ROP SCREENING IMPROVES

A telemedicine project to combat retinopathy of prematurity (ROP) in Indian infants has met with significant success and could serve as a useful model for future efforts in developing countries, according to Anand Vinekar MD, FRCS.

Addressing the World Ophthalmology Congress, Dr Vinekar, head of the Paediatric Vitreo-Retina Department at Narayana Nethralaya Postgraduate Institute of Ophthalmology, Bangalore, India, said that the true incidence of ROP is not reflected in the currently available statistics.

“The World Health Organization says that India and other middle-income countries are facing the ‘third epidemic’ of ROP. Extrapolating government data, every two hours in India three babies have reached the threshold for treatment. Up to 22 per cent of childhood blindness in India has a retinal cause, and ROP is the most important of these causes, especially when we consider that the disease is preventable,†he said.

There are a number of different reasons for this pending epidemic, said Dr Vinekar, including high birth rates, high rates of pre-term births and a dearth of screening and treatment programmes due to lack of awareness, skilled personnel and financial constraints. Ironically, the improvement in survival rates in developing countries has also played a part in the resurgence of ROP.

“Neonatal care practices have improved a great deal in India over the past decade and babies who would not have survived before in small towns are surviving in greater numbers. But while that has improved control of mortality and morbidity issues, somewhere along the line ROP is not given the prominence it merits. So usually by the time that the child reaches the retinal specialist, he or she is probably already legally blind,†he said.

Dr Vinekar said it was vital to refute some of the myths surrounding ROP in order to implement more effective strategies. The first myth, he said, stems from paediatricians who usually report that they have never seen a child going blind from ROP.

“Studies have shown, however, that the paediatricians never saw these blind babies because they never reached them in the first place. In addition broader guidelines are needed to ensure screening for at-risk infants,†he said.

The second myth cited by Dr Vinekar is that ROP does not develop in babies who have not been given supplemental oxygen.

“This is an old concept and while oxygen plays a role it is not a causative factor. Between 11 per cent to 24 per cent of babies that never receive oxygen may still develop ROP and we need to remember that there are at least 27 studied factors classified as risks for ROP,†he said.

Another myth is that babies weighing more than 1,500 grammes at birth do not need to be screened, said Dr Vinekar.

“As we showed in data pooled from six districts in southern India, applying the US or British cut-off rate of 1,500 grammes meant that between 18 per cent to 23 per cent of severe ROP cases were missed. So Western guidelines should not apply to middle income countries and India when it comes to birth weight, and this is especially true when we look at rural areas†he said.

Another prevalent myth is that gestational age is as important as birth weight as ROP screening criteria, said Dr Vinekar.

“This may be fine in urban areas but cannot be applied in a rural setting where a variety of factors make it almost impossible to date the pregnancy. Therefore basing an entire screening programme on post-conceptional ages is sure to cause problems. This is why we need to stick to birth weight as a criteria for ROP screening, since every baby gets weighed immediately or soon after birth,†he said.

Triple ‘T’ philosophy

Dr Vinekar said that the Karnataka Internet-Assisted Diagnosis of ROP (KIDROP) has been extremely successful in saving the sight of babies that would otherwise have gone blind from ROP. The network is based on the triple ‘T’ philosophy, said Dr Vinekar – tele-ROP, training of peripheral ophthalmologists and ophthalmic assistants and talking to neonatologists, paediatricians and gynaecologists.

Dr Vinekar and colleagues have trained teams of technicians to use a RetCam to take wide-field digital fundus images of infants in over 50 rural and semi-urban neonatal care centres spread over 12 districts in the state of Karnataka. The portable RetCam (Shuttle) is easily transferable between hospitals and clinics. They have also developed a comprehensive Tele-ROP platform that allows image transfer from the outreach sites to be viewed and reported remotely by the expert on his smart phone (iPhone in 2009) or PC. Over 25,000 imaging sessions have been completed to date.

“Some time ago we were named one of the largest tele-ROP networks in the world and we now screen in about 53 hospitals over 12 districts. We estimate that 4,258 babies have been screened so far by the programme, and 436 of them have been treated for ROP,†he said.

The cost-effectiveness of the programme has been a major argument in persuading the Indian authorities to support tele-ROP in the first public-private partnership for childhood blindness in India, said Dr Vinekar. At the congress, Dr Vinekar presented a study wherein the KIDROP model was compared with three alternate strategies of screening for ROP in rural areas and showed that a single RetCam per zone was the most cost-effective strategy.

“If we estimate that these 436 infants that were treated would contribute a per capita income of Rs 40,000 annually for a lifetime of 65 years, which is the average life expectancy in India, that is a total of

Rs 1.13bn. That amounts to a federal saving of about $25.2m for an investment of $0.7m, which are the kind of figures that make sense to the Government when we try to solicit their support,†he said. The programme has now entered into a public private partnership with the Government and is set for a phased expansion into other states of the country.