Validity of a telemedicine system for the evaluation of acute-phase retinopathy of prematurity

Graham E. Quinn, Gui Shuang Ying, Ebenezer Daniel, P. Lloyd Hildebrand, Anna Ells, Agnieshka Baumritter, Alex R. Kemper, Eleanor B. Schron, Kelly Wade, Trang B. Duros, Lisa Erbring, Michael X. Repka, Jennifer A. Shepard, Pamela Donohue, David Emmert, C. Mark Herring, Deborah VanderVeen, Suzanne Johnston, Carolyn Wu, Jason MantagosDanielle Ledoux, Tamar Winter, Frank Weng, Theresa Mansfield, Don L. Bremer, Richard Golden, Mary Lou McGregor, Catherine Olson Jordan, David L. Rogers, Rae R. Fellows, Suzanne Brandt, Brenda Mann, David Wallace, Sharon Freedman, Sarah K. Jones, Du Tran-Viet, Rhonda Michelle Young, Charles C. Barr, Rahul Bhola, Craig Douglas, Peggy Fishman, Michelle Bottorff, Brandi Hubbuch, Rachel Keith, Erick D. Bothun, Inge DeBecker, Jill Anderson, Ann Marie Holleschau, Nichole E. Miller, Darla N. Nyquist, R. Michael Siatkowski, Lucas Trigler, Marilyn Escobedo, Karen Corff, Michelle Huynh-Blunt, Kelli Satnes, Monte D. Mills, Will Anninger, Gil Binenbaum, Karen A. Karp, Denise Pearson, Alice Gong, John Stokes, Clio Armitage Harper, Laurie Weaver, Carmen McHenry, Kathryn Conner, Rosalind Heemer, Elnora Cokley, Robin Tragus, Robert Hoffman, David Dries, Katie Jo Farnsworth, Deborah Harrison, Bonnie Carlstrom, Cyrie Ann Frye, David Morrison, Sean Donahue, Nancy Benegas, Sandy Owings, Sandra Phillips, Scott Ruark, Patrick Mitchell, April Ingram, Rosie Sorbie, Maureen Maguire, Mary Brightwell-Arnold, Max Pistilli, Kathleen McWilliams, Sandra Harris, Claressa Whearry, E. Revell Martin, Candace R. Parker Ostroff, Krista Sepielli, Eli Smith, Antonio Capone, G. Baker Hubbard, Kerry Davis, G. Carl Gibson, Regina Hansen, Lisa Prosser, David C. Musch, Stephen P. Christiansen, Ditte J. Hess, Steven M. Kymes, Srinivas R. Sadda, Ryan Spaulding

Research output: Contribution to journalArticlepeer-review

145 Scopus citations


CONCLUSIONS AND RELEVANCE: When compared with the criterion standard diagnostic examination, these results provide strong support for the validity of remote evaluation by trained nonphysician readers of digital retinal images taken by trained nonphysician imagers from infants at risk for RW-ROP.

INTERVENTIONS: Infants underwent regularly scheduled diagnostic examinations by an ophthalmologist and digital imaging by nonphysician staff using a wide-field digital camera. Ophthalmologists documented findings consistent with referral-warranted (RW) ROP (ie, zone I ROP, stage 3 ROP or worse, or plus disease). A standard 6-image set per eye was sent to a central server and graded by 2 trained, masked, nonphysician readers. A reading supervisor adjudicated disagreements.

MAIN OUTCOMES AND MEASURES: The validity of grading retinal image setswas based on the sensitivity and specificity for detecting RW-ROP compared with the criterion standard diagnostic examination.

ESULTS A total of 1257 infants (mean birth weight, 864 g; mean gestational age, 27 weeks) underwent a median of 3 sessions of examinations and imaging. Diagnostic examination identified characteristics of RW-ROP in 18.2%of eyes (19.4%of infants). Remote grading of images of an eye at a single session had sensitivity of 81.9% (95%CI, 77.4-85.6) and specificity of 90.1% (95%CI, 87.9-91.8). When both eyes were considered for the presence of RW-ROP, as would routinely be done in a screening, the sensitivity was 90.0%(95%CI, 85.4-93.5), with specificity of 87.0% (95%CI, 84.0-89.5), negative predictive value of 97.3%, and positive predictive value of 62.5%at the observed RW-ROP rate of 19.4%.

DESIGN, SETTING, AND PARTICIPANTS: An observational study of premature infants starting at 32 weeks' postmenstrual age was conducted. This study involved 1257 infants with birth weight less than 1251 g in neonatal intensive care units in 13 North American centers enrolled from May 25, 2011, through October 31, 2013.

IMPORTANCE: The present strategy to identify infants needing treatment for retinopathy of prematurity (ROP) requires repeated examinations of at-risk infants by physicians. However, less than 10% ultimately require treatment. Retinal imaging by nonphysicians with remote image interpretation by nonphysicians may provide a more efficient strategy.

OBJECTIVE: To evaluate the validity of a telemedicine system to identify infants who have sufficiently severe ROP to require evaluation by an ophthalmologist.

Original languageEnglish (US)
Pages (from-to)1178-1184
Number of pages7
JournalJAMA Ophthalmology
Issue number10
StatePublished - Oct 1 2014

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© 2014 American Medical Association. All rights reserved.


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