In Reply Dr Orellana suggests that telemedicine for detection of diabetic retinopathy depends on the reliability of the telemedicine graders. Because of word limits, our article referenced our previous article1 for agreement between the 2 reviewers, which was 97% for both macular edema and stage of diabetic retinopathy. The program included ongoing quality control and education. While we agree that quality control and standardization are important, a key finding of our study is that a telemedicine program (even a program that is “perfect”) does not guarantee a high percentage of annual eye examinations. Other barriers to attaining an eye examination exist.2