Use of Telemedicine in Retinopathy of Prematurity
Daniel T. Weaver, MD
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Why Telemedicine for Retinopathy of Prematurity (ROP)?
The role of telemedicine in specialty consultation has been in use for several decades but has recently expanded rapidly, coincident with the increasing ease and availability of Internet access and improvement in Internet speed. This technology is especially suited to image-based specialties, including ophthalmology, dermatology, pathology, and radiology. The use of wide-field retinal imaging is well established in screening for diabetic retinopathy in adult patients and for expanding the ease of remote expert consultation.1 Telemedicine diagnosis of ROP involves the capture of digital images obtained with a wide-angle camera (eg, RetCam; Clarity Medical Systems, Pleasanton, CA) at the crib side by trained personnel, and subsequently transferred through Internet connection to an expert in a remote location for interpretation.2–10 The RetCam3 has a 130-degree field of view with interchangeable high-magnification lenses that applanate the corneal surface of the infant with coupling gel under topical anesthesia. This photographic technique provides objective information for careful study and review, and also produces documentation for the medical record. Traditionally, ROP screening has been performed by ophthalmologists at the crib side utilizing binocular indirect ophthalmoscopy, but this approach is presently limited by the decreasing availability of adequately trained ophthalmologists who are able and willing to assume care for these infants. Telemedicine has many unique applications in the care of premature infants at significant risk for ROP. Multiple studies over the past decade have demonstrated the utility of telemedicine both in screening for the presence of any ROP and in the detection of clinically significant ROP.4–15 Clinically significant ROP is defined as treatmentrequiring (eg, type 1 or worse) or referral-warranted (eg, type 2 or worse) disease based on current examination guidelines and the Early INTERNATIONAL OPHTHALMOLOGY CLINICS Volume 54, Number 3, 9–20 r 2014, Lippincott Williams & Wilkins
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Treatment for ROP studies.16–18 Several ongoing remote telemedicine screening programs have demonstrated 100% sensitivity in detecting clinically significant ROP without the benefit of on-site comparison with indirect ophthalmoscopy.13–15 ’
ROP is a Major Cause of Childhood Blindness
ROP remains a leading cause of childhood blindness worldwide. The World Health Organization estimates that >12 million preterm births occur per year.19 Retinal disease causes most childhood blindness in the United States and other developed countries; ROP is the most prevalent underlying cause within this category. ROP now seems to be most prevalent in middle-income countries with rates of childhood blindness as high as 15% to 35% in Latin America, Eastern Europe, and Asia.20–22 This has been characterized as the ‘‘third epidemic’’ of ROP.23 This followed the first epidemic of ROP blindness in premature infants during the 1950s, which was associated with the administration of high levels of supplemental oxygen in the newborn nursery. Oxygen use in these infants was markedly curtailed subsequent to this, resulting in an increase in cerebral palsy and cognitive impairment resulting directly from iatrogenic hypoxia. During the next decade (1960s), more moderate levels of supplemental oxygen administration were reintroduced in premature infants, therefore leading directly to the second epidemic of ROP. Increasing survival of preterm infants in developing countries has markedly increased the need for ROP screening. Childhood blindness due to ROP in the third world is increasing and creates social and financial burdens for families, individuals, and growing economies. Despite the availability of good treatment, babies continue to go blind from ROP in part because they have not been screened in a timely manner, and one of the main reasons is that not enough physicians are available. The camera allows them to be.’’24 This statement could be applied to premature infants with ROP anywhere in the world today. ’
ROP Screening: 2014
The current joint policy statement on ROP screening produced by the American Academy of Pediatrics, the American Academy of Ophthalmology, and the American Association for Pediatric Ophthalmology and Strabismus recommends the performance of a dilated retinal examination for babies delivered at a gestational age of r30 weeks or a birthweight of 30 weeks with an unstable clinical course are also screened at the discretion of the attending neonatologist. Infants www.internat-ophthalmology.com
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born before 25 weeks gestational age should also be considered for earlier screening based on the severity of comorbid conditions to enable earlier identification of aggressive posterior ROP which is more likely to occur in this extremely high-risk population. The ROP screening examination is conducted in the neonatal intensive care unit (NICU) by an ophthalmologist experienced in ROP. Subsequent decisions regarding the need for laser photocoagulation can then be made in accordance with the treatment guidelines as detailed in the Early Treatment for ROP trial.17,18 In the setting of adequate clinician availability, this approach to screening and treatment has been effective in preventing and/or ameliorating the advance complications of ROP, including retinal detachment and blindness.
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Why is ROP Still a Major Problem in Preterm Infants?
There are several factors that limit the effectiveness of current ROP screening strategies: (1) in the United States only 11% of all ophthalmologists are able to perform screening examinations for ROP and only 6% provide treatment, and these numbers may be decreasing going forward due to the liability incurred in caring for this patient population and the attendant medical legal risk25; (2) the logistics of traveling to a hospital NICU by a non–hospital-based ophthalmologist on a regular basis can be time consuming and expensive.26 Reimbursement is often not commensurate with the time and effort involved, and the increase in personal liability insurance now required by most malpractice carriers to perform these duties also has a quantifiable cost. This may have been the result of significant awards in closed ROP malpractice claims in 1 recent report27; (3) the recording of ROP examination findings in the written medical record can introduce variability and make treatment decisions less than objective. Chart drawing, diagrams, and descriptions are inadequate and often not helpful in recording disease progression. This is especially true if >1 examiner is involved in diagnostic screening examinations28; and (4) previous studies have documented the stress incurred by the neonate during screening for ROP.29,30 A more recent study demonstrated less infant physiological stress induced during contact retinal imaging compared with that produced by conventional binocular indirect ophthalmoscopic examination with scleral depression.31 These factors collectively make telemedicine screening utilizing the wide-angle digital camera a valuable tool in managing ROP. Replacing in-person examination for ROP is not the sole purpose of telemedicine in this setting, but image capture for retrieval and subsequent study can provide a valuable adjunct in caring for this difficult patient population. www.internat-ophthalmology.com
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Current Telemedicine Practice and Accuracy in Detection of Clinically Significant ROP
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Use of the wide-angle digital retinal camera (RetCam) for image capture in premature infants in the NICU for ROP has been extensively documented in previous reports.3–15 Comparison with the established standard of binocular indirect ophthalmoscopy has been favorable overall.4–6,8,9,14,32,33 Digital retinal imaging can be performed by an ophthalmologist, a neonatologist, nurse, or any appropriately trained individual.7 Outreach programs utilizing neonatal nursing staff and trained technicians have been adopted in large programs in the United States,13 Western Europe,12 Latin America,34 and India.35–37 The images are recorded on a secure server and sent through Internet connection for interpretation by an ophthalmologist experienced in ROP diagnosis and management. Williams et al38 compared the accuracy of telemedical ROP diagnosis between experts and trained nonexperts and concluded that input from an expert ophthalmologist is still required. Temporary morphologic changes induced during contact digital imaging have been described in previous studies, including the appearance of retinal hemorrhages, variation in appearance of zone 1 ROP, and the artifactual masking of plus disease by camera compression.39–41 Overall, the most critical function of digital retinal imaging in the infant with ROP is to detect disease that will require laser treatment (type 1 ROP) with 100% accuracy, thus preventing the life-long visual disability associated with childhood blindness. In a recent in depth Ophthalmic Technology Assessment by Chiang and colleagues, multivariate analysis of numerous recent studies supports telemedicine for ROP to achieve this goal. This group of investigators examined previously published studies specifically on the ability to detect clinically significant ROP using wide-angle digital retinal photography. This comprehensive analysis assessed 414 PubMed citations encompassing 82 studies that potentially met the inclusion criteria. Ultimately, 10 studies met inclusion criteria after exclusion for redundancy and were subsequently abstracted for study design, interventions, outcomes, and study quality. Overall, the report concluded that digital retinal photography has high accuracy for the detection of clinically significant ROP, and in addition, provides potential advantages through objective documentation of examination findings, improved recognition of disease progression by comparison with prior photographs, and the creation of image libraries for education and research.42 In another recent study, Myung et al43 demonstrated that comparison of current images with previous ones can be an accurate way to identify vascular progression in ROP utilizing digital imaging, and further noted that response times for image analysis by examining experts were significantly faster when utilizing dynamic flickering image pairs compared with static side-by-side image pairs. www.internat-ophthalmology.com
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Telemedicine for ROP Education
The ability to archive retinal photographs from prior examinations for comparison is a significant advantage of telemedicine imaging systems. Previous studies have shown that there may be significant disagreement in both the diagnosis of plus disease and whether or not treatment is indicated, even among expert examiners.44–46 Images can be sent easily over the Internet for consultation and review by more experienced readers when difficult situations arise. Digital retinal photography can also be helpful in educating parents and neonatal staff on the various aspects of ROP. Parents are therefore able to better appreciate the extent of disease when viewing images of their premature infant, underscoring for them the importance of follow-up ophthalmic examination after discharge from the NICU.47 Recent studies have specifically examined the use of retinal images in the education of trainees in pediatric ophthalmology and retinal fellowship programs.48,49 Significant errors were not uncommon, highlighting the need for further education, and emphasizing the importance of image retrieval for retrospective analysis as an integral part of the medical record. In a recent editorial, Wallace50 discusses the importance of using an image-based instructional program to enhance fellowship training for ROP, noting that up to 15% of pediatric ophthalmology training programs expose their fellows to minimal or no ROP. Two recent studies detailing Web-based surveys of ophthalmology fellowship51 and residency52 training programs in the United States both indicate that there is currently a need for increased emphasis on ROP education. ’
Risk Assessment
The liability surrounding ROP screening, diagnosis, and treatment has previously been reviewed and represents a major obstacle to increasing ophthalmologist involvement in providing care for neonates at risk for ROP.53–55 Previous studies have emphasized the importance of follow-up care for neonates with ROP after discharge from the NICU.56–58 Failure to transfer care appropriately and delay of treatment have both been noted as important causes of malpractice claims.27,59 One insurance company has suggested an approach in follow-up ROP care which involves crosschecking by different caregivers to provide a ‘‘safety net.’’60 A recent review details the importance of documentation of ROP examination findings before infant transfer and also the need to involve the parents in the screening process to ensure smooth and safe continuity of care. The interaction of neonatology, nursing, and ophthalmology is deemed of paramount importance to insure the success of ROP screening programs.61 Telemedicine documentation can potentially facilitate management and increase communication between caregivers after infant transfer. Images www.internat-ophthalmology.com
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that can be stored, sent for expert interpretation, and recalled later for comparison with current examination findings represent a valuable addition to the medical record. Trese28 has suggested that the cost of a single malpractice award or avoiding blindness even in 1 child easily offsets the relatively high cost of a wide-angle telemedicine camera. ’
Telemedicine for ROP in Underserved Areas
In areas where expert physicians are located distant to the NICU, nurses can be trained to perform serial digital imaging. The use of experienced neonatal nurse practitioners proved essential to the success of a telemedicine program in the rural Western United States. In this study, in-person binocular indirect ophthalmoscopy was not possible due to the lack of available ophthalmologists, making telemedicine the only option for ROP screening. The decision to transfer infants for diagnostic examination (and treatment when indicated) was based solely on telemedicine images viewed remotely.15 Use of the digital camera in screening for ROP has been used on a large scale in telemedicine networks in Germany (since 2001) and California (since 2005).12,13 In 2010, the Armenian EyeCare Project trained local ophthalmologists with no prior ROP experience to manage this disease. A recent update on this project by Brown et al62 found good diagnostic agreement between newly trained Armenian ophthalmologists and remotely located experts in the United States, underscoring the importance of telemedicine in ROP education (and mentorship) in developing countries. This has important implications in Latin America, Eastern Europe, China, and India where there is also a shortage of screening personnel for ROP.22,23,37,63,64 A practical application of this technology has been utilized in Bangalore, India to assemble the largest published cohort (to date) of infants screened for ROP. In the absence of available screening personnel, the KIDROP telemedicine program (Karnataka Internet Assisted Diagnosis of Retinopathy of Prematurity) initiated screenings in a remote area utilizing the Retcam shuttle. Trained technicians in Karnataka state visit 81 hospitals on a regular schedule in a region with a population of 64 million people.35,36 Downloaded images can be viewed on a smartphone, tablet, or computer utilizing a standardized template, demonstrating the application of current technology to serve a patient population in the undeveloped world where there is a lack of available providers to perform in-person binocular indirect ophthalmoscopy.37 ’
Looking Forward
Computer-based image analysis has the potential to provide an objective and quantitative assessment of retinal vessels. As the presence of plus disease now represents a critical factor in determining whether or www.internat-ophthalmology.com
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not to treat ROP, obtaining retinal images for analysis may become an integral part of future disease management. Automated detection algorithms have been utilized for several years for the early detection of diabetic retinopathy; computerized detection performance approaches that of best clinical practice.65 Several image analysis systems have been developed for ROP including Retinal Image multiScale Analysis (RISA), ROPtool, and VesselMap.66 Wilson et al67 note that Computer-Aided Image Analysis of the Retina (CAIAR) was developed from RISA to enable quicker image analysis, owing to its more accurate image-segmentation techniques. Kwon et al68 utilized the CAIAR system to demonstrate the decrease in vascular width and tortuosity after laser photocoagulation. Other recent studies confirm that quantitative retinal image analysis can correlate with clinical ROP examinations.69–70 The ability of these semiautomated systems to detect plus disease accurately is comparable with or even better than that of expert examiners.66,71,72 A recent review by Wilson and colleagues discusses the multiple factors that determine the threshold for ROP screening. They suggest that retinal vessel image analysis may be valuable not only to identify infants with treatment-warranted ROP, but that it may also facilitate the development of a nonphysician screening program and thereby detect infants who do NOT require physician examination during their hospital course.73 This may become an important contribution of digital retinal imaging as the vast majority (>90%) of neonates screened for ROP develop either no ROP or mild disease which resolves without requiring treatment. This has significant implications in developing countries where access is limited and also in high-income countries where screening consumes disproportionate health care resources. In a recent editorial, Chiang74 opines that ‘‘remaining gaps in knowledge must be addressed before these systems can be deployed for real-world use.’’ A current NIH-sponsored multicenter trial (e-ROP) will compare the accuracy of remote interpretation of digital images of ROP with binocular indirect ophthalmoscopy performed on the same day. The primary outcome measure is the detection of referral-warranted ROP. This study will help further define the role of digital retinal imaging in the management of acute-phase ROP.75 ’
Potential Barriers
Limitations to the broad implementation of digital retinal imaging for use in managing ROP include the relatively high cost of the camera and the cost of maintaining consistent and secure Internet access. In the developing world, programs have been implemented in which the portable digital camera travels to the point of care, creating a more economically viable situation.37 Other potential limitations include www.internat-ophthalmology.com
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parental and staff acceptance, licensure and liability issues, and lack of consistent insurance coverage and reimbursement.76 The quality of digital images directly determines the ability of the reader to accurately diagnose the presence and extent of ROP. Therefore, the training of dedicated and consistent staff to perform digital imaging is essential when initiating and maintaining a telemedicine program to obtain reliable and reproducible results. Certification for telemedicine screening staff has been implemented in the KIDROP program and is being further defined in the current e-ROP trial.36,37,75 This factor has been specifically noted as contributing to the success of 2 ongoing ROP telemedicine programs in the United States.13,15 ’
Conclusions
Telemedicine for ROP utilizing digital retinal imaging has moved from research tool to routine clinical use over the past decade. The sensitivity and specificity of this technique as currently practiced are now acceptable for detecting clinically significant ROP. Comparisons with the established standard of binocular indirect ophthalmoscopy are favorable and there is evidence that digital imaging may even be superior in some aspects.55 Digital retinal imaging will not replace in-person infant examination at the crib side, but the pool of examiners willing and able to screen for ROP is not keeping pace with the increasing incidence of this disease, making alternative screening strategies important in both the developed and undeveloped world. The ability to store and retrieve retinal images is valuable for both educational and medicolegal purposes, and facilitates ease of consultation in difficult cases through Internet connection. Image storage, transfer, and interpretation with ROP grading software is already being facilitated with the use of currently available technology through the iPad and smartphone. The use of computer-assisted retinal vessel image analysis software may help further objectify the diagnosis of plus disease and is possible only with digital retinal imaging. The use of telemedicine for ROP now seems to be clearly established as a valuable tool in the management of this potentially blinding disease of premature infants.
The author declares that there are no conflicts of interest to disclose.
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References
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Daniel T. Weaver, MD
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Why Telemedicine for Retinopathy of Prematurity (ROP)?
The role of telemedicine in specialty consultation has been in use for several decades but has recently expanded rapidly, coincident with the increasing ease and availability of Internet access and improvement in Internet speed. This technology is especially suited to image-based specialties, including ophthalmology, dermatology, pathology, and radiology. The use of wide-field retinal imaging is well established in screening for diabetic retinopathy in adult patients and for expanding the ease of remote expert consultation.1 Telemedicine diagnosis of ROP involves the capture of digital images obtained with a wide-angle camera (eg, RetCam; Clarity Medical Systems, Pleasanton, CA) at the crib side by trained personnel, and subsequently transferred through Internet connection to an expert in a remote location for interpretation.2–10 The RetCam3 has a 130-degree field of view with interchangeable high-magnification lenses that applanate the corneal surface of the infant with coupling gel under topical anesthesia. This photographic technique provides objective information for careful study and review, and also produces documentation for the medical record. Traditionally, ROP screening has been performed by ophthalmologists at the crib side utilizing binocular indirect ophthalmoscopy, but this approach is presently limited by the decreasing availability of adequately trained ophthalmologists who are able and willing to assume care for these infants. Telemedicine has many unique applications in the care of premature infants at significant risk for ROP. Multiple studies over the past decade have demonstrated the utility of telemedicine both in screening for the presence of any ROP and in the detection of clinically significant ROP.4–15 Clinically significant ROP is defined as treatmentrequiring (eg, type 1 or worse) or referral-warranted (eg, type 2 or worse) disease based on current examination guidelines and the Early INTERNATIONAL OPHTHALMOLOGY CLINICS Volume 54, Number 3, 9–20 r 2014, Lippincott Williams & Wilkins
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Treatment for ROP studies.16–18 Several ongoing remote telemedicine screening programs have demonstrated 100% sensitivity in detecting clinically significant ROP without the benefit of on-site comparison with indirect ophthalmoscopy.13–15 ’
ROP is a Major Cause of Childhood Blindness
ROP remains a leading cause of childhood blindness worldwide. The World Health Organization estimates that >12 million preterm births occur per year.19 Retinal disease causes most childhood blindness in the United States and other developed countries; ROP is the most prevalent underlying cause within this category. ROP now seems to be most prevalent in middle-income countries with rates of childhood blindness as high as 15% to 35% in Latin America, Eastern Europe, and Asia.20–22 This has been characterized as the ‘‘third epidemic’’ of ROP.23 This followed the first epidemic of ROP blindness in premature infants during the 1950s, which was associated with the administration of high levels of supplemental oxygen in the newborn nursery. Oxygen use in these infants was markedly curtailed subsequent to this, resulting in an increase in cerebral palsy and cognitive impairment resulting directly from iatrogenic hypoxia. During the next decade (1960s), more moderate levels of supplemental oxygen administration were reintroduced in premature infants, therefore leading directly to the second epidemic of ROP. Increasing survival of preterm infants in developing countries has markedly increased the need for ROP screening. Childhood blindness due to ROP in the third world is increasing and creates social and financial burdens for families, individuals, and growing economies. Despite the availability of good treatment, babies continue to go blind from ROP in part because they have not been screened in a timely manner, and one of the main reasons is that not enough physicians are available. The camera allows them to be.’’24 This statement could be applied to premature infants with ROP anywhere in the world today. ’
ROP Screening: 2014
The current joint policy statement on ROP screening produced by the American Academy of Pediatrics, the American Academy of Ophthalmology, and the American Association for Pediatric Ophthalmology and Strabismus recommends the performance of a dilated retinal examination for babies delivered at a gestational age of r30 weeks or a birthweight of 30 weeks with an unstable clinical course are also screened at the discretion of the attending neonatologist. Infants www.internat-ophthalmology.com
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born before 25 weeks gestational age should also be considered for earlier screening based on the severity of comorbid conditions to enable earlier identification of aggressive posterior ROP which is more likely to occur in this extremely high-risk population. The ROP screening examination is conducted in the neonatal intensive care unit (NICU) by an ophthalmologist experienced in ROP. Subsequent decisions regarding the need for laser photocoagulation can then be made in accordance with the treatment guidelines as detailed in the Early Treatment for ROP trial.17,18 In the setting of adequate clinician availability, this approach to screening and treatment has been effective in preventing and/or ameliorating the advance complications of ROP, including retinal detachment and blindness.
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Why is ROP Still a Major Problem in Preterm Infants?
There are several factors that limit the effectiveness of current ROP screening strategies: (1) in the United States only 11% of all ophthalmologists are able to perform screening examinations for ROP and only 6% provide treatment, and these numbers may be decreasing going forward due to the liability incurred in caring for this patient population and the attendant medical legal risk25; (2) the logistics of traveling to a hospital NICU by a non–hospital-based ophthalmologist on a regular basis can be time consuming and expensive.26 Reimbursement is often not commensurate with the time and effort involved, and the increase in personal liability insurance now required by most malpractice carriers to perform these duties also has a quantifiable cost. This may have been the result of significant awards in closed ROP malpractice claims in 1 recent report27; (3) the recording of ROP examination findings in the written medical record can introduce variability and make treatment decisions less than objective. Chart drawing, diagrams, and descriptions are inadequate and often not helpful in recording disease progression. This is especially true if >1 examiner is involved in diagnostic screening examinations28; and (4) previous studies have documented the stress incurred by the neonate during screening for ROP.29,30 A more recent study demonstrated less infant physiological stress induced during contact retinal imaging compared with that produced by conventional binocular indirect ophthalmoscopic examination with scleral depression.31 These factors collectively make telemedicine screening utilizing the wide-angle digital camera a valuable tool in managing ROP. Replacing in-person examination for ROP is not the sole purpose of telemedicine in this setting, but image capture for retrieval and subsequent study can provide a valuable adjunct in caring for this difficult patient population. www.internat-ophthalmology.com
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Current Telemedicine Practice and Accuracy in Detection of Clinically Significant ROP
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Use of the wide-angle digital retinal camera (RetCam) for image capture in premature infants in the NICU for ROP has been extensively documented in previous reports.3–15 Comparison with the established standard of binocular indirect ophthalmoscopy has been favorable overall.4–6,8,9,14,32,33 Digital retinal imaging can be performed by an ophthalmologist, a neonatologist, nurse, or any appropriately trained individual.7 Outreach programs utilizing neonatal nursing staff and trained technicians have been adopted in large programs in the United States,13 Western Europe,12 Latin America,34 and India.35–37 The images are recorded on a secure server and sent through Internet connection for interpretation by an ophthalmologist experienced in ROP diagnosis and management. Williams et al38 compared the accuracy of telemedical ROP diagnosis between experts and trained nonexperts and concluded that input from an expert ophthalmologist is still required. Temporary morphologic changes induced during contact digital imaging have been described in previous studies, including the appearance of retinal hemorrhages, variation in appearance of zone 1 ROP, and the artifactual masking of plus disease by camera compression.39–41 Overall, the most critical function of digital retinal imaging in the infant with ROP is to detect disease that will require laser treatment (type 1 ROP) with 100% accuracy, thus preventing the life-long visual disability associated with childhood blindness. In a recent in depth Ophthalmic Technology Assessment by Chiang and colleagues, multivariate analysis of numerous recent studies supports telemedicine for ROP to achieve this goal. This group of investigators examined previously published studies specifically on the ability to detect clinically significant ROP using wide-angle digital retinal photography. This comprehensive analysis assessed 414 PubMed citations encompassing 82 studies that potentially met the inclusion criteria. Ultimately, 10 studies met inclusion criteria after exclusion for redundancy and were subsequently abstracted for study design, interventions, outcomes, and study quality. Overall, the report concluded that digital retinal photography has high accuracy for the detection of clinically significant ROP, and in addition, provides potential advantages through objective documentation of examination findings, improved recognition of disease progression by comparison with prior photographs, and the creation of image libraries for education and research.42 In another recent study, Myung et al43 demonstrated that comparison of current images with previous ones can be an accurate way to identify vascular progression in ROP utilizing digital imaging, and further noted that response times for image analysis by examining experts were significantly faster when utilizing dynamic flickering image pairs compared with static side-by-side image pairs. www.internat-ophthalmology.com
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Telemedicine for ROP Education
The ability to archive retinal photographs from prior examinations for comparison is a significant advantage of telemedicine imaging systems. Previous studies have shown that there may be significant disagreement in both the diagnosis of plus disease and whether or not treatment is indicated, even among expert examiners.44–46 Images can be sent easily over the Internet for consultation and review by more experienced readers when difficult situations arise. Digital retinal photography can also be helpful in educating parents and neonatal staff on the various aspects of ROP. Parents are therefore able to better appreciate the extent of disease when viewing images of their premature infant, underscoring for them the importance of follow-up ophthalmic examination after discharge from the NICU.47 Recent studies have specifically examined the use of retinal images in the education of trainees in pediatric ophthalmology and retinal fellowship programs.48,49 Significant errors were not uncommon, highlighting the need for further education, and emphasizing the importance of image retrieval for retrospective analysis as an integral part of the medical record. In a recent editorial, Wallace50 discusses the importance of using an image-based instructional program to enhance fellowship training for ROP, noting that up to 15% of pediatric ophthalmology training programs expose their fellows to minimal or no ROP. Two recent studies detailing Web-based surveys of ophthalmology fellowship51 and residency52 training programs in the United States both indicate that there is currently a need for increased emphasis on ROP education. ’
Risk Assessment
The liability surrounding ROP screening, diagnosis, and treatment has previously been reviewed and represents a major obstacle to increasing ophthalmologist involvement in providing care for neonates at risk for ROP.53–55 Previous studies have emphasized the importance of follow-up care for neonates with ROP after discharge from the NICU.56–58 Failure to transfer care appropriately and delay of treatment have both been noted as important causes of malpractice claims.27,59 One insurance company has suggested an approach in follow-up ROP care which involves crosschecking by different caregivers to provide a ‘‘safety net.’’60 A recent review details the importance of documentation of ROP examination findings before infant transfer and also the need to involve the parents in the screening process to ensure smooth and safe continuity of care. The interaction of neonatology, nursing, and ophthalmology is deemed of paramount importance to insure the success of ROP screening programs.61 Telemedicine documentation can potentially facilitate management and increase communication between caregivers after infant transfer. Images www.internat-ophthalmology.com
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that can be stored, sent for expert interpretation, and recalled later for comparison with current examination findings represent a valuable addition to the medical record. Trese28 has suggested that the cost of a single malpractice award or avoiding blindness even in 1 child easily offsets the relatively high cost of a wide-angle telemedicine camera. ’
Telemedicine for ROP in Underserved Areas
In areas where expert physicians are located distant to the NICU, nurses can be trained to perform serial digital imaging. The use of experienced neonatal nurse practitioners proved essential to the success of a telemedicine program in the rural Western United States. In this study, in-person binocular indirect ophthalmoscopy was not possible due to the lack of available ophthalmologists, making telemedicine the only option for ROP screening. The decision to transfer infants for diagnostic examination (and treatment when indicated) was based solely on telemedicine images viewed remotely.15 Use of the digital camera in screening for ROP has been used on a large scale in telemedicine networks in Germany (since 2001) and California (since 2005).12,13 In 2010, the Armenian EyeCare Project trained local ophthalmologists with no prior ROP experience to manage this disease. A recent update on this project by Brown et al62 found good diagnostic agreement between newly trained Armenian ophthalmologists and remotely located experts in the United States, underscoring the importance of telemedicine in ROP education (and mentorship) in developing countries. This has important implications in Latin America, Eastern Europe, China, and India where there is also a shortage of screening personnel for ROP.22,23,37,63,64 A practical application of this technology has been utilized in Bangalore, India to assemble the largest published cohort (to date) of infants screened for ROP. In the absence of available screening personnel, the KIDROP telemedicine program (Karnataka Internet Assisted Diagnosis of Retinopathy of Prematurity) initiated screenings in a remote area utilizing the Retcam shuttle. Trained technicians in Karnataka state visit 81 hospitals on a regular schedule in a region with a population of 64 million people.35,36 Downloaded images can be viewed on a smartphone, tablet, or computer utilizing a standardized template, demonstrating the application of current technology to serve a patient population in the undeveloped world where there is a lack of available providers to perform in-person binocular indirect ophthalmoscopy.37 ’
Looking Forward
Computer-based image analysis has the potential to provide an objective and quantitative assessment of retinal vessels. As the presence of plus disease now represents a critical factor in determining whether or www.internat-ophthalmology.com
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not to treat ROP, obtaining retinal images for analysis may become an integral part of future disease management. Automated detection algorithms have been utilized for several years for the early detection of diabetic retinopathy; computerized detection performance approaches that of best clinical practice.65 Several image analysis systems have been developed for ROP including Retinal Image multiScale Analysis (RISA), ROPtool, and VesselMap.66 Wilson et al67 note that Computer-Aided Image Analysis of the Retina (CAIAR) was developed from RISA to enable quicker image analysis, owing to its more accurate image-segmentation techniques. Kwon et al68 utilized the CAIAR system to demonstrate the decrease in vascular width and tortuosity after laser photocoagulation. Other recent studies confirm that quantitative retinal image analysis can correlate with clinical ROP examinations.69–70 The ability of these semiautomated systems to detect plus disease accurately is comparable with or even better than that of expert examiners.66,71,72 A recent review by Wilson and colleagues discusses the multiple factors that determine the threshold for ROP screening. They suggest that retinal vessel image analysis may be valuable not only to identify infants with treatment-warranted ROP, but that it may also facilitate the development of a nonphysician screening program and thereby detect infants who do NOT require physician examination during their hospital course.73 This may become an important contribution of digital retinal imaging as the vast majority (>90%) of neonates screened for ROP develop either no ROP or mild disease which resolves without requiring treatment. This has significant implications in developing countries where access is limited and also in high-income countries where screening consumes disproportionate health care resources. In a recent editorial, Chiang74 opines that ‘‘remaining gaps in knowledge must be addressed before these systems can be deployed for real-world use.’’ A current NIH-sponsored multicenter trial (e-ROP) will compare the accuracy of remote interpretation of digital images of ROP with binocular indirect ophthalmoscopy performed on the same day. The primary outcome measure is the detection of referral-warranted ROP. This study will help further define the role of digital retinal imaging in the management of acute-phase ROP.75 ’
Potential Barriers
Limitations to the broad implementation of digital retinal imaging for use in managing ROP include the relatively high cost of the camera and the cost of maintaining consistent and secure Internet access. In the developing world, programs have been implemented in which the portable digital camera travels to the point of care, creating a more economically viable situation.37 Other potential limitations include www.internat-ophthalmology.com
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parental and staff acceptance, licensure and liability issues, and lack of consistent insurance coverage and reimbursement.76 The quality of digital images directly determines the ability of the reader to accurately diagnose the presence and extent of ROP. Therefore, the training of dedicated and consistent staff to perform digital imaging is essential when initiating and maintaining a telemedicine program to obtain reliable and reproducible results. Certification for telemedicine screening staff has been implemented in the KIDROP program and is being further defined in the current e-ROP trial.36,37,75 This factor has been specifically noted as contributing to the success of 2 ongoing ROP telemedicine programs in the United States.13,15 ’
Conclusions
Telemedicine for ROP utilizing digital retinal imaging has moved from research tool to routine clinical use over the past decade. The sensitivity and specificity of this technique as currently practiced are now acceptable for detecting clinically significant ROP. Comparisons with the established standard of binocular indirect ophthalmoscopy are favorable and there is evidence that digital imaging may even be superior in some aspects.55 Digital retinal imaging will not replace in-person infant examination at the crib side, but the pool of examiners willing and able to screen for ROP is not keeping pace with the increasing incidence of this disease, making alternative screening strategies important in both the developed and undeveloped world. The ability to store and retrieve retinal images is valuable for both educational and medicolegal purposes, and facilitates ease of consultation in difficult cases through Internet connection. Image storage, transfer, and interpretation with ROP grading software is already being facilitated with the use of currently available technology through the iPad and smartphone. The use of computer-assisted retinal vessel image analysis software may help further objectify the diagnosis of plus disease and is possible only with digital retinal imaging. The use of telemedicine for ROP now seems to be clearly established as a valuable tool in the management of this potentially blinding disease of premature infants.
The author declares that there are no conflicts of interest to disclose.
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References
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