Digital imaging detects sight-threatening retinopathy of prematurity

1. Through study of a simulated Neonatal Intensive Care Unity (NICU), the use of digital imaging for retinopathy of prematurity (ROP) screening was found to reduce the number of ophthalmological examinations an infant would require, but increase the interventions an infant would need.

2. The provision of ROP examinations at discharge from a NICU may reduce the number of infants requiring follow-up.

Study Rundown: ROP is a disease process affecting premature infants and can lead to severe visual impairment. Routine surveillance by ophthalmologists of at-risk infants is currently standard of care, but is costly and difficult as there is a shortage of qualified physicians, ophthalmologists, where neonatal care is provided. Recently, use of digital imaging by non-physician providers has allowed remote evaluation of ROP. Through simulated study, researchers examined the use of digital imaging completed by nonphysicians and standard serial ROP examinations by ophthalmologists. Researchers found that the use digital imaging would be as effective at detecting type 1 ROP, the most concerning form of ROP, but would require more interventions (including imaging sessions, ROP examinations, and follow-up) than other evaluation methods. However, the performance of an ROP examination at discharge or transfer to lower acuity would reduce the need for follow-up. Total cost for digital imaging appears to be higher than that of ROP examination alone.

This simulation-based study was limited by assumptions regarding input data originating from a group of high risk infants, possibly overestimating the prevalence of ROP. In addition, it focused only on the most severe type of ROP and did not have the power to investigate other classifications. Cost estimations were based on Medicare data, which rarely reflects true cost or payment by other insurers. While the use of digital imaging may reduce the need for ophthalmologist-led evaluation, it does appear to increase the total number of examinations and need for follow-up. The addition of a discharge or transfer ROP examination may reduce the follow-up burden, but when combined with digital imaging, remains more costly than traditional serial ophthalmological examinations.

Click to read the study, published today in Pediatrics

Relevant Reading: Validated System for Centralized Grading of Retinopathy of Prematurity: Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity (e-ROP) Study

In-Depth [simulation]: This study examined a simulated cohort of 650 infants aged 23 to 30 weeks (average gestational age of 27 weeks) who would have received ophthalmoscopy or digital imaging evaluation to detect type 1 ROP. ROP examination and digital imaging were modeled based on guidelines, with examinations beginning at 32 weeks of age for those with gestational age <30 weeks, and 34 weeks for those with gestational age of 30 weeks. Five strategies were examined: ROP examination only, digital imaging, digital imaging with discharge ROP examination, digital imaging with a “low-risk stopping rule” (where infants >36 weeks age without ROP on 2 consecutive digital imaging sessions would no longer be evaluated), and digital imaging with a  low-risk stopping rule and discharge ROP examination.

Each strategy detected almost all cases of ROP by the time of discharge, transfer, or 40 weeks’ age. Only digital imaging with discharge examination detected all cases. While ROP examination resulted in the fewest interventions required, examination alone missed cases in infants who had scheduled follow-up, but no examination the week of discharge. Digital imaging with an ROP examination at discharge would require the highest number of interventions (63% more than ROP examination alone), increasing cost by 29%, but decreasing the total number of examinations by 37%. While the use of a low-risk stopping rule would result in reduced cost, there would be a 20% risk of missing a single case of type 1 ROP in an infant not scheduled for follow-up.

Image: PD

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