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Background  Early detection can reduce irreversible blindness from retinal diseases. This study aims to assess the intra- and inter-rater agreement of retinal pathologies observed on fundus photographs between an ophthalmologist and two-mid level ophthalmic personnel (MLOPs).    Method  A population-based, cross-sectional study was conducted among subjects 60 years and above in the Bhaktapur district of Nepal. Fundus photographs of 500 eyes of 500 subjects were assessed. The macula-centered 45-degree photographs were graded twice by one ophthalmologist and two MLOPs. Intra-rater and inter-rater agreements were assessed for the ophthalmologist and the MLOPs.    Result  Mean age was 70.22 years ± 6.94 (SD). Retinal pathologies were observed in 55.6 % of photographs (age-related macular degeneration: 34.2 %; diabetic retinopathy: 4.2 %; retinal vein occlusion: 3.8 %). Twelve (2.4 %) fundus pictures were non-gradable. The intra-rater agreement for overall retinal pathologies, retinal hemorrhage, and maculopathy were substantial both for the ophthalmologist as well as for the MLOPs. There was moderate inter-rater agreement between the ophthalmologist and the first MLOP on second rating for overall retinal pathologies, [kappa  (k) ;  95 % CI  = 0.59 (0.51–0.66)], retinal hemorrhage [ k;  95  % CI  = 0.60 (0.41–0.78)], and maculopathy [ k;  95  % CI  = 0.52 (0.43–0.60)]. Inter-rater agreement between the ophthalmologist and the second MLOP for second rating was moderate for overall retinal pathologies [ k; 95 % CI  = 0.52 (0.44–0.60)], substantial agreement for retinal hemorrhage [ k; 95 % CI  = 0. 68 (0.52–0.84)], moderate agreement for maculopathy [ k; 95 % CI  = 0.59 (0.50–0.67)].    Conclusion  There is moderate agreement between the MLOPs and the ophthalmologist in grading fundus photographs for retinal hemorrhages and maculopathy.    Electronic supplementary material  The online version of this article (doi:10.1186/s12886-016-0295-0) contains supplementary material, which is available to authorized users.

bmc ophthalmology

Intra- and inter-rater agreement between an ophthalmologist and mid-level ophthalmic personnel to diagnose retinal diseases based on fundus photographs at a primary eye center in Nepal: the Bhaktapur Retina Study