Article Text

Download PDFPDF
An interrater reliability study of a new ‘zonal’ classification for reporting the location of retinal haemorrhages in childhood for clinical, legal and research purposes
  1. Brian W Fleck1,2,3,
  2. Anamika Tandon1,
  3. Patricia A Jones3,
  4. Alan O Mulvihill1,2,
  5. Robert A Minns2,3
  1. 1Princess Alexandra Eye Pavilion, Edinburgh, UK
  2. 2Royal Hospital for Sick Children, Edinburgh, UK
  3. 3Child Life and Health, University of Edinburgh, Edinburgh, UK
  1. Correspondence to Dr Brian W Fleck, Princess Alexandra Eye Pavilion, Chalmers Street, Edinburgh EH3 9HA, UK; brian.fleck{at}


Background/Aims To develop and assess a zonal classification of the retina to facilitate description of the location of retinal haemorrhages in children.

Methods A novel zonal classification of the retina was devised based on the anatomical landmarks of the optic disc and vascular arcades, by reviewing a large number of wide field digital retinal images drawn from our database of children with accidental and non-accidental head injury and other encepthalopathies. Four expert examiners then independently ‘located’ 142 retinal haemorrhages by zone, from 31 high quality photographs.

Results Cohen's unweighted κ scores for all possible pairs of the four raters (ie, six pairs) ranged from 0.86 to 0.92, that is ‘almost perfect’ agreement. Fleiss' κ for agreement between multiple raters (four) and for multiple categories (three) was 0.8841, that is ‘almost perfect’ agreement. Cohen's unweighted κ statistic for intrarater reliability gave an overall concordance that ranged from ‘substantial’ to ‘perfect’ agreement.

Conclusion This new retinal zone classification and the use of photographs and templates is a very reliable tool for reporting the location of retinal haemorrhages from multiple aetiologies in children, and may be useful for research and medico-legal reports.

  • accidental traumatic brain injury
  • child health (paediatrics)
  • imaging
  • medico-legal reports
  • non-accidental (inflicted) traumatic brain injury
  • retinal haemorrhages
  • retinal zones
  • trauma

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Funding This study was supported by the RS MacDonald Charitable Trust and the Royal College of Surgeons Edinburgh (Ophthalmology Grant-Royal Blind).

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Lothian Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.