1

Fundus Screening Assessment Manual
Introduction
Visual impairment is not only an important health problem, but also a significant issue that may lead toincrements in medical expenses and the number of people involved in medical care in Japan.1,2 Eyediseases listed as major causes of blindness include glaucoma, diabetic retinopathy, and age-related
macular degeneration in adult Japanese individuals. Early detection of these blinding eye diseases may
be benefited to prevent blindness or serious visual impairment by initiating treatments at an appropriate
timing. Fundus screening for this purpose is non-invasive and simple, and is performed with a fundus
camera without mydriasis. In addition, fundus screening by screening by retinal images can provide
screening for multiple eye diseases at aa time ensuring its cost effectiveness. Fundus images also provide
an opportunity to serve as part of cardiovascular risk assessment. Screening for eye diseases, inparticular age-related eye diseases causing blindness in an adult population meets the requirements for
successful disease screening proposed by the World Health Organization in 1968 (Table 1).
In Japan, fundus examination has been used to evaluate microvascular damage as one of the target-organ
damages associated with hypertension; therefore, it has been performed as part of cardiovascular
screening. On the other hand, systemic fundus screening aiming to achieve early detection andprevention of eye diseases has been performed scarcely. The opportunity for systemic eye disease
screening is limited to date. In 2008, fundus examination has been deleted from the essential items in
the Specific Health Checkup program, the public and systemic health screening program provided byhealth insurer. Opportunistic health insurer screening such as the “Ningen Dock” program in Japan plays
therefore an important role providing an opportunities for both cardiovascular assessment of
microvascular target-organ damage in the retina as well as a screening for blinding eye diseases aiming
to blindness prevention.
Here, the Japan Society of Ningen Dock and the Japan Ophthalmological Society revised the Fundus
Screening Assessment Manual to update classifications of retinal vascular signs as part of cardiovascular
screening with risk categories matched with specific recommendations; updated classification of eyediseases such as diabetic retinopathy, glaucoma, and age-related macular degeneration are provided
following the latest evidence.

1) Retinal vascular signs in cardiovascular disease screening (Tables 2, 3, and 43)
Assessment criteria for hypertensive fundus findings include Scheie’s classification (Table 2) and theKeith-Wagener classification modified by Keio University (Table 3). Along with the improvement in
the management of hypertension in the modern era, the number of patients with severe retinal findings
has decreased. There have been scarce updates on the evidence for those who have mild findings inthese classifications toto date, and there is a criticism that there has been no updated recommendation
specific to each fundus signs to be used in a clinical practice, where the meaning of those milder signs
are not definitive in the management of hypertension and cardiovascular risk factors

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In recent years, there is an accumulated evidence regarding retinal vascular signs and hypertension or
atherosclerotic diseases from large-scale epidemiological studies mainly in Western countries. Also,
there are population-based cohort studies reporting that risk of incident cardiovascular disease such as
stroke increases up to 2-fold in individuals with fundus findings of Keith-Wagener classification grade
1 to 2 (i.e., arteriolar narrowing, arterio-venous crossing, and increased reflex), more than 2-fold inindividuals with findings corresponding to Keith-Wagener classification grade 3 (i.e., retinal
hemorrhages and exudates known as hypertensive retinopathy), and that those with Keith-Wagener
classification grade 4 (i.e., papilledema) have risk of increased cardiovascular death. Based on such
updated evidence, Wong-Mitchell proposed a new simplified classification where severity of fundus
findings is matched to risks of cardiovascular disease (Table 4).4 Treatment Guidelines for Hypertension
2014 also lists hypertensive retinopathy corresponding to Keith-Wagener Classification grade 3 or more,which corresponds to “moderate” in Wong-Mitchell classification as an organ damage caused byhypertension and can be a “prognostic factor used in risk stratification for hypertension management
plan,”5. Based on the recommendation in the guideline, for example, immediate consideration of
hypotensive medication is recommended for even a case of high normal blood pressure (130-139/85-89
mmHg) in addition to instruction of lifestyle adjustment if “hypertensive retinopathy” is present. The
Wong-Mitchell classification provides a simplified evidence-based classification to fully utilize fundus
assessmentin

cardiovascular

screening.

Comparisons

betweenclassificationsofhypertensive/arteriosclerotic retinal vascular findings are shown in Table 4.

2)Fundus screening in diabetes patients and individuals suspected to havediabetes (Table 5)
Diabetic retinopathy is a microangiopathy in patients with diabetes. Because early diabetic retinopathy
presents little or no subjective symptoms, health screening can be an opportunity to detect diabetic
retinopathy. For an individual who has already been diagnosed as having diabetes mellitus, however, it
is recommended to have detailed fundus examination with pupil dilation by ophthalmologists on regularbasis, and simplified fundus screening in a health screening program is not sensitive enough to capture
the disease and potentially overlook diabetic retinopathy. Health screening providers should share thisfact with all individuals with diabetes having simplified fundus screening in a health screening program.
Evidence-Based Medical Care Guideline for Diabetes Mellitus 20136 states “patients should visit anophthalmologist to be evaluated for presence of diabetic retinopathy” if they are definitely diagnosed ashaving diabetes mellitus, and “thereafter, it is desirable to have regular consultation at least once a year,
and having consultations in shorter intervals is advisable for cases at risk.” Here, consultation by
ophthalmologists is recommended for patients who have already been diagnosed as having diabetes
because fundus photographs without mydriasis commonly used in a health screening program have riskof overlooking diabetic retinopathy in the peripheral retina. Hence, once a patient is diagnosed as having
diabetes, he/she should be recommended to have thorough fundoscopy with mydriasis immediately andregularly by an ophthalmologist instead of relying on the results of fundoscopy in the health screening.
Because diabetic retinopathy may be present even in individuals with prediabetes or new-onset diabetes,
fundoscopy in a health screening program could be valuable in such patients.

3Classifications of diabetic retinopathy include Scott’s classification, New Fukuda classification, andmodified Davis classification. Scott’s classification is no longer used in the clinical ophthalmology,
because it does not match current understandings of pathology and progression pattern. New Fukuda
classification is capable of providing detailed categorization. However, in a health screening program,
most cases of diabetic retinopathy are at mild stage, and a simpler assessment would be sufficient.
Modified Davis classification is simple and roughly classifies into 4 stages: no retinopathy, simple
retinopathy, pre-proliferative retinopathy, and proliferative retinopathy. In recent years, International
Severity Classification has been proposed as a classification linking severities and their corresponding
evidence (Table 5).7 This classifies the severity of diabetic retinopathy into non-proliferative retinopathy
and proliferative retinopathy, and then non-proliferative retinopathy is further classified into mild,moderate, and severe. It is based on the Early Treatment Diabetic Retinopathy Study (ETDRS)
classification that is often used in clinical studies, and this allows to match the evidence from a numberof clinical studies into clinical practice. Comparisons of classifications for diabetic retinopathy anddiabetic maculopathy are shown in Tables 5A and 5B.8

3) Fundus screening for early detection and prevention of ocular diseases
3-1) Glaucoma
Glaucoma is a common eye disease in Japanese older than 40 years with a prevalence as high as 5.0%
and is the most frequent cause frequent of blindness in Japan.9 Prevalence of glaucoma increases withage, and it is expected to continue to increase with accelerated population aging in Japan. In the Tajimi
Study, only 10% of the subjects with identified as having glaucoma had been diagnosed at the time ofscreening. Hence, eye screening can be an important opportunity to screen patients with asymptomaticglaucoma.
In health screening, suspected glaucoma is assessed based on evaluation of optic disc on a fundus
photograph in addition to intra-ocular pressure measurement. The optic disc cupping is evaluated bydefining the ratio of the maximum vertical diameter of optic disc cupping to the maximum vertical
diameter of the optical disc as vertical C/D ratio, and considering the ratio ≥0.7 as suspected glaucoma.
The area between the outer edge of the optic disc and the outer edge of the optic disc cupping is referred
to as rim. The ratio of the width of rim to the diameter of optic disc passing through the center of thedisc is defined as R/D ratio. If the R/D ratio from the rim width in the top polar (11 to 1 o’clock direction)or the bottom polar (5 to 7 o’clock direction) is ≤0.1, it is considered to be suspected glaucoma (seeTreatment Guideline for Glaucoma p. 813 Figure).9
In addition, if there are retinal nerve fiber layer defect, optic disc hemorrhages, or other glaucomatouschange in the optic disc is observed, the case is assessed as being suspected glaucoma.
Suspected glaucoma (enlarged optic disc cupping, retinal nerve fiber layer defect, optic dischemorrhages, or glaucomatous optic disc change) is all classified in the assessment category D2:
Thorough examination needed (Table 6).
Intra-ocular pressure is the strongest association on the development of glaucoma and its progression
where the higher the intra-ocular pressure, the faster the progress of glaucoma. Thus, if a patient has
higher intra-ocular pressure at the screening, the case may have a rapid progress within a year even4
without glaucomatous change in a fundus at that time. Hence, it should be noted that assessment of afundus image is not sufficient to screen glaucoma in such cases.
3-2) Age-related macular degeneration
Age-related macular degeneration is an important cause of blindness in elderly people. There has beena report that oral anti-oxidant supplement in addition to smoking cessation is expected to reduce risk ofdeveloping the disease in persons with pre-clinical signs of age-related macular degeneration i.e.,presence of large drusen in either eye or age-related macular degeneration has already developed in one
eye. Therefore, screening for pre-clinical signs of age-related macular degeneration is desirable. The useof oral anti-oxidant supplement has been proposed by the Age-Related Eye Disease Study (AREDS).
Even in a severe case, early detection leads to maintenance of visual acuity, as well as improvement ofvisual acuity by treatment (e. g., intravitreal injection of anti-vascular endothelial cell growth factor).10
According to AREDS, oral anti-oxidant supplement is expected to reduce risk of progression if agerelated macular degeneration (wet type or dry type) has already been developed in one eye(corresponding to AREDS category 4) or having a preclinical signs of large drusen (sized ≥125 μm;
approximately corresponding to the diameter of the retinal venule running through the optic disc rim)
or a multiple smaller drusen are present (corresponding to AREDS category 3).
Assessment categories for suspected age-related macular degeneration are D2: Thorough examinationneeded for preclinical signs of age-related macular degeneration (drusen, abnormal retinal pigment
epithelium) and D1: treatment needed for age-related macular degeneration (wet type or dry type) (Table6).). (See Treatment Guidance for Age-Related Macular Degeneration).103-3) Other eye diseases
There are other eye diseases such as abnormal optic disc, suspected diabetic retinopathy (if diabetes is
not confirmed), other retinopathy findings, retinal vascular disorder, abnormal macula appearance,
chorio-retinal atrophy, myelinated nerve fiber, and others are assessed ad libitum as indicated in Table
6.
If the assessment of fundus images are difficult or impossible due to the presumed opacity of the optic
media such as cataract, are assessed as D2: thorough examination needed. If other causes are likely,
assessment category will be selected at the assessing physician’s decision.

4) Procedure for taking fundus photograph4-1) Method
Photographs should be taken by accurately focusing on the adequate field with an appropriate brightness
in a short period of time in a health screening program workflow. In a health screening, fundoscopy is
performed in most cases using a non-mydriatic digital fundus camera without pupil dilation. Fundus
photography has advantages to maintain reproducibility and objectiveness ensured through accuracy
control and unified assessment criteria, storage of examination results allowing evaluation of timedependent change or re-assessment in comparison with previous images, and short period of timerequired to complete the examination.

54-2) Image angle
Fundus photographs should be taken at the point where the center of the line connecting the optic discand the fovea of the macula, including the upper and lower vascular arcades using a fundus camera with
angle of view ≥45º. The nasal side of the optic disc is included by approximately the diameter of the
optic nerve, allowing assessment of vascular findings in all four quadrants: upper/lower temporal/nasal
quadrants with the optic disc centered. It is also desirable that the technician of fundus photography
confirms whether the image taken indicates the site suitable to assessment clearly in an appropriate
brightness on site and takes another photograph if the image is unclear.
4-3) Importance of screening fundus photographs for both eyes
Fundus photographs of both eyes should be screened for ophthalmologic diseases. If only one eye isscreened, it may overlook a number of eye diseases. Recent non-mydriatic digital fundus cameras uses
much lower flash light intensity, allowing photographing both eyes in a short interval by using a darkroom or screen. The pupils open more easily if the individual closes the eyes gently after one eye isphotographed, and then the other eye is photographed. If images taken by non-mydriatic fundus camera
resulted an image with dark region around the macula it is because the pupil was not large enough. In
such a case, the photograph is taken after waiting for sufficient time until the pupils open in a dark roomor screen. Although some fundus cameras are equipped with small pupil mode allowing their range ofphotograph is narrowed. Standardized procedure should be predetermined for such individuals withsmall pupil in advance as a standard protocol for procedures in each institution.

5) Quality control of the grading
Quality control is important to ensure that there is no significant difference in assessment between image
graders if more than one image grader is present and each image grader provides comparable assessmentwith other image graders. At the beginning of the assessment, it is helpful to confirm the assessment
criteria by using training image set and to compare the results from the same fundus photograph between
image graders to confirm the results are comparable. It is desirable that ophthalmologists or physicians
who routinely conduct ophthalmologic practice make the assessment if possible.

6) Accuracy indices for grading reproducibility, and follow-up research
It is important for both patients and screening institutions to recognize that accurate performance offundus screening is secured. It is desirable to establish a close cooperative relationship with medical
institutions providing thorough examinations. Retinal vascular lesions detected in cardiovascular
screening are useful to identify individuals with high risk of stroke or ischemic heart diseases and help
those individuals to initiate a treatment of hypertension for the primary prevention of cardiovasculardiseases. Therefore, cooperation between screening institutions and physicians for both internal
medicine and ophthalmology is also important. In diabetic retinopathy screening, cooperative work with
ophthalmologists should be needed when the disease is severe immediately after the screening,, in
addition to cooperation with diabetologists. For a screening program for eye diseases, a partnership with

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ophthalmologists is important.
It is also important to monitor the screening program with performance indices such as the prevalenceof abnormal findings, the proportion of individuals who needed secondary examinations, and the
proportion of actual attendance at the secondary examination be collected and by conducting a followup research to evaluate diagnostic accuracy such as the secondary examination, treatment status after
secondary screening, and recommendation of the secondary examination for non-attender andindividuals with past history of abnormal findings.

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Table 1. Major causes of adult blindness from the view of disease screening requirement
Important disease

Glaucoma

Diabetic retinopathy

Age-related macular degeneration

5% prevalence in the population

Diabetes prevalence is 10% in adults,

1 to 2% prevalence in the population older

older than 40 years of age. The

and retinopathy is found in 35% of thethan 50 years of age. The number of

number of patients increases indiabetic population. Without treatment,

patients increases in association withassociation with increasing elderly

diabetic retinopathy poses a great risk ofincreasing elderly population. Once it

population. Without ocular

adult blindness that not only damages

occurs, it progresses rapidly, posing a great

hypotensive treatment, it has highthe patient’s daily motion, function, andrisk of visual disorders.

risk of blindness, although it

quality of life but also increases social

progresses slowly.

burdens such as workforce loss, family
burden, and medical expenses.

Simple, accurate, and non-Fundus photograph non-invasively provides definite diagnosis. Fundus cameras have already been popularized commonly andinvasive test for diagnosis

are relatively cheap. Digital imaging is also suitable for remote diagnosis.

Post-diagnostic prevention,

Although prevention of onset ofMedical and surgical treatments have

Although prevention of onset of age-related

treatment, and rehabilitation

glaucoma is difficult, ocularbeen established for prevention of onset

macular degeneration is difficult, smoking

established.

hypotensive treatment from earlyand evolution of diabetic retinopathy andcessation is recommended for smokers.

detection, prevention of evolution,

recovery of visual acuity. Treatments at

Smoking cessation is also important inand maintenance of visual acuity andappropriate timings can prevent

prevention of evolution. In cases of AREDS

visual field has been established.

blindness in almost all cases. Now

category ≥3 or 4, anti-oxidizing supplement

improvement of visual acuity is expected.

is effective for prevention of evolution.

Early detection and post-

Simulation has demonstrated great

Simulation has demonstrated great

Simulation has demonstrated great medical

diagnostic treatment by

medical effect of screening

medical effect and cost effectiveness ofeffect of screening age-related macular

screening is cost-effective.

glaucoma.

screening diabetic retinopathy.

degeneration.

Δ Cost effectiveness requires setting

Δ Cost effectiveness requires setting ofof condition for evaluation.

condition for evaluation, because of its hightreatment expense.

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Table 2. Scheie Classification
ScheieSclerotic change (S)Characteristics ofSpecific

Assessme

Hypertensive vascularSpecific

Assessmsclerotic vessels

healthntchangehealthent*

01Hypertensive change (H)Arterial wall reflex ischeckupcheckup

code

code

1

A

2

B

Although mild diffuse

potentiated. Mildnarrowing is present inarteriovenous

the retinal arterycrossing is present.

system, caliber

1

A

2

B

3

C

4

D2

5

D2

variation is not definite.
Severe narrowing may
occasionally bepresent at the second
arterial branch or
lower.
2

Arterial wall reflex is3

B

Mild diffuse narrowing

severely potentiatedof retinal artery is mild

with moderateor severe witharteriovenous

additional definite

crossing.

localized narrowing
with caliber variation.

3

4

Copper wire artery,4

C

Narrowing artery andthat is, the artery

caliber variation

changed in its color

become more

and radiance to aprominent and seem

copper wire-like

like thread. Either orappearance.

both of bleeding andArteriovenous

white patches appear

crossing is severe.

on the retinal surface.

The arterial wall

5

C

Papilledema of various

looks like silver wireseverities is present in(silver wire artery)

addition to the 3rdor white wire indegree findings.

some cases.
*Select taking age and arteriosclerosis risk factor into consideration.
Assessment categories A: Normal, B: Mild abnormality without problems, C: Following up needed, D: Medicalcare needed (D1: Treatment needed, D2: Thorough examination needed), and E: Under treatment.

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Table 3. Keith-Wagener Classification
FundusClassification

Fundus findings

diseaseNormalGroup I
Hypertensive

Group IIaSpecific health

Assessment

checkup code*

S0H0 without findings

1

A

Mild narrowing and sclerosis of arteriole (modified Scheie I)

2

B

Obvious arteriosclerosis (modified Scheie II or higher) with narrowing

3

B or C

Arteriosclerotic retinopathy or retinal vein occlusion in addition to the above

4

D2

Vasospastic retinopathy is present in addition to marked sclerotic change.

5

D2

6

D2

severer than Group I
bGroup III

Retinal edema, cotton wool patches, and bleeding are present with marked
arterial narrowing.
Group IV

Papilledema severer than measurable degree in addition to the findings in
the above Group III*Select taking age and arteriosclerosis risk factor into consideration.
Assessment categories A: Normal, B: Mild abnormality without problems, C: Following up needed, D: Medical care needed (D1: Treatment needed,
D2: Thorough examination needed), and E: Under treatment.

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Table 4. Table of correspondence between hypertensive retinal vascular lesion classifications by Wong-Mitchell and Scheie
Classification
Classification

Findings

Relationship to systemic

Assessment*

Keith-Wagener

Scheieclassification

classification**A

Group 0

H0S0

B or CGroup I/II

H0S1-4diseasesNone

No findings

None

Mild

Diffuse narrowing of retinal arteriole,

Increasing risks of cerebral

local narrowing/caliber variation of

apoplexy, non-syndromic

H1S0-4the retinal arteriole, arteriovenous

cerebral apoplexy, coronary

H2S0-4crossing phenomenon, and enhanced

disease, and cardiovascularreflection/opacity (copper wire artery)death (odds ratio 1 to 2)

Retinopathy findings such as retinal

High risks of cerebral apoplexy,

bleeding (patchy, spotty, flammeus),

non-syndromic cerebral

capillary aneurysm, cotton wool

apoplexy, lowered recognition,

patches, and hard exudate

and cardiovascular death (odds

Moderate

D2Group III

H3S0-4

D2Group IV

H4S0-4

ratio ≥2)***
SeverePapilledema in addition to retinopathy

High cardiovascular death risk

findings*Select taking age and arteriosclerosis risk factor into consideration.
**Retinal vascular findings may be present without hypertension. It was reported that even individuals with high normal blood pressure may have suchretinal vascular lesions and that retinal vascular lesion have relationship independent from blood pressure to future onset of hypertension andcardiovascular disease. Select categories taking into consideration age and arteriosclerosis risk factors other than blood pressure.
*** They correspond to “hypertensive retinopathy” equivalent to “B. Visceral disorders/cardiovascular diseases” of “Prognostic factors used in risk
stratification for hypertension management plan” in “Treatment Guidelines for Hypertension 2014.” These are in “3rd risk stratum,” that is to say, they
indicate that cardiovascular disease risk is high and treatment for hypertension should immediately be considered in addition to lifestyle adjustment.
Assessment categories A: Normal, B: Mild abnormality without problems, C: Following up needed, D: Medical care needed (D1: Treatment needed,
D2: Thorough examination needed), and E: Under treatment.

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Table 5A. Table for correspondence of international severity criteria for diabetic retinopathy to Modified Davis classification, New Fukuda
classification, and Scott classification

Severity classification

Fundus findings

Assessment

Modified Davis

New Fukuda

classification

classification
No retinopathy

No retinopathy

A1

Phase Ia/phase II

A2Phase IIIa/phase IIIb

B1

Phase Ib

Proliferative

A3-5

Phase IV

retinopathy

B2-5

Phase Va/phase Vb

No definite retinopathy

NormalA

No retinopathy

Mild non-proliferative

Capillary aneurysm only

D2

Simplediabetic retinopathy

Scott classification

retinopathy

Moderate non-

Although abnormal capillary aneurysm lesion isproliferative diabetic

present, it is milder than severe non-retinopathy

proliferative retinopathy.

Severe non-proliferative

One or more of the following findings are

diabetic retinopathy

present without proliferative retinopathy

D2

D2

Pre-proliferative
retinopathy

findings:
1. More than 20 intraretinal bleedings in all four
fundus quadrants
2. Definite moniliform veins in 2 or more fundus
quadrants
3. Definite intraretinal microvascularabnormalities in one or more fundus quadrants
Proliferative diabetic

Either of the following findings:

retinopathy

1. Neovascularity

D2

2. Vitreous body bleeding/preretinal bleeding
Note: Those who have already been diagnosed as having diabetes or those who are suspected to have diabetes should be recommended to have regularophthalmologic examination by an ophthalmologist.
Assessment categories A: Normal, B: Mild abnormality without problems, C: Following up needed, D: Medical care needed (D1: Treatment needed, D2:
Thorough examination needed), and E: Under treatment.

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Table 5B. International Severity Classification for diabetic macular edema

Severity classification

Fundus findings

Assessment

No diabetic macular edema

Thickening of posterior pole of the fundus due to retinal edema, without hard exudate

A

Diabetic macular edema present

Thickening of posterior pole of the fundus due to retinal edema, with hard exudate

D2*

Mild diabetic macular edema

Retinal thickening and hard exudate are present but far from the macula

D2

Moderate diabetic macular edema

Retinal thickening and hard exudate are present not including the central macula

D2

Severe diabetic macular edema

Retinal thickening and hard exudate are present including the macula

D2* Diabetic macular edema is difficult to detect and assess for its severity in a fundus photograph taken by fundus camera without mydriasis.
Classify in mild, moderate, and severe only if possible.
Assessment categories A: Normal, B: Mild abnormality without problems, C: Following up needed, D: Medical care needed (D1: Treatment needed,
D2: Thorough examination needed), and E: Under treatment.

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Table 6. Ophthalmologic screening items
Suspected disease

Findings

Suspected glaucoma

Enlarged optic disc cupping

D2

Retinal nerve fiber layer defect

D2

Optic disc bleeding

D2

Suspected glaucomatous optic disc change

D2

Suspected age-related

Precursor lesion of age-related macular degeneration

D2

macular degeneration(drusen, and abnormal retinal pigment epithelium)
Age-related macular degeneration (wet type or dry

Assessment

D2

type)
Other suspected eye diseases
Optic disc abnormality

Papilledema/congestive optic discD2

Other optic disc abnormality

D2

Suspected diabetic

Soft exudate

D2

retinopathy (if diabetes is not

Hard exudate

D2

confirmed) and other

Retinal bleeding (spotty/blot)

D2

retinopathy findings

Spotty bleeding

D2

Retinal vascular disorder

Central retinal vein occlusion

D2

Branch retinal vein occlusion

D2

Central retinal artery occlusion

D2

Preretinal (epiretinal) membrane

D2

Myopic maculopathy

D2

Other macular abnormality

D2

Retinal/choroidal degeneration/atrophy

D2

Myelinated nerve fiber

Myelinated nerve fiber

B

OthersVitreous body opacity

D2

Neoplasms

D2

Pigmented spot in the retinal/choroidal membrane

D2

Post-laser therapy

B/C

Suspected cataract, etc.

D2

Macular abnormality

Retinal/choroidal
degeneration/atrophy

Difficult/impossible to Assess

Uninterpretable

Brank*

Assessment categories A: Normal, B: Mild abnormality without problems, C: Following up needed, D:
Medical care needed (D1: Treatment needed, D2: Thorough examination needed), and E: Under treatment.
*Ophthalmologic examination is recommended depending on cases.

14Japan Society of Ningen Dock
Image inspection decision manual making committee
Chairman: Takashi Wada (Professor, Health Science Center, Jikei University School of
Medicine)
Members : Akira Murakami (M.D., Ph.D., Department of Ophthalmology)
Goji Tomita (Professor, Department of Ophthalmology, Toho University Schoolof Medicine, Tokyo, Japan; Director, Department ofOphthalmology, Toho University Ohashi Medical Center, Tokyo,
Japan)
Ryo Kawasaki (Graduate School of Medicine. Department of Public Health,
Yamagata University Faculty of Medicine)
April, 2015