Dataset Information

Accuracy and reliability of retinal photo grading for diabetic retinopathy: Remote graders from a developing country and standard retinal photo grader in Australia.

ABSTRACT:

Background

To evaluate the accuracy and reliability of fundus retinal photos graded by local graders in Bangladesh with those graded by an expert at the Centre for Eye Research Australia (CERA) in the context of mass scale diabetic retinopathy (DR) screening in Bangladesh.

Methods

A population-based cross-sectional study of 3,104 adults identified 213 (7.2%) eligible patients with diabetes of age ? 40 years in 2012-2013. Retinal photographs were collected using a non-mydriatic digital fundus retinal camera and a two-field imaging protocol. The photos were graded by two remote graders (G1 and G2) who were trained by a retinal specialist (RS) in Bangladesh, by the RS himself, and by a Centre for Eye Research Australia (CERA) grader. The local graders up skilled their grading ability by comparing 30% of the photos graded by the CERA grader with their own grades. Learning from that exercise was applied to the remaining 70% of photos, which were re-graded. Reliability and accuracy of grading amongst the graders were reported using cross tabulation, inter- and intra-grader reliability, and with sensitivity and specificity.

Results

Of 122 eyes from 61 patients, the mild (R1) DR was estimated to be 14 to 25%, pre-proliferative (R2) DR 4-8%, and proliferative (R3) DR 0.8 to 1.6%, whereas 25%, 8%, 18%, and 15% were found to be ungradable by CERA, RS, G1, and G2, respectively. Of 8 (6.6%) eyes identified as R2 by the CERA grader, 5 (63%), 3 (38%) and 3 (38%) were correctly classified as R2, whereas the rest were classified either as R1 or R3 but none were classified as no DR (R0) or ungradable by the RS, G1 and G2, respectively. After getting experience reviewing the 30% test set graded by the CERA grader, the local graders graded moderate and severe DR with 100% accuracy. After excluding ungradable photos, the sensitivity (specificity) relative to the CERA grader was 82% (88%) before and 80% (93%) after training for G1 and 56% (87%) before and 77% (90%) after training for G2. In case of maculopathy, the CERA grader reported 11.2% eyes with maculopathy, which included 100% of the 4.9% by RS, 6.6% by G1, and 7.4% by G2.

Conclusions

Local graders in Bangladesh are able to grade retinal photos with high accuracy if the DR is at least of a moderate level. With appropriate training and experience, local graders have the ability to contribute significantly to the grading of millions of retinal photos, which required grading in resource- poor countries.

SUBMITTER: Islam FMA

PROVIDER: S-EPMC5478124 | biostudies-literature | 2017

REPOSITORIES: biostudies-literature

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Publications

Accuracy and reliability of retinal photo grading for diabetic retinopathy: Remote graders from a developing country and standard retinal photo grader in Australia.

Islam Fakir M Amirul FMA

PloS one 20170620 6

<h4>Background</h4>To evaluate the accuracy and reliability of fundus retinal photos graded by local graders in Bangladesh with those graded by an expert at the Centre for Eye Research Australia (CERA) in the context of mass scale diabetic retinopathy (DR) screening in Bangladesh.<h4>Methods</h4>A population-based cross-sectional study of 3,104 adults identified 213 (7.2%) eligible patients with diabetes of age ≥ 40 years in 2012-2013. Retinal photographs were collected using a non-mydriatic dig ...[more]

PMID: 28632764

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Project description:Importance:Telemedicine in retinopathy of prematurity (ROP) has the potential for delivering timely care to premature infants at risk for serious ROP. Objective:To describe the characteristics of eyes at risk for ROP to provide insights into what types of ROP are most easily detected early by image grading. Design, Setting, and Participants:Secondary analysis of eyes with referral-warranted (RW) ROP (stage 3 ROP, zone I ROP, plus disease) on diagnostic examination from the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity (e-ROP) study was conducted from May 1, 2011, to October 31, 2013, in 1257 premature infants with birth weights less than 1251 g in 13 neonatal units in North America. Data analysis was performed between February 1, 2016, and June 5, 2017. Interventions:Serial imaging sessions with concurrent diagnostic examinations for ROP. Main Outcomes and Measures:Time of detecting RW-ROP on image evaluation compared with clinical examination. Results:In the e-ROP study, 246 infants (492 eyes) were included in the analysis; 138 (56.1%) were male. A total of 447 eyes had RW-ROP on diagnostic examination. Image grading in 123 infants (mean [SD] gestational age, 24.8 [1.4] weeks) detected RW-ROP earlier than diagnostic examination (early) in 191 (42.7%) eyes by about 15 days and detected RW-ROP in 123 infants (mean [SD] gestational age, 24.6 [1.5] weeks) at the same time (same) in 200 (44.7%) eyes. Most of the early eyes (153 [80.1%]) interpreted as being RW-ROP positive on imaging evaluation agreed with examination findings when the examination subsequently documented RW-ROP. At the sessions in which RW-ROP was first found by examination, stage 3 or more in 123 infants (mean [SD] gestational age, 24.8 [1.4] weeks) ROP was noted earlier on image evaluation in 151 of 191 early eyes (79.1%) and in 172 of 200 of same eyes (86.0%) (P?=?.08); the presence of zone I ROP was detected in 57 of 191 (29.8%) early eyes vs 64 of 200 (32.0%) same eyes (P?=?.90); and plus disease was noted in 30 of 191 (15.7%) early eyes and 45 of 200 (22.5%) same eyes (P?=?.08). Conclusions and Relevance:In both early and same eyes, zone I and/or stage 3 ROP determined a significant proportion of RW-ROP; plus disease played a relatively minor role. In most early RW-ROP eyes, the findings were consistent with clinical examination and/or image grading at the next session. Because ROP telemedicine is used more widely, development of standard approaches and protocols is essential.

Project description:BackgroundClinical examination of trachoma is used to justify intervention in trachoma-endemic regions. Currently, field graders are certified by determining their concordance with experienced graders using the kappa statistic. Unfortunately, trachoma grading can be highly variable and there are cases where even expert graders disagree (borderline/marginal cases). Prior work has shown that inclusion of borderline cases tends to reduce apparent agreement, as measured by kappa. Here, we confirm those results and assess performance of trainees on these borderline cases by calculating their reliability error, a measure derived from the decomposition of the Brier score.Methods and findingsWe trained 18 field graders using 200 conjunctival photographs from a community-randomized trial in Niger and assessed inter-grader agreement using kappa as well as reliability error. Three experienced graders scored each case for the presence or absence of trachomatous inflammation-follicular (TF) and trachomatous inflammation-intense (TI). A consensus grade for each case was defined as the one given by a majority of experienced graders. We classified cases into a unanimous subset if all 3 experienced graders gave the same grade. For both TF and TI grades, the mean kappa for trainees was higher on the unanimous subset; inclusion of borderline cases reduced apparent agreement by 15.7% for TF and 12.4% for TI. When we assessed the breakdown of the reliability error, we found that our trainees tended to over-call TF grades and under-call TI grades, especially in borderline cases.ConclusionsThe kappa statistic is widely used for certifying trachoma field graders. Exclusion of borderline cases, which even experienced graders disagree on, increases apparent agreement with the kappa statistic. Graders may agree less when exposed to the full spectrum of disease. Reliability error allows for the assessment of these borderline cases and can be used to refine an individual trainee's grading.

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Dataset Information

Accuracy and reliability of retinal photo grading for diabetic retinopathy: Remote graders from a developing country and standard retinal photo grader in Australia.

Background

Methods

Results

Conclusions

Publications

Accuracy and reliability of retinal photo grading for diabetic retinopathy: Remote graders from a developing country and standard retinal photo grader in Australia.

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