Use of Telemedicine in the Management of Retinopathy of Prematurity

The twin financial disincentives of large malpractice awards and low reimbursement have precipitated a crisis for retinopathy of prematurity (ROP) screening in the United States. Talented individuals with the training necessary to monitor at-risk infants are leaving this field in droves, and the remaining individuals are overwhelmed by the expansion of screening criteria and recommended screening intervals. The dwindling supply of willing and able screeners in combination with the rapidly increasing number of patients eligible for screening and the increased number of examinations will reach a crisis point shortly, unless a new paradigm is implemented. Telemedicine for ROP promises to expand the range of those remaining practitioners with expertise in ROP while simultaneously increasing screening flexibility.

ROP Screening Crisis

In February 2006, the American Academy of Ophthalmology (AAO), the American Academy of Pediatrics’s (AAP) section on Ophthalmology, and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) introduced new screening criteria (Table 1), which increased the eligibility for ROP screening from 28 weeks postmenstrual age (PMA) or less to 30 weeks or less while maintaining the birth weight criteria (Pediatrics. 2006;117:572-576).

Whereas previously birth weight was the dominant factor in deciding which infants to screen, gestational age has now assumed an equal or greater footing. To illustrate the magnitude of the impact of this recommendation, in 2004 there were 30,670 births less than 28 weeks and a whopping 81,645 births = 31 weeks PMA compared to a total of 60,640 infants < 1500 grams birth weight (Natl Vital Stat Rep. 2006;55:1-104). This represents an increase of 33% in eligible patients who meet either criteria. Additionally, the guidelines included recommendations for screening as often as twice a week for certain stages of ROP (Pediatrics. 2006;117:572-576).

Meanwhile, a recent AAO survey of pediatric ophthalmologists and retina specialists has shown that only 54% of those physicians surveyed presently screen for ROP, and only 77% of plan to continue in the future (American Academy of Ophthalmology Retinopathy of Prematurity Survey, February 2006). The top 3 reasons for discontinuing ROP screening included medical liability (67%), complexity of care scheduling (50%), and insurance reimbursement (37%).

The expansion of screening criteria coupled with the decline of trained and willing ROP screeners has created an opportunity for the implementation of telemedicine techniques in the field of ROP screening. The advantages include expansion of access, centralized reading with experienced screeners, flexibility in screening schedules, longitudinal view, hard-copy images, and continuity of care.

Telemedicine for ROP

The use of telemedicine for ROP screening has been shown to be effective at detecting disease.^4,5 Telemedicine images from the PhotoROP trial, which were captured using the RetCam and read at a central reading center, demonstrated 100% sensitivity and 97% specificity for detection of referral-warranted disease when compared to the gold standard ophthalmologist with binocular indirect ophthalmoscopy (Retina Pre-Meeting, AAO, New Orleans, LA 2004).

Today, this technique is employed on a regular basis by nurses in the neonatal intensive care units of regional hospitals as part of the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP). The nurses are trained by certified ophthalmic photographers and use the RetCam II to obtain standardized images (Figure 1), which can be sent digitally via file transfer protocol (FTP) or secure email in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Reports are generated within 24 hours of receipt, and recommendations for screening frequency are made.

Image courtesy Darius M. Moshfeghi, MD.

Figure 1. RetCam II The right and left eye protocol images.

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In SUNDROP, one hospital’s patients were exclusively screened for ROP for 11 months, while another hospital’s patients were screened for 8 months. The telemedicine approach identified referral-warranted disease and showed 1 patient in need of laser surgery. More importantly, telemedicine has brought screening recommendations into alignment at the 2 enrolled hospitals and allowed these facilities to continue to offer comprehensive neonatal services to patients in their own community. Furthermore, when patients require the more frequent 48-96 hour screening examinations, the SUNDROP network offers the flexibility to perform these exams without requiring transfer to a hospital near the screening physician. Finally, because the SUNDROP network is web-based and HIPAA-compliant, screening may continue unabated with the physician evaluating images from afar, thus minimizing the interruption of service that can occur when a physician is out of town.

What’s Not to Like?

The limitations of telemedicine are straightforward. The images are only as reliable as the skill of the photographer and the resolution of the camera. With presently available systems utilizing nurses, almost all of zone 2 and the posterior pole is readily identifiable, but peripheral zone 3 remains beyond the scope of the camera without scleral depression. Additionally, while plus disease can be easily identified, distinguishing between stage 1 and stage 2 or stage 2 and stage 3 is more difficult. Almost all conditions that require treatment will present in zones 1 or 2 or be distinguished by the presence of plus disease. Fortunately, the cameras used to date have demonstrated excellent capture of these types of disease.

Additionally, according to the PhotoROP trial, intervention was recommended a full 2 weeks prior to the current ophthalmologist gold standard (Retina Pre-Meeting, AAO, New Orleans, LA 2004). One might postulate that this recommendation is the direct result of the RetCam’s ability to provide a longitudinal view of the infant’s retinal development, which is decidedly superior to schematic representations that have traditionally been hand drawn into the chart. The hard copy printouts of the RetCam images are useful for educating the family about ROP and for medicolegal documentation.

References

1.	Section on Ophthalmology American Academy of Pediatrics; American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus. Screening examination of premature infants for retinopathy of prematurity. Pediatrics. 2006;117:572-576.
2.	Martin JA, Hamilton BE, Sutton PD, et al. Births: Final data for 2004. Natl Vital Stat Rep. 2006;55:1-104.
3.	American Academy of Ophthalmology Retinopathy of Prematurity Survey, February 2006.
4.	Ells AL, Holmes JM, Astle WF, et al. Telemedicine approach to screening for severe retinopathy of prematurity: a pilot study. Ophthalmology. 2003;110:2113-2117.
5.	Chiang MF, Keenan JD, Starren J et al. Accuracy and reliability of remote retinopathy of prematurity diagnosis. Arch Ophthalmol. 2006;124:322-327.

Author Disclosure

The author states that he has no financial relationship with the manufacturer or provider of any product or service discussed in this article or with the manufacturer or provider of any competing product or service. Since publication, the author has joined the Scientific Advisory Board of Clarity Medical Systems.