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Telemedicine Screening for Retinopathy of Prematurity
Among the enrolled infants, 19.4 % developed RW-ROP in one or both eyes
on diagnostic examination. In the primary outcome report, 6 all images from
the 244 infants who developed RW-ROP and a random sample of 691 infants
who never developed RW-ROP were graded. The result of each diagnostic
examination was compared with the result of the image set grading from
the same session. The sensitivity for detecting the presence of RW-ROP
in either eye of an infant, as would be performed in a clinical setting, was
90.0 % (95 % CI 85.4–93.5 %) with a specificity of 87 % (95 % CI 84.0–89.5 %)
and a negative predictive value of 97.3 %. When only the last session before
treatment was considered, sensitivity increased to 98.2 % (95 % CI 94.4–
99.4 %) for detecting those 162 infants who underwent treatment with a
specificity of 80.2 % and a negative predictive value of 99.6 %. Only three
infants who were treated by the clinical center ophthalmologist were not
found to have RW-ROP in retinal images of either eye.
In summary, the e-ROP study results provide strong support for the validity
of a telemedicine system to detect the presence of potentially serious ROP.
The study successfully trained nonphysician imagers at the clinical centers to
obtain images for remote grading and nonphysicians readers to grade those
images reliably. It provides further evidence that telemedicine in ROP is a
promising approach to providing excellent ROP screening in the US and other
countries with well-developed neonatal intensive care unit (NICU) systems.
Since there is a limited supply of ophthalmologists available for ROP
examinations, such an approach will allow physicians to examine only
1. Blencowe H, Lawn JE, Vazquez T, et al., Preterm-associated
visual impairment and estimates of retinopathy of prematurity
at regional and global levels for 2010, Pediatr Res,
2. World Health Organization, Born too soon: the global action
report on preterm birth, World Health Organization Press,
2012. Available at: http://www.who.int/pmnch/media/
news/2012/201204_borntoosoon-report.pdf (last accessed
February 2, 2015).
U S Oph th a l mic Review
those most at-risk infants. One advantage of such a system is the ability
to assess remotely the need for transferring an infant to another center
where treatment can be given. In addition, the imaging session in a NICU
need not be constrained by the ophthalmologist’s schedule, but can be
conducted at an optimal time for the infant.
In other regions of the world with developing NICU systems and a limited
number of ophthalmologists available, providing a telemedicine system
can increase the likelihood of detecting potentially serious ROP. This may
be particularly important in countries with widely dispersed populations
and a limited number of ophthalmologists.
Still there are a number of matters that need to be addressed as we
consider telemedicine in ROP. We must deal with licensing and liability
concerns for telemedicine and establish reliable and consistent grading
of the images. Timely reporting of these time-sensitive gradings to
the physicians caring for the at-risk infant must be expedited. The
cost-effectiveness of such a technology is yet to be established. In
addition, the best schedule and optimal frequency for imaging of an
individual infant needs to be developed and tailoring such a schedule
will likely include various risk factors such as birth weight, gestational
age, postmenstrual age, and weight gain. Further, thus far level 1
telemedicine ROP studies have only dealt with the period during which
the infant is in the NICU and not addressed when a child can be safely
discharged from care. n
3. Chiang MF, Melia M, Buffenn AN, et al., Detection of clinically
significant retinopathy of prematurity using wide-angle digital
retinal photography, Ophthalmology, 2012;119:1272–80.
4. Fierson WM, Capone A, The American Academy Of Pediatrics
Section On Ophthalmology, American Academy Of Ophthalmology,
And American Association Of Certified Orthoptists. Telemedicine
for Evaluation of Retinopathy of Prematurity, Pediatrics,
2015;135:e238–54. 5. Quinn GE; e-ROP Cooperative Group, Telemedicine approaches
to evaluating acute-phase retinopathy of prematurity: study
design, Ophthalmic Epidemiol, 2014;21:256–67.
6. Quinn GE, Ying GS, Daniel E, et al., for the e-ROP Cooperative
Group. Validity of a telemedicine system for the evaluation of
acute-phase retinopathy of prematurity, JAMA Ophthalmol,
2014;132:1178–84. 7. Ells AL, Holmes JM, Astle WF, et al., Telemedicine approach to
screening for severe retinopathy of prematurity: a pilot study,