Objective: To assess the accuracy of grading diabetic retinopathy (DR) using single-field digital fundus photography compared with clinical grading from a dilated slit-lamp fundus examination in Indigenous Australians living in Central Australia. Design, setting and participants: Cross-sectional study comparing DR gradesin participants with diabetes mellitus presenting for examination at remotecommunity clinics from 1 July 2005 to 30 June 2008. Main outcome measures: Sensitivity and specificity of grading using digital photography compared with the clinical gold standard of slit-lamp fundus examination. Results: Of the 1884 participants recruited for the study, 1040 had self-reported diabetes mellitus and, of those, 360 had fundus photographs available (706 eyes) that were able to be graded. On clinical grading, 163 eyes had any DR and 51 eyes had vision-threatening DR (VTDR). The sensitivity and specificity for detecting any DR were 74% (95% CI, 67%-80%) and 92% (95% CI, 90%-94%), respectively. The sensitivity and specificity for detecting VTDR were 86% (95% CI, 77%-96%) and 95% (95% CI, 93%-97%), respectively. Conclusion: Single-field digital fundus photography is a valid screening tool for DR in remote communities of central Australia and may be used to provide eye care services to this region with acceptable accuracy.