To evaluate if simple- or multiple-field digital color nonmydriatic (NM) retinal images
can replace 7 standard stereoscopic fundus photographs in the screening of diabetic
retinopathy (DR).
Prospective, masked, comparative case series.
One hundred and eight eyes of 55 diabetics were studied to determine single lesions
and to grade clinical levels of DR and diabetic macular edema (DME) using both 1 and
3 NM digital color retinal images compared with the Early Treatment Diabetic Retinopathy
Study (ETDRS) 7 standard 35-mm stereoscopic color fundus photographs (7F-ETDRS). All
eyes underwent NM 45-degree field images of 1 central field (1F-NM), NM 45-degree
field images of 3 fields (3F-NM), and, after pupil dilatation, 30-degree 7F-ETDRS
photography. Images were analyzed by 2 independent, masked retinal specialists (S.V.
and E.B.), lesion-by-lesion according to the ETDRS protocol and for clinical severity
level of DR and DME according to the international classification of DR.
Using 7F-ETDRS as the gold standard, agreement was substantial for grading clinical
levels of DR and DME (kappa = 0.69 and kappa = 0.75) vs 3F-NM; moderate for DR level
(kappa = 0.56) and substantial for DME (kappa = 0.66) vs 1F-NM; almost perfect for
detecting presence or absence of DR (kappa = 0.88) vs both 1F-NM and 3F-NM; and almost
perfect for presence or absence of DME (kappa = 0.97) vs 3F-NM and substantial (kappa
= 0.75) vs 1F-NM. Sensitivity and specificity for detecting referable levels of DR
were 82% and 92%, respectively, for 3F-NM and 71% and 96%, respectively, for 1F-NM.
Three color 45-degree NM fundus fields may be an effective tool in a screening setting
to determine critical levels of DR and DME for prompt specialist referral. One central
45-degree image is sufficient to determine absence or presence of DR and DME, but
not for grading it.