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Singapore Med J. 2012 Nov;53(11):715-9.

Accuracy of diabetic retinopathy screening by trained non-physician graders using non-mydriatic fundus camera.

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Singapore Eye Research Institute, Singapore National Eye Centre, Singapore.



We compared the agreement of diabetic retinopathy (DR) assessment between trained non-physician graders (NPGs) and family physicians (FPs) in a primary healthcare setting.


This was a cross-sectional study conducted retrospectively over a period of one month. The participants were diabetic patients from two primary healthcare clinics (polyclinics) in Singapore. Single-field digital retinal images were obtained using a non-mydriatic 45-degree fundus camera. Retinal images were graded for the presence or absence of DR by FPs at the polyclinics and by NPGs at a central ocular grading centre. The FPs' and NPGs' assessments of DR were compared with readings by a single retinal specialist (reference standard).


A total of 367 diabetic patients (706 eyes) were included in the study. The mean age of the patients was 63 years, and the majority were Chinese (83.8%). For DR assessment, the agreement between NPGs and the retinal specialist was substantial (ĸ = 0.66), while the agreement between FPs and the retinal specialist was only fair (ĸ = 0.40). NPGs' assessment showed higher sensitivity (70% vs. 45%) and comparable specificity (94% vs. 92%) as compared to FPs' assessment. The area under the receiver operating characteristic curve of NPGs' assessment of DR was greater than that of the FPs' (0.82 vs. 0.69, p < 0.001).


This study has demonstrated that trained NPGs are able to provide good detection of DR and maculopathy from fundus photographs. Our findings suggest that DR screening by trained NPGs may provide a costeffective alternative to FPs.

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