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Screening for ROP with telemedicine highly sensitive, specific
SUNDROP investigator not surprised by study results.
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Remote retinal photography used to detect the need for treatment in infants with retinopathy of prematurity was 100% sensitive and 99.8% specific, according to 5-year data from the Stanford University Network for Diagnosis of Retinopathy of Prematurity.
The study period for the ongoing telemedicine initiative spanned from December 2005 to November 2010, during which time 1,022 eyes were screened from six satellite neonatal intensive care units (NICUs) in Northern California. In all, 16 eyes were deemed “treatment warranted” for ROP, of which 15 underwent laser photocoagulation.
The only false-positive finding was for a twin infant with Early Treatment of Retinopathy of Prematurity (ETROP) type 2, whose ROP eventually spontaneously regressed.
Overall, the study found 93.8% positive predictive value and 100% negative predictive value for detection of treatment-warranted ROP.
Darius M. Moshfeghi
Results support experience
None of the impressive results of the 5-year study, which appeared in Ophthalmic Surgery, Lasers and Imaging Retina, come as a surprise to co-author Darius M. Moshfeghi, MD, an associate professor of ophthalmology at Byers Eye Institute at Stanford University School of Medicine.
“The results confirm my experience over the years,” he said.
Moshfeghi is the founder and director of the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP), which started in November 2005. Initially, “it was kind of a fringe activity, as viewed by the pediatric ophthalmology community and other screeners,” Moshfeghi told Ocular Surgery News. “But over the past 8 years, we have been able to publish enough data to help sway opinion toward telemedicine as a way to screen; not only is it a method to screen, it is a way to standardize the practice and improve the quality of care you are bringing about and allow for greater educational training and research opportunities for all involved.”
Joint endorsement
For the first time, in 2013, the American Academy of Ophthalmology, the American Academy of Pediatrics and the American Association for Pediatric Ophthalmology and Strabismus issued a joint statement endorsing telemedicine as a viable means for screening for ROP.
None of the study infants developed adverse anatomic outcomes, including vision loss or retinal detachment.
The screening population for ROP has increased by about 30%, starting in 2006, because of widening screening criteria that now encompasses infants born at 30 weeks instead of 32 weeks.
“Ultimately there will be screening by cameras with skilled readers in a central location,” Moshfeghi said. “Babies will be seen in person only if they are deemed to be treatment warranted or if they have been transferred to another facility for treatment, and then obviously upon discharge from the hospital to terminate acute-phase screening.”
It is rare — less than 0.5% of cases — to retake retinal images because of inadequate exposure or poor visualization of the periphery.
Although an investment of $60,000 to $100,000 for the study’s retinal imaging device, the RetCam II (Clarity Medical Systems), may seem high, it is about the same cost as for a NICU incubator, according to Moshfeghi. Plus, by standardizing the process of screening with telemedicine, the risk for adverse events associated with ROP is decreased, thus lowering the liability.
“Data from SUNDROP and other telemedicine programs have established that the technology is very safe, effective and scalable. It does not miss babies and is easy to perform,” Moshfeghi said. “Parents love it because they can view the images if they have questions, NICUs like it, attending neonatologists like it, and of course, the readers like it. On top of that, babies do not go blind, which is what we are trying to prevent. Most blindness from ROP occurs because the baby was not looked at.” – by Bob Kronemyer
Reference:
Fijalkowski N, et al. Ophthalmic Surg Lasers Imaging Retina. 2014;doi:10.3928/23258160-20140122-01.For more information:
Darius M. Moshfeghi, MD, can be reached at Byers Eye Institute, Horngren Family Vitreoretinal Center, Department of Ophthalmology, Stanford University School of Medicine, 2452 Watson Court, Room 2277, Palo Alto, CA 94303; 650-721-6888; email: dariusm@stanford.edu.Disclosure: Moshfeghi has no relevant financial disclosures.
Perspective
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Andrew P. Schachat, MD
The authors report their experience with remote telemedicine review of RetCam II images obtained by trained NICU nurses in a first-world group of level 1, 2 and 3 nurseries. Approximately 1,000 eyes of 500 infants were screened between 2005 and 2010. Fifteen children, about 3%, had treatment-warranted retinopathy of prematurity (TW-ROP). Very high sensitivity (100%), specificity (99.8%), positive predictive value (93.8%) and negative predictive value (100%) for TW-ROP were achieved. The authors cite a 2012 American Academy of Ophthalmology report on wide-angle digital imaging for ROP. I agree with the report’s conclusions: “[Digital screening] has the potential to complement standard ROP care. It may provide advantages through objective documentation of clinical examination findings, improved recognition of disease progression by comparing previous photographs, and the creation of image libraries for education and research.” ROP screening is challenging, and the Stanford group has much to teach on this topic.
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