OBJECTIVE -To evaluate the validity and reproducibility of software for reading digital images and grading diabetic retinopathy. RESEARCH DESIGN AND METHODS -A prospective, comparative observational study was conducted on a series of patients with type 2 diabetes who presented at the retina clinic of a tertiary care center in India. A total of 210 eyes of 105 patients were allocated to one of three ophthalmologists, who performed dilated indirect and direct ophthalmoscopy and subsequently assessed the digital images of the same group of patients who were masked to the patient's identity. The interobserver and intertest agreement between clinical assessments and grading of diabetic retinopathy using the software was estimated. RESULTS -Moderate nonproliferative diabetic retinopathy (NPDR) was most frequently diagnosed, both clinically and on evaluating digital images. The overall agreement between the clinical grading of diabetic retinopathy and the grading of images was 81.3% ( ϭ 0.69, SE 0.04, P Ͻ 0.0001); there was good agreement (81.3%) for NPDR ( ϭ 0.61, SE 0.05, P Ͻ 0.0001), but agreement was not as good (54.6%) for proliferative diabetic retinopathy ( ϭ 0.29, SE 0.11, P ϭ 0.005). Clinically significant macular edema was diagnosed in 33.3% (70 of 210) of eyes clinically and in 40.2% (84 of 209) of eyes by grading images, and there was good agreement (89.5%) between the two ( ϭ 0.77, SE 0.07, P Ͻ 0.0001). CONCLUSIONS -Aravind Diabetic Retinopathy Screening 3.0 is a simple and valid tool to assist in the detection of sight-threatening retinopathy and could supplement dilated fundus examinations by ophthalmologists on patients to detect diabetic retinopathy. D iabetic retinopathy resulting from microvascular end-organ damage to the retina is found in 60% (1) of people 20 years after onset of type 2 diabetes; sight-threatening retinopathy is found in 2.0% of people who have had diabetes for Ͻ5 years and in 15.5% of people who have had diabetes for Ն15 years. Identifying these patients occurs primarily through opportunistic case detection (2) in a country like India (prevalence of retinopathy is 17.6% among urban diabetic subjects aged Ͼ20 years), since a routine screening program for people known to have diabetes is not a feasible option considering the poor attendance; 11% of new diabetic subjects and 55% of known diabetic subjects attend these camps (3). The current gold standard for diagnosing diabetic retinopathy is through fundus photography (comparing the fundus pathology with that seen on stereoscopic viewing of seven standard photographs for grading retinopathy or through fluorescein angiographic diagnosis). However, even in countries in which facilities for close monitoring of diabetes are available, there is no consensus on cost-effective, valid methods to screen for diabetic retinopathy (4). Telemedicine has resulted in new possibilities, such as capturing images at a remote location and transmitting them to a skilled grader at a specialist center. Though reducing costs while maintaining good quality care, the deployment of telemedicine intensifies the need to validate using digital images as a tool for diagnosing diabetic retinopathy and following its progression (5,6). This study compares the Aravind Diabetic Retinopathy Screening (ADRES) 3.0 reading and grading system with clinical assessments as the current practice gold standard with regard to its validity and reproducibility in the assessment of diabetic retinopathy. METHODS -A prospective, comparative observational study was conducted on a series of patients with type 2 diabetes who presented for the first time at the retina clinic of a tertiary care center in India. The patients who consented to participate were enrolled by the clinic coordinator during May and June 2006 and assigned to the grader (one of three trained retina specialists) who was attending to outpatients on that day. Each patient underwent a routine detailed comprehensive ophthalmic examination by any single grader, and digital fundus photographs were taken by a technician through the dilated pupil. The same three clinicians subsequently graded the digital images using the manual software ADRES 3.0 reading and grading system while being masked to the clinical grading assigned to individual patients. For the sake of comparability, all three graders were assigned five consecutive patients on the last day of enrollment, which they assessed independently in the same manner. The eye examination included measurement of Snellen's visual acuity, slitlamp biomicroscopy aided with the three-mirror contact lens when required, dilated fundoscopy using a 60-or 90-dioptre lens, and indirect ophthalmos-
The Aravind diabetic retinopathy screening (ADRES) 3.0, developed and presented by Permalsamy et al. REF , is a software for reading and grading the diabetic retinopathy.
Software for reading and grading diabetic retinopathy: Aravind Diabetic Retinopathy Screening 3.0.
Diabetes care
Diabetes care
Medicine