Retina Today - Progress in ROP Management Through Tele-ophthalmology (November/December 2010)

摘要

Approximately 16,000 premature infants are affected by retinopathy of prematurity (ROP) in the United States every year.1 Screening guidelines for ROP in the United States stipulate that ROP screening be performed by experienced ophthalmologists using binocular indirect ophthalmoscopy (BIO).2 In middle income and emerging economies, such as India or Latin America, where the majority of the reported 50,000 children who are blind from ROP worldwide reside, screening guidelines for ROP must be more broad, Anand Vinekar, MD, FRCS, of Narayana Nethralaya Postgraduate Institute of Ophthalmology in Bangalore, India, said at the American Academy of Ophthalmology Annual Meeting in Chicago.3,4 Ideally, all babies in India with a birth weight less than 2,000 g should be screened by an ROP-trained ophthalmologist within the first 4 weeks of life, with subsequent screenings determined by the initial findings. 5 Unfortunately, applying this ideal model is extremely difficult in a country with few ROP-trained ophthalmologists, limited resources, and a plethora of underserved areas, Dr. Vinekar said. a??In India, we have 1.2 billion people and 400 retinal surgeons. Fewer than 15 of these surgeons practice comprehensive ROP care,a?? Dr. Vinekar said in his presentation. a??We have 27 million live births per year. Around 2 million of these are born weighing less than 2,000 g and are at risk of ROP. This means that one in two babies (47%) will develop some ROP and about 15% to 20% of them will require treatment. In fact, every 2 hours, somewhere in India, three babies require treatment.a?? Possible reasons for the dramatic difference between rates of ROP in low-income countries compared with the United States and other developed countries include higher birth rates and higher rates of premature births; insufficient resources for neonatal care, which leads to higher rates of severe ROP in premature and mature infants; and a shortage of screening and treatment programs due to lack of awareness, lack of skilled personnel, and financial constraints.5 TELE-OPHTHALMOLOGY FOR ROP SCREENINGThe challenge, Dr. Vinekar said, is harnessing limited resources to reach rural areas and villages where infants do not receive the timely treatment necessary to prevent irreversible blindness. To address this challenge, Dr. Vinekar and colleagues developed a tele- ROP program called KIDROP (Karnataka Internet- Assisted Diagnosis of Retinopathy of Prematurity) in 2007. Specially trained technicians, who do not have a background in ophthalmology, use the portable RetCam Shuttle (Clarity Medical, Pleasanton, CA) to take widefield digital fundus images of infants currently in 24 neonatal intensive care units (NICUs) in several districts of Karnataka in a fixed-day, fixed-center program. Often, the centers are filled with mothers who travel 50 to 100 kilometers with their infants to be imaged by Dr. Vinekara??s team. The program has now been approved as the countrya??s first public-private partnership for infant blindness management, and it is anticipated to expand to 36 more NICUs over 12 more districts of the state and eventually other parts of the country, Dr. Vinekar said. PORTABLE IMAGINGThe RetCam is a fully integrated widefield digital imaging system capable of capturing ophthalmic images from premature infants and children (Figure 1). The Shuttle version is easily transportable between hospitals and clinics. The digital images can be transferred to any networked system for timely transmission of patient images to experts, who can then view and evaluate them remotely (Figure 2). Studies have demonstrated that the RetCam can detect all cases of ROP in which treatment is a necessity.6 Additionally, digital imaging with the RetCam requires significantly less time compared with BIO examination.7 To identify infants at risk of ROP, the technicians capture, process, and store the images. They ha