Efficacy and reliability of fundus digital camera as a screening tool
for diabetic retinopathy in Kuwait
Khalid Al Sabti
*, Seemant Raizada
, Vivek B. Wani
, Mubarak Al Ajmi
, T.N. Sugathan
Faculty of Medicine, Kuwait University, Kuwait
Al-Bahar Eye Center, Ibn-Sina Hospital, Kuwait
Received 10 December 2001; received in revised form 16 January 2003; accepted 23 January 2003
Objective: Many screening and follow-up methods are available for detecting diabetic retinopathy (DR). However, once patients develop
retinopathy, it is unclear as to what method should be used for their review. This study is designed to assess the correlation between fundus
digital image and clinical examination and to develop a screening program for the early detection of sight-threatening DR using a Canon CF
60 UV fundus camera. Methods: Patients who were not treated for DR earlier were enrolled in the study. All patients underwent digital
fundus photography. The photographs were evaluated and compared with the clinical findings as recorded by retinal specialists. DR and
macular edema were analyzed separately, and the correlation was statistically measured. The kappa statistic was used to estimate the extent of
the agreement between the two procedures. Results: A total of 92 eyes of 51 patients were eligible to be entered in the study. Comparison of
the digital image of the fundus and the examination by an ophthalmologist showed a good correlation. The kappa score for retinopathy was
estimated to be 93% with 95.6% concordance. The kappa score for diabetic maculopathy was 88% with concordance of 92.2%. Conclusion:
We conclude that digital images provide an efficient method for diagnosing and classifying sight-threatening DR, particularly proliferative
diabetic retinopathy (PDR). However, agreement between the digital fundus camera and clinical examination by an ophthalmologist for
diabetic maculopathy detection, though substantial statistically, was not very satisfactory. It was also felt that the digital photographs can be
used as a tool for teleophthalmology and can be integrated as a screening system in Kuwait.
D 2003 Elsevier Inc. All rights reserved.
Keywords: Diabetic retinopathy; Clinically significant macular edema; Screening; Fundus digital images; Telemedicine; Kuwait
Diabetes is one of the leading causes of blindness world-
wide (Diabetic Retinopathy Study Research Group, 1976;
Early Treatment Diabetic Retinopathy Study Research
Group, 1991). Diabetic retinopathy (DR) starts as asympto-
matic retinal dot and blot hemorrhages or microaneurysms
(Kohner, 1993), which can be detected by an ophthal-
moscopic examination or fundus photography. It is well
known that laser photocoagulation can delay the progression
of early-detected cases and reduces chances of visual loss
(Backlund, Algvere, & Rosenquist, 1997; Kohner, 1993;
World Health Organisation/International Diabetes Founda-
tion Europe, 1990). Despite the advances in the treatment of
DR, visual loss can occur in some patients especially those
with long standing diabetes (Backlund et al., 1997). The
progression of DR is slow and visual loss usually develops
several years after the diagnosis of diabetes (The Diabetes
Control and Complications Trial Research Group, 1993).
Therefore, screening detects cases of sight-threatening DR
before symptoms develop and can thus reduce the compli-
cations by early intervention (Javitt & Aiello, 1996). Close
contact and cooperation between health care providers
involved in diabetic care and multidisciplinary approach
involving the ophthalmologist ensure a better outcome (Abi-
Said et al., 1991; Singer, Nathan, Fogel, & Schachat, 1992).
However, some patients may be managed inappropriately as
communication between primary care doctors, diabetolo-
gists, and ophthalmologists is sometimes poor (Davies,
Sullivan, & Canning, 1996). It has been estimated that
1056-8727/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved.
* Corresponding author. Retina Unit, Al-Bahar Eye Center, Kuwait.
Tel.: +965-566-3238; fax: +965-481-1314.
E-mail address: email@example.com (K. Al Sabti).
Journal of Diabetes and Its Complications 17 (2003) 229 – 233