Major article
Telemedicine screening for retinopathy of prematurity in developing countries using digital retinal images: A feasibility project

https://doi.org/10.1016/j.jaapos.2007.11.009Get rights and content

Purpose

To determine the feasibility in a middle-level human development country of onsite training, image collection, Internet transfer, and remote grading of digital retinal images from babies screened for retinopathy of prematurity (ROP).

Methods

Two experienced nurses in a neonatal nursery in Lima, Peru, were trained to take posterior pole (30°) digital retinal images. Nurses obtained posterior pole retinal images from babies undergoing routine ROP screening and selected images for uploading via Internet for remote evaluation by five masked ROP experts. Results of gradings were compared with same-day clinical diagnostic examinations by an experienced ophthalmologist. Success rates for image acquisition and transfer for grading by expert readers were calculated.

Results

Serial image sets from 26 of the 28 babies enrolled in this study were obtained; two babies were too unstable for imaging. Fifty-six of 58 (96.6%) imaging sessions were successful in obtaining retinal images. Three hundred thirty of 336 (98.2%) images obtained were successfully uploaded to an interactive database. Remote graders judged 93.6% to 97.3% of image sets suitable for ROP grading. Preliminary results indicate sensitivities for detection of serious ROP from 45.5% to 95.2% among individual readers, with specificities of 61.7% to 96.2% when images were gradable.

Conclusions

A telemedicine approach for ROP screening using digital retinal images obtained by nonophthalmologists is feasible in rapidly developing countries that lack ROP-trained ophthalmologists. If remote grading of digital images is validated as an effective method for identifying referral-warranted ROP (RW-ROP), images obtained by nonphysicians may provide a means of identifying babies who require a diagnostic examination by an ophthalmologist.

Section snippets

Subjects

Institutional Review Board (IRB) approval was obtained for the project at both participating institutions, and IRB-approved consent forms were developed, translated into Spanish, and back-translated as required by the IRB at the Children's Hospital of Philadelphia. Parents of all eligible infants undergoing routine screening for ROP at the Hospital Nacional Edgardo Rebagliati Martins EsSalud in Lima, Peru, between April 4 and May 29, 2006, were asked to participate in this study. Babies were

Patient Data

During this 10-week feasibility study, 35 babies underwent at least one clinical diagnostic examination for ROP at the Hospital Nacional Edgardo Rebagliati Martins EsSalud. Of these babies, 28 (80%) were enrolled in this study. The remaining seven babies were not enrolled due to failure to obtain informed consent or unstable clinical condition as determined by clinical neonatologist staff. Among enrolled babies, mean birth weight of babies undergoing ROP screening was 1134 g (range, 530 g to

Discussion

The results of this study demonstrate the feasibility of remote evaluation for ROP using retinal images taken by trained local nonophthalmologist personnel in an MHDC. With instruction, nonophthalmologists familiar with handling small babies were able to acquire the necessary digital imaging and computer skills for obtaining and selecting high-quality retinal images of premature babies at risk for ROP. Using available technology and expertise, all retinal images obtained and saved by the nurse

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    This work is supported in part by a grant from the University Research Fund from the University of Pennsylvania and a grant from the Global Initiative Fund, University of Pennsylvania.

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