Telemedicine can be useful tool for ROP screening
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Despite developments such as the FDA approval of Eylea, disparities are still present in access to care for retinopathy of prematurity.
Healio | OSN Pediatrics/Strabismus Board Members discussed the current state of telemedicine and screening for ROP.
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Robert S. Gold, MD: A topic that comes up a lot is telemedicine and telemedicine screening for ROP. Ophthalmic Mutual Insurance Company has its own protocol for this, and these guidelines are currently being updated. There should be a consent sign if you do telemedicine for ROP to include exactly what you are doing and where you are sending the images. There has to be, at some point in the process, usually at discharge, an indirect ophthalmoscopy exam. Protocols need to be followed.
We have two NICUs in Orlando, one with 140 beds and one with 90 beds. I saw 40 infants between the two NICUs today. We do not do telemedicine, but we do have cameras that our retina specialists will use to take photos of risky patients, as well as fluoresceins when needed. So, we do have that equipment, but the images are not sent to us.
Dr. Chan, where do you think this is going?
R.V. Paul Chan, MD: Telemedicine is a great way to improve access to care in the United States and internationally. In the United States, we have a lot of great people who know how to screen for ROP using indirect ophthalmoscopy, so if you have the availability of an in-person examiner, that fills the need. But we do recognize that there are communities out there that just do not have enough people to perform screening exams. For example, Tom Lee, who is based in Los Angeles, screens for ROP in the Phoenix area, and the program he has developed is very successful in providing care for these children. He is screening a number of NICUs through telemedicine, and he flies there routinely. Darius Moshfeghi, who has done SUNDROP for years, and so many other people in the pediatric retina and pediatric ophthalmology community have shown that telemedicine works.
But there are limitations, such as the cost of the camera. It is unclear where the camera industry is going. We now have a number of different models to choose from, and the upfront cost is sometimes prohibitive. So, the hardware is an issue. Then you still need people who know how to treat with laser or anti-VEGF injection (and now we have aflibercept for ROP). Also, do you need fluorescein angiography if you inject with anti-VEGF? The management of ROP and screening through telemedicine is more complex than just saying, “OK, let’s put a camera in the NICU, screen them and then you’re done with it.” There is a whole system and network of people that you need to be in place in order for telemedicine screening programs to be successful.
And then, of course, what do we do about artificial intelligence once it is approved for ROP care? How is AI going to affect our management paradigm and how we care for ROP patients? As for telemedicine, it is here now, and we have to think about how our workflows are going to change as technology evolves.
Jordana M. Smith, MD: I agree that there are a lot of complex issues with using telemedicine for ROP and that it is a valuable discussion. Technological support for uploading and storing photographs must be guaranteed by the hospital system. Another critical element is training the staff who obtain the photos — not only training them on how to do the photography and what constitutes good pictures but also how to handle parents who may be bedside. It has also been a challenge during times of nursing shortages to keep protected time for the photographers to round. I have found that being available, supportive and flexible creates an engaged team that provides the best care for our patients.
One last consideration is the screening workforce. I was at the American Academy of Ophthalmology Mid-Year Forum, where we talked a lot about the workforce shortages in pediatric ophthalmology. Screenings for ROP are time consuming — driving between hospitals, seeing all the infants and providing counseling. Many of us in pediatrics are booked out many months in overbooked clinics, and the ability to save hours per week can add an extra half day of clinic to see patients. I think when provided with the appropriate support system, telemedicine is a great way to efficiently screen infants for ROP, and I would anticipate more systems initiating these protocols over time.
- For more information:
- R.V. Paul Chan, MD, of Illinois Eye and Ear Infirmary, University of Illinois at Chicago, can be reached at rvpchan@uic.edu.
- Robert S. Gold, MD, of Eye Physicians of Central Florida, can be reached at rsgeye@gmail.com.
- Jordana M. Smith, MD, of University of Arizona College of Medicine, can be reached at jsmith@eyes.arizona.edu.
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