R2 or Not? September 2017

Total: 131 responses

Image 1 (click on image to view larger)

Overall Result:

R2: 79%

Not R2: 21%

Broken down by grader level:

Trainee Graders (20)

• R2: 55%
• Not R2: 45%

Qualified Graders (78)

• R2: 83%
• Not R2: 17%

ROG/L3 Graders (33)

• R2: 85%
• Not R2: 15%

Comments from those who said R2:

• IRMA
• IRMA
• 4 o'clock from disc
• Irma present
• IRMA 6 o'clock
• I was taught that with multiple cws to be careful to look for IRMA - I think IRMA are present and visible in red therefore R2
• Visible IRMA in colour image
• IRMAs = intraretinal microvascular abnormalities
• Can see IRMA
• evident IRMA
• Multiple IRMA present in colour image - nasal to disc
• Few patches of IRMA
• Subtle area of IRMA 4 o'clock to the disc
• Irma
• looks like IRMA 2 o'clock - not R2 based on multiple blots and dots
• IRMA
• IRMA can be seen in red near ischaemic areas
• presence of irma
• IRMA present
• IRMA
• There is IRMA, it's quite early and probably more hypertensive in its background. The appropriate management would be a letter to Primary care asking BP, cholesterol and diabetic workup to minimise risk and this patient could be seen in Surveillance clinic in 6 months to re-evaluate.
• This is the most borderline image of the 3
• IRMA
• ? R2 some areas of IRMA/dilated vessels, so difficult to tell for sure.
• 5 o'clock from disc
• IRMA superiorly visible in colour photo

Comments from those who said NOT R2:

• Collateral
• may just be dilated capillaries as only a few background changes can be seen
• ? IRMA right upper quadrant
• I would say R1
• Haems are not deep, what could be IRMA look more like dilated vessels, just not enough going on to warrant R2
• Collaterals - crossing vessels
• there are possible IRMA but in the whole the retina looks not very active, I would recall in 6/12 and advise the px to keep good diabetes controls

Image 2 (Click on image to view larger)

Overall Result:

R2: 92%

Not R2: 8%

Broken down by grader level:

Trainee Graders (20)

• R2: 85%
• Not R2: 15%

Qualified Graders (78)

• R2: 91%
• Not R2: 8%

ROG/L3 Graders (33)

• R2: 97%
• Not R2: 3%

Comments from those who said R2:

• IRMA
• IRMA AND MBH
• Multiple haem and IRMAs
• IRMA and multiple
• blot haemorrhages and IRMA
• graded R2 due to IRMAS
• blot haems and venous beading and possible IRMA
• Multiple blot haemorrhages present
• MBH
• IRMA inferior to disc and nasal and more pathology can be seen.
• Multiple blot hge with patches of IRMA
• Irma present
• Areas of IRMA, CWS and haems
• more than 10 blots over 3 quadrants
• Multiple blots and Irma
• Multi Blot Haem
• Dilated veins, deep blots and IRMA some exudates and ischaemia = R2
• R2 based on IRMA and multiple dots and blots
• IRMA can be seen in red near ischaemic area
• multiple haems and IRMA
• Multiple haemorrhages and IRMA
• Multiple microanuerysms, CW spots and areas of definite IRMA - this eye is becoming hypoxic and is at higher risk of progression if diabetic control is not brought in line. This would be referred and likely monitoring in eye clinic will be on a 6 monthly basis
• IRMA+MBH
• D's & B's
• Verging on R3A. Would request "urgent" R2 referral. Goes down as routine on Optomize but patient seen more promptly in HES
• image 2 shows a much more active retina than image 1 with mult. haemorrhages and some definate IRMA, would refer px ICO
• 5 o'clock from disc
• Definite R2 with venous engorgement and early beading
• MBH

Comments from those who said NOT R2:

• would call R3
• there looks to be new vessels R3 if not IRMA
• I would grade this image as R3 NV inferior nasal area.
• nve inferior right
• Possible NVD would grade with caution possible R3.
• Possible new vessels 5 o'clock to disc?

Image 3 (Click on image to view larger)

Overall Result:

R2: 65%

Not R2: 35%

Broken down by grader level:

Trainee Graders (20)

• R2: 80%
• Not R2: 20%

Qualified Graders (78)

• R2: 55%
• Not R2: 45%

ROG/L3 Graders (33)

• R2: 79%
• Not R2: 21%

Comments from those who said R2:

• IRMA - need some cases with MBHs as that's where confusion is
• IRMA
• due to that I am unable to enhance the image I would grade R2 but it also could boarder on R3 due to suspicious vessels on the disc
• Its at least R2 because of visible IRMA. Possibly R3A because of the strange blood vessels on the disc
• IRMA
• Quadrant of IRMAs inf
• Looks like NVD so more like R3A
• collaterals at optic disc
• Query IRMA inferiorly
• May all just be normal for patient but if first time screen I would grade as R2
• IRMA
• Multiple IRMA
• Possibly NVD also
• Irma
• irma
• IRMA within inferior arc, would like previous images if possible as disc looks suspicious of NVD developing.
• based on IRMA 6 o'clock
• would like to check past images for ?NVD
• changes to disc without history difficult to assess
• IRMA can be seen in red near ischaemic area. collateral vessel from an occlusion on disc could be confused with a new vessel.
• IRMA present
• would like to have seen the nasal shot as well a lot of vascular changes.
• New vessels on disc?
• CW spots and IRMA- this eye is reacting to hypoxia but the appearance of the small disc vessels corkscrewing indicates that there could be a background of hypertension and this patient could be at risk of a CRVO. Letter to primary care on BP, cholesterol and glyceamic control with a routine HES referral. They would likely monitor x2 times and discharge a patient of this level to be monitored in surveillance if there were no further change.
• IRMA
• I would refer this px not only because it look like just R2 but there are suspicious vessels on the disc and having no previous images for comparison to see if the fine vessels are natural to the px or possible NVD's
• Not liking the look of some of the vessels on the disc, would probably ? NVs if I didn't have a previous image to compare with.
• If not then R3 due to disc vessel reduplication
• Due to fine new looking vessels on disk I would have most likely graded R3

Comments from those who said NOT R2:

• I think it's R3A (NVD), but there is definitely IRMA present
• looks like new vessels at the disc
• vein occlusion. collaterals
• Would call R3 - NVD
• Because of the suspect vessels at the disc I'd punt it on as an R3
• Looks like new vessel on disk so that image is R3
• I would grade this as R3 as NVD are present, but it does have R2 features
• Would mark as R3 - dubious vessels on the disc
• R3A - possible NVD though look more like collaterals
• R3 - NVD
• Would grade as R3 NVD
• IRMA looks like new vessels on the OPTIC DISC R3
• Without previous images to compare I think I would grade this as NVD
• I would grade as R3a due to vessels on the disc
• R3 looks like NVD plus some IRMA
• NVD
• R3
• R3 NV on disc and elsewhere
• Looks like NVD
• nvd
• Is R2 clicked wrong tab - collaterals also
• LOOKS LIKE BRVO
• Some R2 features, NVD possibly?
• R3
• NVD? Hard to tell on first encounter, but if had history then obviously be able to clarify if NVD. If not NVD then would have graded R2
• Not R2 as now R3 NVD
• R3A
• It looks like R3A (NVD), but R2 features are present
• looks like collaterals
• Although this image has R2 features, the disc possibly could have new vessels?