ROP DIAGNOSIS

Innovative telemedicine and teleeducation approaches are helping to overcome current limitations in the diagnosis of retinopathy of prematurity worldwide, according to Michael F Chiang MD, Knowles Professor of Ophthalmology & Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, US.

Speaking at the 2nd World Congress of Paediatric Ophthalmology and Strabismus, Dr Chiang reviewed research showing that telemedicine offers an accurate, costeffective and efficient method for diagnosing ROP, and he discussed tele-education as a method for training ophthalmologists to be competent in managing ROP. “Telemedicine for ROP appears to perform well for achieving the right diagnosis, and it has the potential to improve the quality, accessibility, and cost of ROP care.

Now, major real-world telemedicine programmes are ongoing in the US and internationally, along with additional studies to further define its role,†said Dr Chiang. “In addition, tele-education appears to offer a good approach for addressing significant gaps in ROP diagnosis training and competency. We are excited about collaborative projects ongoing in this area and the efforts under way to apply these principles worldwide to ROP care.â€

Telemedicine diagnosis of ROP involves remote expert review of digital images captured at the point-of-care by a nurse or other personnel trained to properly operate a wide-angle contact camera (e.g. RetCam, Clarity Medical Systems). Compared with the current approach to ROP evaluation and monitoring by serial bedside indirect ophthalmoscopy and documentation of the findings with handdrawn pictures, the photographic method has an advantage for providing more reliable, objective information for detecting disease and its progression.

The appropriateness of telemedicine for ROP diagnosis has been investigated in a number of studies that compared its accuracy to dilated ophthalmoscopy by an expert. In a project sponsored by the American Academy of Ophthalmology, Dr Chiang and colleagues conducted an in-depth review of 28 published studies on detection of clinically significant ROP using wide-angle digital retinal photography [Ophthalmology 2012;1272-80].

The articles included seven papers with 458 infants that were rated as Level I evidence; three other papers, which included 1,462 infants, were considered Level III evidence. In the Level I papers, the sensitivity of the telemedicine approach ranged from 76 per cent to 100 per cent for diagnosing Type- 2 or worse ROP and from 87 per cent to 100 per cent for Type-1 disease, although in many papers, the sensitivity rates were at the upper end of those ranges. Rates for both sensitivity and specificity in all Level III papers were 99 per cent or 100 per cent. Noting that all of the studies in the literature considered bedside ophthalmoscopic exam as the gold standard for ROP detection, Dr Chiang discussed another study, including 206 eyes, that investigated intraphysician agreement of diagnoses based on indirect ophthalmoscopy versus digital images [Ophthalmology 2008;115:1222-8].

The results showed there was a discrepancy between the two methods in 14 per cent of eyes. In onethird of the latter cases, ROP that was identified on the digital images was missed on ophthalmoscopic exam. In 29 per cent of discrepancies, zone I disease was diagnosed by ophthalmoscopy whereas the telemedicine exam diagnosed zone II ROP. “Review of digital images offers the potential for making a more accurate diagnosis in some cases because it enables identification, scrutiny, and direct measurement of landmarks, which can be difficult when examining a moving baby at the bedside,†Dr Chiang said. Results of cost-utility and timemotion analyses also provide support for telemedicine in showing it to be about 40 per cent more cost-effective than ophthalmoscopy [Arch Ophthalmol 2008;126:493-9], and at least three times faster [Am J Ophthalmol 2009;148:136-42].

Broadening and improving training

Use of tele-education for ROP diagnosis teaching aims to increase accessibility to adequately trained physicians throughout the world. A shortage of ophthalmologists able to diagnose ROP is a particular problem in developing countries, but research also highlights there are gaps in patient care and physician competency even in the US. Dr Chiang observed that while, in general, neonatal care in the developing world is rapidly improving, training in ROP diagnosis is still often absent or limited. Online education could be a viable way to solve this problem because these countries often have a good Internet infrastructure.

Yet, results of various studies highlight there is a need for better education on ROP diagnosis even in the US. For example, research in collaboration with Paul Chan MD, evaluating diagnosis of ROP by physicians in US retina and paediatric ophthalmology fellowship programmes found that significant errors were not uncommon. Retina fellows overcalled clinically-significant ROP in up to 50 per cent of cases and missed it completely 10 per cent of the time [Retina 2010;30:958- 65]. In the study of the paediatric ophthalmology fellows, the sensitivity for diagnosing clinically significant ROP averaged only 50 per cent, and of the five participants, some made the wrong diagnosis two-thirds of the time [J AAPOS 2011;15:573-8].

Dr Chiang also cited the findings of a survey to characterise ROP education in paediatric ophthalmology and retina fellowship programmes showing significant variation in the level of training and quality of clinical care. Regarding the latter, up to two-thirds of ROP exams in about 30 per cent of the programmes were done only by the fellow and not by an attending ophthalmologist as well. Preliminary evidence suggests that ROP tele-education works well. To investigate this issue, Dr Chiang collaborated with Tom Lee MD, and others on a proof of concept study in Armenia. After one week of in-country education, the local ophthalmologists did weekly eye exams and captured digital retinal photographs that provided a basis for remote mentoring. “Anecdotally, the diagnostic skills of the Armenian ophthalmologists seemed to improve using this approach. Now, we are collaborating to develop analyses to see if we can confirm that impression,†Dr Chiang said.