Elsevier

Ophthalmology

Volume 115, Issue 7, July 2008, Pages 1222-1228.e3
Ophthalmology

Original article
Telemedical Diagnosis of Retinopathy of Prematurity: Intraphysician Agreement between Ophthalmoscopic Examination and Image-Based Interpretation

Presented at: American Academy of Ophthalmology Annual Meeting, November 2007, New Orleans, Louisiana.
https://doi.org/10.1016/j.ophtha.2007.09.006Get rights and content

Objective

To evaluate the intraphysician agreement between ophthalmoscopic examination and image-based telemedical interpretation for retinopathy of prematurity (ROP) diagnosis, when performed by the same expert physician grader.

Design

Prospective, nonrandomized, comparative study.

Participants

Sixty-seven consecutive premature infants who underwent ROP examination at a major university medical center whose parents consented for participation.

Methods

Infants underwent standard dilated ophthalmoscopy by one of two pediatric ophthalmologists, followed by retinal imaging with a commercially available wide-angle fundus camera by a trained neonatal nurse. Study examinations were performed at 31 to 33 weeks postmenstrual age (PMA) and/or 35 to 37 weeks PMA. Images were uploaded to a Web-based telemedicine system developed by the authors. After a 4- to 12-month period, telemedical interpretations were performed in which each physician graded images from infants upon whom he had initially performed ophthalmoscopic examinations. Diagnoses were classified using an ordinal scale: no ROP, mild ROP, type 2 prethreshold ROP, and treatment-requiring ROP.

Main Outcome Measures

Absolute intraphysician agreement and κ statistic between ophthalmoscopic examination and telemedical interpretation were calculated by eye. All intraphysician discrepancies were reviewed, and underlying causes were classified by eye as no ROP identified by ophthalmoscopic examination, no ROP identified by telemedical interpretation, discrepancy about presence of zone 1 ROP, discrepancy about presence of plus disease, or other discrepancy in classification of ROP stage.

Results

Absolute intraphysician agreement between ophthalmoscopic examination and telemedical interpretation was 86.3%. The κ statistic for intraphysician agreement between examinations ranged from 0.657 (substantial agreement) for diagnosis of treatment-requiring ROP to 0.854 (near-perfect agreement) for diagnosis of mild or worse ROP. Among 206 eye examinations (103 infant examinations), there were 28 (13.6%) intraphysician discrepancies in diagnosis, 8 of which resulted from uncertainty about presence of zone 1 disease and 4 from uncertainty about presence of plus disease.

Conclusions

Intraphysician agreement between ophthalmoscopic examination and telemedical interpretation for ROP was very high. Neither examination modality appeared to have a systematic tendency to overdiagnose or underdiagnose ROP. Diagnosis of zone 1 disease and plus disease were major sources of clinically significant discrepancies.

Section snippets

Infrastructure for Telemedical Interpretation

This study was approved by the Institutional Review Board at Columbia University Medical Center. A neonatal intensive care unit (NICU) nurse was trained to perform wide-angle digital retinal imaging using a commercially available device (RetCam-II; Clarity Medical Systems, Pleasanton, CA). Training included 2-day initial instructional session with the device manufacturer, followed by 6 weekly sessions with the principal investigator (MFC) during regularly scheduled ophthalmoscopic examinations.

Study Population

The study included 67 consecutive infants whose parents consented to participate. This represented 62.0% of the 108 eligible infants hospitalized in the Columbia NICU who met inclusion criteria during the study period. Of the 41 (38.0%) eligible infants who did not participate, 32 (29.6%) parents could not be contacted by study personnel within the study period, 7 (6.5%) parents declined to provide informed consent, and 2 (1.9%) were considered unstable by their neonatologists for imaging.

Discussion

This study found that, first, intraphysician agreement between ophthalmoscopic examination and telemedical interpretation was very high. Second, neither ophthalmoscopy nor telemedicine methods had a systematic tendency to overdiagnose or underdiagnose ROP compared with the other method. Third, many clinically significant diagnostic discrepancies were based on uncertainty about presence of zone 1 or plus disease. By controlling for diagnostic variation among different physician graders, the

Acknowledgments

The authors thank Dr Zhiliang Ying for his statistical assistance with this study.

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    Manuscript no. 2007-613.

    The authors have no commercial, proprietary, or financial interest in any of the products or companies described in the article.

    Supported by a Career Development Award from Research to Prevent Blindness, New York, New York (MFC), and the National Eye Institute, Bethesda, Maryland (grant no. EY13972 [MFC]).

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