Photographic Screening for Retinopathy of Prematurity (Photo-ROP) Cooperative Group. The photographic screening for retinopathy of prematurity study (photo-ROP). Primary outcomes. Retina. 2008;28:S47-S54. [PMID: 18317345 DOI: 10.1097/iae.0b013e31815e987f]

[Interpretation of the UK screening and treatment of retinopathy of prematurity updated 2022 guidelines]

The UK screening and treatment of retinopathy of prematurity (ROP) updated 2022 guidelines were developed by a multidisciplinary guideline development group from the Royal College of Paediatrics and Child Health and the Royal College of Ophthalmologists, following the standards of the National Institute for Health and Care Excellence. They were published on the websites of the Royal College of Paediatrics and Child Health and the Royal College of Ophthalmologists in March 2022, and formally published in Early Human Development in March 2023. The guidelines provide evidence-based recommendations for the screening and treatment of ROP. The most significant change in the 2022 updated version compared to the previous guidelines is the lowering of the gestational age screening criterion to below 31 weeks. The treatment section covers treatment indications, timing, methods, and follow-up visits of ROP. This article interprets the guidelines and compares them with ROP guidelines/consensus in China, providing a reference for domestic peers.

A Literary Pediatric Retina Fellowship With Michael T. Trese, MD

Michael T. Trese, MD (1946-2022), a vitreoretinal surgeon, made significant contributions to the field of retina. Although most known for his work in pediatric retina surgery, he was a pioneer in areas such as medical retina, translational research, and telemedicine. This article reviews his major contributions to spread his knowledge more widely to vitreoretinal trainees and specialists. We discuss six areas where Trese made a lasting impact: lens-sparing vitrectomy, familial exudative vitreoretinopathy, congenital X-linked retinoschisis, autologous plasmin enzyme, regenerative medicine, and telemedicine. [Ophthalmic Surg Lasers Imaging Retina 2023;54:701-712.].

Retinopathy of prematurity detection: a retrospective quality improvement project before-after implementation of retinal digital imaging for screening

Screening of retinopathy of prematurity (ROP) was modified in a level-3 neonatal intensive care unit by the introduction of a wide-field retinal imaging. The aim of this study was to evaluate whether retinopathy of prematurity (ROP) diagnosis was improved or not compared to previously used binocular indirect ophthalmoscopy (BIO). This was a retrospective, uncontrolled, quality improvement project. Records of consecutive premature newborns screened for ROP over two 1-year periods were reviewed. Systemic factors potentially influencing the occurrence of ROP were investigated using uni- and multivariable linear regression followed by stepwise forward regression. ROP screening was performed by ophthalmologists using BIO in 2014, and digital wide-field retinal imaging (Panocam™ pro) in 2019. Records of N = 297 patients were analyzed (N = 159 in 2014 and N = 138 in 2019). The proportion of ROP diagnosed at any stage, over the total number of neonates screened, was significantly higher in 2019 (n = 46/138, 33.1%) compared to 2014 (n = 11/159, 6.9%) (p < 0.0001). Most neonates presented with mild forms of ROP during both 1-year periods analyzed. After adjustment for all parameters influencing ROP occurrence, the variables contributing independently to the diagnosis of any stage of ROP were birth weight (p = 0.002), duration of mechanical ventilation (p = 0.028) and wide-field fundus camera-assisted screening (p < 0.001).

CONCLUSION

After adjusting for many recognized systemic factors influencing the development of ROP, screening by wide-field digital retinal imaging was independently associated with higher ROP detection.

WHAT IS KNOWN

• No consensus has been reached to replace binocular indirect ophthalmoscopy by retinal imaging for ROP screening. • Diagnostic accuracy and high sensitivity and specificity has been reported for wide-field digital imaging.

WHAT IS NEW

• The introduction of wide-field imaging for ROP screening in at level-3 reference center was independently associated to higher ROP detection.

Retinal imaging in infants

Digital retinal imaging is at the core of a revolution that is continually improving the screening, diagnosis, documentation, monitoring, and treatment of infant retinal diseases. Historically, imaging the retina of infants had been limited and difficult to obtain. Recent advances in photographic instrumentation have significantly improved the ability to obtain high quality multimodal images of the infant retina. These include color fundus photography with different camera angles, ultrasonography, fundus fluorescein angiography, optical coherence tomography, and optical coherence tomography angiography. We provide a summary of the current literature on retinal imaging in infants and highlight areas where further research is required.

The Role of Telemedicine to Alleviate an Increasingly Burdened Healthcare System: Retinopathy of Prematurity

Telemedicine-based remote digital fundus imaging (RDFI-TM) offers a promising platform for the screening of retinopathy of prematurity. RDFI-TM addresses some of the challenges faced by ophthalmologists in examining this vulnerable population in both low- and high-income countries. In this review, we studied the evidence on the use of RDFI-TM and analyzed the practical framework for RDFI-TM systems. We assessed the novel technological advances that can be deployed within RDFI-TM systems including noncontact imaging systems, smartphone-based imaging tools, and deep learning algorithms.

Auto-Processed Retinal Vessel Shadow View Images From Bedside Optical Coherence Tomography to Evaluate Plus Disease in Retinopathy of Prematurity

Purpose

To describe the creation of en face retinal vessel shadow view (RVSV) optical coherence tomography (OCT) images and assess the feasibility of using these for evaluating vascular disease in preterm infants at risk for retinopathy of prematurity (ROP).

Methods

In this exploratory study, we selected images from eyes with a range of ROP vascular disease, prospectively acquired from preterm infants using an investigational, noncontact, handheld, bedside swept-source OCT. We autosegmented OCT volumes using custom infant-specific software, extracted RVSV-OCT images from volumetric data bracketed around the retinal pigment epithelium, and automontaged the resulting RVSV-OCT images. Three masked ophthalmologists graded the RVSV-OCT montages as plus, pre-plus, or neither and ranked them by relative vascular disease severity.

Results

We selected images from 17 imaging sessions (7 plus, 4 pre-plus, 6 neither on clinical examination). On review, 15/17 (88%) RVSV-OCT montages were gradable for plus, pre-plus, or neither and all 17 montages were rankable for relative severity. Intergrader agreement for plus, pre-plus, or neither grading was good (κ, 0.67; 95% confidence interval, 0.42–0.86) and for relative severity ranking was excellent (intraclass correlation coefficient, 0.98; 95% confidence interval, 0.96–0.99).

Conclusions

Our novel automatic processing method can create RVSV-OCT montages optimized for retinal vessel visualization for ROP screening. Although our data support the feasibility of using RVSV-OCT montages for ranking relative vascular disease severity, there is room for improved OCT image capture and processing methods in preterm infants screened for ROP.

Translational Relevance

Creation and grading of RVSV-OCT images could eventually be integrated into an alternative method for ROP screening.

Comparison of wide field imaging by nurses with indirect ophthalmoscopy by ophthalmologists for retinopathy of prematurity: a diagnostic accuracy study

OBJECTIVES

Retinopathy of prematurity (ROP) is a vasoproliferative disease of the preterm retina with the potential to cause irreversible blindness. Timely screening and treatment of ROP are critical. Neonatal nurses trained in wide field digital retinal photography (WFDRP) for screening may provide a safe and effective strategy to reduce the burden of ophthalmologists in performing binocular indirect ophthalmoscopy (BIO). The objective of the study was to determine the diagnostic accuracy of WFDRP in the diagnosis of referral warranting ROP (RWROP).

DESIGN

Prospective diagnostic accuracy study.

SETTING

A tertiary neonatal intensive care unit in Perth, Western Australia.

PARTICIPANTS

Preterm infants who fulfilled the Australian ROP screening criteria (gestational age (GA) <31 weeks, birth weight (BW) <1250 g).

INTERVENTION

Sets of 5-6 images per eye (index test) were obtained within 24-48 hours prior to or after the BIO (reference standard), and uploaded onto a secured server. A wide field digital camera (RetCam, Natus, Pleasanton, California, USA) was used for imaging. A paediatric ophthalmologist performed the BIO. The ophthalmologists performing BIO versus reporting the images were masked to each other's findings.

PRIMARY OUTCOME

The area under the receiver operating characteristic (ROC) curve was used as a measure of accuracy of WFDRP to diagnose RWROP.

RESULTS

A total of 85 infants (mean BW; 973.43 g, mean GA; 29 weeks) underwent a median of two sessions of WFDRP. There were 188 episodes of screening with an average of five images per eye. WFDRP identified RWROP in 7.4% (14/188 sessions) of examinations. In one infant, BIO showed bilateral plus disease and WFDRP did not pick up the plus disease. WFDRP image interpretation had a sensitivity of 80%, specificity of 94.5% for the detection of RWROP. The 'area under the ROC curve' was 88% when adjusted for covariates.

CONCLUSIONS

WFDRP by neonatal nurses was feasible and effective for diagnosing RWROP in our set up.

TRIAL REGISTRATION NUMBER

ACTRN12616001386426.

Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy, Third Edition

Contributors The following document and appendices represent the third edition of the Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy. These guidelines were developed by the Diabetic Retinopathy Telehealth Practice Guidelines Working Group. This working group consisted of a large number of subject matter experts in clinical applications for telehealth in ophthalmology. The editorial committee consisted of Mark B. Horton, OD, MD, who served as working group chair and Christopher J. Brady, MD, MHS, and Jerry Cavallerano, OD, PhD, who served as cochairs. The writing committees were separated into seven different categories. They are as follows: 1.Clinical/operational: Jerry Cavallerano, OD, PhD (Chair), Gail Barker, PhD, MBA, Christopher J. Brady, MD, MHS, Yao Liu, MD, MS, Siddarth Rathi, MD, MBA, Veeral Sheth, MD, MBA, Paolo Silva, MD, and Ingrid Zimmer-Galler, MD. 2.Equipment: Veeral Sheth, MD (Chair), Mark B. Horton, OD, MD, Siddarth Rathi, MD, MBA, Paolo Silva, MD, and Kristen Stebbins, MSPH. 3.Quality assurance: Mark B. Horton, OD, MD (Chair), Seema Garg, MD, PhD, Yao Liu, MD, MS, and Ingrid Zimmer-Galler, MD. 4.Glaucoma: Yao Liu, MD, MS (Chair) and Siddarth Rathi, MD, MBA. 5.Retinopathy of prematurity: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 6.Age-related macular degeneration: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 7.Autonomous and computer assisted detection, classification and diagnosis of diabetic retinopathy: Michael Abramoff, MD, PhD (Chair), Michael F. Chiang, MD, and Paolo Silva, MD.

Telemedicine for Retinopathy of Prematurity

Background: Retinopathy of prematurity (ROP) is a disease of the retinal vasculature that remains a leading cause of childhood blindness worldwide despite improvements in the systemic care of premature newborns. Screening for ROP is effective and cost-effective, but in many areas, access to skilled examiners to conduct dilated examinations is poor. Remote screening with retinal photography is an alternative strategy that may allow for improved ROP care. Methods: The current literature was reviewed to find clinical trials and expert consensus documents on the state-of-the-art of telemedicine for ROP. Results: Several studies have confirmed the utility of telemedicine for ROP. In addition, several clinical studies have reported favorable long-term results. Many investigators have reinforced the need for detailed protocols on image acquisition and image interpretation. Conclusions: Telemedicine for ROP appears to be a viable alternative to live ophthalmoscopic examinations in many circumstances. Standardization and documentation afforded by telemedicine may provide additional benefits to providers and their patients. With continued improvements in image quality and affordability of imaging systems as well as improved automated image interpretation tools anticipated in the near future, telemedicine for ROP is expected to play an expanding role for a uniquely vulnerable patient population.

Telemedicine for Retinopathy of Prematurity in 2020

Purpose:

Retinopathy of prematurity (ROP) is the leading cause of visual impairment in premature infants, and middle-income nations are currently experiencing the “third epidemic” of ROP. Screening programs are essential to prevent negative visual outcomes, but screening efforts require a great amount of resources from healthcare systems and are difficult to marshal, particularly in geographically isolated or resource-limited settings. Telemedical screening programs using remote digital fundus imaging (RDFI) systems hold the promise of alleviating many of the burdens that currently make screening for ROP logistically challenging.

Methods:

Literature review of the current evidence for RDFI telescreening for ROP, with editorial discussion and recommendations.

Results:

In this review, we summarize the robust body of literature regarding the efficacy of RDFI, the feasibility of telescreening programs, and experiences from current live telescreening programs. We discuss the strengths and limitations of the current evidence and of the screening programs and consider the best practices in developing de novo telemedical screening programs for ROP. The review concludes with a discussion of promising future areas of research and development.

Conclusions:

RDFI ROP screening programs can be accurate and reliable. They show promise in improving many current challenges in screening infants for ROP, may be able to improve some aspects of care, and have been demonstrated to be cost-effective.

The validity of telemedicine-based screening for retinopathy of prematurity in the Premature Eye Rescue Program in Hungary

PURPOSE

To assess the validity of wide-field digital imaging (WFDI) and telemedicine-based screening compared with examination by binocular indirect ophthalmoscopy (BIO) and to present some of the results from the first five years of telemedicine-based screening in the Premature Eye Rescue Program in Hungary.

METHODS

We performed a retrospective analysis in two periods that aimed to assess (a) the validity of retinal digital imaging and (b) routine bedside screening. The validity was assessed in two neonatal intensive care units (NICUs), one in the First Department of Paediatrics and the other in the Second Department of Obstetrics and Gynaecology, Semmelweis University. The telemedicine-based WFDI (WFDI-TM) screening program was introduced in two phases. In the first phase (from 30 November 2009 to 8 August 2010), BIO and WFDI were performed by the same paediatric ophthalmologist (Group A). In the second phase (from 9 August 2010 to 29 March 2011), BIO was performed by the paediatric ophthalmologist, while retinal images were captured by a trained neonatal transport nurse practitioner (Group B). BIO screening was the reference method as a gold standard in both phases.

RESULTS

During the validity assessment period 634 examinations were performed in 153 preterm infants. Overall, 76 babies were screened in Group A and 80 were screened in Group B. We found lower sensitivity and specificity in cases of any ROP (sensitivity 86%, specificity 99%) compared with those of treatment-requiring retinopathy of prematurity (TR-ROP) (both sensitivity and specificity 100%).In the Premature Eye Rescue Program between 1April 2011 and 31 March 2016, we used WFDI in 3035 infants (4589 procedures). Over this five-year period, 100 (9.6%) infants were treated by laser, and no child who received care in any of the Semmelweis University NICUs became blind from ROP.

CONCLUSIONS

(a) WFDI-TM ROP screening is a useful and efficient approach, although it cannot completely replace BIO; (b) no ROP-related blindness developed among the screened preterm babies; and (c) WFDI-TM ROP screening can be implemented in the logistics of a neonatal emergency and ambulance team infrastructure with neonatal transport nurse practitioners as 'photographers'.

Evaluation of a Remote Telemedicine Screening System for Severe Retinopathy of Prematurity

PURPOSE

To evaluate the validity of remote telemedicine screening for retinopathy of prematurity (ROP) in a population of at-risk preterm infants in Iowa and South Dakota.

METHODS

The medical records for all preterm infants screened for ROP at neonatal intensive care units (NICUs) in Sioux City, Iowa, and Sioux Falls, South Dakota, from September 1, 2017, to July 31, 2018, were retrospectively reviewed. The RetCam Shuttle (Natus Medical Inc., Pleasanton, CA) was used to capture retinal images, which were posted on a secure server for evaluation by a pediatric ophthalmologist. Infants with suspected ROP approaching the criteria for treatment with anti-vascular endothelial growth factor (VEGF) medications were transferred to the Children's Hospital and Medical Center NICU in Omaha, Nebraska, where a comprehensive examination was performed and treatment was administered when indicated. The remaining infants received an outpatient comprehensive examination by one of two pediatric ophthalmologists within 2 weeks of discharge.

RESULTS

A total of 124 telemedicine examinations were performed on 35 infants during the study period. Remote telemedicine screening for referral-warranted ROP using the RetCam Shuttle had a sensitivity of 100%, specificity of 97%, positive predictive value of 66.7%, and negative predictive value of 100%. Of the three infants transferred for referral-warranted ROP, two required treatment with anti-VEGF medications. Good outcomes were noted in all cases, and no patients progressed beyond stage 3 ROP.

CONCLUSIONS

Telemedicine screening reliably detected referral-warranted ROP in at-risk premature infants at two remote sites, with no poor outcomes during the 11-month period. These results demonstrate the validity and utility of remote telemedicine screening for ROP. [J Pediatr Ophthalmol Strabismus. 2019;56(3):157-161.].

The Accuracy of Digital Imaging in Diagnosis of Retinopathy of Prematurity in Iran: A Pilot Study

Purpose:

To evaluate sensitivity and specificity of digital retinal image reading in the diagnosis of referral-warranted retinopathy of prematurity (ROP).

Methods:

Infants referred to the ROP clinic underwent fundus examination through indirect ophthalmoscopy. Fundus photographs were acquired using RetCam (shuttle 2; Clarity medical systems, Pleasanton, CA, USA). Four retinal specialists who were blind to patients’ information reviewed the RetCam fundus photographs. By comparing the results of photographs’ readings with that of indirect ophthalmoscopy as the gold standard, the sensitivity and specificity of telescreening was determined.

Results:

A total of 147 treatment-naïve patients met the inclusion criteria and were enrolled in the study. Mean gestational age (GA) was 28.6 ± 2.0 weeks. Digital retinal imaging had sensitivity of 85% and specificity of 35% in detecting referral-warranted ROP in our study. Positive predictive value of digital photography was 80%, and negative predictive value was 43%.

Conclusion:

Digital photography for diagnosis of ROP may show good potential as a screening modality in developing countries. It can facilitate early diagnosis, prevent unnecessary referrals, and be implemented for investigational purpose. However, the overall study result did not provide evidence to propose digital photography as a substitute for indirect ophthalmoscopy in the diagnosis of ROP.

Imaging in Retinopathy of Prematurity

Retinopathy of prematurity (ROP) is a leading cause of preventable childhood blindness worldwide. Barriers to ROP screening and difficulties with subsequent evaluation and management include poor access to care, lack of physicians trained in ROP, and issues with objective documentation. Digital retinal imaging can help address these barriers and improve our knowledge of the pathophysiology of the disease. Advancements in technology have led to new, non-mydriatic and mydriatic cameras with wider fields of view as well as devices that can simultaneously incorporate fluorescein angiography, optical coherence tomography (OCT), and OCT angiography. Image analysis in ROP is also being employed through smartphones and computer-based software. Telemedicine programs in the United States and worldwide have utilized imaging to extend ROP screening to infants in remote areas and have shown that digital retinal imaging can be reliable, accurate, and cost-effective. In addition, tele-education programs are also using digital retinal images to increase the number of healthcare providers trained in ROP. Although indirect ophthalmoscopy is still an important skill for screening, digital retinal imaging holds promise for more widespread screening and management of ROP.

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.

Diagnostic accuracy of a digital fundus photographic system for detection of retinopathy of prematurity requiring treatment (ROP-RT)

Objectives

To evaluate the diagnostic accuracy of a digital fundus photographic system that consists of taking fundus photographs by a trained technician using a RetCam^® shuttle and interpreting fundus images by an expert to detect Retinotapthy of Prematurity requiring treatment (ROP-RT) which defined as type I ROP according to the Early Treatment for ROP study (ETROP).

Materials and methods

One hundred infants were examined by (1) an expert ophthalmologist experienced in ROP care using indirect ophthalmoscopy; (2) digital wide-field imaging by a trained technician using a RetCam^® shuttle and images were sent remotely for interpretation by two ophthalmologists experienced in ROP care (Reader A, and Reader B); and (3) local ophthalmologists using indirect ophthalmoscopy. The diagnostic acurracy consisting of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were calculated. Agreement between all examiners and readers were evaluated.

Results

A total of 100 infants (mean gestational age 31.1 weeks, mean birth weight 1,511.1 grams) participated in the study. Nine infants were classified as ROP-RT. Reader A and B had very good agreement in detection of ROP- RT (Kappa 1.00, 95% CI 1.00, 1.00). For reader A, diagnostic performance parameters (95% confidence intervals) for detecting ROP-RT were; sensitivity 100.0% (66.4, 100.0), specificity 97.8% (92.1, 99.7), PPV 81.8% (48.2, 97.7), NPV 100.0% (95.8, 100.0), LR+ 44.5 (11.3, 175.2), and LR- 0.1 (0.0, 0.8). For reader B these were; sensitivity 100.0% (66.4, 100.0), specificity 95.6% (89.0, 98.8), PPV 69.2% (38.6, 90.9), NPV 100.0% (95.8, 100.0), LR+ 22.5 (8.6, 58.6), LR- 0.1 (0.0, 0.8). No adverse events were reported.

Conclusions

Diagnosis of ROP-RT from RetCam^® images taken by trained technicians and evaluated remotely by an expert ophthalmologist had good diagnostic accuracy for screening purposes.

Incidence and risk factors for retinopathy of prematurity: a retrospective cohort study

BACKGROUND AND OBJECTIVES

Advances in neonatal care promoted increased survival rates of preterm infants, with a consequent increase in the number of children affected by retinopathy of prematurity (ROP). This study estimates the incidence of ROP and evaluates potential risk factors associated.

METHODS

A retrospective cohort study of preterm infants born in a tertiary neonatal intensive care unit was conducted from March 2005 to August 2015. Six hundred and thirty-nine newborns were included based on the following criteria: infants born with less than 32 weeks' gestation or birth weight below 1500 g; or neonates born with 32-37 weeks' gestation or birth weight above 1500 g and any of the following associated: multiple gestation, respiratory distress syndrome, sepsis, blood transfusions or intraventricular hemorrhage. Neonates were followed up until disease resolution or until treatment criteria was achieved.

RESULTS

A total of 602 newborns were evaluated after applying the exclusion criteria. Mean gestational age was 30.7 ± 2.5 weeks. The incidences of ROP at any stage and of type 1 prethreshold ROP were 33.9 and 5.0% respectively. Logistic regression analysis revealed that risk factors associated with ROP at any stage were extremely low birth weight (ELBW) (odds ratio [OR] = 3.10; 95% confidence interval [95% CI]:1.73-5.55), pulmonary diseases (OR = 2.49; 95% CI: 1.35-4.59), intraventricular hemorrhage (OR = 2.17; 95% CI: 1.10-4.30), and low gestational age (OR = 0.81; 95% CI: 0.73-0.91). The main risk factors associated with type 1 prethreshold ROP were pulmonary diseases (OR = 9.58; 95% CI: 1.27-72.04) and ELBW (OR = 3.66; 95% CI: 1.67-8.00).

CONCLUSION

This study found a significant incidence of ROP (33.9%) in the studied population, and highlighted pulmonary diseases as a significant risk factor for type 1 prethreshold ROP.

A national telemedicine network for retinopathy of prematurity screening

PURPOSE

To report the results of retinopathy of prematurity (ROP) screening by a telemedicine system in Chile and evaluate its usefulness for referring patients who require treatment.

METHODS

Premature infants at risk of developing ROP from 11 neonatal intensive care units were included. Screening was performed on all infants born at a gestational age of <32 weeks and/or birth weight of <1500 g. A trained nonphysician operator used an imaging system to capture retinal images, which were reviewed by two independent ROP experts. All infants that required treatment were referred for further evaluation.

RESULTS

The study included 2,048 eyes of 1,024 premature infants. Mean gestational age was 28.8 ± 2.2 weeks, and mean birth weight was 1128 ± 279 g. A total of 5,263 telemedicine examinations were performed and reported. The average number of image sets per patient was 2.6 ± 2.5. Of the 5,263 images, 4,903 (93%) were recorded to at least the end of zone II; 5,172 (98%) were graded as having good quality, allowing for staging of ROP disease. Forty-two infants (4%) were referred for treatment. Discharged patients with ROP type 2 that regressed did not present with any complications or adverse effects during 6 months' follow-up.

CONCLUSIONS

Our study demonstrates the utility of telemedicine screening for ROP with ophthalmologist readers in a developing country. Telemedicine screening was able to detect treatment-requiring ROP. Most of the images had good quality and showed the end of zone II, two variables sufficient to discharge patients.

Evaluation of retinopathy of prematurity incidence with telemedicine confirmation in Gansu, China: a pilot study

PURPOSE

To determine the incidence of retinopathy of prematurity (ROP) in Gansu, China by combining bedside examinations with remote RetCam (Clarity Medical Systems, Pleasanton, CA, USA) diagnosis.

METHODS

ROP screening via indirect ophthalmoscopy followed by RetCam imaging was performed from 2014 to 2015. Three ROP-experienced ophthalmologists interpreted images remotely. Incidence of ROP was determined by combining bedside and telemedicine diagnoses.

RESULTS

Of 139 examined infants and 137 complete records, 20 (14.6%) patients developed ROP, with 11 (8.0%) stage 1, six (4.4%) stage 2, and three (2.2%) stage 3 based on combined diagnoses. Perinatal asphyxia was significantly associated with ROP incidence (p = 0.01). ROP incidence by combined diagnosis (20/137 or 14.6%) versus clinician diagnosis alone (21/137 or 15.3%, p = 0.50) was similar. Telemedicine changed diagnoses in 4/21 (19.0%) ROP cases.

CONCLUSIONS

Telemedicine may be helpful in confirming ROP incidence and may serve as a training and support model for less experienced and professionally isolated ROP examiners.

Advances in understanding and management of retinopathy of prematurity

The understanding, diagnosis, and treatment of retinopathy of prematurity have changed in the 70 years since the original description of retrolental fibroplasia associated with high oxygenation. It is now recognized that retinopathy of prematurity differs in appearance worldwide and as ever smaller and younger premature infants survive. New methods are being evaluated to image the retina, diagnose severe retinopathy of prematurity, and determine windows of time for treatment to save eyes and improve visual and neural outcomes. New treatments to promote physiologic retinal vascular development, vascular repair, and inhibit vasoproliferation by regulating proteins involved in vascular endothelial growth factor, insulin-like growth factor, or erythropoietin signaling. Reducing excessive oxidative/nitrosative stress and understanding progenitor cells and neurovascular and glial vascular interactions are being studied.

Telemedicine Applications in Pediatric Retinal Disease

Teleophthalmology is a developing field that presents diverse opportunities. One of its most successful applications to date has been in pediatric retinal disease, particularly in screening for retinopathy of prematurity (ROP). Many studies have shown that using telemedicine for ROP screening allows a remote ophthalmologist to identify abnormal findings and implement early interventions. Here, we review the literature on uses of telemedicine in pediatric retinal disease and consider future applications.

Bedside ROP screening and telemedicine interpretation integrated to a neonatal transport system: Economic aspects and return on investment analysis

BACKGROUND AND AIM

Peter Cerny Ambulance Service - Premature Eye Rescue Program (PCA-PERP) uses digital retinal imaging (DRI) with remote interpretation in bedside ROP screening, which has advantages over binocular indirect ophthalmoscopy (BIO) in screening of premature newborns. We aimed to demonstrate that PCA-PERP provides good value for the money and to model the cost ramifications of a similar newly launched system.

METHODS

As DRI was demonstrated to have high diagnostic performance, only the costs of bedside DRI-based screening were compared to those of traditional transport and BIO-based screening (cost-minimization analysis). The total costs of investment and maintenance were analyzed with micro-costing method. A ten-year analysis time-horizon and service provider's perspective were applied.

RESULTS

From the launch of PCA-PERP up to the end of 2014, 3722 bedside examinations were performed in the PCA covered central region of Hungary. From 2009 to 2014, PCA-PERP saved 92,248km and 3633 staff working hours, with an annual nominal cost-savings ranging from 17,435 to 35,140 Euro. The net present value was 127,847 Euro at the end of 2014, with a payback period of 4.1years and an internal rate of return of 20.8%. Our model presented the NPVs of different scenarios with different initial investments, annual number of transports and average transport distances.

CONCLUSIONS

PCA-PERP as bedside screening with remote interpretation, when compared to a transport-based screening with BIO, produced better cost-savings from the perspective of the service provider and provided a return on initial investment within five years after the project initiation.

Evaluation of Visunex Medical's PanoCam(TM) LT and PanoCam(TM) Pro wide-field imaging systems for the screening of ROP in newborn infants

INTRODUCTION

Retinopathy of Prematurity (ROP) is a leading cause of childhood blindness. The incidence of ROP is rising, placing greater demands on the healthcare providers that serve these patients and their families. Telemedicine remote digital fundus imaging (TM-RDFI) plays a pivotal role in ROP management, and has allowed for the expansion of ROP care into previously underserved areas.

AREAS COVERED

A broad literature review through the pubmed index was undertaken with the goal of summarizing the current state of ROP and guidelines for its screening . Furthermore, all currently used telemedicine remote digital fundus imaging devices were analyzed both via the literature and the companies' websites/brochures. Finally, the PanoCam LT™ and PanoCam™ Pro created by Visunex Medical were analyzed via the company website/brochures. Expert commentary: The PanoCam LT™ and PanoCam™ Pro have recently been approved for use within the USA and CE marked for international commercialization in European Union and other countries requiring CE mark. These wide-field imaging systems have the intended use of ophthalmic imaging of all newborn babies and meet the requirements for ROP screening, thereby serving as competition within the ROP screening market previously dominated by one camera imaging system.

Impact of number and quality of retinal images in a telemedicine screening program for ROP: results from the e-ROP study

BACKGROUND

Telemedicine for the detection of retinopathy of prematurity (ROP) is becoming increasingly common; however, obtaining the required multiple retinal images from an infant can be challenging. This secondary analysis from the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity (e-ROP) study evaluated the detection of referral-warranted ROP (RW-ROP) by trained readers when a full set of 5 retinal images could not be obtained.

METHODS

A total of 7,905 image sets from 1,257 infants in the study were evaluated. Retinal location of images and image quality were recorded. Sensitivity and specificity of RW-ROP detection by trained readers were calculated by comparing findings in incomplete image sets to the findings on standard eye examination.

RESULTS

The majority of image sets contained all 5 retinal images (92.8%). The disk center view was the image most likely to be present and to be of acceptable image quality (96.8%). The nasal retina was the most difficult to obtain with acceptable image quality (83.4%). Sensitivity of detection of RW-ROP was 82.1% when 5 retinal images of acceptable quality were submitted for grading, 67.2% when 4 acceptable images were submitted, and 66.7% for 3 or fewer acceptable images (P = 0.02), with corresponding specificity of 82.2%, 89.0%, and 81.7% respectively (P < 0.0001). When images of any quality were evaluated, sensitivity was not increased (P = 0.74).

CONCLUSIONS

The likelihood of detecting RW-ROP by telemedicine screening is decreased when a full set of retinal images is not obtained.

Current screening and treatments in retinopathy of prematurity in the US

Retinopathy of prematurity (ROP) is a complex disease characterized by an aberrant developmental retinal angiogenesis in preterm infants and can carry significant visual morbidity, including retinal detachment and blindness. Though large scale, randomized clinical trials have improved our understanding of the pathophysiology and progression of the disease, the management of ROP remains a challenge for ophthalmologists. This review addresses the up-to-date screening approach, diagnosis, and treatment guidelines for ROP in the US.

Safety of Retinopathy of Prematurity Examination and Imaging in Premature Infants

OBJECTIVES

To describe adverse events (AEs) and noteworthy clinical or ocular findings associated with retinopathy of prematurity (ROP) evaluation procedures.

STUDY DESIGN

Descriptive analysis of predefined AEs and noteworthy findings reported in a prospective observational cohort study of infants <1251 g birth weight who had ROP study visits consisting of both binocular indirect ophthalmoscopy (BIO) and digital retinal imaging. We compared infant characteristics during ROP visits with and without AEs. We compared respiratory support, nutrition, and number of apnea, bradycardia, or hypoxia events 12 hours before and after ROP visits.

RESULTS

A total of 1257 infants, mean birth weight 802 g, had 4263 BIO and 4048 imaging sessions (total 8311 procedures). No serious AEs were related to ROP visits. Sixty-five AEs were reported among 61 infants for an AE rate of 4.9% infants (61/1257) or 0.8% total procedures (65/8311 BIO + imaging). Most AEs were due to apnea, bradycardia, and/or hypoxia (68%), tachycardia (16%), or emesis (8%). At ROP visit, infants with AEs, compared with those without, were more likely to be on mechanical ventilation (26% vs 12%, P = .04) even after adjustment for weight and postmenstrual age. Noteworthy clinical findings were reported during 8% BIO and 15% imaging examinations. Respiratory and nutrition support were not significantly different before and after ROP evaluations.

CONCLUSIONS

Retinal imaging by nonphysicians combined with BIO was safe. Noteworthy clinical findings occurred during both procedures. Ventilator support was a risk factor for AEs. Monitoring rates of AEs and noteworthy findings are important to the safe implementation of ROP imaging protocols.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT01264276.

A new modified technique for the treatment of high-risk prethreshold ROP under the direct visual control of RetCam 3

PURPOSE

To describe a new modified technique in the treatment of ROP (retinopathy of prematurity) using the RetCam 3 digital imaging system - Camera-Assisted Laser photocoagulation and Cryotherapy of the Retina (CALCR).

METHODS

From Nov 2011 to Oct 2013, 113 infants were diagnosed with ROP. The average post-conceptual age (PCA) at the time of diagnosis was the 35(th) week of PCA; the average birth weight was 1,041 g. According to the ETROP study, the avascular part of the retina of infants with high-risk prethreshold ROP was treated with a trans-scleral diode laser or with cryotherapy within 48-72 h after the diagnosis. The intervention was performed under general anaesthesia under the direct visual control of the RetCam 3.

RESULTS

The CALCR technique was used in all 23 infants (46 eyes) diagnosed with high-risk prethreshold ROP. The average age of these infants at the time of the intervention was the 38(th) week of PCA. None of the infants had any serious complications during the CALCR procedure. In contrast to the traditional technique, CALCR offers many benefits: the image of the retina is real, magnified and not inverted, it shows details of the retina in a high resolution, photo and video documentation is available. Therefore the preoperative, intraoperative and postoperative condition of the retina can be precisely evaluated and compared on a fully standardized basis.

CONCLUSIONS

The CALCR procedure represents a new technique providing greater accuracy when targeting the avascular part of the retina, enables better visualisation and more precise treatment, and reduces the risk of unintended damage to healthy retinal tissue.

Current understanding and management of aggressive posterior retinopathy of prematurity

Aggressive posterior retinopathy of prematurity (ROP), previously referred to as “Rush disease”, is a rapidly progressive form of ROP. This form of ROP typically presents in very low birth weight babies of early gestational age. Historically, anatomical and functional outcomes have been poor with standard treatment. This review is designed to discuss current knowledge and treatment regarding this aggressive form of ROP. Recommendations regarding management of these difficult cases are detailed.

A pilot study of less invasive surfactant administration in very preterm infants in a Chinese tertiary center

BACKGROUND

Less invasive surfactant administration (LISA) to spontaneously breathing preterm infants has been reported to reduce the duration of mechanical ventilation and the incidence of bronchopulmonary dysplasia (BPD) in previous study. The objective of this study was to explore the feasibility and potential benefits of LISA in early preterm infants on nasal continuous positive airway pressure (nCPAP) compared to conventional endotracheal instillation.

METHODS

All infants with respiratory distress born at 28-32 weeks' gestational age from January 2012 to December 2012 (n=90), who were eligible for exogenous pulmonary surfactant (PS) therapy were randomized to receive PS by intubation with an endotracheal tube (Intubation group, n=43), or by intubation using a catheter while on nCPAP (LISA group, n=47). Respiratory indices were recorded every 30 seconds during PS administration, and every 1 hour thereafter for the first day. The rate of mechanical ventilation (MV) in the first 72 hours, mean duration of both MV and nCPAP, mean duration of oxygen requirement and neonatal outcomes were recorded.

RESULTS

PS was successfully administered in 43 (100%) out of 43 babies using the conventional approach and in 46 (97%) out of 47 babies using LISA. The duration of both MV and nCPAP was significantly shorter in LISA group, when compared with intubation group. However, there were no significant differences in both the rate of MV in the first 72 hours and mean duration of oxygen requirement. There were also no differences in the mortality or in the incidence of bronchopulmonary dysplasia, intraventricular hemorrhage, retinopathy of prematurity and necrotizing enterocolitis, or in the duration of respiratory support.

CONCLUSIONS

LISA in spontaneously breathing infants on nCPAP is an alternative therapy for PS delivery, avoiding intubation with an endotracheal tube. The method is feasible and potentially effective, and deserves further clinical trials.

TRIAL REGISTRATION

Current Controlled Trials ChiCTR-ICR-15006001. Registered 20 February 2015.

Telemedicine for evaluation of retinopathy of prematurity

Retinopathy of prematurity (ROP) remains a significant threat to vision for extremely premature infants despite the availability of therapeutic modalities capable, in most cases, of managing this disorder. It has been shown in many controlled trials that application of therapies at the appropriate time is essential to successful outcomes in premature infants affected by ROP. Bedside binocular indirect ophthalmoscopy has been the standard technique for diagnosis and monitoring of ROP in these patients. However, implementation of routine use of this screening method for at-risk premature infants has presented challenges within our existing care systems, including relative local scarcity of qualified ophthalmologist examiners in some locations and the remote location of some NICUs. Modern technology, including the development of wide-angle ocular digital fundus photography, coupled with the ability to send digital images electronically to remote locations, has led to the development of telemedicine-based remote digital fundus imaging (RDFI-TM) evaluation techniques. These techniques have the potential to allow the diagnosis and monitoring of ROP to occur in lieu of the necessity for some repeated on-site examinations in NICUs. This report reviews the currently available literature on RDFI-TM evaluations for ROP and outlines pertinent practical and risk management considerations that should be used when including RDFI-TM in any new or existing ROP care structure.

Validity of a telemedicine system for the evaluation of acute-phase retinopathy of prematurity

IMPORTANCE

The present strategy to identify infants needing treatment for retinopathy of prematurity (ROP) requires repeated examinations of at-risk infants by physicians. However, less than 10% ultimately require treatment. Retinal imaging by nonphysicians with remote image interpretation by nonphysicians may provide a more efficient strategy.

OBJECTIVE

To evaluate the validity of a telemedicine system to identify infants who have sufficiently severe ROP to require evaluation by an ophthalmologist.

DESIGN, SETTING, AND PARTICIPANTS

An observational study of premature infants starting at 32 weeks' postmenstrual age was conducted. This study involved 1257 infants with birth weight less than 1251 g in neonatal intensive care units in 13 North American centers enrolled from May 25, 2011, through October 31, 2013.

INTERVENTIONS

Infants underwent regularly scheduled diagnostic examinations by an ophthalmologist and digital imaging by nonphysician staff using a wide-field digital camera. Ophthalmologists documented findings consistent with referral-warranted (RW) ROP (ie, zone I ROP, stage 3 ROP or worse, or plus disease). A standard 6-image set per eye was sent to a central server and graded by 2 trained, masked, nonphysician readers. A reading supervisor adjudicated disagreements.

MAIN OUTCOMES AND MEASURES

The validity of grading retinal image sets was based on the sensitivity and specificity for detecting RW-ROP compared with the criterion standard diagnostic examination.

RESULTS

A total of 1257 infants (mean birth weight, 864 g; mean gestational age, 27 weeks) underwent a median of 3 sessions of examinations and imaging. Diagnostic examination identified characteristics of RW-ROP in 18.2% of eyes (19.4% of infants). Remote grading of images of an eye at a single session had sensitivity of 81.9% (95% CI, 77.4-85.6) and specificity of 90.1% (95% CI, 87.9-91.8). When both eyes were considered for the presence of RW-ROP, as would routinely be done in a screening, the sensitivity was 90.0% (95% CI, 85.4-93.5), with specificity of 87.0% (95% CI, 84.0-89.5), negative predictive value of 97.3%, and positive predictive value of 62.5% at the observed RW-ROP rate of 19.4%.

CONCLUSIONS AND RELEVANCE

When compared with the criterion standard diagnostic examination, these results provide strong support for the validity of remote evaluation by trained nonphysician readers of digital retinal images taken by trained nonphysician imagers from infants at risk for RW-ROP.

TRIAL REGISTRATION

clinicaltrials.gov Identifier:NCT01264276.

Telemedicine approaches to evaluating acute-phase retinopathy of prematurity: study design

PURPOSE

Detecting sight-threatening retinopathy of prematurity (ROP) relies on a diagnostic examination (DE) performed by an experienced ophthalmologist. An alternative may be a telemedicine system where retinal images of at-risk infants are graded by readers to determine features of ROP indicating the need for a DE.

METHODS

The multicenter Telemedicine Approaches to Evaluating Acute-phase ROP (e-ROP) Study is a cohort study of 2000 infants with birth weights <1251 g. At each visit, ophthalmologists perform DEs and non-physician imagers obtain iris and five retinal images with the disc positioned in the center, right, left, up and down. Images are uploaded to a secure server for grading by non-physician readers for the detection of plus disease, stage 3 ROP and/or zone I disease, any of which indicates "referral-warranted ROP" (RW-ROP). Images from all infants with RW-ROP and a random sample of infants without RW-ROP (based on DEs) are selected for grading. Gradings are compared to DEs to determine the validity and evaluate reliability, feasibility, safety, and cost-effectiveness of the telemedicine system.

RESULTS

e-ROP is conducted in 12 Clinical Centers in the US and Canada with Study Headquarters, the Data Coordinating Center and the Image Reading Center in Philadelphia and the ROP Data Center in Oklahoma City. A total of 27 study center coordinators, 34 ophthalmologists, 26 imagers, and 4 readers have been certified. All study data are submitted using a secure web-based system.

CONCLUSION

The design and findings of this study will be useful to conduct other ROP studies or evaluate telemedicine for other diseases.

Plus disease diagnosis in retinopathy of prematurity: vascular tortuosity as a function of distance from optic disk

PURPOSE

To examine vascular tortuosity as a function of distance from the optic disk in infants with retinopathy of prematurity.

METHODS

Thirty-four wide-angle retinal images from infants with retinopathy of prematurity were reviewed by 22 experts. A reference standard for each image was defined as the diagnosis (plus vs. not plus) given by the majority of experts. Tortuosity, defined as vessel length divided by straight line distance between vessel end points, was calculated as a function of distance from the disk margin for arteries and veins using computer-based methods developed by the authors.

RESULTS

Mean cumulative tortuosity increased with distance from the disk margin, both in 13 images with plus disease (P = 0.007 for arterial tortuosity [n = 62 arteries], P < 0.001 for venous tortuosity [n = 58 veins] based on slope of best fit line by regression), and in 21 images without plus disease (P < 0.001 for arterial tortuosity [n = 94 arteries], P <0 .001 for venous tortuosity [n = 85 veins]). Images with plus disease had significantly higher vascular tortuosity than images without plus disease (P < 0.05), up to 7.0 disk diameters from the optic disk margin.

CONCLUSION

Vascular tortuosity was higher peripherally than centrally, both in images with and without plus disease, suggesting that peripheral retinal features may be relevant for retinopathy of prematurity diagnosis.

Plus disease in retinopathy of prematurity: qualitative analysis of diagnostic process by experts

IMPORTANCE

Plus disease is the most important parameter that characterizes severe treatment-requiring retinopathy of prematurity, yet diagnostic agreement among experts is imperfect and the precise factors involved in clinical diagnosis are unclear. This study is designed to address these gaps in knowledge by analyzing cognitive aspects of the plus disease diagnostic process by experts.

OBJECTIVE

To examine the diagnostic reasoning process of experts for plus disease in retinopathy of prematurity using qualitative research techniques.

DESIGN

Cognitive walk-through, with qualitative analysis of videotaped expert responses and quantitative analysis of expert diagnoses.

SETTING

Experimental setting in which experts were videotaped while reviewing study data.

PARTICIPANTS

A panel of international retinopathy of prematurity experts who had the experience of using qualitative retinal features as their primary basis for clinical diagnosis.

INTERVENTION

Six experts were video recorded while independently reviewing 7 wide-angle retinal images from infants with retinopathy of prematurity. Experts were asked to explain their diagnostic process in detail (think-aloud protocol), mark findings relevant to their reasoning, and diagnose each image (plus vs pre-plus vs neither). Subsequently, each expert viewed the images again while being asked to examine arteries and veins in isolation and answer specific questions. Video recordings were transcribed and reviewed. Diagnostic process of experts was analyzed using a published cognitive model.

MAIN OUTCOME AND MEASURES

Interexpert and intraexpert agreement.

RESULTS

Based on the think-aloud protocol, 5 of 6 experts agreed on the same diagnosis in 3 study images and 3 of 6 experts agreed in 3 images. When experts were asked to rank images in order of severity, the mean correlation coefficient between pairs of experts was 0.33 (range, -0.04 to 0.75). All experts considered arterial tortuosity and venous dilation while reviewing each image. Some considered venous tortuosity, arterial dilation, peripheral retinal features, and other factors. When experts were asked to rereview images to diagnose plus disease based strictly on definitions of sufficient arterial tortuosity and venous dilation, all but 1 expert changed their diagnosis compared with the think-aloud protocol.

CONCLUSIONS AND RELEVANCE

Diagnostic consistency in plus disease is imperfect. Experts differ in their reasoning process, retinal features that they focus on, and interpretations of the same features. Understanding these factors may improve diagnosis and education. Future research defining more precise diagnostic criteria may be warranted.

The use of digital imaging in the identification of skip areas after laser treatment for retinopathy of prematurity and its implications for education and patient care

PURPOSE

To describe the utility of using wide-angle digital imaging in the training for retinopathy of prematurity with laser and in identifying common locations of skip areas that were present after initial panretinal photocoagulation with indirect ophthalmoscopy by ophthalmologists-in-training.

METHODS

Retrospective review of digital retinal images of 22 eyes of 12 infants who had undergone laser treatment for retinopathy of prematurity performed by ophthalmologists-in-training. Presence of skip areas was determined by masked review of photographs. The location of skip areas was classified based on two axes: 1) circumferential (in one of six clock-hour regions) and 2) radial (adjacent to the retinal ridge, adjacent to the ora serrata, or isolated patches of greater than one laser burn width).

RESULTS

A total of 30 skip areas were identified in the 22 eyes treated with laser photocoagulation. Based on the circumferential location, a significant difference in skip area distribution was found (P = 0.02). Regions with the highest percentage of skip areas were between the clock hours 11:00 to 1:00 (45%) and 5:00 to 7:00 (41%). Based on the radial location, 40% of all skip areas were found near the ora serrata, 17% near the ridge, and 43% as isolated patches (P = 0.14).

CONCLUSION

Skip areas after indirect panretinal laser photocoagulation by ophthalmologists-in-training were easily visualized by wide-angle digital imaging, after being missed by the trainee during the initial treatment procedure. Most skip areas in this study occurred in the superior or inferior retina. Digital imaging can assist ophthalmologists in visualizing all regions of the retina, can identify inadequate areas of laser treatment, and may reduce the need for retreatment after initial laser for retinopathy of prematurity.

Telemedicine for retinopathy of prematurity

PURPOSE OF REVIEW

To examine and review digital retinal imaging via telemedicine as an important screening and diagnostic tool in the management of retinopathy of prematurity (ROP).

RECENT FINDINGS

The use of wide-angle digital retinal photography to detect clinically significant ROP has been described in numerous reports since 2000. Comparisons with the gold standard of binocular indirect ophthalmoscopy have been favorable. Digital image capture can provide more objective information for disease detection, thereby facilitating internet consultation and retrospective analysis as part of the electronic medical record. As the presence of plus disease in ROP is now the most important criteria for determining the need for laser treatment, computer-based image analysis can potentially provide additional benefit to digital retinal imaging. Telemedicine screening also allows for the extension of diagnostic expertise to underserved areas in both the developed and third world. The role of telemedicine in ROP education will impact both screening efforts and traditional fellowship training in future years.

SUMMARY

As the worldwide incidence of ROP continues to rise, the use of telemedicine for screening, diagnostic and educational purposes will assume increasing importance in the delivery of healthcare for premature infants.

The challenge of screening for retinopathy of prematurity

Screening for retinopathy of prematurity (ROP) and the optimum treatment of sight-threatening disease requires detailed understanding of the infants at risk and timely identification. Despite a plethora of guidelines, not all populations and situations are adequately covered, so that what should be preventable visual disability still occurs. This article considers the design of screening guidelines and the possibility of a global guideline, although in certain parts of the world manpower for ROP screening is not available. Algorithms linked to the increase in weight of preterm infants over time may refine the number of babies needing to undergo treatment.

Comparison of profile of retinopathy of prematurity in semiurban/rural and urban NICUs in Karnataka, India

PURPOSE

To identify and compare the profile of retinopathy of prematurity (ROP) in premature babies in urban and semiurban neonatal intensive care units (NICUs).

METHODS

A prospective study of babies admitted to NICUs of two urban and seven semiurban centres. They were <36 weeks of gestational age and were subjected to fundus photography with a RetCam shuttle camera. Photos and NICU details were uploaded on a secure website. Photographs were read by a single observer. Infants were followed till retinal vascularisation was complete, or 45 weeks post conceptional age. Babies developing severe ROP were lasered.

RESULTS

500 babies were screened (243, urban group; 257, semiurban group). Incidence of ROP in the urban and semiurban groups was 16.5% (40) and 14.8% (38) respectively. Mean gestational age was 30.90 weeks and 31.53 weeks respectively. Mean birth weight was 1344 g and 1375 g respectively. 28 babies were lasered, 15 and 13 from each group respectively. There was no statistically significant difference between any of the parameters compared. Level of significance was fixed at 0.05.

CONCLUSIONS

The magnitude of the burden of ROP is comparable between urban and semiurban NICUs stressing the need for effective screening strategies in semiurban and rural areas as well.

Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP): four-years of screening with telemedicine

PURPOSE

To report the four-year experience of the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP) telemedicine initiative, which was developed to reduce the risk of blindness from retinopathy of prematurity (ROP).

MATERIALS AND METHODS

A retrospective analysis of the SUNDROP archival data between 12/1/2005 and 11/30/2009. A total of 410 consecutively enrolled infants meeting ROP screening criteria had nurse-obtained fundoscopic images evaluated remotely by an ROP specialist. Every infant then received at least one dilated bedside binocular indirect ophthalmoscope (BIO) examination within one week of discharge. All infants were then followed with both telemedicine images and bedside evaluation in clinic according to recommended screening timelines. Primary outcomes were treatment-warranted ROP (TW-ROP), defined as Early Treatment of ROP Type 1, and adverse anatomical outcomes.

RESULTS

The SUNDROP telemedicine screening initiative has not missed any TW-ROP in its four-year evaluation period. A total of 410 infants (820 eyes) were imaged, resulting in 1486 examinations and 18,097 unique images. An average of 12.2 images were obtained per patient. Fourteen infants met TW-ROP criteria on telemedicine examination. After bedside evaluation, 13 infants required laser photocoagulation and one was followed until he spontaneously regressed. Infants with TW-ROP had a significantly lower gestational age (24.9 weeks), birth weight (658.7 grams), and were more likely to be male than the no TW-ROP cohort (all p values <0.00001). Telemedicine had a calculated sensitivity of 100%, specificity of 99.8%, positive predicative value of 92.9% and negative predictive value of 100% for the detection of TW-ROP. No patient progressed to retinal detachment or any adverse anatomical outcome.

CONCLUSIONS

The SUNDROP initiative demonstrated a high degree of diagnostic reliability and was able to capture all infants with TW-ROP. Telemedicine offers a cost-effective, reliable and accurate screening methodology for identifying infants with TW-ROP without sacrificing quality of care.