***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: PURPOSE To compare nonmydriatic stereoscopic Optomap ultrawide field images with dilated stereoscopic Early Treatment Diabetic Retinopathy Study 7-st and ard field 35-mm color 30-degree fundus photographs ( ETDRS photography ) and clinical examination for determining diabetic retinopathy ( DR ) and diabetic macular edema ( DME ) severity . DESIGN Single-site , prospect i ve , comparative , instrument validation study . METHODS One hundred three diabetic patients ( 206 eyes ) representing the full spectrum of DR severity underwent nonmydriatic ultrawide field 100-degree and 200-degree imaging , dilated ETDRS photography , and dilated fundus examination by a retina specialist  . Two independent readers grade d images to determine DR and DME severity . A third masked retina specialist adjudicated discrepancies . RESULTS Based on ETDRS photography ( n = 200 ) , the results were as follows : no DR ( n = 25 eyes [ 12.5 % ] ) , mild nonproliferative DR ( NPDR ; 47 [ 23.5 % ] ) , moderate NPDR ( 61 [ 30.5 % ] ) , severe NPDR ( 11 [ 5.5 % ] ) , very severe NPDR ( 3 [ 1.5 % ] ) , and proliferative DR ( 52 [ 2.5 % ] ) . One ( 0.5 % ) eye was ungradable and 6 eyes did not complete ETDRS photography . No DME was found in 114 eyes ( 57.0 % ) , DME was found in 28 eyes ( 14.0 % ) , and clinical ly significant DME was found in 47 eyes ( 23.5 % ) , and 11 ( 5.5 % ) eyes were ungradable . Exact DR severity agreement between ultrawide field 100-degree imaging and ETDRS photography occurred in 84 % , with agreement within 1 level in 91 % ( K(W ) = 0.85 ; K = 0.79 ) . Nonmydriatic ultrawide field images exactly matched clinical examination results for DR in 70 % and were within 1 level in 93 % ( K(W ) = 0.71 ; K = 0.61 ) . Nonmydriatic ultrawide field imaging acquisition time was less than half that of dilated ETDRS photography ( P < .0001 ) . CONCLUSIONS Nonmydriatic ultrawide field images compare favorably with dilated ETDRS photography and dilated fundus examination in determining DR and DME severity ; however , they are acquired more rapidly . If confirmed in broader diabetic population s , nonmydriatic ultrawide field imaging may prove to be beneficial in DR evaluation in research and clinical setting The Early Treatment Diabetic Retinopathy Study included use of nonsimultaneous stereoscopic fluorescein angiography to assess severity of characteristics such as capillary loss and fluorescein leakage and to guide treatment of macular edema .  Two 30 degrees photographic fields were taken , extending along the horizontal meridian from about 25 degrees nasal to the disc to about 20 degrees temporal to the macula , and a classification system was constructed to allow assessment of selected characteristics . This classification system relies on comparisons with st and ard and example photographs to evaluate the presence and severity of capillary loss and dilatation , arteriolar abnormalities , leakage of fluorescein dye ( including characterization of source ) , abnormalities of the retinal pigment epithelium , cystoid changes , and several other features . The classification is described and illustrated and its reproducibility between grade rs assessed by calculating percentages of agreement and kappa statistics for duplicate gradings of baseline angiograms . Agreement was substantial ( weighted kappa , 0.61 to 0.80 ) for severity of fluorescein leakage and cystoid spaces , and moderate ( weighted kappa , 0.41 to 0.60 ) for capillary loss , capillary dilatation , narrowing/pruning of arteriolar side branches , staining of arteriolar walls , and source of fluorescein leakage ( microaneurysms versus diffusely leaking capillaries ) PURPOSE To compare grading of diabetic retinopathy ( DR ) and diabetic macular edema ( DME ) from stereoscopic film versus stereoscopic digital photographs obtained from a subset of Diabetic Retinopathy Clinical Research Network ( DRCR.net ) participants . METHODS In this photographic media comparison study , digital and film images were obtained at a single study visit from some of the subjects enrolled in active DRCR.net clinical study protocol s.  Digital camera systems and digital and film photographers were certified to obtain images according to st and ard procedures . Images were grade d for DR severity and DME in a masked fashion by Fundus Photograph Reading Center ( Madison , WI ) grade rs . Agreement between gradings was assessed by calculating the percentage of agreement and κ statistics . RESULTS Images obtained with both film and digital media were su bmi tted for 155 eyes of 96 study participants . On a nine-step Early Treatment Diabetic Retinopathy study DR severity scale , grading agreed exactly in 74 % , and was within one step of agreement in 93 % , with a weighted κ statistic of 0.82 ( 95 % confidence interval [ CI ] , 0.71 - 0.92 ) . On a nine-step DME severity scale and three-step clinical ly significant macular edema ( CSME ) scale , grading agreed exactly in 39 % and 88 % , respectively , and within one step in 70 % and 92 % ( weighted κ statistic , 0.44 [ 95 % Cl , 0.34 - 0.54 ] and 0.72 [ 95 % Cl , 0.55 - 0.90 ] , respectively ) . CONCLUSIONS Among clinical sites participating in the DRCR.net , agreement between film and digital images was substantial to almost perfect for DR severity level and moderate to substantial for DME and CSME severity levels , respectively . Replacement of film fundus images with digital images for DR severity level should not adversely affect clinical trial quality . ( Clinical Trials.gov numbers , NCT00367133 , NCT00369486 , NCT00444600 , NCT00445003 , NCT00709319 . PURPOSE To evaluate if simple- or multiple-field digital color nonmydriatic ( NM ) retinal images can replace 7 st and ard stereoscopic fundus photographs in the screening of diabetic retinopathy ( DR ) . DESIGN Prospect i ve , masked , comparative case series . METHODS One hundred and eight eyes of 55 diabetics were studied to determine single lesions and to grade clinical levels of DR and diabetic macular edema ( DME ) using both 1 and 3 NM digital color retinal images compared with the Early Treatment Diabetic Retinopathy Study ( ETDRS ) 7 st and ard 35-mm stereoscopic color fundus photographs ( 7F-ETDRS ) . All eyes underwent NM 45-degree field images of 1 central field ( 1F-NM ) , NM 45-degree field images of 3 fields ( 3F-NM ) , and , after pupil dilatation , 30-degree 7F-ETDRS photography . Images were analyzed by 2 independent , masked retinal specialists ( S.V. and E.B. ) , lesion-by-lesion according to the ETDRS protocol and for clinical severity level of DR and DME according to the international classification of DR . RESULTS Using 7F-ETDRS as the gold st and ard , agreement was substantial for grading clinical levels of DR and DME ( kappa = 0.69 and kappa = 0.75 ) vs 3F-NM ; moderate for DR level ( kappa = 0.56 ) and substantial for DME ( kappa = 0.66 ) vs 1F-NM ; almost perfect for detecting presence or absence of DR ( kappa = 0.88 ) vs both 1F-NM and 3F-NM ; and almost perfect for presence or absence of DME ( kappa = 0.97 ) vs 3F-NM and substantial ( kappa = 0.75 ) vs 1F-NM . Sensitivity and specificity for detecting referable levels of DR were 82 % and 92 % , respectively , for 3F-NM and 71 % and 96 % , respectively , for 1F-NM . CONCLUSIONS Three color 45-degree NM fundus fields may be an effective tool in a screening setting to determine critical levels of DR and DME for prompt specialist referral . One central 45-degree image is sufficient to determine absence or presence of DR and DME , but not for grading it BACKGROUND The use of nonmydriatic cameras , which offer ease of screening and 45 degrees immediate imaging of the fundus , is gaining increasing acceptance for screening programs tailored to diverse conditions . We performed a study to evaluate the effectiveness and safety of screening for diabetic retinopathy with two nonmydriatic camera images compared with the seven st and ard stereoscopic 30 degrees fields ( 7SF ) . We also wished to determine whether safe screening guidelines could be established to identify patients needing referral to an ophthalmologist . METHODS In this prospect i ve masked cross-sectional study , we evaluated agreement in the assessment of the severity of diabetic retinopathy by means of two 45 degrees images centred on the optic disc and on the macula obtained with the Topcon CRW6 nonmydriatic camera and by means of 7SF photography and ophthalmologic slit-lamp biomicroscopy , both performed with pupil dilation . Between November 2000 and June 2001 , 98 adult patients known to have type 1 or 2 diabetes mellitus who presented for the first time to the diabetic retinopathy clinic of a tertiary care centre in Montreal were enrolled consecutively . Thus , patient recruitment was weighted toward more severe retinopathy to ensure sufficient representation of less frequent but more severe levels . Each patient underwent nonmydriatic fundus photography of both eyes , followed by a complete ophthalmologic examination with pupil dilation by a single retina specialist and 7SF photography of both eyes with pupil dilation . The level of retinopathy was grade d independently in each eye from the 7SF photographs according to the Early Treatment Diabetic Retinopathy Study ( ETDRS ) scale by two grade rs ; an independent retina specialist adjudicated the rare instances of interreader disagreement in a masked fashion . Two months later , two grade rs independently grade d the nonmydriatic images in a blinded fashion according to the ETDRS scale ; a third observer adjudicated the rare instances of interreader disagreement . We measured concordance between grading results with the various screening techniques using the weighted and unweighted kappa statistic . We used sensitivity and specificity indices to determine safe screening guidelines to identify patients needing referral to an ophthalmologist . RESULTS There was substantial agreement in the grading of retinopathy with nonmydriatic camera imaging and with 7SF photography , both for all eyes ( kappa = 0.626 [ st and ard deviation ( SD ) 0.045 ] ) and for the eye with more severe disease ( kappa = 0.654 [ SD 0.063 ] ) . With nonmydriatic camera imaging , screening thresholds for patient referral to an ophthalmologist of very mild retinopathy ( ETDRS grade 20 ) , mild retinopathy ( ETDRS grade 35 ) and moderate retinopathy ( EDTRS grade 43 ) had sensitivity values of 97.9 % , 97.1 % and 53.3 % respectively and specificity values of 81.3 % , 95.5 % and 96.9 % respectively . Screening thresholds of very mild or mild retinopathy both correctly identified 100 % of eyes with severe nonproliferative or proliferative retinopathy . With a screening threshold of mild retinopathy , screening with the nonmydriatic camera would lead to referral to an ophthalmologist of 37.8 % of patients because of detected disease and of an additional 17.3 % because of insufficient image quality in at least one eye , for a total of 55.1 % . The overall sensitivity and specificity of a two-field nonmydriatic screening strategy with a threshold of mild retinopathy for referral of patients with insufficient image quality in at least one eye are 97.7 % and 84.0 % respectively . INTERPRETATION Our results suggest that two-field nonmydriatic camera imaging is a safe screening strategy that may identify the patients with diabetes most in need of ophthalmologic care PURPOSE This study analyzed the accuracy of the Inoveon Diabetic Retinopathy ( DR-3DT ) system ( Inoveon Corp. , Oklahoma City , OK ) , a scalable evaluation method for the management of diabetic retinopathy using high- quality digital retinal imaging . DESIGN An independent , masked , cross-sectional , clinical validation study . PARTICIPANTS Two hundred ninety adult patients with diabetes from the Chickasaw Nation 's Carl Albert Indian Health Facility in Ada , Oklahoma . METHODS All participants underwent DRS7 imaging using a Zeiss FF450 fundus camera with images recorded on 35-mm film and a K 
    Output:
    
The diagnostic accuracy of telemedicine using digital imaging in DR is overall high .
It can be used widely for DR screening .
Telemedicine based on the digital imaging technique that combines mydriasis with a wide angle field ( 100 - 200 ° ) is the best choice in detecting the absence of DR and the presence of mild NPDR