Screening for diabetic retinopathy (DR) is an important component of diabetes management to prevent vision loss, yet many diabetic patients do not receive screening eye examinations.1 Tele-ophthalmology programs administering fundus photographs offer a potential solution, and technological advances have made automated photo-interpretation a real possibility.2 Automated algorithms are typically trained on images whose disease status has been classified by a human, so the validity of human grading is important.