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Al-Khaled T, Patel SN, Valikodath NG, Jonas KE, Ostmo S, Allozi R, Hallak J, Campbell JP, Chiang MF, Chan RVP. Characterization of Errors in Retinopathy of Prematurity Diagnosis by Ophthalmologists-in-Training in the United States and Canada. J Pediatr Ophthalmol Strabismus 2023; 60:337-343. [PMID: 36263935 DOI: 10.3928/01913913-20220609-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To identify the prominent factors that lead to misdiagnosis of retinopathy of prematurity (ROP) by ophthalmologists-in-training in the United States and Canada. METHODS This prospective cohort study included 32 ophthalmologists-in-training at six ophthalmology training programs in the United States and Canada. Twenty web-based cases of ROP using wide-field retinal images were presented, and ophthalmologists-in-training were asked to diagnose plus disease, zone, stage, and category for each eye. Responses were compared to a consensus reference standard diagnosis for accuracy, which was established by combining the clinical diagnosis and the image-based diagnosis by multiple experts. The types of diagnostic errors that occurred were analyzed with descriptive and chi-squared analysis. Main outcome measures were frequency of types (category, zone, stage, plus disease) of diagnostic errors; association of errors in zone, stage, and plus disease diagnosis with incorrectly identified category; and performance of ophthalmologists-in-training across postgraduate years. RESULTS Category of ROP was misdiagnosed at a rate of 48%. Errors in classification of plus disease were most commonly associated with misdiagnosis of treatment-requiring (plus error rate = 16% when treatment-requiring was correctly diagnosed vs 81% when underdiagnosed as type 2 or pre-plus; mean difference: 64.3; 95% CI: 51.9 to 76.7; P < .001) and type 2 or pre-plus (plus error rate = 35% when type 2 or pre-plus was correctly diagnosed vs 76% when overdiagnosed as treatment-requiring; mean difference: 41.0; 95% CI: 28.4 to 53.5; P < .001) disease. The diagnostic error rate of postgraduate year (PGY)-2 trainees was significantly higher than PGY-3 trainees (PGY-2 category error rate = 61% vs PGY-3 = 35%; mean difference, 25.4; 95% CI: 17.7 to 33.0; P < .001). CONCLUSIONS Ophthalmologists-in-training in the United States and Canada misdiagnosed ROP nearly half of the time, with incorrect identification of plus disease as a leading cause. Integration of structured learning for ROP in residency education may improve diagnostic competency. [J Pediatr Ophthalmol Strabismus. 2023;60(5):337-343.].
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Sikder A, Mehta P, Galoyan T, Parekh E, Dickhoner J, Yeghiazaryan N, Harutyunyan R, Hovhannisyan T, Lee T, Espinoza J. Using a Facebook Virtual Examination Room to Enhance ROP Training in Armenia. Clin Ophthalmol 2022; 16:2311-2322. [PMID: 35911845 PMCID: PMC9332928 DOI: 10.2147/opth.s371360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/13/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Retinopathy of prematurity (ROP) is a leading cause of worldwide childhood blindness with increasing incidence in low and middle income countries (LMICs) due to advances in neonatal care. There are insufficient numbers of healthcare professionals specialized in ROP management and few local training opportunities in LMICs. Social media platforms provide a promising solution to enable interactive medical education across geographic and logistic barriers. As an adjunct to an ROP training program for ophthalmologists in Armenia, we implemented a Facebook Virtual Examination Room (VER) for case discussion with a global community of collaborators and preceptors. To evaluate training through VER, we operationalized engagement as a multilayer meta-construct that includes cognitive, behavioral, and social-emotional domains. Methods A concurrent mixed methods approach was taken to collect and analyze data from comments and activities within VER. Quantitative data was analyzed for descriptive statistics on group utilization, participant activity, and clinical metrics. Qualitative data was analyzed by conducting thematic analysis involving initial and pattern coding. Results Ten participants (7 trainees and 3 preceptors) interacted in the Facebook group across 153 unique cases, with 218 threads, 414 comments, and 216 likes. Of the 120 unique cases eligible for consensus evaluation, treatment was mentioned most frequently (87), followed by location (68), staging (65), and plus disease (31), with agreement ranging from 67% to 97%. Based on the qualitative analysis, the most common themes of discussion were clinical management, dilemma resolution, knowledge growth, and gratitude. Conclusion A closed Facebook group for case-based discussions can be a useful adjunct to an existing ROP training program by engaging learners across social-emotional, behavioral, and cognitive domains. For international training partnerships, the financial and logistical advantages can be significant, though focus should remain on the primary curriculum and training modality.
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Affiliation(s)
- Abu Sikder
- Innovation Studio, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Preeya Mehta
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Tamara Galoyan
- School of Education, Drexel University, Philadelphia, PA, USA
| | - Eeshika Parekh
- Innovation Studio, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - James Dickhoner
- Innovation Studio, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | | | | | | | - Thomas Lee
- Department of Surgery, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Juan Espinoza
- Division of General Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Correspondence: Juan Espinoza, Division of General Pediatrics, Children’s Hospital Los Angeles, 4650 Sunset Blvd., Mailstop #76, Los Angeles, CA, 90027, USA, Tel +1 323.361.2721, Fax +1 323.361.4429, Email
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Al-Khaled T, Acaba-Berrocal L, Cole E, Ting DSW, Chiang MF, Chan RVP. Digital Education in Ophthalmology. Asia Pac J Ophthalmol (Phila) 2022; 11:267-272. [PMID: 34966034 PMCID: PMC9240107 DOI: 10.1097/apo.0000000000000484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Accessibility to the Internet and computer systems has prompted the gravitation towards digital learning in medicine, including ophthalmology. Using the PubMed database and Google search engine, current initiatives in ophthalmology that serve as alternatives to traditional in-person learning with the purpose of enhancing clinical and surgical training were reviewed. This includes the development of teleeducation modules, construction of libraries of clinical and surgical videos, conduction of didactics via video communication, and the implementation of simulators and intelligent tutoring systems into clinical and surgical training programs. In this age of digital communication, teleophthalmology programs, virtual ophthalmological society meetings, and online examinations have become necessary for conducting clinical work and educational training in ophthalmology, especially in light of recent global events that have prevented large gatherings as well as the rural location of various populations. Looking forward, web-based modules and resources, artificial intelligence-based systems, and telemedicine programs will augment current curricula for ophthalmology trainees.
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Affiliation(s)
- Tala Al-Khaled
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, US
| | - Luis Acaba-Berrocal
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, US
| | - Emily Cole
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, US
| | - Daniel S W Ting
- Singapore Eye Research institute, Singapore National Eye centre, Singapore
- Duke-NUS Medical School, National University Singapore, Singapore
| | - Michael F Chiang
- National Eye Institute, National Institutes of Health, Bethesda, MD, US
| | - R V Paul Chan
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, US
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Navarro-Blanco C, Pastora-Salvador N, Sánchez-Ramos C, Peralta-Calvo J. Assessment of non-expert ophthalmologists in the analysis of retinopathy of prematurity. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2022; 96:147-148. [DOI: 10.1016/j.anpede.2020.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 10/31/2020] [Indexed: 11/27/2022] Open
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Chen JS, Coyner AS, Chan RP, Hartnett ME, Moshfeghi DM, Owen LA, Kalpathy-Cramer J, Chiang MF, Campbell JP. Deepfakes in Ophthalmology. OPHTHALMOLOGY SCIENCE 2021; 1:100079. [PMID: 36246951 PMCID: PMC9562356 DOI: 10.1016/j.xops.2021.100079] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/01/2021] [Accepted: 10/29/2021] [Indexed: 02/06/2023]
Abstract
Purpose Generative adversarial networks (GANs) are deep learning (DL) models that can create and modify realistic-appearing synthetic images, or deepfakes, from real images. The purpose of our study was to evaluate the ability of experts to discern synthesized retinal fundus images from real fundus images and to review the current uses and limitations of GANs in ophthalmology. Design Development and expert evaluation of a GAN and an informal review of the literature. Participants A total of 4282 image pairs of fundus images and retinal vessel maps acquired from a multicenter ROP screening program. Methods Pix2Pix HD, a high-resolution GAN, was first trained and validated on fundus and vessel map image pairs and subsequently used to generate 880 images from a held-out test set. Fifty synthetic images from this test set and 50 different real images were presented to 4 expert ROP ophthalmologists using a custom online system for evaluation of whether the images were real or synthetic. Literature was reviewed on PubMed and Google Scholars using combinations of the terms ophthalmology, GANs, generative adversarial networks, ophthalmology, images, deepfakes, and synthetic. Ancestor search was performed to broaden results. Main Outcome Measures Expert ability to discern real versus synthetic images was evaluated using percent accuracy. Statistical significance was evaluated using a Fisher exact test, with P values ≤ 0.05 thresholded for significance. Results The expert majority correctly identified 59% of images as being real or synthetic (P = 0.1). Experts 1 to 4 correctly identified 54%, 58%, 49%, and 61% of images (P = 0.505, 0.158, 1.000, and 0.043, respectively). These results suggest that the majority of experts could not discern between real and synthetic images. Additionally, we identified 20 implementations of GANs in the ophthalmology literature, with applications in a variety of imaging modalities and ophthalmic diseases. Conclusions Generative adversarial networks can create synthetic fundus images that are indiscernible from real fundus images by expert ROP ophthalmologists. Synthetic images may improve dataset augmentation for DL, may be used in trainee education, and may have implications for patient privacy.
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Affiliation(s)
- Jimmy S. Chen
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
| | - Aaron S. Coyner
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
| | - R.V. Paul Chan
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - M. Elizabeth Hartnett
- Department of Ophthalmology, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah
| | - Darius M. Moshfeghi
- Byers Eye Institute, Horngren Family Vitreoretinal Center, Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California
| | - Leah A. Owen
- Department of Ophthalmology, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah
| | - Jayashree Kalpathy-Cramer
- Department of Radiology, Massachusetts General Hospital/Harvard Medical School, Charlestown, Massachusetts
- Massachusetts General Hospital & Brigham and Women’s Hospital Center for Clinical Data Science, Boston, Massachusetts
| | - Michael F. Chiang
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - J. Peter Campbell
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
- Correspondence: J. Peter Campbell, MD, MPH, Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, 515 SW Campus Drive, Portland, OR 97239.
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Tsai AS, Chou HD, Ling XC, Al-Khaled T, Valikodath N, Cole E, Yap VL, Chiang MF, Chan RVP, Wu WC. Assessment and management of retinopathy of prematurity in the era of anti-vascular endothelial growth factor (VEGF). Prog Retin Eye Res 2021; 88:101018. [PMID: 34763060 DOI: 10.1016/j.preteyeres.2021.101018] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 02/06/2023]
Abstract
The incidence of retinopathy of prematurity (ROP) continues to rise due to the improved survival of very low birth weight infants in developed countries. This epidemic is also fueled by increased survival of preterm babies with variable use of oxygen and a lack of ROP awareness and screening services in resource-limited regions. Improvements in technology and a basic understanding of the disease pathophysiology have changed the way we screen and manage ROP, educate providers and patients, and improve ROP awareness. Advancements in imaging techniques, expansion of telemedicine services, and the potential for artificial intelligence-assisted ROP screening programs have created opportunities to improve ROP care in areas with a shortage of ophthalmologists trained in ROP. To address the gap in provider knowledge regarding ROP, the Global Education Network for Retinopathy of Prematurity (GEN-ROP) created a web-based tele-education training module that can be used to educate all providers involved in ROP, including non-physician ROP screeners. Over the past 50 years, the treatment of severe ROP has evolved from limited treatment modalities to cryotherapy and laser photocoagulation. More recently, there has been growing evidence to support the use of anti-vascular endothelial growth factor (VEGF) agents for the treatment of severe ROP. However, VEGF is known to be important in organogenesis and microvascular maintenance, and given that intravitreal anti-VEGF treatment can result in systemic VEGF suppression over a period of at least 1-12 weeks, there are concerns regarding adverse effects and long-term ocular and systemic developmental consequences of anti-VEGF therapy. Future research in ophthalmology to address the growing burden of ROP should focus on cost-effective fundus imaging devices, implementation of artificial intelligence platforms, updated treatment algorithms with optimal use of anti-VEGF and careful investigation of its long-term effects, and surgical options in advanced ROP. Addressing these unmet needs will aid the global effort against the ROP epidemic and optimize our understanding and treatment of this blinding disease.
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Affiliation(s)
- Andrew Sh Tsai
- Singapore National Eye Centre, Singapore; DUKE NUS Medical School, Singapore
| | - Hung-Da Chou
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Xiao Chun Ling
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Tala Al-Khaled
- Department of Ophthalmology & Visual Sciences, University of Illinois at Chicago, Illinois Eye and Ear Infirmary, Chicago, IL, USA
| | - Nita Valikodath
- Department of Ophthalmology & Visual Sciences, University of Illinois at Chicago, Illinois Eye and Ear Infirmary, Chicago, IL, USA
| | - Emily Cole
- Department of Ophthalmology & Visual Sciences, University of Illinois at Chicago, Illinois Eye and Ear Infirmary, Chicago, IL, USA
| | - Vivien L Yap
- Division of Newborn Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Michael F Chiang
- National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - R V Paul Chan
- Department of Ophthalmology & Visual Sciences, University of Illinois at Chicago, Illinois Eye and Ear Infirmary, Chicago, IL, USA.
| | - Wei-Chi Wu
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Sarin-Gulian L, Espinoza J, Lee TC, Choe JYU, Fichera S. Development and Evaluation of a Tele-Education Program for Neonatal ICU Nurses in Armenia. J Pediatr Nurs 2021; 57:e9-e14. [PMID: 32981807 DOI: 10.1016/j.pedn.2020.08.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 08/23/2020] [Accepted: 08/31/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Neonatal mortality currently accounts for more than 60% of all infant mortality in Armenia. The majority of health professionals in Neonatal Intensive Care Units (NICU) however, have had no specialized training in neonatology. Local and global agencies have emphasized the need for improvement in the education and skills of NICU health professionals. The objective of this study was to design, implement, and evaluate an innovative tele-education program for NICU nurses in Armenia. DESIGN AND METHODS Seven online tele-education courses were designed on various neonatal nursing topics using Final Cut Pro and translated professionally to Armenian. The videos were uploaded to YouTube. All NICU nurses employed in two hospitals (n = 35) in Yerevan, Armenia, completed a diagnostic pretest, course viewing, a posttest, and a satisfaction survey for each topic. A difference in knowledge was defined as the number of correct test answers obtained before and after the course. Participant satisfaction was measured using a Likert scale. RESULTS The combined average for completed pre-tests for all courses was 45% and 71% for post-tests, which was statistically significant for each course (p < 0.05). A majority of the nurses either agreed or strongly agreed with all of the satisfaction parameters of the course. CONCLUSIONS These results support a tele-education model for effectively providing continuing education to NICU nurses in Armenia. A similar platform could be used to establish nationwide certification programs for neonatal nurses. PRACTICE IMPLICATIONS Tele-education technology can be used effectively by nursing educators working in global health as part of international learning collaboratives.
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Affiliation(s)
| | - Juan Espinoza
- Children's Hospital Los Angeles, Los Angeles, CA, United States.
| | - Thomas C Lee
- Children's Hospital Los Angeles, Los Angeles, CA, United States.
| | | | - Sharon Fichera
- Children's Hospital Los Angeles, Los Angeles, CA, United States.
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Neves LM, Haefeli LM, Zin AA, Steffen RE, Vasconcelos ZFM, Pinto M. Cost-Utility Analysis of Wide-Field Imaging as an Auxiliary Technology for Retinopathy of Prematurity Care in Brazil. Front Pediatr 2021; 9:757258. [PMID: 34976892 PMCID: PMC8716796 DOI: 10.3389/fped.2021.757258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/26/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose: To evaluate the cost-utility of wide-field imaging (WFI) as a complementary technology for retinopathy of prematurity (ROP) screening from the Brazilian Unified Health System's perspective. Introduction: ROP is one of the leading causes of avoidable childhood blindness worldwide, especially in middle-income countries. The current ROP screening involves indirect binocular ophthalmoscopy (IBO) by ROP expert ophthalmologists. However, there is still insufficient ROP screening coverage. An alternative screening strategy is the combination of WFI with IBO. Methods: A cost-utility analysis was performed using a deterministic decision-tree simulation model to estimate incremental cost-utility for ROP care. Two screening strategies were compared: (1) IBO and (2) combination of WFI of all eligible preterm infants and IBO for type 2 ROP or worse and for non-readable images. Eligible population included preterm infants <32 weeks of gestational age or birth weight equal to or <1,500 g. The temporal horizon was lifetime. Visual outcome data was converted to utility, and the health benefits were estimated on quality-adjusted life-years (QALY). Incremental cost per QALY gained was calculated from the health system perspective. Costs were estimated considering equipment, maintenance, consumables, and staff. A micro-costing approach was used for WFI. Two technician nurses were trained for imaging execution and had their time evaluated. Two ROP expert ophthalmologists had their time evaluated for imaging reading. One-way sensitivity analysis and probabilistic sensitivity analysis were performed. Results: Combined screening strategy resulted in a cost-effective program considering 90% ROP screening coverage. Costs per examination: (1) screening with IBO: US dollar (US $) 34.36; (2) screening with combination: US $58.20; (3) laser treatment: US $642.09; (4) long-term follow-up: ranged from US $69.33 to 286.91, based on the infant's visual function. Incremental cost per QALY gained was US $1,746.99/QALY per infant screened with the combination strategy. One-way sensitivity analysis resulted in cost-effectiveness for all parameters. Probabilistic sensitivity analyses yielded a 100% probability of combination being cost-effective in a willingness-to-pay threshold of US $1,800/QALY. Conclusion: The combined strategy for ROP screening was cost-effective. It enhances access for appropriate ROP care in middle-income countries and dminishes opportunity costs for ophthalmologists.
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Affiliation(s)
- Luiza M Neves
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Lorena M Haefeli
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Andrea A Zin
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Ricardo E Steffen
- Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.,Departamento de Medicina, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janerio, Brazil
| | - Zilton F M Vasconcelos
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Márcia Pinto
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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Navarro-Blanco C, Pastora-Salvador N, Sánchez-Ramos C, Peralta-Calvo J. [Assessment of non-expert ophthalmologists in the analysis of retinopathy of prematurity]. An Pediatr (Barc) 2020; 96:S1695-4033(20)30479-3. [PMID: 33342689 DOI: 10.1016/j.anpedi.2020.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 10/24/2020] [Accepted: 10/31/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
| | | | - Celia Sánchez-Ramos
- Grupo de Neuro-Computación y Neuro-Robótica, Universidad Complutense de Madrid, Madrid, España
| | - Jesús Peralta-Calvo
- Departamento de Oftalmología Infantil, Hospital Universitario La Paz, Madrid, España
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Kapoor S, Eldib A, Hiasat J, Scanga H, Tomasello J, Alabek M, Ament K, Arner D, Benson A, Berret K, Blaha B, Brinza M, Caterino R, Chauhan B, Churchfield W, Fulwylie C, Gruszewski J, Hrinak D, Johnston L, Meyer C, Nanda K, Newton T, Pomycala B, Runkel L, Sanchez K, Skellett S, Steigerwald J, Mitchell E, Pihlblad M, Luchansky C, Keim E, Yu J, Quinn P, Mittal A, Pitetti R, Patil-Chhablani P, Liasis A, Nischal KK. Developing a pediatric ophthalmology telemedicine program in the COVID-19 crisis. J AAPOS 2020; 24:204-208.e2. [PMID: 32890736 PMCID: PMC7467070 DOI: 10.1016/j.jaapos.2020.05.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/29/2020] [Accepted: 05/30/2020] [Indexed: 01/10/2023]
Abstract
PURPOSE To describe our methodology for implementing synchronous telemedicine during the 2019 novel coronavirus (COVID-19) pandemic. METHODS A retrospective review of outpatient records at a single children's hospital from March 21 to April 10, 2020, was carried out to determine the outcome of already-scheduled face-to-face outpatient appointments. The week leading up to the March 21, all appointments in the study period were categorized as follows: (1) requiring an in-person visit, (2) face-to-face visit that could be postponed, and (3) consultation required but could be virtual. Teams of administrators, schedulers, and ophthalmic technicians used defined scripts and standardized emails to communicate results of categorization to patients. Flowcharts were devised to schedule and implement telemedicine visits. Informational videos were made accessible on social media to prepare patients for the telemedicine experience. Simultaneously our children's hospital launched a pediatric on-demand e-consult service, the data analytics of which could be used to determine how many visits were eye related. RESULTS A total of 237 virtual ophthalmology consult visits were offered during the study period: 212 were scheduled, and 206 were completed, of which 43 were with new patients and 163 with returning patients. Following the initial virtual visit, another was required on average in 4 weeks by 21 patients; in-person follow-up was required for 170 patients on average 4.6 months after the initial virtual visit. None needed review within 72 hours. The pediatric on-demand service completed 290 visits, of which 25 had eye complaints. CONCLUSIONS With proper materials, technology, and staffing, a telemedicine strategy based on three patient categories can be rapidly implemented to provide continued patient care during pandemic conditions. In our study cohort, the scheduled clinic e-visits had a low no-show rate (3%), and 8% of the on-demand virtual access for pediatric care was eye related.
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Affiliation(s)
- Saloni Kapoor
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amgad Eldib
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jamila Hiasat
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hannah Scanga
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Michelle Alabek
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kellie Ament
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Debbi Arner
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ashley Benson
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kristine Berret
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bianca Blaha
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melissa Brinza
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Roxanne Caterino
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Baresh Chauhan
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Jessi Gruszewski
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Denise Hrinak
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lori Johnston
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cheryl Meyer
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kaajal Nanda
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Teresa Newton
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Becci Pomycala
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lauren Runkel
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Sarah Skellett
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jess Steigerwald
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ellen Mitchell
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew Pihlblad
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Craig Luchansky
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Erin Keim
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jenny Yu
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick Quinn
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anshul Mittal
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Raymond Pitetti
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Ken K Nischal
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania.
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Horton MB, Brady CJ, Cavallerano J, Abramoff M, Barker G, Chiang MF, Crockett CH, Garg S, Karth P, Liu Y, Newman CD, Rathi S, Sheth V, Silva P, Stebbins K, Zimmer-Galler I. Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy, Third Edition. Telemed J E Health 2020; 26:495-543. [PMID: 32209018 PMCID: PMC7187969 DOI: 10.1089/tmj.2020.0006] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 01/11/2020] [Accepted: 01/11/2020] [Indexed: 12/24/2022] Open
Abstract
Contributors The following document and appendices represent the third edition of the Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy. These guidelines were developed by the Diabetic Retinopathy Telehealth Practice Guidelines Working Group. This working group consisted of a large number of subject matter experts in clinical applications for telehealth in ophthalmology. The editorial committee consisted of Mark B. Horton, OD, MD, who served as working group chair and Christopher J. Brady, MD, MHS, and Jerry Cavallerano, OD, PhD, who served as cochairs. The writing committees were separated into seven different categories. They are as follows: 1.Clinical/operational: Jerry Cavallerano, OD, PhD (Chair), Gail Barker, PhD, MBA, Christopher J. Brady, MD, MHS, Yao Liu, MD, MS, Siddarth Rathi, MD, MBA, Veeral Sheth, MD, MBA, Paolo Silva, MD, and Ingrid Zimmer-Galler, MD. 2.Equipment: Veeral Sheth, MD (Chair), Mark B. Horton, OD, MD, Siddarth Rathi, MD, MBA, Paolo Silva, MD, and Kristen Stebbins, MSPH. 3.Quality assurance: Mark B. Horton, OD, MD (Chair), Seema Garg, MD, PhD, Yao Liu, MD, MS, and Ingrid Zimmer-Galler, MD. 4.Glaucoma: Yao Liu, MD, MS (Chair) and Siddarth Rathi, MD, MBA. 5.Retinopathy of prematurity: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 6.Age-related macular degeneration: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 7.Autonomous and computer assisted detection, classification and diagnosis of diabetic retinopathy: Michael Abramoff, MD, PhD (Chair), Michael F. Chiang, MD, and Paolo Silva, MD.
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Affiliation(s)
- Mark B. Horton
- Indian Health Service-Joslin Vision Network (IHS-JVN) Teleophthalmology Program, Phoenix Indian Medical Center, Phoenix, Arizona
| | - Christopher J. Brady
- Division of Ophthalmology, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Jerry Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Michael Abramoff
- Department of Ophthalmology and Visual Sciences, The University of Iowa, Iowa City, Iowa
- Department of Biomedical Engineering, and The University of Iowa, Iowa City, Iowa
- Department of Electrical and Computer Engineering, The University of Iowa, Iowa City, Iowa
- Department of Ophthalmology, Stephen A. Wynn Institute for Vision Research, The University of Iowa, Iowa City, Iowa
- Iowa City VA Health Care System, Iowa City, Iowa
- IDx, Coralville, Iowa
| | - Gail Barker
- Arizona Telemedicine Program, The University of Arizona, Phoenix, Arizona
| | - Michael F. Chiang
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, Oregon
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon
| | | | - Seema Garg
- Department of Ophthalmology, University of North Carolina, Chapel Hill, North Carolina
| | | | - Yao Liu
- Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Siddarth Rathi
- Department of Ophthalmology, NYU Langone Health, New York, New York
| | - Veeral Sheth
- University Retina and Macula Associates, University of Illinois at Chicago, Chicago, Illinois
| | - Paolo Silva
- Beetham Eye Institute, Joslin Diabetes Center, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Kristen Stebbins
- Vision Care Department, Hillrom, Skaneateles Falls, New York, New York
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Brady CJ, D'Amico S, Campbell JP. Telemedicine for Retinopathy of Prematurity. Telemed J E Health 2020; 26:556-564. [PMID: 32209016 DOI: 10.1089/tmj.2020.0010] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: Retinopathy of prematurity (ROP) is a disease of the retinal vasculature that remains a leading cause of childhood blindness worldwide despite improvements in the systemic care of premature newborns. Screening for ROP is effective and cost-effective, but in many areas, access to skilled examiners to conduct dilated examinations is poor. Remote screening with retinal photography is an alternative strategy that may allow for improved ROP care. Methods: The current literature was reviewed to find clinical trials and expert consensus documents on the state-of-the-art of telemedicine for ROP. Results: Several studies have confirmed the utility of telemedicine for ROP. In addition, several clinical studies have reported favorable long-term results. Many investigators have reinforced the need for detailed protocols on image acquisition and image interpretation. Conclusions: Telemedicine for ROP appears to be a viable alternative to live ophthalmoscopic examinations in many circumstances. Standardization and documentation afforded by telemedicine may provide additional benefits to providers and their patients. With continued improvements in image quality and affordability of imaging systems as well as improved automated image interpretation tools anticipated in the near future, telemedicine for ROP is expected to play an expanding role for a uniquely vulnerable patient population.
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Affiliation(s)
- Christopher J Brady
- Division of Ophthalmology, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Samantha D'Amico
- Division of Ophthalmology, Department of Surgery, University of Vermont Medical Center, Burlington, Vermont
| | - J Peter Campbell
- Casey Eye Institute, Oregon Health and Science University, Portland, Oregon
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13
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Scruggs BA, Chan RVP, Kalpathy-Cramer J, Chiang MF, Campbell JP. Artificial Intelligence in Retinopathy of Prematurity Diagnosis. Transl Vis Sci Technol 2020; 9:5. [PMID: 32704411 PMCID: PMC7343673 DOI: 10.1167/tvst.9.2.5] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/21/2019] [Indexed: 02/06/2023] Open
Abstract
Retinopathy of prematurity (ROP) is a leading cause of childhood blindness worldwide. The diagnosis of ROP is subclassified by zone, stage, and plus disease, with each area demonstrating significant intra- and interexpert subjectivity and disagreement. In addition to improved efficiencies for ROP screening, artificial intelligence may lead to automated, quantifiable, and objective diagnosis in ROP. This review focuses on the development of artificial intelligence for automated diagnosis of plus disease in ROP and highlights the clinical and technical challenges of both the development and implementation of artificial intelligence in the real world.
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Affiliation(s)
- Brittni A. Scruggs
- Casey Eye Institute, Department of Ophthalmology, Oregon Health & Science University, Portland, OR, USA
| | - R. V. Paul Chan
- Department of Ophthalmology, University of Illinois, Chicago, IL, USA
| | - Jayashree Kalpathy-Cramer
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Michael F. Chiang
- Casey Eye Institute, Department of Ophthalmology, Oregon Health & Science University, Portland, OR, USA
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - J. Peter Campbell
- Casey Eye Institute, Department of Ophthalmology, Oregon Health & Science University, Portland, OR, USA
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
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Scruggs BA, Chan RVP, Kalpathy-Cramer J, Chiang MF, Campbell JP. Artificial Intelligence in Retinopathy of Prematurity Diagnosis. Transl Vis Sci Technol 2020. [DOI: 10.1167/tvst.210.2.2010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Brittni A. Scruggs
- Casey Eye Institute, Department of Ophthalmology, Oregon Health & Science University, Portland, OR, USA
| | - R. V. Paul Chan
- Department of Ophthalmology, University of Illinois, Chicago, IL, USA
| | - Jayashree Kalpathy-Cramer
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Michael F. Chiang
- Casey Eye Institute, Department of Ophthalmology, Oregon Health & Science University, Portland, OR, USA
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - J. Peter Campbell
- Casey Eye Institute, Department of Ophthalmology, Oregon Health & Science University, Portland, OR, USA
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
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Kim SJ, Campbell JP, Kalpathy-Cramer J, Ostmo S, Jonas KE, Choi D, Chan RVP, Chiang MF. Accuracy and Reliability of Eye-Based vs Quadrant-Based Diagnosis of Plus Disease in Retinopathy of Prematurity. JAMA Ophthalmol 2019; 136:648-655. [PMID: 29710185 DOI: 10.1001/jamaophthalmol.2018.1195] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Presence of plus disease in retinopathy of prematurity is the most critical element in identifying treatment-requiring disease. However, there is significant variability in plus disease diagnosis. In particular, plus disease has been defined as 2 or more quadrants of vascular abnormality, and it is not clear whether it is more reliably and accurately diagnosed by eye-based assessment of overall retinal appearance or by quadrant-based assessment combining grades of 4 individual quadrants. Objective To compare eye-based vs quadrant-based diagnosis of plus disease and to provide insight for ophthalmologists about the diagnostic process. Design, Setting, and Participants In this multicenter cohort study, we developed a database of 197 wide-angle retinal images from 141 preterm infants from neonatal intensive care units at 9 academic institutions (enrolled from July 2011 to December 2016). Each image was assigned a reference standard diagnosis based on consensus image-based and clinical diagnosis. Data analysis was performed from February 2017 to September 2017. Interventions Six graders independently diagnosed each of the 4 quadrants (cropped images) of the 197 eyes (quadrant-based diagnosis) as well as the entire image (eye-based diagnosis). Images were displayed individually, in random order. Quadrant-based diagnosis of plus disease was made when 2 or more quadrants were diagnosed as indicating plus disease by combining grades of individual quadrants post hoc. Main Outcomes and Measures Intragrader and intergrader reliability (absolute agreement and κ statistic) and accuracy compared with the reference standard diagnosis. Results Of the 141 included preterm infants, 65 (46.1%) were female and 116 (82.3%) white, and the mean (SD) gestational age was 27.0 (2.6) weeks. There was variable agreement between eye-based and quadrant-based diagnosis among the 6 graders (Cohen κ range, 0.32-0.75). Four graders showed underdiagnosis of plus disease with quadrant-based diagnosis compared with eye-based diagnosis (by McNemar test). Intergrader agreement of quadrant-based diagnosis was lower than that of eye-based diagnosis (Fleiss κ, 0.75 [95% CI, 0.71-0.78] vs 0.55 [95% CI, 0.51-0.59]). The accuracy of eye-based diagnosis compared with the reference standard diagnosis was substantial to near-perfect, whereas that of quadrant-based plus disease diagnosis was only moderate to substantial for each grader. Conclusions and Relevance Graders had lower reliability and accuracy using quadrant-based diagnosis combining grades of individual quadrants than with eye-based diagnosis, suggesting that eye-based diagnosis has advantages over quadrant-based diagnosis. This has implications for more precise definitions of plus disease regarding the criterion of 2 or more quadrants, clinical care, computer-based image analysis, and education for all ophthalmologists who manage retinopathy of prematurity.
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Affiliation(s)
- Sang Jin Kim
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland.,Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - J Peter Campbell
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland
| | - Jayashree Kalpathy-Cramer
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown.,Massachusetts General Hospital and Brigham and Women's Hospital Center for Clinical Data Science, Boston
| | - Susan Ostmo
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland
| | - Karyn E Jonas
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago
| | - Dongseok Choi
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland.,Graduate School of Dentistry, Kyung Hee University, Seoul, Republic of Korea
| | - R V Paul Chan
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago.,Center for Global Health, College of Medicine, University of Illinois at Chicago
| | - Michael F Chiang
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland.,Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland
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16
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Silva JC, Zin A, Gilbert C. Retinopathy of prematurity prevention, screening and treatment programmes: Progress in South America. Semin Perinatol 2019; 43:348-351. [PMID: 31182224 DOI: 10.1053/j.semperi.2019.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Retinopathy of prematurity (ROP) is the main cause of blindness and visual impairment in Latin America and prevention, detection and treatment have been a priority in the Region in the last two decades. There is progress in the number of eligible babies screened and treated in at least half of the countries with strong regulations on ROP, but screening is not yet available in all provinces in most. More effort is needed to increase national protocols and legislation, strengthening of services and human resources to cover all national provinces; telemedicine might be a promising strategy.
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Affiliation(s)
- Juan Carlos Silva
- Pan-American Health Organization-PAHO, Calle 66 # 11 - 50, Bogotá, Colombia.
| | - Andrea Zin
- Clinical Research Unit, Fernandes Figueira Institute, Av Rui Barbosa 716, Flamengo, Rio de Janeiro 22250-020, Brazil
| | - Clare Gilbert
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
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17
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Al-Khaled T, Mikhail M, Jonas KE, Wu WC, Anzures R, Amphonphruet A, Chuluunbat T, Wu L, Chiang MF, Campbell JP, Chan RVP. Training of Residents and Fellows in Retinopathy of Prematurity Around the World: An International Web-Based Survey. J Pediatr Ophthalmol Strabismus 2019; 56:282-287. [PMID: 31545861 DOI: 10.3928/01913913-20190717-01] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 07/15/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE To characterize retinopathy of prematurity (ROP) training practices in international residency and fellowship programs. METHODS A publicly available online-based platform (http://www.SurveyMonkey.com) was used to develop a 28-question multiple-choice survey that targeted ROP screening and treatment methods. The authors solicited training programs in the Philippines, Thailand, and Taiwan. RESULTS Programs from three countries participated in the survey, and a total of 95 responses collected from residents, fellows, and attending ophthalmologists were analyzed. A descriptive analysis demonstrated that 45 participants (47%) reported 1% to 33% of ROP screenings were performed under direct supervision of attending ophthalmologists, and 35 (37%) reported the use of formal assessments. The majority of participants (Country A: 87%, Country B: 71%, and Country C: 75%) estimated 1% to 33% of their practice was spent screening for ROP. Notably, 44 participants (46%) reported performing zero laser photocoagulation treatments for ROP during training (Country A: 65%, Country B: 38%, and Country C: 38%). CONCLUSIONS International ophthalmology trainees perform a limited number of ROP examinations and laser interventions. ROP screenings are often unsupervised and lead to no formal evaluation by an attending ophthalmologist. Limited ROP training among ophthalmologists may lead to misdiagnosis and ultimately mismanagement of a patient. Loss of vision and exposure to unwarranted treatments are among the implications of such errors. The findings highlight the need to improve ROP training in international ophthalmology residency and fellowship programs. [J Pediatr Ophthalmol Strabismus. 2019;56(5):282-287.].
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18
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Wang W, Yan W, Müller A, Keel S, He M. Association of Socioeconomics With Prevalence of Visual Impairment and Blindness. JAMA Ophthalmol 2019; 135:1295-1302. [PMID: 29049446 DOI: 10.1001/jamaophthalmol.2017.3449] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Vision loss is the third most common impairment worldwide. Although cost-effective interventions are available for preventing or curing most causes of vision loss, availability of these interventions varies considerably between countries and districts. Knowledge of the association between vision loss and socioeconomic factors is informative for public health planning. Objectives To explore correlations of the prevalence of visual impairment with socioeconomic factors at country levels and to model and estimate a socioeconomic-adjusted disease burden based on these data. Design, Setting, and Participants In this cross-sectional study, the following data were collected from 190 countries and territories: the age-standardized prevalence of moderate to severe visual impairment (MSVI) and blindness from January 1 to December 31, 2010, across countries, human development index (HDI), gross domestic product (GDP) per capita, total health expenditure, total health expenditure as percentage of GDP (total health expenditure/GDP), public health expenditure as percentage of total health expenditure (public/total health expenditure), and out-of-pocket expenditure as percentage of total health expenditure (out-of-pocket/total health expenditure). Countries were divided into 4 levels (low, medium, high, and very high) by HDI. Data analysis was conducted from September 1, 2016, to July 1, 2017. Main Outcomes and Measures The correlations between prevalence data and socioeconomic indices were assessed. Results A strong negative association between prevalence rates of MSVI and blindness and socioeconomic level of development was observed. The mean (SD) age-standardized prevalence of MSVI decreased from 4.38% (1.32%) in low-HDI regions to 1.51% (1.00%) in very-high-HDI regions (P < .001). The national HDI level was attributable to 56.3% of global variation in prevalence rates of MSVI and 67.1% of global variation in prevalence rates of blindness. Higher prevalence rates were also associated with lower total health expenditure per capita, total health expenditure/GDP (β = −0.236 [95% CI, −0.315 to −0.157] for prevalence of MSVI; β = −0.071 [95% CI, −0.100 to −0.042] for prevalence of blindness), public/total health expenditure (β = −0.041 [95% CI, −0.052 to −0.031] for prevalence of MSVI; β = −0.014 [95% CI, −0.018 to −0.010] for prevalence of blindness), and higher percentage of out-of-pocket/total health expenditure (β = 0.044 [95% CI, 0.032-0.055] for prevalence of MSVI; β = 0.013 [95% CI, 0.009-0.017] for prevalence of blindness). Countries with increased burden of visual impairment and blindness can be easily identified by the results of the linear models. Socioeconomic factors could explain 69.4% of the global variations in prevalence of MSVI and 76.3% of the global variations in prevalence of blindness. Conclusions and Relevance Burden of visual impairment and socioeconomic indicators were closely associated and may help to identify countries requiring greater attention to these issues. The regression modeling described may provide an opportunity to estimate appropriate public health targets that are consistent with a country’s level of socioeconomic development.
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Affiliation(s)
- Wei Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - William Yan
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, University of Melbourne, East Melbourne, Victoria, Australia,Department of Ophthalmology, University of Melbourne, Parkville, Victoria, Australia
| | - Andreas Müller
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, University of Melbourne, East Melbourne, Victoria, Australia,World Health Organization Collaborating Center for Prevention of Blindness, Center for Eye Research Australia, University of Melbourne, East Melbourne, Victoria, Australia
| | - Stuart Keel
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, University of Melbourne, East Melbourne, Victoria, Australia,Department of Ophthalmology, University of Melbourne, Parkville, Victoria, Australia
| | - Mingguang He
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China,Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, University of Melbourne, East Melbourne, Victoria, Australia,Department of Ophthalmology, University of Melbourne, Parkville, Victoria, Australia,World Health Organization Collaborating Center for Prevention of Blindness, Center for Eye Research Australia, University of Melbourne, East Melbourne, Victoria, Australia
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Roohipoor R, Alvarez R, Brodowska K, Yaseri M, Kloek C, Riazi M, Nourinia R, Nikkhah H, Prajna NV, Krishnan C, Tuli S, Green L, Srikumaran D, Shah AS, Mantagos IS, Chiang M, Chan RVP, Loewenstein J. Evaluation of computer-based retinopathy of prematurity (ROP) education for ophthalmology residents: a randomized, controlled, multicenter study. J AAPOS 2019; 23:86.e1-86.e7. [PMID: 30885809 DOI: 10.1016/j.jaapos.2018.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 07/24/2018] [Accepted: 11/11/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate the effect of a computer-based training program-Massachusetts Eye & Ear ROP Trainer-on residents' knowledge of retinopathy of prematurity (ROP) management. METHODS In this prospective, randomized study, ophthalmology residents from nine different training programs consented to participate. Those who completed the study were randomly assigned to either the Trainer or the control group. The ROP Trainer was created using clinical cases encompassing the stages of ROP in digital pictures and videos. It includes sections on screening decisions, examination techniques, and diagnosis, and a reference section with the expert video clips and a searchable image library. Subjects in the control group were asked to study standard print material on ROP. A pre- and post-test, consisting of theoretical and practical (diagnosis) questions, and a post-intervention satisfaction test were administered. Accuracy of ROP diagnosis was assessed. RESULTS A total of 180 residents agreed to participate, of whom 60 completed the study. Residents in the Trainer group had statistically significant improvements (P = 0.003) in ROP knowledge and diagnostic ability (P = 0.005). Residents randomized to the Trainer group were more satisfied with the training materials than were those in the control group. There was no significant difference in improving knowledge by year of training, sex, or country. Considering all training levels, a statistically significant increase was observed in sensitivity for the diagnosis of preplus or worse, zone I or II, ROP stage, category, and aggressive posterior ROP in the Trainer group. CONCLUSIONS In this study, the Trainer was shown to significantly improve ROP knowledge and diagnostic skills of residents, regardless of sex, year, of training, or country.
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Affiliation(s)
- Ramak Roohipoor
- Massachusetts Eye and Ear, Harvard Medical School, Department of Ophthalmology, Boston, Massachusetts; Farabi Eye Hospital, Eye Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | - Mehdi Yaseri
- Biostatistics Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Carolyn Kloek
- Massachusetts Eye and Ear, Harvard Medical School, Department of Ophthalmology, Boston, Massachusetts
| | - Mohamad Riazi
- Farabi Eye Hospital, Eye Research Center, Tehran University of Medical Sciences, Tehran, Iran; Department of Ophthalmology, Gavin Herbert Eye Institute, University of California Irvine, Irvine, California
| | - Ramin Nourinia
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Homayoun Nikkhah
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | | | - Sonal Tuli
- Department of Ophthalmology, University of Florida, Gainesville, Florida
| | | | - Divya Srikumaran
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ankoor S Shah
- Boston Children's Hospital, Harvard Medical School Departments of Ophthalmology, Boston, Massachusetts
| | - Iason S Mantagos
- Boston Children's Hospital, Harvard Medical School Departments of Ophthalmology, Boston, Massachusetts
| | - Michael Chiang
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon; Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - R V Paul Chan
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, Illinois; Center for Global Health, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - John Loewenstein
- Massachusetts Eye and Ear, Harvard Medical School, Department of Ophthalmology, Boston, Massachusetts.
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20
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Valikodath N, Cole E, Chiang MF, Campbell JP, Chan RVP. Imaging in Retinopathy of Prematurity. Asia Pac J Ophthalmol (Phila) 2019; 8:178-186. [PMID: 31037876 PMCID: PMC7891847 DOI: 10.22608/apo.201963] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 04/16/2019] [Indexed: 01/29/2023] Open
Abstract
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.
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Affiliation(s)
- N Valikodath
- From the Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, United States; and Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, OR, United States
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21
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Yapa HM, Bärnighausen T. Implementation science in resource-poor countries and communities. Implement Sci 2018; 13:154. [PMID: 30587195 PMCID: PMC6307212 DOI: 10.1186/s13012-018-0847-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 12/18/2022] Open
Abstract
Background Implementation science in resource-poor countries and communities is arguably more important than implementation science in resource-rich settings, because resource poverty requires novel solutions to ensure that research results are translated into routine practice and benefit the largest possible number of people. Methods We reviewed the role of resources in the extant implementation science frameworks and literature. We analyzed opportunities for implementation science in resource-poor countries and communities, as well as threats to the realization of these opportunities. Results Many of the frameworks that provide theoretical guidance for implementation science view resources as contextual factors that are important to (i) predict the feasibility of implementation of research results in routine practice, (ii) explain implementation success and failure, (iii) adapt novel evidence-based practices to local constraints, and (iv) design the implementation process to account for local constraints. Implementation science for resource-poor settings shifts this view from “resources as context” to “resources as primary research object.” We find a growing body of implementation research aiming to discover and test novel approaches to generate resources for the delivery of evidence-based practice in routine care, including approaches to create higher-skilled health workers—through tele-education and telemedicine, freeing up higher-skilled health workers—through task-shifting and new technologies and models of care, and increasing laboratory capacity through new technologies and the availability of medicines through supply chain innovations. In contrast, only few studies have investigated approaches to change the behavior and utilization of healthcare resources in resource-poor settings. We identify three specific opportunities for implementation science in resource-poor settings. First, intervention and methods innovations thrive under constraints. Second, reverse innovation transferring novel approaches from resource-poor to research-rich settings will gain in importance. Third, policy makers in resource-poor countries tend to be open for close collaboration with scientists in implementation research projects aimed at informing national and local policy. Conclusions Implementation science in resource-poor countries and communities offers important opportunities for future discoveries and reverse innovation. To harness this potential, funders need to strongly support research projects in resource-poor settings, as well as the training of the next generation of implementation scientists working on new ways to create healthcare resources where they lack most and to ensure that those resources are utilized to deliver care that is based on the latest research results.
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Affiliation(s)
- H Manisha Yapa
- The Kirby Institute, University of New South Wales, Sydney, Australia.,Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | - Till Bärnighausen
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa. .,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA. .,Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, INF 130.3, 69120, Heidelberg, Germany.
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22
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Kakisaka Y, Jin K, Fujikawa M, Kitazawa Y, Nakasato N. Teleconference-based education of epileptic seizure semiology. Epilepsy Res 2018; 145:73-76. [PMID: 29913406 DOI: 10.1016/j.eplepsyres.2018.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/22/2018] [Accepted: 06/11/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND To evaluate whether a teleconference-based lecture provides similar understanding of seizure semiology to a face-to-face lecture for physicians. METHODS Subjects were 66 physicians consisting of adult and pediatric neurologists, neurosurgeons, psychiatrists, and general practitioners. All attended the 30-minute lecture to introduce various types of seizure semiology using video-clips by one of the authors (Yo.K.) and then joined the comprehensive case conference which discussed three cases in 1.5 h. Group A received the lecture and conference using a teleconference system (N = 43) and Group B attended in person (N = 23) for geographical reasons. After the conference, 32 subjects (23 in Group A and nine in Group B) scored their own post-lecture understanding of seizure semiology using the four-point Likert scale from 1 (not at all) to 4 (very well) as well as the estimated pre-lecture score. Data was analyzed to assess whether their understanding was improved after the lecture. RESULTS No significant difference was found in improvement of understanding after the lecture between Group A (43%) and Group B (22%; p = 0.42). Pre-lecture score of subjects with improved understanding was significantly lower (2.3 +/- 0.2) than those without improvement (3.7 +/- 0.1) (p < 0.05). SIGNIFICANCE Teleconference-based lectures can be a useful tool to educate seizure semiology for physicians, especially at the inexperienced level, by overcoming geographical limitations.
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Affiliation(s)
- Yosuke Kakisaka
- Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.
| | - Kazutaka Jin
- Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Mayu Fujikawa
- Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yu Kitazawa
- Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Nobukazu Nakasato
- Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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23
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Darwish D, Chee RI, Patel SN, Jonas K, Ostmo S, Campbell JP, Chiang MF, Chan RP. Anti-Vascular Endothelial Growth Factor and the Evolving Management Paradigm for Retinopathy of Prematurity. Asia Pac J Ophthalmol (Phila) 2018; 7:136-144. [PMID: 29808629 PMCID: PMC7880609 DOI: 10.22608/apo.201850] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
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.
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Affiliation(s)
- Dana Darwish
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, Illinois
| | - Ru-Ik Chee
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, Illinois
| | - Samir N. Patel
- Department of Ophthalmology, Wills Eye Hospital, Philadelphia, Pennsylvania
| | - Karyn Jonas
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, Illinois
| | - Susan Ostmo
- Department of Ophthalmology, Casey Eye Institute at Oregon Health & Science University, Portland, Oregon
| | - J. Peter Campbell
- Department of Ophthalmology, Casey Eye Institute at Oregon Health & Science University, Portland, Oregon
| | - Michael F. Chiang
- Department of Ophthalmology, Casey Eye Institute at Oregon Health & Science University, Portland, Oregon
| | - R.V. Paul Chan
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, Illinois
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24
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Cernichiaro-Espinosa LA, Tran KD, Berrocal AM. Imaging Modalities in Pediatric Vitreoretinal Disorders. CURRENT OPHTHALMOLOGY REPORTS 2018. [DOI: 10.1007/s40135-018-0159-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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25
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Chee RI, Chan RVP. Universal newborn eye screening: an effective strategy to improve ocular health? Eye (Lond) 2017; 32:50-52. [PMID: 28731056 DOI: 10.1038/eye.2017.133] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- R I Chee
- Department of Ophthalmology, Weill Cornell Medical College, New York City, NY, USA.,Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, USA
| | - R V P Chan
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, USA.,Center for Global Health, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
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