: S
authors.lastname: Lewallen
authors.affiliation: Department of Eye and Vision Science, University of Liverpool, Liverpool, UK. s.p.harding@liv.ac.uk.|St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK. s.p.harding@liv.ac.uk.
authors.forename: Simon P
authors.initials: SP
authors.lastname: Harding
mesh_terms: D000328:Adult; D000792:Angiography / Q000379:methods*; D005260:Female; D019793:Fluorescein / Q000032:analysis; D006801:Humans; D007091:Image Processing, Computer-Assisted / Q000379:methods*; D016779:Malaria, Cerebral / Q000150:complications*; D016778:Malaria, Falciparum / Q000150:complications*; D008297:Male; D008875:Middle Aged; D012164:Retinal Diseases / Q000175:diagnosis* / Q000473:pathology*; D012720:Severity of Illness Index; D013194:Staining and Labeling / Q000379:methods*
chemical_list: D019793:Fluorescein