Predictors of treatment-warranted retinopathy of prematurity in the SUNDROP cohort: influence of photographic features

Validation of DIGIROP models and decision support tool for prediction of treatment for retinopathy of prematurity on a contemporary Swedish cohort

BACKGROUND/AIMS

Retinopathy of prematurity (ROP) is currently diagnosed through repeated eye examinations to find the low percentage of infants that fulfil treatment criteria to reduce vision loss. A prediction model for severe ROP requiring treatment that might sensitively and specifically identify infants that develop severe ROP, DIGIROP-Birth, was developed using birth characteristics. DIGIROP-Screen additionally incorporates first signs of ROP in different models over time. The aim was to validate DIGIROP-Birth, DIGIROP-Screen and their decision support tool on a contemporary Swedish cohort.

METHODS

Data were retrieved from the Swedish national registry for ROP (2018-2019) and two Swedish regions (2020), including 1082 infants born at gestational age (GA) 24 to <31 weeks. The predictors were GA at birth, sex, standardised birth weight and age at the first sign of ROP. The outcome was ROP treatment. Sensitivity, specificity and area under the receiver operating characteristic curve (AUC) with 95% CI were described.

RESULTS

For DIGIROP-Birth, the AUC was 0.93 (95% CI 0.90 to 0.95); for DIGIROP-Screen, it ranged between 0.93 and 0.97. The specificity was 49.9% (95% CI 46.7 to 53.0) and the sensitivity was 96.5% (95% CI 87.9 to 99.6) for the tool applied at birth. For DIGIROP-Screen, the cumulative specificity ranged between 50.0% and 78.7%. One infant with Beckwith-Wiedemann syndrome who fulfilled criteria for ROP treatment and had no missed/incomplete examinations was incorrectly flagged as not needing screening.

CONCLUSIONS

DIGIROP-Birth and DIGIROP-Screen showed high predictive ability in a contemporary Swedish cohort. At birth, 50% of the infants born at 24 to <31 weeks of gestation were predicted to have low risk of severe ROP and could potentially be released from ROP screening examinations. All routinely screened treated infants, excluding those screened for clinical indications of severe illness, were correctly flagged as needing ROP screening.

Ocular Pigmentation Impact on Retinal Versus Choroidal Optical Coherence Tomography Imaging in Preterm Infants

Purpose

To evaluate the association of fundus pigmentation with the visibility of retinal versus choroidal layers on optical coherence tomography (OCT) in preterm infants.

Methods

For infants enrolled in BabySTEPS, ophthalmologists recorded fundus pigmentation (blond, medium, or dark) at the first retinopathy of prematurity (ROP) examination. Bedside OCT imaging was performed at each examination, and a masked grader evaluated all OCT scans from both eyes of each infant for visibility (yes/no) of all retinal layers and of the chorio-scleral junction (CSJ). Multivariable logistic regression was used to assess associations between fundus pigmentation and visibility of all retinal layers and CSJ, controlling for potential confounders (i.e., birth weight, gestational age, sex, OCT system, pupil size, and postmenstrual age at imaging).

Results

Among 114 infants (mean birth weight, 943 grams; mean gestational age, 27.6 weeks), 43 infants (38%) had blond, 56 infants (49%) had medium, and 15 infants (13%) had dark fundus pigmentation. Of 1042 scans, all retinal layers were visible in 977 (94%) and CSJ in 895 (86%). Pigmentation was not associated with retinal layer visibility (P = 0.49), but medium and dark pigmentation were associated with decreased CSJ visibility (medium: odds ratio [OR] = 0.34, P = 0.001; dark: OR = 0.24, P = 0.009). For infants with dark pigmentation, retinal layer visibility increased (OR = 1.87 per week; P ≤ 0.001) and CSJ visibility decreased (OR = 0.78 per week; P = 0.01) with increasing age.

Conclusions

Although fundus pigmentation was not associated with the visibility of all retinal layers on OCT, darker pigmentation decreased CSJ visibility, and this effect increased with age.

Translational Relevance

The ability of bedside OCT to capture retinal layer microanatomy in preterm infants, regardless of fundus pigmentation, may represent an advantage over fundus photography for ROP telemedicine.

Diagnostic Accuracy of Wide-Field Digital Retinal Images in Retinopathy of Prematurity Detection: Systematic Review and Meta-Analysis

PURPOSE

To evaluate the diagnostic accuracy of the wide-field digital retinal imaging (WFDRI) for the detection of Retinopathy of Prematurity (ROP) in premature infants as compared to the binocular indirect ophthalmoscopy (BIO).

METHODS

This systematic review and meta-analysis included the publications searched through PubMed (Medline), EMBASE, Scopus, Web of Science, Cochrane Library databases and Clinical Trials. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2, the hierarchical summary receiver operating characteristic, meta-regression, publication bias analyses, and the GRADE methodology for the certainty of the overall evidence were conducted. The pooled effect sizes of the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR) and diagnostic odds ratio (DOR) were calculated.

RESULTS

Total sixteen eligible studies from 10 articles were included with total 2,537 image interpretations from 697 premature infants. Less than 50% risk of bias and low concern were found in each domain across all articles by QUADAS-2. The pooled effect sizes showed the sensitivity of 0.77 (95% confidence interval (C.I.): 0.69-0.84), specificity of 0.96 (95% C.I.: 0.92-0.98), PLR of 20.9 (95% C.I.: 10.2-42.5), NLR of 0.23 (95% C.I.: 0.17-0.33) and DOR of 89 (95% C.I.: 43-185) as compared to BIO. The income level, setting, mean/median birth weight and gestational age contributed to the significant differences in sensitivity (p < 0.001). No publication bias was found among these 16 studies. The GRADE quality of evidence showed moderate for the pooled sensitivity and high for the pooled specificity.

CONCLUSIONS

The diagnostic accuracy based on WFDRI is substantial and comparable to BIO, supporting its application in the ROP screening programs.

Retinopathy of Prematurity: Advances in the Screening and Treatment of Retinopathy of Prematurity Using a Single Center Approach

PURPOSE

To focus on the longitudinal evaluation of high-risk infants for the development of retinopathy of prematurity (ROP) at a single tertiary neonatal intensive care unit (NICU), and to evaluate evolving demographics of ROP and the transition of treatment-warranted disease.

DESIGN

Retrospective cohort study.

METHODS

A consecutive retrospective review was performed of all infants screened for ROP between 1990 and 2019 at the Jackson Memorial Hospital neonatal intensive care unit. All inborn infants meeting a birth criteria of <32 weeks' gestational age (GA) or a birthweight (BW) of 1500 g were included. Longitudinal demographic, diagnostic, and treatment data were reported.

RESULTS

Between January 1, 1990, and June 20, 2019, a total of 25,567 examinations were performed and 7436 patients were included. Longitudinal trends over 3 decades demonstrated a decreasing incidence of ROP (P < .05). Although the mean BW and GA increased over 3 decades, patients with ROP demonstrated lower BW and GA over time (P < .05). The prevalence of micro-premature infants (as defined by BW <750 g) continues to rise over time. Micro-preemies demonstrated increasing severity of zone and stage grading, plus disease, and propensity to require treatment (P < .05). The rate of progression of ROP to stage 4 and 5 disease has decreased over time, and there has been an associated increased adoption of intravitreal bevacizumab as primary and salvage therapy.

CONCLUSIONS

Understanding the evolution of ROP infants and treatment over time is critical in identifying high-risk infants and in reducing the incidence of severe-stage ROP. Micro-prematurity is one of the significant risk factors for treatment-warranted ROP that continues to increase as neonatal care improves. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Key factors in a rigorous longitudinal image-based assessment of retinopathy of prematurity

To describe a database of longitudinally graded telemedicine retinal images to be used as a comparator for future studies assessing grader recall bias and ability to detect typical progression (e.g. International Classification of Retinopathy of Prematurity (ICROP) stages) as well as incremental changes in retinopathy of prematurity (ROP). Cohort comprised of retinal images from 84 eyes of 42 patients who were sequentially screened for ROP over 6 consecutive weeks in a telemedicine program and then followed to vascular maturation or treatment, and then disease stabilization. De-identified retinal images across the 6 weekly exams (2520 total images) were graded by an ROP expert based on whether ROP had improved, worsened, or stayed the same compared to the prior week’s images, corresponding to an overall clinical “gestalt” score. Subsequently, we examined which parameters might have influenced the examiner’s ability to detect longitudinal change; images were graded by the same ROP expert by image view (central, inferior, nasal, superior, temporal) and by retinal components (vascular tortuosity, vascular dilation, stage, hemorrhage, vessel growth), again determining if each particular retinal component or ROP in each image view had improved, worsened, or stayed the same compared to the prior week’s images. Agreement between gestalt scores and view, component, and component by view scores was assessed using percent agreement, absolute agreement, and Cohen’s weighted kappa statistic to determine if any of the hypothesized image features correlated with the ability to predict ROP disease trajectory in patients. The central view showed substantial agreement with gestalt scores (κ = 0.63), with moderate agreement in the remaining views. Of retinal components, vascular tortuosity showed the most overall agreement with gestalt (κ = 0.42–0.61), with only slight to fair agreement for all other components. This is a well-defined ROP database graded by one expert in a real-world setting in a masked fashion that correlated with the actual (remote in time) exams and known outcomes. This provides a foundation for subsequent study of telemedicine’s ability to longitudinally assess ROP disease trajectory, as well as for potential artificial intelligence approaches to retinal image grading, in order to expand patient access to timely, accurate ROP screening.

Systemic Solutions in Retinopathy of Prematurity

PURPOSE

To describe a framework for screening and treatment of retinopathy of prematurity (ROP) using telemedicine screening with laser and/or vascular endothelial growth factor inhibitor treatment strategies.

DESIGN

Literature review and perspective.

METHODS

Review of the literature and the author's experience.

RESULTS

Undetermined.

CONCLUSIONS

Telemedicine can be deployed on a national basis to provide quaternary-level screening for ROP. At-risk patients for treatment could then be directed to receive either laser photocoagulation or vascular endothelial growth factor inhibitor intravitreal injections followed at a later time by examination under anesthesia, fluorescein angiography, and diode laser photocoagulation as indicated.