Telemedicine Imaging May Speed Diagnosis, Management of ROP

Marcia Frellick

January 22, 2015

Telemedicine-based imaging may help expand options in diagnosing and treating retinopathy of prematurity (ROP), which remains a significant threat to vision for extremely premature infants.

Bedside binocular indirect ophthalmoscopy has been the standard technique for diagnosing and monitoring infants who have ROP, but that therapy is challenged by the local scarcity of qualified ophthalmologist examiners in some areas, as well as the remote location of some neonatal intensive care units.

Walter M. Fierson, MD, a pediatric ophthalmologist in Arcadia, California, and colleagues reviewed the literature on the success of telemedicine-based remote digital fundus imaging (RDFI-TM) and found it does not eliminate the need for binocular indirect ophthalmoscopy but can expand options for treatment and improve outcomes for some at-risk patients. Their findings were published online December 29, 2014, in Pediatrics.

The researchers outlined some considerations in using RDFI-TM. Advantages include the ability to integrate it into EHRs, increase the number of infants evaluated, improve patient and staff education about ROP, and extend the expertise of ROP experts.

Disadvantages include the cost and the fact that RDFI-TM collects considerably less information than is required to fully stage the extent of ROP on the basis of the International Classification of Retinopathy of Prematurity consensus statement, the authors note. Detractors cite the difficulty in imaging the retinal periphery, problems with image quality in certain circumstances (eyes with poor dilation, media haze, or dark fundus pigmentation), and variations in interpretations of images even among highly skilled clinicians.

Considerations should include costs for a digital fundus camera system, image management software, training for nursing teams, and an ophthalmologist with expertise in ROP.

Contributing to the small numbers of these experts are high awards in malpractice cases, the authors say.

"Although malpractice claims against ophthalmologists and neonatologists for failure of diagnosis or mismanagement of ROP are relatively uncommon, awards can be extremely high because of the age of the patients involved and the severity of visual disability that may occur," they write.

A RDFI-TM model takes a hub-and-spoke approach. The hub comprises a centralized reading center and physician graders. Various neonatal intensive care units are the spokes. Images are captured locally and transferred electronically in a Health Insurance Portability and Accountability Act–compliant fashion to the reading center. There, images are downloaded onto a secure server for evaluation and management by the ophthalmologist.

Telemedicine may present licensing issues for ophthalmologists when images are transferred across state lines. Physicians considering telemedicine should contact the medical board in the state or states in which their practice is located, as well as each state in which patients present for diagnosis, imaging, or other services to make sure they are in compliance.

The authors conclude that further studies are needed to assess RDFI-TM management programs for ROP to confirm they adequately address access to care, clinical benefit, and cost-effectiveness.

Pediatrics. Published online December 29, 2014. Full text

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