The following is a summarization with excerpts from an article appearing in March 2014 issue of EyeNet

ROP Screening and Telemedicine, Part 1: Has Its Time Arrived?

Original article by Annie Stuart, Contributing Writer Interviewing Michael F. Chiang, MD, Darius M. Moshfeghi, MD, Graham E. Quinn, MD, MSCE, and Daniel T. Weaver, MD

Despite the availability of good treatment, babies continue to go blind from ROP, in large part because they have not been screened in a timely manner. “One of the main reasons is that not enough physicians are available,” said Darius M. Moshfeghi, MD, director of telemedicine at Byers Eye Institute at Stanford University. “The camera allows them to be.”

An emerging technology, store-and-forward telemedicine involves capturing medical data to be interpreted by a remote expert. It may hold special promise for retinopathy of prematurity (ROP), a condition on the rise at a time of decline in the number of adequately trained ophthalmologists able or willing to perform in-person exams.1

With better Internet access, a commercially available portable wide-angle digital retinal camera, and a dozen or so studies suggesting success in infants, telemedicine seems poised to play a larger role in the screening of ROP.1

In 2012, the Academy published an Ophthalmic Technology Assessment (OTA) on the use of wide-angle digital retinal photography for ROP screening. It reviewed evidence from seven level I studies and three level III studies, which included 450 babies screened with telemedicine.1

In summarizing the bottom line drawn from these studies, Michael F. Chiang, MD of Oregon Health & Science University stated that you can generally get the same diagnosis from a photograph as you can from an eye exam.”

SUNDROP. One of the longest-running telemedicine programs in the country is the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP), led by Dr. Moshfeghi. The singular goal of the program, he said, is to take standardized images of eyes to identify babies who need treatment. “With eight years of data from about 700 babies, we have identified—100 percent of the time—all retinopathy that requires treatment. We’ve lost no babies to blindness.”

e-ROP. A multicenter clinical trial sponsored by the National Eye Institute, e-ROP will soon add to the pool of knowledge. In October 2013, it completed enrollment of 1,284 babies from 12 neonatal intensive care units (NICUs) in the United States and Canada. “Previous studies have generally had a small number of babies and varying outcome measures,” said Graham E. Quinn, MD, MSCE, lead investigator for e-ROP, at Children’s Hospital of Philadelphia. “We needed to do a sufficiently powered study to evaluate validity, safety, feasibility, and cost-effectiveness.”

In e-ROP, trained non-physician ROP imagers use standard protocols to capture five retinal images in each eye and upload them for remote evaluation by trained non-physician readers to identify morphology consistent with referral-warranted ROP: zone I ROP, stage 3 or worse ROP, and/or plus disease.2 This is the first ROP study to use non-physician readers, said Dr. Quinn. Doctors perform binocular indirect ophthalmoscopy (BIO) at the same session as images are taken, and the results from image evaluation will then be compared with results from exam.2

Other studies, such as Photo-ROP,3,4 have similarly compared photographs with BIO, and sometimes the results don’t agree. The question is, what conclusion should be drawn in case of inconsistency, especially when the photograph is right and BIO—the current gold standard—is mistaken? It’s also true that the camera may miss disease, said Dr. Moshfeghi, but this disease is almost certainly in zone III (the peripheral temporal retina), where it is of less concern because, under current guidelines, it would not trigger a treatment recommendation.

BIO is an imperfect gold standard, agreed Dr. Quinn. And, for this reason, Dr. Chiang speculates about a future gold standard that combines the two.

Shortage of ROP specialists. BIO is resource- and time-intensive. And there is a mismatch between where the babies and the physicians who treat them are located, said Dr. Moshfeghi, who is one of fewer than three dozen pediatric retina specialists in the United States. Other physicians who may examine these babies include general ophthalmologists, pediatric ophthalmologists, and retina specialists.

Making matters worse is the continuing exodus of ophthalmologists from ROP screening altogether—largely due to concerns about liability, compensation, and other financial issues.

According to a 2006 Academy survey, only about half of retina specialists and pediatric ophthalmologists were willing to do ROP screening, said Dr. Chiang. “Of those, 20 percent planned to quit soon.” Telemedicine allows these dwindling resources to stretch further.

More efficient use of resources. According to current guidelines, fewer than 10 percent of babies who are screened end up needing treatment, said Dr. Quinn. “That means the serial exams of those babies snowball, and you have a huge manpower expenditure to detect a small number of babies needing treatment.”

On the other hand, telemedicine allows you to have continuous coverage with fewer resources—and you can get an immediate second opinion from anyone on Earth, said Dr. Moshfeghi. “With one click you can send it off in a HIPAA-compliant manner to world experts and say, ‘what do you think?’”

Overcoming geographic limitations. Telemedicine is a special boon to premature babies in remote rural areas or developing countries. Daniel T. Weaver, MD, a pediatric ophthalmologist in Billings, Mont., can attest to that. He was one of three pediatric ophthalmologists in Montana until 2006, when one relocated, leaving a Level 3B NICU in Great Falls without coverage for ROP. The NICU faced closure, and the hospital was threatened with a potential financial loss, he said.

Although he and the other pediatric ophthalmologist considered traveling to the babies, Montana’s size, terrain, and severe weather posed major challenges. They agreed instead to help set up a telemedicine program, modeled closely after SUNDROP but on a smaller scale. They consulted with Dr. Moshfeghi and brought in one of Stanford’s nurses to assist in training Great Falls nursing staff.

Objective documentation. Describing the hand-drawn images that ophthalmologists must create to record BIO findings, Dr. Moshfeghi asked, “Can you imagine someone drawing out an EKG? Why draw the retina when you can photograph it?”

Hand-drawn images are not standardized; thus, independent verification of the diagnosis may be difficult, as is following progress week to week in serial drawings, said Dr. Moshfeghi. But a series of photos can easily be laid side by side or on top of one another to compare progression, said Dr. Chiang. “That is, in essence, the beauty of telemedicine,” added Dr. Moshfeghi. Telemedicine also encourages you to systematically write down all your findings, he said, which can facilitate spotting any errors and provide a kind of belt-and-suspenders approach.

 

The full article can be found at https://www.aao.org/eyenet/article/rop-screening-telemedicine-part-1-has-its-time-arr-2