Journal Information
Vol. 96. Issue 2.
Pages 147-148 (01 February 2022)
Vol. 96. Issue 2.
Pages 147-148 (01 February 2022)
Scientific Letter
Open Access
Assessment of non-expert ophthalmologists in the analysis of retinopathy of prematurity
Evaluación de oftalmólogos no expertos en el análisis de la retinopatía del prematuro
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Carolina Navarro-Blancoa,
Corresponding author
cnavarro@clinicarementeria.es

Corresponding author.
, Natalia Pastora-Salvadorb, Celia Sánchez-Ramosc, Jesús Peralta-Calvod
a Departamento de Oftalmología, Clínica Rementería, Madrid, Spain
b Departamento de Oftalmología, Hospital Universitario Infanta Leonor, Madrid, Spain
c Grupo de Neuro-Computación y Neuro-Robótica, Universidad Complutense de Madrid, Madrid, Spain
d Departamento de Oftalmología Infantil, Hospital Universitario La Paz, Madrid, Spain
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Tables (2)
Table 1. Intraobserver agreement for the ROP variable in the 17 sets of images repeated at random.
Table 2. Sensitivity, specificity and kappa statistic for the diagnosis of ROP and referral to a specialist (ROP type 1 + 2) by the 8 participating ophthalmologists compared to the reference diagnosis performed by a paediatric ophthalmologist expert in ROP.
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Dear Editor:

Retinopathy of prematurity (ROP) is currently one of the leading causes of potentially preventable blindness in children. While not every infant that develops ROP of any degree experiences severe disease or requires treatment, early detection is critical to achieve the best possible vision outcomes.1 However, every day, neonatology and technological advances improve the care and survival of increasingly premature infants, thereby increasing the number of newborn infants at risk of developing ROP.2

A concern in Europe when it comes to ROP screening, and in Spain in particular, is that not every hospital that offers neonatal care has ophthalmologists on staff that specialise in the care of premature infants. Moral Pumarega et al. analysed ROP screening in neonatal units in a total of 99 public and private hospitals that managed neonates with birth weights under 1500 g. They found that only 39% of surveyed hospitals had specialised paediatric ophthalmologists, while in all other centres evaluations may be performed by any of the ophthalmologists on staff.3

But what happens when a seasoned ophthalmologist that is not an expert in ROP performs the screening? The examination of the peripheral retina requires specific training and experience, and the procedure has systemic effects on the premature infant.4,5 We conducted a pilot study to assess the role of the different specialities in clinical ophthalmology in the detection of ROP and referral to a specialist, for which clinicians were asked to analyse retinal images with and without signs of ROP. First, we ought to highlight that intraobserver agreement was excellent in all clinicians, with values ranging from 82% to 98% (Table 1).

Table 1.

Intraobserver agreement for the ROP variable in the 17 sets of images repeated at random.

  Speciality  Intraobserver agreement (%) 
Dr. 1  Anterior segment  90 
Dr. 2  Retina  91 
Dr. 3  Anterior segment  90 
Dr. 4  Anterior segment  98 
Dr. 5  General  82 
Dr. 6  Retina  95 
Dr. 7  Retina specialist expert in ROP  98 
Dr. 8  General  98 

The specificity of screening was high for all clinicians (83%–100%), but the sensitivity varied substantially between observers (49%–88%), as only the 2 general ophthalmologists and the expert in ROP exhibited a high sensitivity in the detection of ROP (Table 2). When it came to the referral to a specialist, the results differed substantially between observers and in relation to the results obtained in the other variable. Only the ophthalmologist that was an expert in ROP had acceptable results in both variables (diagnosis of ROP and referral to a specialist). Analysing each clinician individually, we found that the results of a renowned retina specialist of the Community of Madrid (Dr. 2) were poorer than even those of a beginner retina specialist (Dr. 6).

Table 2.

Sensitivity, specificity and kappa statistic for the diagnosis of ROP and referral to a specialist (ROP type 1 + 2) by the 8 participating ophthalmologists compared to the reference diagnosis performed by a paediatric ophthalmologist expert in ROP.

ROP  Speciality  Sensitivity, % (95% CI)  Specificity, % (95% CI)  Kappa (standard error) 
Dr. 1  Anterior segment  49 (7)  100 (0)  0.3655 (0.0786) 
Dr. 2  Retina  67 (7)  100 (0)  0.5531 (0.0878) 
Dr. 3  Anterior segment  70 (7)  100 (0)  0.5808 (0.0903) 
Dr. 4  Anterior segment  74 (6)  100 (0)  0.6243 (0.0871) 
Dr. 5  General  86 (5)  83 (11)  0.6216 (0.1197) 
Dr. 6  Retina  73 (6)  100 (0)  0.6210 (0.0876) 
Dr. 7  Retina specialist expert in ROP  88 (5)  95 (5)  0.7771 (0.0788) 
Dr. 8  General  82 (6)  100 (0)  0.7273 (0.0816) 
Referral  Speciality  Sensitivity. % (95% CI)  Specificity. % (95% CI)  Kappa (standard error) 
Dr. 1  Anterior segment  8 (4)  100 (0)  0.0638 (0.0368) 
Dr. 2  Retina  2 (2)  100 (0)  0.0203 (0.0203) 
Dr. 3  Anterior segment  87 (6)  81 (8)  0.6808 (0.0975) 
Dr. 4  Anterior segment  12 (5)  100 (0)  0.1032 (0.0461) 
Dr. 5  General  23 (8)  43 (19)  −0.1657 (0.1147) 
Dr. 6  Retina  30 (7)  100 (0)  0.2609 (0.0722) 
Dr. 7  Retina specialist expert in ROP  85 (6)  59 (9)  0.4536 (0.1080) 
Dr. 8  General  37 (8)  97 (3)  0.2942 (0.0813) 

The definition of retinography equipment is likely to increase over time, which will probably result in an improvement in the treatment of ROP through telemedicine. Recent studies have analysed artificial intelligence as a diagnostic method, an additional step in the objective assessment of retinopathy that does not require an expert in ROP.6 Still, further research is required in this emerging field. Timing is crucial in ROP screening, and telemedicine helps overcome many of the limitations of the conventional approach to diagnosis. This approach could allow excellence in care in the assessment and management of infants with ROP.

In this day and age, allowing the occurrence of totally preventable cases of blindness is completely unacceptable. First, on account of affected children and their families, and, if this were not enough reason, due to the economic cost for the state of a visually impaired individual. On the other hand, we need to consider the legal repercussions that may be faced by ophthalmologists. Thus, we should prioritise training of ROP specialists able to provide rigorous care and follow-up.

In conclusion, our pilot study evinced substantial variability in the assessment of ROP by experienced ophthalmologists, independently of the years of experience or the subspeciality of ophthalmology, and that the diagnosis and treatment of ROP require specific training. Retinopathy of prematurity and its sequelae can cause problems throughout the lifespan, so correct assessment is crucial to reduce the potentially devastating impact of this disease, which is surging in countries with different incomes and levels of development. Therefore, until effective artificial intelligence models are developed, we need to ensure the availability of ophthalmologists specialised in ROP who can make an accurate diagnosis through telemedicine.

Acknowledgments

We want to thank the Neonatal Intensive Care Unit of the Hospital Universitario La Paz and the entire staff of the Clínica Rementería, both in Madrid, Spain, for their collaboration.

References
[1]
G.E. Quinn.
Retinopathy of prematurity blindness worldwide: phenotypes in the third epidemic.
Eye Brain., 8 (2016), pp. 31-36
[2]
T.S. Raghuveer, R. Zackula.
Strategies to prevent severe retinopathy of prematurity: a 2020 update and meta-analysis.
Neoreviews., 21 (2020), pp. 249-263
[3]
M.T. Moral Pumarega, C.R. Pallás Alonsoa, J. Cruz Bértolob, P. Tejada Palacios, S. Caserío Carbonero.
Cribado de la retinopatía de la prematuridad en las unidades neonatales españolas.
An Pediatr (Barc)., 69 (2008), pp. 548-556
[4]
S.N. Patel, M.A. Martinez-Castellanos, D. Berrones-Medina, R. Swan, M.C. Ryan, K.E. Jonas, et al.
Assessment of a tele-education system to enhance retinopathy of prematurity training by international ophthalmologists-in-training in Mexico.
Ophthalmology., 124 (2017), pp. 953-961
[5]
T. Al-Khaled, M. Mikhail, K.E. Jonas, W.C. Wu, R. Anzures, A. Amphonphruet, et al.
Global Education Network for Retinopathy of Prematurity (GEN-ROP). Training of residents and fellows in retinopathy of prematurity around the world: an international web-based survey.
J Pediatr Ophthalmol Strabismus., 56 (2019), pp. 282-287
[6]
M.F. Greenwald, I.D. Danford, M. Shahrawat, S. Ostmo, J. Brown, J. Kalpathy-Cramer, et al.
Evaluation of artificial intelligence-based telemedicine screening for retinopathy of prematurity.
J AAPOS., 24 (2020), pp. 160-162

Please cite this article as: Navarro-Blanco C, Pastora-Salvador N, Sánchez-Ramos C, Peralta-Calvo J. Evaluación de oftalmólogos no expertos en el análisis de la retinopatía del prematuro. An Pediatr (Barc). 2022;96:147–148.

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