Smartphone guided wide-field imaging for retinopathy of prematurity in neonatal intensive care unit - a Smart ROP (SROP) initiative

Clinical Applications and Future Directions of Smartphone Fundus Imaging

The advent of smartphone fundus imaging technology has marked a significant evolution in the field of ophthalmology, offering a novel approach to the diagnosis and management of retinopathy. This review provides an overview of smartphone fundus imaging, including clinical applications, advantages, limitations, clinical applications, and future directions. The traditional fundus imaging techniques are limited by their cost, portability, and accessibility, particularly in resource-limited settings. Smartphone fundus imaging emerges as a cost-effective, portable, and accessible alternative. This technology facilitates the early detection and monitoring of various retinal pathologies, including diabetic retinopathy, age-related macular degeneration, and retinal vascular disorders, thereby democratizing access to essential diagnostic services. Despite its advantages, smartphone fundus imaging faces challenges in image quality, standardization, regulatory considerations, and medicolegal issues. By addressing these limitations, this review highlights the areas for future research and development to fully harness the potential of smartphone fundus imaging in enhancing patient care and visual outcomes. The integration of this technology into telemedicine is also discussed, underscoring its role in facilitating remote patient care and collaborative care among physicians. Through this review, we aim to contribute to the understanding and advancement of smartphone fundus imaging as a valuable tool in ophthalmic practice, paving the way for its broader adoption and integration into medical diagnostics.

ROP: 80 Years after Its Detection - Where Do We Stand and How Long Will We Continue to Laser?

BACKGROUND

Retinopathy of prematurity (ROP), a potentially blinding disease, is increasing worldwide because of the increased survival of extremely preterm and preterm infants born where oxygen monitoring and ROP screening programs are insufficient. Repeated retinal examinations are stressful for infants, and laser photocoagulation treatment for sight-threatening ROP is destructive. The use of anti-VEGF agents instead of lasers is widespread but requires a long-term follow-up because of late recurrence of the disease. In addition, the optimal anti-VEGF agent dosage and long-term systemic effects require further study.

SUMMARY

Interventions preventing ROP would be far preferable, and systemic interventions might promote better development of the brain and other organs. Interventions such as improved oxygen control, provision of fresh maternal milk, supplementation with arachidonic acid and docosahexaenoic acid, and fetal hemoglobin preservation by reducing blood sample volumes may help prevent ROP and reduce the need for treatment. Free readily available online tools to predict severe ROP may reduce unnecessary eye examinations and select, for screening, those at a high risk of needing treatment.

KEY MESSAGES

Treatment warranting ROP is a sign of impaired neurovascular development in the central nervous system. Preventative measures to improve the outcomes are available. Screening can be refined using tools that can predict severe ROP. Laser treatment and anti-VEGF agents are valuable treatment modalities that may complement each other in recurrent ROP.

Ophthalmic imaging in abusive head trauma

BACKGROUND

Ophthalmic imaging plays an increasingly important role the evaluation of abusive head trauma, however these imaging modalities may be unfamiliar to non-ophthalmologists.

OBJECTIVE

To provide pediatricians and child abuse pediatric professionals with background on ophthalmic imaging techniques in the context of suspected abuse, as well as information on commercial options and costs for those interested in augmenting their ophthalmic imaging capabilities.

METHODS

We performed a review of the ophthalmic imaging literature for fundus photography, ocular coherence tomography, fluorescein angiography, ocular ultrasound, computed tomography, magnetic resonance imaging and postmortem imaging. We also contacted individual vendors for equipment pricing information.

RESULTS

For each ophthalmic imaging modality, we demonstrate its role in the evaluation of abusive head trauma including indications, potential findings, sensitivity and specificity of findings for abuse, and commercial options.

CONCLUSIONS

Ophthalmic imaging is an important supportive component of the evaluation for abusive head trauma. When used in conjunction with clinical examination, ophthalmic imaging can improve diagnostic accuracy, support documentation, and possibly improve communication in medicolegal contexts.

Global Disparities in Retinopathy of Prematurity: A Literature Review

PURPOSE

To provide an overview of the impact of retinopathy of prematurity (ROP), and the challenges in the screening, diagnosis, and treatment of ROP worldwide.

METHODS

A comprehensive search was conducted using the PubMed database from January 2011 to October 2021 using the following keywords: retinopathy of prematurity, laser, and anti-vascular endothelial growth factor (VEGF). Data on patient characteristics, ROP treatment type, and recurrence rates were collected. The countries included in these studies were classified based on 2021-2022 World Bank definitions of high, upper-middle, lower-middle, and low-income groups. Moreover, a search for surgical outcomes for ROP and screening algorithms and artificial intelligence for ROP was conducted.

RESULTS

Thirty-nine studies met the inclusion criteria. ROP treatment and outcomes showed a trend towards intravitreal anti-VEGF injections as the initial treatment for ROP globally and the treatment of recurrent ROP in high-income countries. However, laser remains the treatment of choice for ROP recurrence in middle-income countries. Surgical outcomes for ROP stage 4A, 4B and 5 are similar worldwide. The incidence of ROP and ROP-related visual impairment continue to increase globally. Although telemedicine and artificial intelligence offer potential solutions to ROP screening in resource-limited areas, the current models require further optimization to reflect the global diversity of ROP patients.

CONCLUSION

ROP screening and treatment paradigms vary widely based on country income group due to disparities in resources, limited access to care, and lack of universal guidelines.

Pediatric Glaucoma-From Screening, Early Detection to Management

Pediatric glaucoma (PG) covers a rare and heterogeneous group of diseases with variable causes and presentations. Delayed diagnosis of PG could lead to blindness, bringing emotional and psychological burdens to patients' caregivers. Recent genetic studies identified novel causative genes, which may provide new insight into the etiology of PG. More effective screening strategies could be beneficial for timely diagnosis and treatment. New findings on clinical characteristics and the latest examination instruments have provided additional evidence for diagnosing PG. In addition to IOP-lowering therapy, managing concomitant amblyopia and other associated ocular pathologies is essential to achieve a better visual outcome. Surgical treatment is usually required although medication is often used before surgery. These include angle surgeries, filtering surgeries, minimally invasive glaucoma surgeries, cyclophotocoagulation, and deep sclerectomy. Several advanced surgical therapies have been developed to increase success rates and decrease postoperative complications. Here, we review the classification and diagnosis, etiology, screening, clinical characteristics, examinations, and management of PG.

Advances in retinopathy of prematurity imaging

Retinopathy of prematurity (ROP) remains the leading cause of childhood blindness worldwide. Recent advances in ROP imaging have significantly improved our understanding of the pathogenesis and pathophysiological course of ROP including the acute phase, regression, reactivation, and late complications, known as adult ROP. Recent progress includes various contact and noncontact wide-field imaging devices for fundus imaging, smartphone-based fundus photography, wide-field fluorescein angiography, handheld optical coherence tomography (OCT) devices for wide-field en face OCT images, and OCT angiography. Images taken by those devices were incorporated in the recently updated guidelines of ROP, the International Classification of Retinopathy of Prematurity, Third Edition (ICROP3). ROP imaging has also allowed the real-world adoption of telemedicine- and artificial intelligence (AI)-based screening. Recent study demonstrated proof of concept that AI has a high diagnostic performance for the detection of ROP in a real-world screening. Here, we summarize the recent advances in ROP imaging and their application for screening, diagnosis, and management of ROP.

Retinopathy of prematurity screening: A narrative review of current programs, teleophthalmology, and diagnostic support systems

PURPOSE

Neonatal care in middle-income countries has improved over the last decade, leading to a "third epidemic" of retinopathy of prematurity (ROP). Without concomitant improvements in ROP screening infrastructure, reduction of ROP-associated visual loss remains a challenge worldwide. The emergence of teleophthalmology screening programs and artificial intelligence (AI) technologies represents promising methods to address this growing unmet demand in ROP screening. An improved understanding of current ROP screening programs may inform the adoption of these novel technologies in ROP care.

METHODS

A critical narrative review of the literature was carried out. Publications that were representative of established or emerging ROP screening programs in high-, middle-, and low-income countries were selected for review. Screening programs were reviewed for inclusion criteria, screening frequency and duration, modality, and published sensitivity and specificity.

RESULTS

Screening inclusion criteria, including age and birth weight cutoffs, showed significant heterogeneity globally. Countries of similar income tend to have similar criteria. Three primary screening modalities including binocular indirect ophthalmoscopy (BIO), wide-field digital retinal imaging (WFDRI), and teleophthalmology were identified and reviewed. BIO has documented limitations in reduced interoperator agreement, scalability, and geographical access barriers, which are mitigated in part by WFDRI. Teleophthalmology screening may address limitations in ROP screening workforce distribution and training. Opportunities for AI technologies were identified in the context of these limitations, including interoperator reliability and possibilities for point-of-care diagnosis.

CONCLUSION

Limitations in the current ROP screening include scalability, geographical access, and high screening burden with low treatment yield. These may be addressable through increased adoption of teleophthalmology and AI technologies. As the global incidence of ROP continues to increase, implementation of these novel modalities requires greater consideration.

Trends in Neonatal Ophthalmic Screening Methods

Neonatal ophthalmic screening should lead to early diagnosis of ocular abnormalities to reduce long-term visual impairment in selected diseases. If a treatable pathology is diagnosed within a few days after the birth, adequate therapy may be indicated to facilitate the best possible conditions for further development of visual functions. Traditional neonatal ophthalmic screening uses the red reflex test (RRT). It tests the transmittance of the light through optical media towards the retina and the general disposition of the central part of the retina. However, RRT has weaknesses, especially in posterior segment affections. Wide-field digital imaging techniques have shown promising results in detecting anterior and posterior segment pathologies. Particular attention should be paid to telemedicine and artificial intelligence. These methods can improve the specificity and sensitivity of neonatal eye screening. Both are already highly advanced in diagnosing and monitoring of retinopathy of prematurity.

Assessment of Neonatal Intensive Care Unit Sound Exposure Using a Smartphone Application

OBJECTIVE

This study aimed to determine the impact of neonatal intensive care unit (NICU) design and environmental factors on neonatal sound exposures. We hypothesized that monitoring with a smartphone application would identify modifiable environmental factors in different NICU design formats.

STUDY DESIGN

Minimum, maximum, and peak decibel (dB) recordings were obtained using the Decibel X phone app, and the presence of noise sources was recorded in each patient space at three NICUs over a 6-month period (December 2017 to May 2018). Data were analyzed by Student's t-test and ANOVA with Bonferroni correction. Data were collected at the University of Maryland Medical Center single family room (SFR) level IV and St. Agnes Healthcare hybrid pod/single family room level III NICU, Baltimore, MD and at Prince George's Hospital Center open-pod design Level III NICU, Cheverly, MD.

RESULTS

All recordings in the three NICUs exceeded the American Academy of Pediatrics (AAP) recommended <45 dB level. The maximum and peak dB were highest in the open pod format level III NICU. Conversations/music alone and combined with other factors contributed to increased sound exposure. Sound exposure varied by day/night shift, with higher day exposures at the level III hybrid and open pod NICUs and higher night exposures at the level IV SFR NICU.

CONCLUSION

Although sound exposure varied by NICU design, all recordings exceeded the AAP recommendation due, in part, to potentially modifiable environmental factors. A smartphone application may be useful for auditing NICU sound exposure in quality improvements efforts to minimize environmental sound exposure.

KEY POINTS

· Smartphone application was used to assess NICU sound exposure.. · All cases of sound exposure exceed recommendations.. · A smartphone application was used to identify modifiable factors..

[Smartphone-based fundus imaging: applications and adapters]

BACKGROUND

Smartphone-based fundus imaging (SBFI) is an innovative and low-cost alternative for color fundus photography. Since the first reports on this topic more than 10 years ago a large number of studies on different adapters and clinical applications have been published.

OBJECTIVE

The aim of this review article is to provide an overview on the development of SBFI and adapters and clinical applications published so far.

MATERIAL AND METHODS

A literature search was performed using the MEDLINE and Science Citation Index Expanded databases without time restrictions.

RESULTS

Overall, 11 adapters were included and compared in terms of exemplary image material, field of view, acquisition costs, weight, software, application range, smartphone compatibility and certification. Previously published SBFI applications are screening for diabetic retinopathy, glaucoma and retinopathy of prematurity as well as the application in emergency medicine, pediatrics and medical education/teaching. Image quality of conventional retinal cameras is in general superior to SBFI. First approaches on automatic detection of diabetic retinopathy through SBFI are promising and the use of automatic image processing algorithms enables the generation of wide-field image montages.

CONCLUSION

SBFI is a versatile, mobile, low-cost alternative to conventional equipment for color fundus photography. In addition, it facilitates the delegation of ophthalmological examinations to assistance personnel in telemedical settings, could simplify retinal documentation, improve teaching, and improve ophthalmological care, particularly in countries with low and middle incomes.

Development of 3D Printed Smartphone-Based Multi-Purpose Fundus Camera (MultiScope) for Retinopathy of Prematurity

Retinopathy of Prematurity (ROP) is a prominent source of low vision and blindness in preterm babies. Wide-Field Digital Retinal Imaging (WFDRI) systems acquire accurate digital images which are very useful for identification, documentation and transmitting the various retinal diseases. This telemedicine technique has potential for an alternative tool for Binocular Indirect Ophthalmoscopy (BIO) in ROP screening, but it is very expensive and accessibility for poor communities is limited. Capabilities of good illumination, high resolution camera and processing speed of the modern smartphones are being identified as a substitute. Potential applications of 3D printing is that it provides a severe impact in medical field, especially in ophthalmology sector. Competences of 3D printing are very useful for the development of retinal camera from any smartphone with the help of 3D printable devices. The primary aim of this study is to develop a handheld 3D printed smartphone-based multi-purpose fundus camera for ROP screening. The secondary aim is to check the feasibility and compare the digital fundus images obtained from the developed fundus camera against the commercial RetCam imaging. The proposed cost effective and remote reading device is an alternative to WFDRI for ROP screening and can improve the potential of ROP care for low resource communities.

Assessment and management of retinopathy of prematurity in the era of anti-vascular endothelial growth factor (VEGF)

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.

Validation of smartphone-based screening for retinopathy of prematurity in a low-resource setting

PURPOSE

To study the validity of smartphone-based screening to detect moderate-to-severe levels of retinopathy of prematurity (ROP) in a low-resource setting.

METHODS

In this observational validation study, all new patients at a single center who met screening criteria for ROP (birth weight of ≤1700 g and gestational age of ≤35 weeks) were examined by a pediatric ophthalmologist using indirect ophthalmoscopy. At the first ROP examination, a trained photographer captured fundus images using a smartphone fitted on an adapter, the Paxos Scope. The photographs were graded by two retina specialists masked to results of the gold standard examination.

RESULTS

A total of 100 children (200 eyes) were included. ROP was detected in 27.4% by indirect ophthalmoscopy, 16% of whom had moderate-to-severe ROP, defined as stage 3 in zone I or II, stage 2 in zone I or II, or pre-plus or plus disease. Sensitivity of fundus images reviewed by grader 1 against the gold standard in detecting moderate-to-severe ROP was 87.5%, and specificity was 82.1%. The positive predictive value was 48.3 %; the negative predictive value, 97.2%. The sensitivity of fundus images reviewed by grader 2 was 87.5%; the specificity, 81.6%. Positive predictive value was 47.5%; negative predictive value, 97.2%. The measured κ coefficient for intergrader agreement was 0.94.

CONCLUSIONS

Our study is one of the few studies on smartphone-based telescreening for ROP. The results suggest that smartphones may have potential as a screening tool for ROP in low-resource settings.

Teleophthalmology and Artificial Intelligence As Game Changers in Ophthalmic Care After the COVID-19 Pandemic

The current COVID-19 pandemic has boosted a sudden demand for telemedicine due to quarantine and travel restrictions. The exponential increase in the use of telemedicine is expected to affect ophthalmology drastically. The aim of this review is to discuss the utility, effectiveness and challenges of teleophthalmological new tools for eyecare delivery as well as its implementation and possible facilitation with artificial intelligence. We used the terms: “teleophthalmology,” “telemedicine and COVID-19,” “retinal diseases and telemedicine,” “virtual ophthalmology,” “cost effectiveness of teleophthalmology,” “pediatric teleophthalmology,” “Artificial intelligence and ophthalmology,” “Glaucoma and teleophthalmology” and “teleophthalmology limitations” in the database of PubMed and selected the articles being published in the course of 2015-2020. After the initial search, 321 articles returned as relevant. A meticulous screening followed and eventually 103 published manuscripts were included and used as our references. Emerging in the market, teleophthalmology is showing great potential for the future of ophthalmological care, benefiting both patients and ophthalmologists in times of pandemics. The spectrum of eye diseases that could benefit from teleophthalmology is wide, including mostly retinal diseases such as diabetic retinopathy, retinopathy of prematurity, age-related macular degeneration but also glaucoma and anterior segment conditions. Simultaneously, artificial intelligence provides ways of implementing teleophthalmology easier and with better outcomes, contributing as significant changing factors for ophthalmology practice after the COVID-19 pandemic.

Analysis of the parental satisfaction for retinopathy of prematurity screening using binocular indirect ophthalmoscopy versus wide field retinal imaging

Purpose:

Analysis of the parental satisfaction for retinopathy of prematurity screening using binocular indirect ophthalmoscopy versus wide field retinal imaging.

Methods:

This was an observational, questionnaire survey-based study. The study cohort comprised of parents/legal guardians of consecutive Asian Indian premature infants enrolled for retinopathy of prematurity screening (for infants less than 2000 gms and/or 34-weeks gestational age) using binocular indirect ophthalmoscopy (BIO) with scleral depression and b) wide field retinal imaging using the 3Nethra Neo Camera (Forus Health, India). We evaluated the retina for the presence or absence of stages of ROP and plus disease. The survey analysis used closed-ended (multiple-choice) and open-ended questions for assessing 1) parents’ experience/preference among the two screening modalities namely, BIO and wide field imaging used in the study, 2) knowledge prior to ROP screening, 3) knowledge gained post ROP screening, in the outpatient ophthalmologic care unit in our hospital.

Results:

Parents/legal guardians of 90 infants were included in the study. Among the 90 parents who filled in the questionnaire, 62.3% were referred by their pediatrician, 23.3% came for self check-up and 14.4% incidentally came to the hospital for complaints like ocular discharge and were screened. 93.3% parents were satisfied with either ROP screening modality in our study, with 54.4% stated a preference for retinal imaging. In the study 20% of the parents felt that retinal imaging was painful for the infant and 31.1% felt that BIO was painful for the infant.

Conclusion:

Wide field imaging is increasingly becoming an effective tool and screening tool in ROP screening and helps in better understanding of the disease amongst parents.

A brief history of telemedicine and the evolution of teleneonatology

Over a century of innovations in technology and medical care have led to the current day capabilities in telemedicine. In this chapter, we discuss the evolution of telemedicine over the last century and highlight various applications in neonatal care. We hope this chapter demonstrates the exponential adoption of telemedicine, particularly in neonatology, and the breadth and depth of the technology being used.

Clinical Role of Smartphone Fundus Imaging in Diabetic Retinopathy and Other Neuro-retinal Diseases

Purpose: In today's life, many electronic gadgets have the potential to become invaluable health care devices in future. The gadgets in this category include smartphones, smartwatches, and others. Till now, smartphone role has been highlighted on many occasions in different areas, and they continue to possess immense role in clinical documentation, clinical consultation, and digitalization of ocular care. In last one decade, many treatable conditions including diabetic retinopathy, glaucoma, and other pediatric retinal diseases are being imaged using smartphones.Methods: To comprehend this cumulative knowledge, a detailed medical literature search was conducted on PubMed/Medline, Scopus, and Web of Science till February 2021.Results: The included literature revealed a definitive progress in posterior segment imaging. From simple torch light with smartphone examination to present day compact handy devices with artificial intelligence integrated software's have changed the very perspectives of ocular imaging in ophthalmology. The consistently reproducible results, constantly improving imaging techniques, and most importantly their affordable costs have renegotiated their role as effective screening devices in ophthalmology. Moreover, the obtained field of view, ocular safety, and their key utility in non-ophthalmic specialties are also growing.Conclusions: To conclude, smartphone imaging can now be considered as a quick, cost-effective, and digitalized tool for posterior segment screenings, however, their definite role in routine ophthalmic clinics is yet to be established.

Deep learning-assisted (automatic) diagnosis of glaucoma using a smartphone

BACKGROUND/AIMS

To validate a deep learning algorithm to diagnose glaucoma from fundus photography obtained with a smartphone.

METHODS

A training dataset consisting of 1364 colour fundus photographs with glaucomatous indications and 1768 colour fundus photographs without glaucomatous features was obtained using an ordinary fundus camera. The testing dataset consisted of 73 eyes of 73 patients with glaucoma and 89 eyes of 89 normative subjects. In the testing dataset, fundus photographs were acquired using an ordinary fundus camera and a smartphone. A deep learning algorithm was developed to diagnose glaucoma using a training dataset. The trained neural network was evaluated by prediction result of the diagnostic of glaucoma or normal over the test datasets, using images from both an ordinary fundus camera and a smartphone. Diagnostic accuracy was assessed using the area under the receiver operating characteristic curve (AROC).

RESULTS

The AROC with a fundus camera was 98.9% and 84.2% with a smartphone. When validated only in eyes with advanced glaucoma (mean deviation value < -12 dB, N=26), the AROC with a fundus camera was 99.3% and 90.0% with a smartphone. There were significant differences between these AROC values using different cameras.

CONCLUSION

The usefulness of a deep learning algorithm to automatically screen for glaucoma from smartphone-based fundus photographs was validated. The algorithm had a considerable high diagnostic ability, particularly in eyes with advanced glaucoma.

Assistive Framework for Automatic Detection of All the Zones in Retinopathy of Prematurity Using Deep Learning

Retinopathy of prematurity (ROP) is a potentially blinding disorder seen in low birth weight preterm infants. In India, the burden of ROP is high, with nearly 200,000 premature infants at risk. Early detection through screening and treatment can prevent this blindness. The automatic screening systems developed so far can detect "severe ROP" or "plus disease," but this information does not help schedule follow-up. Identifying vascularized retinal zones and detecting the ROP stage is essential for follow-up or discharge from screening. There is no automatic system to assist these crucial decisions to the best of the authors' knowledge. The low contrast of images, incompletely developed vessels, macular structure, and lack of public data sets are a few challenges in creating such a system. In this paper, a novel method using an ensemble of "U-Network" and "Circle Hough Transform" is developed to detect zones I, II, and III from retinal images in which macula is not developed. The model developed is generic and trained on mixed images of different sizes. It detects zones in images of variable sizes captured by two different imaging systems with an accuracy of 98%. All images of the test set (including the low-quality images) are considered. The time taken for training was only 14 min, and a single image was tested in 30 ms. The present study can help medical experts interpret retinal vascular status correctly and reduce subjective variation in diagnosis.

Nigerian neonatologists perception and experience with retinopathy of prematurity

BACKGROUND

Retinopathy of Prematurity (ROP) is an avoidable condition that affects premature infants exposed to oxygen stresses at or soon after birth. In low- and middle-income countries, like Nigeria, neonatal mortality rates are high and very few infants live to develop ROP. With recent better care, ROP is now being diagnosed.

OBJECTIVE

This study aimed to characterize what Nigerian neonatologists understand about ROP.

METHODS

At a joint meeting of Nigerian pediatric ophthalmologists and neonatologists in Kebbi State held 26-29 July 2018, questionnaires collected attendees' perspective and experience with ROP including causes, risk factors and experiences.

RESULTS

Fifty-one neonatologists out of 71 returned a completed questionnaire (response rate: 71.8%). The male:female ratio was 1:1.8, and approximately 40% were aged 41-50 years (n=20, 39.22%). Only 3 (6.39%) had experience managing infants below 500g that survived. A majority managed babies with a mean weight of 913g ± 300.37 and age of 27.87 weeks ±2.37. Most had no access to oxygen monitors (n=39,78%). Most had 10 babies to one monitor and used average settings of 90-95%. One third had seen a case of ROP (n=15,29.41%). Only 5.88% (n=3) were unaware of uncontrolled oxygen use as a risk factor. Only 4 (8.89%) had a functional screening team. None were aware of local screening guidelines.

CONCLUSIONS

Regular educational programs, collaborative clinical presentations and webinars about ROP targeted at the neonatologists and parents, including establishment of screening programs across country will likely help reduce the burden of ROP blindness in Nigeria.

Imaging the pediatric retina: An overview

Recent decade has seen a shift in the causes of childhood blinding diseases from anterior segment to retinal disease in both developed and developing countries. The common retinal disorders are retinopathy of prematurity and vitreoretinal infections in neonates, congenital anomalies in infants, and vascular retinopathies including type 1 diabetes, tumors, and inherited retinal diseases in children (up to 12 years). Retinal imaging helps in diagnosis, management, follow up and prognostication in all these disorders. These imaging modalities include fundus photography, fluorescein angiography, ultrasonography, retinal vascular and structural studies, and electrodiagnosis. Over the decades there has been tremendous advances both in design (compact, multifunctional, tele-consult capable) and technology (wide- and ultra-wide field and noninvasive retinal angiography). These new advances have application in most of the pediatric retinal diseases though at most times the designs of new devices have remained confined to use in adults. Poor patient cooperation and insufficient attention span in children demand careful crafting of the devices. The newer attempts of hand-held retinal diagnostic devices are welcome additions in this direction. While much has been done, there is still much to do in the coming years. One of the compelling and immediate needs is the pediatric version of optical coherence tomography angiography. These needs and demands would increase many folds in future. A sound policy could be the simultaneous development of adult and pediatric version of all ophthalmic diagnostic devices, coupled with capacity building of trained medical personnel.

Teaching Smartphone Funduscopy with 20 Diopter Lens in Undergraduate Medical Education

Purpose

To assess attitudes of pre-clinical undergraduate medical students toward learning smartphone funduscopy (SF) and its appropriateness as a teaching tool.

Patients and Methods

Second year medical students received instruction on direct ophthalmoscopy (DO) and SF; they were then paired with a peer and randomly assigned to perform DO or SF first. The SF technique involved freehand alignment of the axes of the smartphone camera with a condenser lens. Both techniques were done through a maximally dilated pupil. A questionnaire was completed to acquire data on baseline experience, performance of both examination techniques, attitudes, and appropriateness. Statistical significance testing and Bland-Altman analysis were used to determine differences between DO and SF, and a multivariable mixed regression model was fitted to identify any predictors for positive attitudes toward DO or SF.

Results

One hundred thirty-seven (137) individuals completed the study. A similar proportion of students could identify the optic nerve, macula, and vessels using DO and SF. However, self-reported quality scores were higher for DO for the optic nerve (p = 0.006) and macula (p = 0.08). The mean (standard deviation) attempts to identify these major structures were 2.7 (SD 2.3) for DO and 4.5 (SD 2.9) for SF (p < 0.001). Attitudes of students were consistently more positive toward DO across the five questions assessed. A small subset of students had equally positive attitudes toward DO and SF. Improved quality scores were predictive of positive attitudes for both DO and SF. Ultimately, 24% of students preferred SF over DO.

Conclusion

Among inexperienced examiners of the fundus through a dilated pupil, SF is a non-inferior technique to DO in identifying structures. Despite overall favorable attitudes towards the more familiar DO, those students who quickly learned the SF technique had similar satisfaction scores. Teaching SF should be considered in undergraduate medical education.

Digital technology, tele-medicine and artificial intelligence in ophthalmology: A global perspective

The simultaneous maturation of multiple digital and telecommunications technologies in 2020 has created an unprecedented opportunity for ophthalmology to adapt to new models of care using tele-health supported by digital innovations. These digital innovations include artificial intelligence (AI), 5th generation (5G) telecommunication networks and the Internet of Things (IoT), creating an inter-dependent ecosystem offering opportunities to develop new models of eye care addressing the challenges of COVID-19 and beyond. Ophthalmology has thrived in some of these areas partly due to its many image-based investigations. Tele-health and AI provide synchronous solutions to challenges facing ophthalmologists and healthcare providers worldwide. This article reviews how countries across the world have utilised these digital innovations to tackle diabetic retinopathy, retinopathy of prematurity, age-related macular degeneration, glaucoma, refractive error correction, cataract and other anterior segment disorders. The review summarises the digital strategies that countries are developing and discusses technologies that may increasingly enter the clinical workflow and processes of ophthalmologists. Furthermore as countries around the world have initiated a series of escalating containment and mitigation measures during the COVID-19 pandemic, the delivery of eye care services globally has been significantly impacted. As ophthalmic services adapt and form a "new normal", the rapid adoption of some of telehealth and digital innovation during the pandemic is also discussed. Finally, challenges for validation and clinical implementation are considered, as well as recommendations on future directions.

Telemedicine in neonatal medicine and resuscitation

PURPOSE OF REVIEW

Telehealth in neonatology is a rapidly expanding modality for providing care to neonatal patient populations. In this review, we describe the most recent published innovations in neonatal telehealth, spanning the neonatal ICU (NICU), community/rural hospitals and the patient's home.

RECENT FINDINGS

Telemedicine for neonatal subspecialty care has continued to expand, from well established uses in retinopathy of prematurity screening and tele-echocardiography, to applications in genetics and neurology. Within the NICU itself, neonatologist-led remote rounding has been shown to be a feasible method of increasing access to expert care for neonates in rural hospitals. Telehealth has improved parental and caregiver education, eased the NICU-to-home transition experience and expanded access to lactation services for rural mothers. Telemedicine-assisted neonatal resuscitation has improved the quality of resuscitation and reduced unnecessary neonatal transports to higher levels of care. Finally, the global COVID-19 pandemic has accelerated the expansion of neonatal telehealth.

SUMMARY

Telehealth provides increased access to expert neonatal care and improves patient outcomes, while reducing the cost of care for neonates in diverse settings. Continued high-quality investigation of the impacts of telehealth on patient outcomes and healthcare systems is critical to the continued development of neonatal telemedicine best practices.

Clinically useful smartphone ophthalmic imaging techniques

Imaging devices in ophthalmology are numerous, and most of them are sophisticated and specialized for specific regions of the eye. In addition, these are fixed and involve close interaction of the patient and the examiner; therefore, simple, portable and tele facility-imbibed imaging tools can be considered optimal alternatives to routine exercises. In the last 10 years, utility of smartphones in ophthalmology is being continuously explored to unearth their potential benefits. In this direction, a smartphone device with/without simple attachments has been noted to aid in detailed, high-quality imaging of the ocular adnexa, cornea, angle, iris, lens, optic disc, and the retina including its periphery. In addition, such utility has also been extended in strabismology workup and intraocular pressure measurements. Hence, using these clinician friendly tools and techniques or by devising newer and more comprehensive tool kits, ophthalmic care can be well-managed with apt use of technology. Also, the smartphone companies are encouraged to collaborate with the medical experts to endeavor more, and help and serve the people better.

Retinal imaging in infants

Digital retinal imaging is at the core of a revolution that is continually improving the screening, diagnosis, documentation, monitoring, and treatment of infant retinal diseases. Historically, imaging the retina of infants had been limited and difficult to obtain. Recent advances in photographic instrumentation have significantly improved the ability to obtain high quality multimodal images of the infant retina. These include color fundus photography with different camera angles, ultrasonography, fundus fluorescein angiography, optical coherence tomography, and optical coherence tomography angiography. We provide a summary of the current literature on retinal imaging in infants and highlight areas where further research is required.

Smartphone-Based Fundus Imaging-Where Are We Now?

With the advent of smartphone-based fundus imaging (SBFI), a low-cost alternative to conventional digital fundus photography has become available. SBFI allows for a mobile fundus examination, is applicable both with and without pupil dilation, comes with built-in connectivity and post-processing capabilities, and is relatively easy to master. Furthermore, it is delegable to paramedical staff/technicians and, hence, suitable for telemedicine. Against this background a variety of SBFI applications have become available including screening for diabetic retinopathy, glaucoma, and retinopathy of prematurity and its applications in emergency medicine and pediatrics. In addition, SBFI is convenient for teaching purposes and might serve as a surrogate for direct ophthalmoscopy. First wide-field montage techniques are available and the combination of SBFI with machine learning algorithms for image analyses is promising. In conclusion, SBFI has the potential to make fundus examinations and screenings for patients particularly in low- and middle-income settings more accessible and, therefore, aid tackling the burden of diabetic retinopathy, glaucoma, and retinopathy of prematurity screening. However, image quality for SBFI varies substantially and a reference standard for grading appears prudent. In addition, there is a strong need for comparison of different SBFI approaches in terms of applicability to disease screening and cost-effectiveness.

Diagnostic Images of the Ocular Fundus Using a Low-Cost Portable Endoscope in Premature Patients at Risk of Developing Retinopathy of Prematurity

The purpose of this article is to describe how fundus images are obtained using a low-cost device: the “Visual Ear Wax Cleaner Tool” portable endoscope (Soonhua Inc., China) connected to a smartphone, after installation of free applications (“Inskam” and “CameraFI”) using the smartphone screen as a monitor and after medication mydriasis, local anesthesia, and blepharostat placement. With this endoscope, video recording and fundus imaging are easily performed, for the case of patients at the risk of developing retinopathy of prematurity (ROP), facilitating timely screening in order to start treatment in patients who require it. This fundus imaging technique shares certain similarities with the RetCam® (Clarity, Pleasaton California) system, which performs real-time fundus imaging providing the ability to record and document findings and capture images from the video footage, with high quality and definition, although with a smaller angle of vision. The capture of images using a smartphone allows storing and sharing the images. These are devices which are generally accessible and portable and which use simplified energy sources, requiring very simple training. The low-cost, easy-to-learn technique and quick sharing of images through communication networks make this a tool to be considered for the practice of telemedicine.

Non-contact smartphone-based fundus imaging compared to conventional fundus imaging: a low-cost alternative for retinopathy of prematurity screening and documentation

Retinopathy of prematurity (ROP) is a frequent cause of treatable childhood blindness. The current dependency of telemedicine-based ROP screening on cost-intensive equipment does not meet the needs in economically disadvantaged regions. Smartphone-based fundus imaging (SBFI) allows for affordable and mobile fundus examination and, therefore, could facilitate cost-effective telemedicine-based ROP screening in low-resources settings. We compared non-contact SBFI and conventional contact fundus imaging (CFI) in terms of feasibility for ROP screening and documentation. Twenty-six eyes were imaged with both SBFI and CFI. Field-of-view was smaller (ratio of diameters, 1:2.5), level of detail was equal, and examination time was longer for SBFI as compared to CFI (109.0 ± 57.8 vs. 75.9 ± 36.3 seconds, p < 0.01). Good agreement with clinical evaluation by indirect funduscopy was achieved for assessment of plus disease and ROP stage for both SBFI (squared Cohen's kappa, 0.88 and 0.81, respectively) and CFI (0.86 and 0.93). Likewise, sensitivity/specificity for detection of plus disease and ROP was high for both SBFI (90%/100% and 88%/93%, respectively) and CFI (80%/100% and 100%/96%). SBFI is a non-contact and low-cost alternative to CFI for ROP screening and documentation that has the potential to considerably improve ROP care in middle- and low-resources settings.

Development and validation of a machine learning, smartphone-based tonometer

BACKGROUND/AIMS

To compare intraocular pressure (IOP) measurements using a prototype smartphone tonometer with other tonometers used in clinical practice.

METHODS

Patients from an academic glaucoma practice were recruited. The smartphone tonometer uses fixed force applanation and in conjunction with a machine-learning computer algorithm is able to calculate the IOP. IOP was also measured using Goldmann applanation tonometry (GAT) in all subjects. A subset of patients were also measured using ICare, pneumotonometry (upright and supine positions) and Tono-Pen (upright and supine positions) and the results were compared.

RESULTS

92 eyes of 81 subjects were successfully measured. The mean difference (in mm Hg) for IOP measurements of the smartphone tonometer versus other devices was +0.24 mm Hg for GAT, -1.39 mm Hg for ICare, -3.71 mm Hg for pneumotonometry and -1.30 mm Hg for Tono-Pen. The 95% limits of agreement for the smartphone tonometer versus other devices was -4.35 to 4.83 mm Hg for GAT, -6.48 to 3.70 mm Hg for ICare, -7.66 to -0.15 mm Hg for pneumotonometry and -5.72 to 3.12 mm Hg for Tono-Pen. Overall, the smartphone tonometer results correlated best with GAT (R²=0.67, p<0.001). Of the 92 videos, 90 (97.8%) were within ±5 mm Hg of GAT and 58 (63.0%) were within ±2 mm Hg of GAT.

CONCLUSIONS

Preliminary IOP measurements using a prototype smartphone-based tonometer was grossly equivalent to the reference standard.