Influence of Computer-Generated Mosaic Photographs on Retinopathy of Prematurity Diagnosis and Management

Auto-Processed Retinal Vessel Shadow View Images From Bedside Optical Coherence Tomography to Evaluate Plus Disease in Retinopathy of Prematurity

Purpose

To describe the creation of en face retinal vessel shadow view (RVSV) optical coherence tomography (OCT) images and assess the feasibility of using these for evaluating vascular disease in preterm infants at risk for retinopathy of prematurity (ROP).

Methods

In this exploratory study, we selected images from eyes with a range of ROP vascular disease, prospectively acquired from preterm infants using an investigational, noncontact, handheld, bedside swept-source OCT. We autosegmented OCT volumes using custom infant-specific software, extracted RVSV-OCT images from volumetric data bracketed around the retinal pigment epithelium, and automontaged the resulting RVSV-OCT images. Three masked ophthalmologists graded the RVSV-OCT montages as plus, pre-plus, or neither and ranked them by relative vascular disease severity.

Results

We selected images from 17 imaging sessions (7 plus, 4 pre-plus, 6 neither on clinical examination). On review, 15/17 (88%) RVSV-OCT montages were gradable for plus, pre-plus, or neither and all 17 montages were rankable for relative severity. Intergrader agreement for plus, pre-plus, or neither grading was good (κ, 0.67; 95% confidence interval, 0.42–0.86) and for relative severity ranking was excellent (intraclass correlation coefficient, 0.98; 95% confidence interval, 0.96–0.99).

Conclusions

Our novel automatic processing method can create RVSV-OCT montages optimized for retinal vessel visualization for ROP screening. Although our data support the feasibility of using RVSV-OCT montages for ranking relative vascular disease severity, there is room for improved OCT image capture and processing methods in preterm infants screened for ROP.

Translational Relevance

Creation and grading of RVSV-OCT images could eventually be integrated into an alternative method for ROP screening.

Telemedicine for Retinopathy of Prematurity in 2020

Purpose:

Retinopathy of prematurity (ROP) is the leading cause of visual impairment in premature infants, and middle-income nations are currently experiencing the “third epidemic” of ROP. Screening programs are essential to prevent negative visual outcomes, but screening efforts require a great amount of resources from healthcare systems and are difficult to marshal, particularly in geographically isolated or resource-limited settings. Telemedical screening programs using remote digital fundus imaging (RDFI) systems hold the promise of alleviating many of the burdens that currently make screening for ROP logistically challenging.

Methods:

Literature review of the current evidence for RDFI telescreening for ROP, with editorial discussion and recommendations.

Results:

In this review, we summarize the robust body of literature regarding the efficacy of RDFI, the feasibility of telescreening programs, and experiences from current live telescreening programs. We discuss the strengths and limitations of the current evidence and of the screening programs and consider the best practices in developing de novo telemedical screening programs for ROP. The review concludes with a discussion of promising future areas of research and development.

Conclusions:

RDFI ROP screening programs can be accurate and reliable. They show promise in improving many current challenges in screening infants for ROP, may be able to improve some aspects of care, and have been demonstrated to be cost-effective.

MII RetCam assisted smartphone based fundus imaging for retinopathy of prematurity

Purpose:

The gold standard for evaluating Retinopathy of prematurity (ROP), a potentially blinding disease in preterm babies, is by indirect ophthalmoscopy which is quite subjective. Digital imaging with RetCam, an advanced wide field imaging system is more precise but it is not easily available or affordable. Smartphones are being explored as an alternate cost effective and accessible imaging tool. This is possible because of the good illumination and the built-in high resolution cameras available in modern smartphones. The aim of this study is to illustrate the utility of MII RetCam assisted smartphone based fundus imaging (MSFI) in the documentation and monitoring of ROP.

Methods:

Single-centre, retrospective observational study of all the preterm babies subjected to MSFI as part of ROP screening from September 2017 to November 2018. iPhone 4S and + 20 Diopter lens attached to the MII RetCam device was used for fundus imaging at baseline and during follow up. The statistical analysis used for the same is the SPSS statistical software.

Results:

Good quality images of central and peripheral retina could be captured in 33 out of 42 babies (78.57%) with ROP. Serial imaging done in 24 babies with ROP helped in precise monitoring of the disease and planning management. Incidentally detected non-ROP findings were also documented. Unique design of the device enabled imaging by a single examiner. Image database created was useful for academic and counselling purposes. Smaller field images which can cause difficulty in distinguishing the zones is a limitation.

Conclusion:

MSFI is a potential alternate imaging tool enabling objective documentation and monitoring of ROP in low resource settings.

Asymmetry of Retinopathy of Prematurity Border in the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity Study

PURPOSE

To measure the location of the retinopathy of prematurity (ROP) border in a sample of premature infants developed ROP and to determine the location for predicting subsequent development of referral-warranted ROP (defined as stage 3 ROP, zone I ROP, or plus disease) or treated ROP.

DESIGN

Secondary analysis of data from an observational cohort study, the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity study.

PARTICIPANTS

Infants with birth weight (BW) of less than 1251 g with at least 1 examination and imaging session at 34 weeks postmenstrual age (PMA) or younger with ROP not meeting referral-warranted ROP and at least 1 subsequent examination at 36 weeks PMA or older.

METHODS

The 5-image set from the first imaging session for each eligible eye was mosaicked, and measurements of the ROP border were made using Image J. Measurements were compared among 3 groups of eyes with ROP: (1) those that never developed referral-warranted ROP or received treatment, (2) those that developed referral-warranted ROP but did not receive treatment, and (3) those that received treatment.

MAIN OUTCOME MEASURES

Referral-warranted ROP and treated ROP.

RESULTS

Three hundred seventeen eyes from 217 infants with mean BW of 755 g, mean gestational age (GA) of 25 weeks, and mean PMA of 33 weeks at first examination met study criteria. Of 211 eyes (66.6%) with sufficient-quality images for grading, 147 (69.7%) did not develop referral-warranted ROP or receive treatment, 36 (17.1%) developed referral-warranted ROP not requiring treatment, and 28 (13.3%) received treatment for ROP. Among all eyes, the disc-to-ROP border distance followed a consistent pattern, with nasal less than inferior less than superior less than temporal. In multivariate analysis adjusted by BW and GA, nasal ROP border distance was a significant predictor of the subsequent development of ROP that was treated (odds ratio, 0.86 for every 10-pixel increase in distance; P = 0.002).

CONCLUSIONS

Retinopathy of prematurity is located asymmetrically around the optic disc and is closest to the optic disc nasally. Location of ROP nasally at first imaging is a significant predictor for subsequent development of ROP that was treated.

Imaging in Retinopathy of Prematurity

Retinopathy of prematurity (ROP) is a leading cause of preventable childhood blindness worldwide. Barriers to ROP screening and difficulties with subsequent evaluation and management include poor access to care, lack of physicians trained in ROP, and issues with objective documentation. Digital retinal imaging can help address these barriers and improve our knowledge of the pathophysiology of the disease. Advancements in technology have led to new, non-mydriatic and mydriatic cameras with wider fields of view as well as devices that can simultaneously incorporate fluorescein angiography, optical coherence tomography (OCT), and OCT angiography. Image analysis in ROP is also being employed through smartphones and computer-based software. Telemedicine programs in the United States and worldwide have utilized imaging to extend ROP screening to infants in remote areas and have shown that digital retinal imaging can be reliable, accurate, and cost-effective. In addition, tele-education programs are also using digital retinal images to increase the number of healthcare providers trained in ROP. Although indirect ophthalmoscopy is still an important skill for screening, digital retinal imaging holds promise for more widespread screening and management of ROP.

Anti-Vascular Endothelial Growth Factor and the Evolving Management Paradigm for Retinopathy of Prematurity

Diagnosis and management of pediatric retinal conditions such as retinopathy of prematurity (ROP) have been evolving significantly with the availability of new technology and treatments. New imaging systems, telemedicine, tele-education, and anti‒vascular endothelial growth factor (VEGF) intravitreal pharmacotherapy are all changing the way we diagnose and deliver care to children with pediatric retinal disease. Fluorescein angiography and optical coherence tomography have the potential to improve our diagnosis and management of disease, and with improvements in retinal imaging, telemedicine is becoming more feasible. Telemedicine, tele-education, and computer-based image analysis may overcome many of the challenges we face in providing adequate care and access for children with pediatric retinal disease. Treatment options have also expanded with the use of anti-VEGF therapy. Although the use of intravitreal anti-VEGF for ROP has been documented in the literature for more than a decade, many questions still remain about its safety in the pediatric patient population. Several ongoing prospective studies are exploring the utility of anti-VEGF agents for ROP, with attention to the optimal dose of drug, systemic safety, and our understanding of recurrence of disease. This review aims to provide an update on current diagnostic and therapeutic modalities, focusing predominantly on the role of anti-VEGF therapy, for the management of ROP and other pediatric retinal vascular diseases.