Worldwide ophthalmologists are challenged by the rapid rise in the prevalence of diabetes. Diabetic retinopathy (DR) is the most common complication in diabetes, and possible consequences range from mild visual impairment to blindness. Repetitive screening for DR is cost-effective, but it is also a costly and strenuous affair. Several studies have examined the application of automated image analysis to solve this problem. Large populations are needed to assess the efficacy of such programs, and a standardized and rigorous methodology is important to give an indication of system performance in actual clinical settings.