{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T11:21:04Z","timestamp":1787829664493,"version":"build-2784847793"},"reference-count":13,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T00:00:00Z","timestamp":1787788800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"},{"start":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T00:00:00Z","timestamp":1787788800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Acta Ophthalmologica"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Manual diabetic retinopathy (DR) grading may prefer certain regions and underestimate others. It is unclear if inexperienced graders' initial marking strategy reflects a specialist's marking pattern.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aims<\/jats:title>\n                    <jats:p>By the virtual ocular learning platform (VIOLA), we evaluated if initial DR\u2010lesion markings among inexperienced graders spatially corresponded to a specialist\u2010based lesion map.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Materials and Methods<\/jats:title>\n                    <jats:p>\n                      We used retinal 6\u2010field VIOLA images with at least 500 DR\u2010lesion markings covering all DR\u2010levels (0\u20134) according to the international clinical diabetic retinopathy (ICDR) scale. We divided images into quadrants and counted the initial three markings per lesion type, per image, per grader. A retinal specialist served reference for annotation of all DR\u2010lesions. The primary outcome was difference in spatial distribution of DR\u2010markings across quadrants relative to the reference, further characterised with spatial metrics.\n                      <jats:italic>p<\/jats:italic>\n                      \u2010Value &lt;\u20090.05 indicated statistical significance.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Across 24 images, 97 graders marked 16\u2009925 DR\u2010lesions: 1633 microaneurysms (MA), 3228 haemorrhages, 1549 hard exudates (HE), 3081 cotton wool spots (CWS), 3844 intraretinal microvascular abnormalities (IRMA), 1832 new vessels (NV) and 1758 panretinal photocoagulation scars (PRP). A difference was observed across all lesion types (\n                      <jats:italic>\u03c7<\/jats:italic>\n                      <jats:sup>2<\/jats:sup>\n                      \u2010test,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001) relative to the reference lesion map.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>Most lesion types demonstrated high sensitivity, but low PPV, indicating a liberal marking approach. Distribution of initial markings from inexperienced graders spatially misaligns with a specialist\u2010derived lesion map across all lesion types.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>As the ICDR\u2010scale depends on identifying the most severe lesion type, systematically inconsistent search strategies may pose a risk for overlooking important lesions under time constraints. The results support the promotion of attention guiding during DR\u2010training.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/aos.70224","type":"journal-article","created":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T10:46:00Z","timestamp":1787827560000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Evaluation of spatial distribution of initial marking strategy among inexperienced graders in diabetic retinopathy: A retrospective cross\u2010sectional analysis"],"prefix":"10.1111","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2882-5739","authenticated-orcid":false,"given":"Simon Joel Ellerup","family":"Lowater","sequence":"first","affiliation":[{"name":"Department of Ophthalmology Odense University Hospital  Odense Denmark"},{"name":"Department of Clinical Research University of Southern Denmark  Odense Denmark"},{"name":"Steno Diabetes Center Odense, Odense University Hospital  Odense Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-4279-3699","authenticated-orcid":false,"given":"Andrea Blasi","family":"N\u00fa\u00f1ez","sequence":"additional","affiliation":[{"name":"Department of Mathematics and Computer Science University of Southern Denmark  Odense Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3238-868X","authenticated-orcid":false,"given":"Jakob Kristian Holm","family":"Andersen","sequence":"additional","affiliation":[{"name":"The M\u00e6rsk McKinney M\u00f8ller Institute the Faculty of Engineering, University of Southern Denmark  Odense Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sebastian","family":"Dinesen","sequence":"additional","affiliation":[{"name":"Department of Otorhinolaryngology Odense University Hospital  Odense Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thiusius Rajeeth","family":"Savarimuthu","sequence":"additional","affiliation":[{"name":"The M\u00e6rsk McKinney M\u00f8ller Institute the Faculty of Engineering, University of Southern Denmark  Odense Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5019-0736","authenticated-orcid":false,"given":"Jakob","family":"Grauslund","sequence":"additional","affiliation":[{"name":"Steno Diabetes Center Odense, Odense University Hospital  Odense Denmark"},{"name":"Faculty of Health Sciences University of Southern Denmark  Odense Denmark"},{"name":"Vestfold Hospital Trust  T\u00f8nsberg Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,8,27]]},"reference":[{"key":"e_1_2_10_2_1","doi-asserted-by":"publisher","DOI":"10.1186\/s40942-024-00534-8"},{"key":"e_1_2_10_3_1","doi-asserted-by":"publisher","DOI":"10.1111\/aos.15123"},{"key":"e_1_2_10_4_1","doi-asserted-by":"publisher","DOI":"10.1186\/s41235-019-0159-2"},{"key":"e_1_2_10_5_1","unstructured":"Dansk Oftalmologisk Selskab. (2023)National retningslinje for screening af diabetisk retinopati 2023. Dansk Oftalmologisk Selskab."},{"key":"e_1_2_10_6_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0161-6420(13)38012-9"},{"key":"e_1_2_10_7_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00125-009-1450-4"},{"key":"e_1_2_10_8_1","doi-asserted-by":"publisher","DOI":"10.1111\/aos.15000"},{"key":"e_1_2_10_9_1","doi-asserted-by":"publisher","DOI":"10.3390\/healthcare9060745"},{"key":"e_1_2_10_10_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41433-025-03633-4"},{"key":"e_1_2_10_11_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ophtha.2018.01.034"},{"key":"e_1_2_10_12_1","doi-asserted-by":"publisher","DOI":"10.1034\/j.1600-0420.2000.078004374.x"},{"key":"e_1_2_10_13_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ophtha.2021.04.027"},{"key":"e_1_2_10_14_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0161-6420(03)00475-5"}],"container-title":["Acta Ophthalmologica"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/aos.70224","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/aos.70224","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/aos.70224","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T10:46:01Z","timestamp":1787827561000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/aos.70224"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,27]]},"references-count":13,"alternative-id":["10.1111\/aos.70224"],"URL":"https:\/\/doi.org\/10.1111\/aos.70224","archive":["Portico"],"relation":{},"ISSN":["1755-375X","1755-3768"],"issn-type":[{"value":"1755-375X","type":"print"},{"value":"1755-3768","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,27]]},"assertion":[{"value":"2026-01-21","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-08-05","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-08-27","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"aos.70224"}}