Diabetic Retinopathy Assessment Variability among Eye Care Providers in an Urban Teleophthalmology Program

Teleophthalmology is an evidence-based method for diabetic eye screening. It is unclear whether the type of eye care provider performing teleophthalmology interpretation produces significant variability. We assessed grading variability between an optometrist, general ophthalmologist, and retinal specialist using images from an urban, diabetic retinopathy teleophthalmology program. Methods: Three readers evaluated digital retinal images in 100 cases (178 eyes from 90 patients with type 2 diabetes). Fisher's exact test, percent agreement, and the observed proportion of positive (P _pos ) or negative agreement (P _neg ) were used to assess variability. Results: Among cases deemed gradable by all three readers (n = 65), there was substantial agreement on absence of any retinopathy (88% ± 4.6%, P _neg = 0.91-0.95), presence of moderate nonproliferative or worse retinopathy (87% ± 3.9%, P _pos = 0.67-1.00), and presence of macular edema (99% ± 0.9%, P _pos = 0.67-1.00). There was limited agreement regarding presence of referable nondiabetic eye pathology (61% ± 11%, P _pos = 0.21-0.59) and early, nonroutine referral for a follow-up clinical eye exam (66% ± 8.1%, P _pos = 0.19-0.54). Among all cases (n = 100), there was acceptable agreement regarding which had gradable images (77% ± 5.0%, P _pos = 0.50-0.90). Discussion: Inclusion of multiple types of eye care providers as teleophthalmology readers is unlikely to produce significant variability in the assessment of diabetic retinopathy among high-quality images. Greater variability was found regarding image gradability, nondiabetic eye pathology, and recommended clinical referral times. Conclusions: Our results suggest that more extensive training and uniform referral standards are needed to improve consensus on image gradability, referable nondiabetic eye pathology, and recommended clinical referral times.