Review of the evidence for dilating eye drops in a Diabetic Eye Screening Programme following the introduction of new camera technologies
Main Article Content
Abstract
Purpose: To review the literature to determine if new technologies have reduced the need for dilation in a Diabetic Eye Screening Programme
Methods: Two approaches were used:
- A review of the literature relating to screening for diabetic retinopathy that has been on-going by the second author (PHS) since March 2000. The results are held in Endnote which was subsequently searched using keywords.
- Our local library conducted a search using a combination of keywords and subject headings were used to formulate search strategies on Medline (Ovid), Embase (Ovid), CINAHL (EBSCO), and the Cochrane Library
Results: A total of 133 articles were identified, separated into 117 original articles and 16 review articles. After discarding those that did not appear relevant, 76 original articles and 15 reviews remained. These were analysed to determine whether they helped to answer the main question, and 49 references have been quoted. The sensitivities and specificities of mydriatic digital photography for detection of referable diabetic retinopathy have been consistently high since the early studies with sensitivities of >80% and specificities of > 85% against recognised reference standards in the majority of studies. The specificity achieved is often above 90% if ungradable images are not counted as test positive. Non-mydriatic digital photography performs well in those in whom gradable images can be obtained. In Scotland, which has a long history of performing staged mydriasis, they currently dilate 30% of their screened population. This has risen slowly from 24% in 2002 because of increasing ageing of the population which is one of the risk factors for poor quality images.
Recent studies using confocal technology have demonstrated that the percentage of ungradable images without eye drops can be reduced to under 5.1% and after staged mydriasis to under 3.4%. This will depend on the age group and the percentage of untreated cataract in the population.
Conclusions: The results of this review are encouraging that, with the development of less expensive confocal cameras, this technology is likely to be used routinely in diabetic eye screening programmes around the world using staged mydriasis.
Article Details
How to Cite
GHATGE, Arya; SCANLON, Peter H..
Review of the evidence for dilating eye drops in a Diabetic Eye Screening Programme following the introduction of new camera technologies.
Medical Research Archives, [S.l.], v. 14, n. 1, mar. 2026.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/7165>. Date accessed: 05 apr. 2026.
doi: https://doi.org/10.18103/mra.v14i1.7165.
Section
Review Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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2. Jacob J, Stead J, Sykes J, Taylor D, Tooke JE. A report on the use of technician ophthalmoscopy combined with the use of the Canon non-mydriatic camera in screening for diabetic retinopathy in the community. Diabetic medicine : a journal of the British Diabetic Association. May 1995;12(5):419-25.
3. Harding SP, Broadbent DM, Neoh C, White MC, Vora J. Sensitivity and specificity of photography and direct ophthalmoscopy in screening for sight threatening eye disease: the Liverpool Diabetic Eye Study. BMJ. Oct 28 1995;311(7013):1131-5.
4. Scanlon PH, Malhotra R, Thomas G, et al. The effectiveness of screening for diabetic retinopathy by digital imaging photography and technician ophthalmoscopy. Diabetic medicine : a journal of the British Diabetic Association. Jun 2003;20(6):467-74.
5. Stefansson E. Prevention of diabetic blindness. Br J Ophthalmol. Jan 2006;90(1):2-3.
6. Bek T. Diabetic retinopathy: a review of the Aarhus approach to studies on epidemiology, computerised grading, and the pathophysiology of the disease. Horm Metab Res. Apr 2005;37 Suppl 1:35-8.
7. Agardh E, Agardh CD, Hansson-Lundblad C. The five-year incidence of blindness after introducing a screening programme for early detection of treatable diabetic retinopathy. Diabetic medicine : a journal of the British Diabetic Association. Jul 1993;10(6):555-9.
8. Pugh JA, Jacobson JM, Van Heuven WA, et al. Screening for diabetic retinopathy. The wide-angle retinal camera. Diabetes care. Jun 1993;16(6):889-95.
9. Lin DY, Blumenkranz MS, Brothers RJ, Grosvenor DM. The sensitivity and specificity of single-field nonmydriatic monochromatic digital fundus photography with remote image interpretation for diabetic retinopathy screening: a comparison with ophthalmoscopy and standardized mydriatic color photography. Am J Ophthalmol. Aug 2002;134(2):204-13.
10. Herbert HM, Jordan K, Flanagan DW. Is screening with digital imaging using one retinal view adequate? Eye. May 2003;17(4):497-500.
11. Facey K, Cummins E, Macpherson K, Morris A, Reay L, Slattery J. Organisation of Services for Diabetic Retinopathy Screening. 2002:1-224.
12. NSC. A National Screening Programme for Sight-Threatening Diabetic Retinopathy. www.nscretinopathy.org.uk. www.nscretinopathy.org.uk
13. Chew EY. Screening options for diabetic retinopathy. Curr Opin Ophthalmol. Dec 2006;17(6):519-22.
14. Higgs ER, Harney BA, Kelleher A, Reckless JP. Detection of diabetic retinopathy in the community using a non-mydriatic camera. Diabetic medicine : a journal of the British Diabetic Association. Jul 1991;8(6):551-5.
15. Scanlon PH, Foy C, Malhotra R, Aldington SJ. The influence of age, duration of diabetes, cataract, and pupil size on image quality in digital photographic retinal screening. Diabetes care. Oct 2005;28(10):2448-53. doi:10.2337/diacare.28.10.2448
16. Klein R, Klein BE, Neider MW, Hubbard LD, Meuer SM, Brothers RJ. Diabetic retinopathy as detected using ophthalmoscopy, a nonmydriatic camera and a standard fundus camera. Ophthalmology. Apr 1985;92(4):485-91.
17. Murgatroyd H, Cox A, Ellingford A, Ellis JD, Macewen CJ, Leese GP. Can we predict which patients are at risk of having an ungradeable digital image for screening for diabetic retinopathy? Eye. Mar 2008;22(3):344-8.
18. Bursell SE, Cavallerano JD, Cavallerano AA, et al. Stereo nonmydriatic digital-video color retinal imaging compared with Early Treatment Diabetic Retinopathy Study seven standard field 35-mm stereo color photos for determining level of diabetic retinopathy. Ophthalmology. Mar 2001;108(3):572-85.
19. Massin P, Erginay A, Ben Mehidi A, et al. Evaluation of a new non-mydriatic digital camera for detection of diabetic retinopathy. Diabetic medicine : a journal of the British Diabetic Association. Aug 2003;20(8):635-41.
20. Scanlon PH, Malhotra R, Greenwood RH, et al. Comparison of two reference standards in validating two field mydriatic digital photography as a method of screening for diabetic retinopathy. Br J Ophthalmol. Oct 2003;87(10):1258-63.
21. Rajalakshmi R, Arulmalar S, Usha M, et al. Validation of Smartphone Based Retinal Photography for Diabetic Retinopathy Screening. vol 10. 2015:e0138285.
22. Salongcay RP, Aquino LAC, Salva CMG, et al. Comparison of Handheld Retinal Imaging with ETDRS 7-Standard Field Photography for Diabetic Retinopathy and Diabetic Macular Edema. Ophthalmology Retina. Jul 2022;6(7):548-556. doi:10.1016/j.oret.2022.03.002
23. Jacoba CMP, Salongcay RP, Aquino LAC, et al. Comparisons of handheld retinal imaging devices with ultrawide field images for determining diabetic retinopathy severity. Acta Ophthalmol. Feb 27 2023;doi:10.1111/aos.15651
24. Piyasena M, Yip JLY, MacLeod D, Kim M, Gudlavalleti VSM. Diagnostic test accuracy of diabetic retinopathy screening by physician graders using a hand-held non-mydriatic retinal camera at a tertiary level medical clinic. BMC ophthalmology. Apr 8 2019;19(1):89. doi:10.1186/s12886-019-1092-3
25. Gajiwala UR, Pachchigar S, Patel D, et al. Non-mydriatic fundus photography as an alternative to indirect ophthalmoscopy for screening of diabetic retinopathy in community settings: a comparative pilot study in rural and tribal India. BMJ Open. Apr 8 2022;12(4):e058485. doi:10.1136/bmjopen-2021-058485
26. Sengupta S, Sindal MD, Besirli CG, et al. Screening for vision-threatening diabetic retinopathy in South India: comparing portable non-mydriatic and standard fundus cameras and clinical exam. Clinical Study. Eye. 09/15/online 2017;32:375. doi:10.1038/eye.2017.199 https://www.nature.com/articles/eye2017199#supplementary-information
27. Schwartz S, Harasawa M, Baldivieso V, Sabel AL, Mandava N, Quiroz-Mercado H. Nonmydriatic fundus camera for diabetic retinopathy screening in a safety net hospital: effectiveness, prevalence, and risk factors. European journal of ophthalmology. Mar-Apr 2015;25(2):145-52. doi:10.5301/ejo.5000515
28. Mizrachi Y, Knyazer B, Guigui S, et al. Evaluation of diabetic retinopathy screening using a non-mydriatic retinal digital camera in primary care settings in south Israel. saved in research folder International Ophthalmology. 2014;34:831-837. doi: 10.1007/s10792-013-9887-3
29. Piyasena M, Murthy GVS, Yip JLY, et al. Systematic review and meta-analysis of diagnostic accuracy of detection of any level of diabetic retinopathy using digital retinal imaging. Systematic reviews. Nov 7 2018;7(1):182. doi:10.1186/s13643-018-0846-y
30. Kanclerz P, Tuuminen R, Khoramnia R. Imaging Modalities Employed in Diabetic Retinopathy Screening: A Review and Meta-Analysis. Diagnostics (Basel, Switzerland). Sep 29 2021;11(10) doi:10.3390/diagnostics11101802
31. Abou Taha A, Dinesen S, Vergmann AS, Grauslund J. Present and future screening programs for diabetic retinopathy: a narrative review. International journal of retina and vitreous. Feb 3 2024;10(1):14. doi:10.1186/s40942-024-00534-8
32. Weng CY, Maguire MG, Flaxel CJ, et al. Effectiveness of Conventional Digital Fundus Photography-Based Teleretinal Screening for Diabetic Retinopathy and Diabetic Macular Edema: A Report by the American Academy of Ophthalmology. Ophthalmology. 2024;doi:10.1016/j.ophtha.2024.02.017
33. NHSE. NHS Diabetic eye screening pathway standards from 1st October 2024. Accessed 15/12/2025, https://www.gov.uk/government/publications/diabetic-eye-screening-programme-standards/nhs-diabetic-eye-screening-pathway-standards-from-1st-october-2024-public-facing-guidance-information
34. Murgatroyd H, Ellingford A, Cox A, et al. Effect of mydriasis and different field strategies on digital image screening of diabetic eye disease. Br J Ophthalmol. Jul 2004;88(7):920-4.
35. Styles C, Lee N, Black M, Ah-See K. Use of Dilating Drops in the Scottish Diabetic Retinopathy Screening Programme. presented at: European Association for the Study of Diabetic Eye Complications (EASDec); 2020;
36. Gupta V, Bansal R, Gupta A, Bhansali A. Sensitivity and specificity of nonmydriatic digital imaging in screening diabetic retinopathy in Indian eyes. Indian J Ophthalmol. Aug 2014;62(8):851-6. doi:10.4103/0301-4738.141039
37. Gajwani P, Zhao D, Guallar E, et al. Ungradable non mydriatic fundus photography in community eye screening. presented at: ARVO; 2019; Vancouver. Accessed 30/12/23 . https://iovs.arvojournals.org/article.aspx?articleid=2746784
38. Wilson PJ, Ellis JD, MacEwen CJ, Ellingford A, Talbot J, Leese GP. Screening for diabetic retinopathy: a comparative trial of photography and scanning laser ophthalmoscopy. Ophthalmologica Journal international d'ophtalmologie International journal of ophthalmology Zeitschrift fur Augenheilkunde. 2010;224(4):251-7.
39. Silva PS, Cavallerano JD, Sun JK, Noble J, Aiello LM, Aiello LP. Nonmydriatic ultrawide field retinal imaging compared with dilated standard 7-field 35-mm photography and retinal specialist examination for evaluation of diabetic retinopathy. American Journal of Ophthalmology. 2012;154(3):549-559.e2.
40. Soliman AZ, Silva PS, Aiello LP, Sun JK. Ultra-wide field retinal imaging in detection, classification, and management of diabetic retinopathy. Seminars in Ophthalmology. 2012;27(5-6):226-232.
41. Aiello LP, Odia I, Glassman AR, et al. Comparison of Early Treatment Diabetic Retinopathy Study Standard 7-Field Imaging With Ultrawide-Field Imaging for Determining Severity of Diabetic Retinopathy. JAMA ophthalmology. Jan 1 2019;137(1):65-73. doi:10.1001/jamaophthalmol.2018.4982
42. Silva PS, Cavallerano JD, Tolls D, et al. Potential efficiency benefits of nonmydriatic ultrawide field retinal imaging in an ocular telehealth diabetic retinopathy program. Diabetes care. Jan 2014;37(1):50-5. doi:10.2337/dc13-1292
43. Silva PS, Horton MB, Clary D, et al. Identification of Diabetic Retinopathy and Ungradable Image Rate with Ultrawide Field Imaging in a National Teleophthalmology Program. Ophthalmology. Jun 2016;123(6):1360-7. doi:10.1016/j.ophtha.2016.01.043
44. Fonda SJ, Bursell SE, Lewis DG, Clary D, Shahon D, Silva PS. Prevalence of Diabetic Eye Diseases in American Indians and Alaska Natives (AI/AN) as Identified by the Indian Health Service's National Teleophthalmology Program Using Ultrawide Field Imaging (UWFI). Ophthalmic epidemiology. Dec 2022;29(6):672-680. doi:10.1080/09286586.2021.1996611
45. Scanlon PH, Gruszka-Goh M, Javed U, et al. The Scanning CONfoCal Ophthalmoscopy foR DIAbetic eye screening (CONCORDIA) study paper 1. Eye (London, England). Dec 2024;38(18):3539-3546. doi:10.1038/s41433-024-03360-2
46. Scanlon PH, Gruszka-Goh M, Javed U, et al. The scanning CONfoCal Ophthalmoscopy foR DIAbetic eye screening (CONCORDIA) study paper 2. Eye (London, England). Oct 11 2024; doi:10.1038/s41433-024-03361-1
47. Piatti A, Rui C, Gazzina S, et al. Diabetic retinopathy screening with confocal fundus camera and artificial intelligence - assisted grading. European journal of ophthalmology. 03// 2025;35(2):679-688. doi:10.1177/11206721241272229
48. Graham-Rowe E, Lorencatto F, Lawrenson JG, et al. Barriers to and enablers of diabetic retinopathy screening attendance: a systematic review of published and grey literature. Diabetic medicine : a journal of the British Diabetic Association. Oct 2018;35(10):1308-1319. doi:10.1111/dme.13686
49. Hipwell AE, Sturt J, Lindenmeyer A, et al. Attitudes, access and anguish: a qualitative interview study of staff and patients' experiences of diabetic retinopathy screening. BMJ Open. 2014;4(12):e005498. doi:10.1136/bmjopen-2014-005498
50. Liew G, Michaelides M, Bunce C. A comparison of the causes of blindness certifications in England and Wales in working age adults (16-64 years), 1999-2000 with 2009-2010. BMJ Open. Feb 12 2014;4(2):e004015. doi:10.1136/bmjopen-2013-004015
51. Scanlon PH. The contribution of the English NHS Diabetic Eye Screening Programme to reductions in diabetes-related blindness, comparisons within Europe, and future challenges. Acta diabetologica. Apr 2021;58(4):521-530. doi:10.1007/s00592-021-01687-w
52. ISRCTN. Evaluating a new camera for diabetic eye disease screening in Afro-Caribbean and Asian populations without pupil dilation. Accessed 16/12/2025, https://www.isrctn.com/ISRCTN18020816
2. Jacob J, Stead J, Sykes J, Taylor D, Tooke JE. A report on the use of technician ophthalmoscopy combined with the use of the Canon non-mydriatic camera in screening for diabetic retinopathy in the community. Diabetic medicine : a journal of the British Diabetic Association. May 1995;12(5):419-25.
3. Harding SP, Broadbent DM, Neoh C, White MC, Vora J. Sensitivity and specificity of photography and direct ophthalmoscopy in screening for sight threatening eye disease: the Liverpool Diabetic Eye Study. BMJ. Oct 28 1995;311(7013):1131-5.
4. Scanlon PH, Malhotra R, Thomas G, et al. The effectiveness of screening for diabetic retinopathy by digital imaging photography and technician ophthalmoscopy. Diabetic medicine : a journal of the British Diabetic Association. Jun 2003;20(6):467-74.
5. Stefansson E. Prevention of diabetic blindness. Br J Ophthalmol. Jan 2006;90(1):2-3.
6. Bek T. Diabetic retinopathy: a review of the Aarhus approach to studies on epidemiology, computerised grading, and the pathophysiology of the disease. Horm Metab Res. Apr 2005;37 Suppl 1:35-8.
7. Agardh E, Agardh CD, Hansson-Lundblad C. The five-year incidence of blindness after introducing a screening programme for early detection of treatable diabetic retinopathy. Diabetic medicine : a journal of the British Diabetic Association. Jul 1993;10(6):555-9.
8. Pugh JA, Jacobson JM, Van Heuven WA, et al. Screening for diabetic retinopathy. The wide-angle retinal camera. Diabetes care. Jun 1993;16(6):889-95.
9. Lin DY, Blumenkranz MS, Brothers RJ, Grosvenor DM. The sensitivity and specificity of single-field nonmydriatic monochromatic digital fundus photography with remote image interpretation for diabetic retinopathy screening: a comparison with ophthalmoscopy and standardized mydriatic color photography. Am J Ophthalmol. Aug 2002;134(2):204-13.
10. Herbert HM, Jordan K, Flanagan DW. Is screening with digital imaging using one retinal view adequate? Eye. May 2003;17(4):497-500.
11. Facey K, Cummins E, Macpherson K, Morris A, Reay L, Slattery J. Organisation of Services for Diabetic Retinopathy Screening. 2002:1-224.
12. NSC. A National Screening Programme for Sight-Threatening Diabetic Retinopathy. www.nscretinopathy.org.uk. www.nscretinopathy.org.uk
13. Chew EY. Screening options for diabetic retinopathy. Curr Opin Ophthalmol. Dec 2006;17(6):519-22.
14. Higgs ER, Harney BA, Kelleher A, Reckless JP. Detection of diabetic retinopathy in the community using a non-mydriatic camera. Diabetic medicine : a journal of the British Diabetic Association. Jul 1991;8(6):551-5.
15. Scanlon PH, Foy C, Malhotra R, Aldington SJ. The influence of age, duration of diabetes, cataract, and pupil size on image quality in digital photographic retinal screening. Diabetes care. Oct 2005;28(10):2448-53. doi:10.2337/diacare.28.10.2448
16. Klein R, Klein BE, Neider MW, Hubbard LD, Meuer SM, Brothers RJ. Diabetic retinopathy as detected using ophthalmoscopy, a nonmydriatic camera and a standard fundus camera. Ophthalmology. Apr 1985;92(4):485-91.
17. Murgatroyd H, Cox A, Ellingford A, Ellis JD, Macewen CJ, Leese GP. Can we predict which patients are at risk of having an ungradeable digital image for screening for diabetic retinopathy? Eye. Mar 2008;22(3):344-8.
18. Bursell SE, Cavallerano JD, Cavallerano AA, et al. Stereo nonmydriatic digital-video color retinal imaging compared with Early Treatment Diabetic Retinopathy Study seven standard field 35-mm stereo color photos for determining level of diabetic retinopathy. Ophthalmology. Mar 2001;108(3):572-85.
19. Massin P, Erginay A, Ben Mehidi A, et al. Evaluation of a new non-mydriatic digital camera for detection of diabetic retinopathy. Diabetic medicine : a journal of the British Diabetic Association. Aug 2003;20(8):635-41.
20. Scanlon PH, Malhotra R, Greenwood RH, et al. Comparison of two reference standards in validating two field mydriatic digital photography as a method of screening for diabetic retinopathy. Br J Ophthalmol. Oct 2003;87(10):1258-63.
21. Rajalakshmi R, Arulmalar S, Usha M, et al. Validation of Smartphone Based Retinal Photography for Diabetic Retinopathy Screening. vol 10. 2015:e0138285.
22. Salongcay RP, Aquino LAC, Salva CMG, et al. Comparison of Handheld Retinal Imaging with ETDRS 7-Standard Field Photography for Diabetic Retinopathy and Diabetic Macular Edema. Ophthalmology Retina. Jul 2022;6(7):548-556. doi:10.1016/j.oret.2022.03.002
23. Jacoba CMP, Salongcay RP, Aquino LAC, et al. Comparisons of handheld retinal imaging devices with ultrawide field images for determining diabetic retinopathy severity. Acta Ophthalmol. Feb 27 2023;doi:10.1111/aos.15651
24. Piyasena M, Yip JLY, MacLeod D, Kim M, Gudlavalleti VSM. Diagnostic test accuracy of diabetic retinopathy screening by physician graders using a hand-held non-mydriatic retinal camera at a tertiary level medical clinic. BMC ophthalmology. Apr 8 2019;19(1):89. doi:10.1186/s12886-019-1092-3
25. Gajiwala UR, Pachchigar S, Patel D, et al. Non-mydriatic fundus photography as an alternative to indirect ophthalmoscopy for screening of diabetic retinopathy in community settings: a comparative pilot study in rural and tribal India. BMJ Open. Apr 8 2022;12(4):e058485. doi:10.1136/bmjopen-2021-058485
26. Sengupta S, Sindal MD, Besirli CG, et al. Screening for vision-threatening diabetic retinopathy in South India: comparing portable non-mydriatic and standard fundus cameras and clinical exam. Clinical Study. Eye. 09/15/online 2017;32:375. doi:10.1038/eye.2017.199 https://www.nature.com/articles/eye2017199#supplementary-information
27. Schwartz S, Harasawa M, Baldivieso V, Sabel AL, Mandava N, Quiroz-Mercado H. Nonmydriatic fundus camera for diabetic retinopathy screening in a safety net hospital: effectiveness, prevalence, and risk factors. European journal of ophthalmology. Mar-Apr 2015;25(2):145-52. doi:10.5301/ejo.5000515
28. Mizrachi Y, Knyazer B, Guigui S, et al. Evaluation of diabetic retinopathy screening using a non-mydriatic retinal digital camera in primary care settings in south Israel. saved in research folder International Ophthalmology. 2014;34:831-837. doi: 10.1007/s10792-013-9887-3
29. Piyasena M, Murthy GVS, Yip JLY, et al. Systematic review and meta-analysis of diagnostic accuracy of detection of any level of diabetic retinopathy using digital retinal imaging. Systematic reviews. Nov 7 2018;7(1):182. doi:10.1186/s13643-018-0846-y
30. Kanclerz P, Tuuminen R, Khoramnia R. Imaging Modalities Employed in Diabetic Retinopathy Screening: A Review and Meta-Analysis. Diagnostics (Basel, Switzerland). Sep 29 2021;11(10) doi:10.3390/diagnostics11101802
31. Abou Taha A, Dinesen S, Vergmann AS, Grauslund J. Present and future screening programs for diabetic retinopathy: a narrative review. International journal of retina and vitreous. Feb 3 2024;10(1):14. doi:10.1186/s40942-024-00534-8
32. Weng CY, Maguire MG, Flaxel CJ, et al. Effectiveness of Conventional Digital Fundus Photography-Based Teleretinal Screening for Diabetic Retinopathy and Diabetic Macular Edema: A Report by the American Academy of Ophthalmology. Ophthalmology. 2024;doi:10.1016/j.ophtha.2024.02.017
33. NHSE. NHS Diabetic eye screening pathway standards from 1st October 2024. Accessed 15/12/2025, https://www.gov.uk/government/publications/diabetic-eye-screening-programme-standards/nhs-diabetic-eye-screening-pathway-standards-from-1st-october-2024-public-facing-guidance-information
34. Murgatroyd H, Ellingford A, Cox A, et al. Effect of mydriasis and different field strategies on digital image screening of diabetic eye disease. Br J Ophthalmol. Jul 2004;88(7):920-4.
35. Styles C, Lee N, Black M, Ah-See K. Use of Dilating Drops in the Scottish Diabetic Retinopathy Screening Programme. presented at: European Association for the Study of Diabetic Eye Complications (EASDec); 2020;
36. Gupta V, Bansal R, Gupta A, Bhansali A. Sensitivity and specificity of nonmydriatic digital imaging in screening diabetic retinopathy in Indian eyes. Indian J Ophthalmol. Aug 2014;62(8):851-6. doi:10.4103/0301-4738.141039
37. Gajwani P, Zhao D, Guallar E, et al. Ungradable non mydriatic fundus photography in community eye screening. presented at: ARVO; 2019; Vancouver. Accessed 30/12/23 . https://iovs.arvojournals.org/article.aspx?articleid=2746784
38. Wilson PJ, Ellis JD, MacEwen CJ, Ellingford A, Talbot J, Leese GP. Screening for diabetic retinopathy: a comparative trial of photography and scanning laser ophthalmoscopy. Ophthalmologica Journal international d'ophtalmologie International journal of ophthalmology Zeitschrift fur Augenheilkunde. 2010;224(4):251-7.
39. Silva PS, Cavallerano JD, Sun JK, Noble J, Aiello LM, Aiello LP. Nonmydriatic ultrawide field retinal imaging compared with dilated standard 7-field 35-mm photography and retinal specialist examination for evaluation of diabetic retinopathy. American Journal of Ophthalmology. 2012;154(3):549-559.e2.
40. Soliman AZ, Silva PS, Aiello LP, Sun JK. Ultra-wide field retinal imaging in detection, classification, and management of diabetic retinopathy. Seminars in Ophthalmology. 2012;27(5-6):226-232.
41. Aiello LP, Odia I, Glassman AR, et al. Comparison of Early Treatment Diabetic Retinopathy Study Standard 7-Field Imaging With Ultrawide-Field Imaging for Determining Severity of Diabetic Retinopathy. JAMA ophthalmology. Jan 1 2019;137(1):65-73. doi:10.1001/jamaophthalmol.2018.4982
42. Silva PS, Cavallerano JD, Tolls D, et al. Potential efficiency benefits of nonmydriatic ultrawide field retinal imaging in an ocular telehealth diabetic retinopathy program. Diabetes care. Jan 2014;37(1):50-5. doi:10.2337/dc13-1292
43. Silva PS, Horton MB, Clary D, et al. Identification of Diabetic Retinopathy and Ungradable Image Rate with Ultrawide Field Imaging in a National Teleophthalmology Program. Ophthalmology. Jun 2016;123(6):1360-7. doi:10.1016/j.ophtha.2016.01.043
44. Fonda SJ, Bursell SE, Lewis DG, Clary D, Shahon D, Silva PS. Prevalence of Diabetic Eye Diseases in American Indians and Alaska Natives (AI/AN) as Identified by the Indian Health Service's National Teleophthalmology Program Using Ultrawide Field Imaging (UWFI). Ophthalmic epidemiology. Dec 2022;29(6):672-680. doi:10.1080/09286586.2021.1996611
45. Scanlon PH, Gruszka-Goh M, Javed U, et al. The Scanning CONfoCal Ophthalmoscopy foR DIAbetic eye screening (CONCORDIA) study paper 1. Eye (London, England). Dec 2024;38(18):3539-3546. doi:10.1038/s41433-024-03360-2
46. Scanlon PH, Gruszka-Goh M, Javed U, et al. The scanning CONfoCal Ophthalmoscopy foR DIAbetic eye screening (CONCORDIA) study paper 2. Eye (London, England). Oct 11 2024; doi:10.1038/s41433-024-03361-1
47. Piatti A, Rui C, Gazzina S, et al. Diabetic retinopathy screening with confocal fundus camera and artificial intelligence - assisted grading. European journal of ophthalmology. 03// 2025;35(2):679-688. doi:10.1177/11206721241272229
48. Graham-Rowe E, Lorencatto F, Lawrenson JG, et al. Barriers to and enablers of diabetic retinopathy screening attendance: a systematic review of published and grey literature. Diabetic medicine : a journal of the British Diabetic Association. Oct 2018;35(10):1308-1319. doi:10.1111/dme.13686
49. Hipwell AE, Sturt J, Lindenmeyer A, et al. Attitudes, access and anguish: a qualitative interview study of staff and patients' experiences of diabetic retinopathy screening. BMJ Open. 2014;4(12):e005498. doi:10.1136/bmjopen-2014-005498
50. Liew G, Michaelides M, Bunce C. A comparison of the causes of blindness certifications in England and Wales in working age adults (16-64 years), 1999-2000 with 2009-2010. BMJ Open. Feb 12 2014;4(2):e004015. doi:10.1136/bmjopen-2013-004015
51. Scanlon PH. The contribution of the English NHS Diabetic Eye Screening Programme to reductions in diabetes-related blindness, comparisons within Europe, and future challenges. Acta diabetologica. Apr 2021;58(4):521-530. doi:10.1007/s00592-021-01687-w
52. ISRCTN. Evaluating a new camera for diabetic eye disease screening in Afro-Caribbean and Asian populations without pupil dilation. Accessed 16/12/2025, https://www.isrctn.com/ISRCTN18020816