Retinopathy of prematurity (ROP) continues to be an ongoing challenge for both ophthalmologists and neonatologists and remains a significant threat to vision for extremely premature infants despite the availability of therapeutic modalities. It remains a leading cause of morbidity despite, (and interestingly) as well as because of, advances in neonatal care, which have improved survival rates of at-risk infants born prematurely. Many controlled clinical trials have shown that application of therapies at the appropriate time is essential to successful outcomes in premature infants affected by ROP.
Bedside examination of these babies with an binocular indirect ophthalmoscopy has been the standard technique for diagnosis and monitoring of ROP. However, implementation of routine use of this screening method for at-risk premature infants has been a challenge, which includes scarcity of trained ophthalmologists in some areas as well as the remote location of some Neonatal Intensive Care Units (NICUs).
Modern technology, including the development of wide-angle ocular digital fundus photography, coupled with the ability to send digital images electronically to remote locations, has led to the development of telemedicine-based remote digital fundus imaging evaluation (and capture) techniques. These techniques have the potential to allow the diagnosis and monitoring of ROP to occur in lieu of the necessity for some repeated on-site examinations in NICUs.
Although there is an ongoing need for screening for ROP, reimbursement issues, liability concerns, and the complexities associated with coordinating ROP services are possibly resulting in insufficient numbers of qualified ophthalmologists willing to provide screening for infants at risk for developing ROP. Although malpractice claims against ophthalmologists and neonatologists for failure of diagnosis or mismanagement of ROP are relatively uncommon, awards can be extremely high because of the age of the patients involved and the severity of visual disability that may occur.
Approximately 9% of infants with high-risk prethreshold ROP will have an unfavorable structural outcome despite timely treatment, which compounds the problem. In addition, decentralization of neonatal care to community hospitals offering higher level NICUs for premature neonates requires ophthalmologists to service one or more facilities with a small number of infants requiring care in these units. The duty of the ophthalmologist providing ROP evaluation services to coordinate and track ongoing care is complex. Lastly, reimbursement may be inadequate to address the liability, travel, and tracking aspects of ROP care.
Walter M. Fierson, MD, and Antonio Capone, Jr, MD reviewed the literature on the success of telemedicine-based remote digital fundus imaging and found it does not eliminate the need for binocular indirect ophthalmoscopy but can expand options for treatment and improve outcomes for some at-risk patients. Their findings were published online in Pediatrics, with some of the details mentioned below.
The researchers outlined some considerations in using telemedicine. Advantages include the ability to integrate it into electronic health records, increase the number of infants evaluated, improve patient and staff education about ROP, and extend the expertise of ROP experts.
Disadvantages include the cost and the fact that the telemedicine systems collect considerably less information than is required to fully stage the extent of ROP on the basis of the International Classification of Retinopathy of Prematurity consensus statement. Detractors cite the difficulty in imaging the retinal periphery, problems with image quality in certain circumstances (eyes with poor dilation, media haze, or dark fundus pigmentation), and variations in interpretations of images even among highly skilled clinicians.
Considerations should include costs for a digital fundus camera system, image management software, training for nursing teams, and an ophthalmologist with expertise in ROP.
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