Remote Digital Fundus Imaging for ROP Surveillance
While the importance of surveillance is undisputable, manpower issues, costs associated with repeated transport of infants to remote tertiary centers for periodic ophthalmic surveillance, and the specter of significant medico-legal liability associated with ROP are barriers to universal surveillance (American Academy of Ophthalmology Retinopathy of Prematurity Survey, February 2006. http://www.aao.org/newsroom/release/20060713.cfm).
Remote digital fundus imaging (RDFI) for ROP surveillance, with onsite acquisition of clinical data relayed to a remote site for interpretation, offers an opportunity to conquer some of these barriers. A trained technician acquires digital fundus images from at-risk infants in a neonatal intensive care unit, followed by transmission to a pre-specified reader or regional Reading Center where infants requiring on-site examination or treatment are identified.
Though technology enabling complete imaging of both the peripheral retina and posterior pole of infants is currently lacking, interval technologies are available. Several reports have spoken to the utility of digital fundus images evaluated remotely to effectively complement on-site management of ROP. The results of recently published e-ROP Study provide strong Level 1 evidence in support of an RDFI paradigm.
A typical standard image set is shown in Figure 10.
Digital fundus imaging would positively impact ROP-related clinical trials as well. The paradigm of a dedicated Reading Center with certified fundus image graders has become the gold standard for the conduct of ophthalmic clinical trials. To date, however, all large trials evaluating ROP treatment efficacy have gathered data by requiring examiners to draw the retinal findings as noted during clinical examination. Neither the examiner nor study center has an opportunity to study an image of the fundus.
Advantages of an RDFI approach include the potential to integrate into contemporary electronic health record initiatives, objectively document retinal findings, increase the number of infants evaluated, fortify the “ROP safety net” construct of disease surveillance, improve parent and staff education about ROP, and make more widely available the experience of ROP experts.
As with all ROP surveillance programs, a recent consensus document of the American Academy Of Pediatrics Section On Ophthalmology, American Academy Of Ophthalmology, and American Association Of Certified Orthoptists recommends that “…specific responsibilities of each individual must be carefully delineated in a written protocol in advance. “ It is also recommended that indirect ophthalmoscopy be performed at least once by a qualified ophthalmologist before treatment or termination of acute phase surveillance of ROP for infants at risk for ROP.
Ells A, Holmes J, Astle W, et al. Telemedicine approach to screening for severe retinopathy of prematurity. Ophthalmology 2003;110:2113-2117.
Photographic Screening for Retinopathy of Prematurity (Photo-ROP) Cooperative Group. The Photographic Screening for Retinopathy of Prematurity Study (Photo-ROP). RETINA 2008;28:S47-S54.
Silva RA, Murakami Y, Lad EM, Moshfeghi DM. Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP): 36-Month Experience with Telemedicine Screening. Ophthalmic Surg Lasers Imaging. 2010 Sep 29:1-8
Lorenz B, Spasovska K, Elflein H, Schneider N. Graefes Arch Clin Exp Ophthalmol. 2009 Sep;247(9):1251-62.
Trese MT. Editorial. What is the real gold standard for ROP screening? RETINA 2008;28:S1-S2.
Quinn GE, Ying GS, Daniel E, Hildebrand PL, Ells A, Baumritter A, Kemper AR, Schron EB, Wade K; for the e-ROP Cooperative Group. Validity of a Telemedicine System for the Evaluation of Acute-Phase Retinopathy of Prematurity. JAMA Ophthalmol. 2014 Jun 26.
Fierson WM, Capone Jr A, American Academy of Pediatrics Section on Ophthalmology; American Academy of Ophthalmology; American Association of Certified Orthoptists. Pediatrics, 2014, accepted for publication