Exhibit 4
Retinal Light Box Reading - Paper Form
FIELD CENTER PATIENT ID EYE Grader ____ Date Graded __ __ / __ __ / __ __
PHOTOGRAPHIC QUALITY
Focus Field Definition Artifacts No Yes
1 Good 1 Good Haze 0 2
2 Fair 2 Fair Dust / dirt 0 2
3 Borderline 3 Borderline Lashes 0 2
4 Inadequate 4 Inadequate Arc 0 2
8 Cannot grade 8 Cannot grade Uneven illum / macula 0 2
Uneven illum / edge 0 2
Uneven illum / disc zone 0 2
Gradability Total blink 0 2
Other 0 2
1 Entire field gradable
2 Disc zone gradable, macula ungradable Comments
3 Macula gradable, disc zone ungradable
4 Disc zone and macula ungradable
5 Entire field ungradable
ARTERIOLAR Abnormalities
Arterial Abnormalities:
W/i Disc Margin Zone to 1/2 DD Generalized Narrowing of Arterioles
0 0 None 0 None
1 1 Questionable 1 Questionable
2 2 Definite 2 Definite
3 3 Severe 3 Severe
8 8 Cannot grade 8 Cannot grade
Focal Narrowing of Arterioles (in Quadrants) Papillary Swelling
ST SN IN IT
0 None
0 0 0 0 None 1 Questionable
1 1 1 1 Questionable 2 Definite
2 2 2 2 Mild 3 Severe
3 3 3 3 Moderate 8 Cannot grade
4 4 4 4 Severe
8 8 8 8 Cannot grade
Sheathing of Arterioles (in Quadrants)
ST SN IN IT
0 0 0 0 None
1 1 1 1 Questionable
2 2 2 2 Mild
3 3 3 3 Moderate
4 4 4 4 Severe
8 8 8 8 Cannot grade
Abnormalities in A/V Crossings (in Quadrants)
ST SN IN IT
0 0 0 0 None
1 1 1 1 Questionable
2 2 2 2 Definite
3 3 3 3 Severe
8 8 8 8 Cannot grade
LESIONS OF DIABETIC RETINOPATHY
Number of Microaneurysms Number of Retinal Hemorrhages Type of Retinal Hemorrhage
0 None 0 None 0 None
1 Questionable 1 Questionable 1 Questionable
2 1 Ma 2 1 RH 2 Flame hemorrhage only
3 2 Ma's 3 > 2 RH's 3 Blot hemorrhage only
4 3 Ma's 8 Cannot grade 4 Blot and flame hemorrhages
5 4 Ma's 8 Cannot grade
6 > 5 Ma's
Hemorrhages/Microaneurysms Hard Exudate Soft Exudate
0 None 0 None 0 None
1 Questionable 1 Questionable 1 Questionable
2 Definite 2 Definite 2 Definite
3 > Std. Photograph #1 in all 4 quadrants 8 Cannot grade 8 Cannot grade
4 > Std. Photograph #2A
5 > Std. Photograph #2A in 2 or 3 quadrants
6 > Std. Photograph #2A in all 4 quadrants
8 Cannot grade
IRMA Venous Beading
0 None 0 None
1 Questionable 1 Questionable
2 Definite 2 Definite
3 Definite in all 4 quadrants 3 Definite in 2 or more quadrants
4 > Std. Photograph #8A 8 Cannot grade
NVD NVE VH/PRH FP
0 None 0 None 0 None 0 None
1 Questionable 1 Questionable 1 Questionable 1 Questionable
2 < Std. #10A 2 < 1/2 DA 2 < 1 DA 2 Definite
3 > Std. #10A 3 > 1/2 DA 3 > 1 DA 8 Cannot grade
8 Cannot grade 8 Cannot grade 8 Cannot grade
Macular Edema Laser Photocoagulation
0 None 0 None
1 Questionable 1 Questionable
2 Present, inferred from HE/other 2 Focal Rx only
3 CSME, inferred from HE/other 3 Scatter and/or local Rx
4 Center involved, inferred from HE/other 4 Focal and scatter Rx
8 Cannot grade 8 Cannot grade
Diabetic Retinal Level Supporting Evidence
90 Cannot grade 903 Cannot grade for proliferative retinopathy
902 Cannot grade for background retinopathy; no proliferative retinopathy present
901 Cannot grade for microaneurysms; no other background retinopathy present
85 Advanced PDR 852 Retinal detachment at center of macula
851 Macula obscured by VH and/or PRH
81 Advanced PDR 811 VH and/or PRH, cannot grade for NVD and/or NVE, center attached
75 DRS HRC 751 NVD > Std Photograph #10A with VH and/or PRH
71 DRS HRC 714 NVD > Std Photograph #10A
713 NVD < Std Photograph #10A with VH and/or PRH
712 NVE > 1/2 DA with VH and/or PRH
711 VH and/or PRH > 1 DA
65 Moderate PDR 654 NVE < 1/2 DA with VH and/or PRH
653 NVD < Std Photograph #10A
652 NVE > 1/2 DA
651 VH and/or PRH < 1 DA
61 Mild PDR 612 NVE < 1/2 DA
611 FPD and/or FPE
53 Severe NPDR 534 Venous beading in 2 or more fields
533 IRMA > Std Photograph #8A
532 H/Ma > Std Photograph #2A in 4 or 5 fields
531 Any two or three of level 47 characteristics
47 Moderately severe NPDR 474 Venous beading in one field
473 H/Ma > Std Photograph #2A in 2 or 3 fields
472 IRMA in 4 or 5 fields
471 Both IRMA and H/Ma characteristics from level 43
43 Moderate NPDR 433 IRMA in 1 to 3 fields
432 H/Ma > Std Photograph #2A in 1 field
431 H/Ma > Std Photograph #1 in 4 or 5 fields
35 Mild NPDR 355 Soft exudate
354 Hard exudate
353 Retinal hemorrhage
352 Questionable SE, IRMA or venous beading
351 Venous loop > code 2
20 Microaneurysms only 201 Microaneurysms only
15 DR questionable 151 Retinal hemorrhage, no microaneurysms
14 DR questionable 143 IRMA, no microaneurysms
142 Soft exudate, no microaneurysms
141 Hard exudate, no microaneurysms
10 DR absent 101 Microaneurysms and other lesions absent
OTHER OCULAR LESIONS
N Q Y N Q Y
0 1 2 Central artery occlusion 0 1 2 Cellophane reflex
0 1 2 Branch artery occlusion 0 1 2 Surface wrinkling retinopathy
0 1 2 Central vein occlusion with or without tension lines
0 12 Branch vein occlusion
0 1 2 Hollenhorst plaque 0 1 2 Soft drusen
0 1 2 Asteroid hyalosis 0 12 RPE depigmentation
0 1 2 Hyperpigmentation
0 1 2 Lg cup/disc ratio 0 12 SSR detachment
0 12 RH within disc margin 0 1 2 Subretinal hemorrhage
0 1 2 Peripapillary atrophy 0 1 2 Subretinal fibrous
0 12 Other disc abnormality 0 1 2 Geographic atrophy
0 1 2 Glial / vitreous thickening 0 1 2 Chorioretinal scars
0 1 2 Medullated nerve fibers 0 1 2 Nevus
0 1 2 Retinal detachment
COMMENTS
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