Indirect Ophthalmoscopy for ROP Examination

Is It Necessary?

dr Angela Nurini Agni, Sp.M(K), M.Kes

Department of Ophthalmology
FK UGM – RSUP Dr. Sardjito
Retinopathy of Prematurity (ROP)

A disorder of developing retina of low birth

weight preterm infant that potentially
leads to blindness.
 Epidemiology of ROP 3

Worldwide/Outside
Asia Indonesia
Asia
•ROP leads to blindness • In China, ROP was •ROP contributes for
in approximately 50.000 diagnosed in11.9% 1.1% of blindness in
children per year preterm/LBW infants children.5
worldwide.1 and 2% receiving
treatment.3
•In US, ROP diagnosed
in 59% preterm/LBW • In India, approximately
infants from 2003-2007 2 million are <2000 g in
(16% ROP stage 3, 12% weight and are at risk of
need intervention).2 developing ROP.
Incidence is 38-51.9% in
LBW infants.4

1. A. Zin and G. A. Gole, “Retinopathy of prematurity-incidence today,” Clinics in Perinatology, vol. 40, no. 2, pp. 185–200, 2013.
2. Stoll BJ, Hansen NI, Bell EF, Shankaran S, Laptook AR, Walsh MC, et al. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics. 2010;126(3):443-56.
3. Li Q, Wang Z, Wang R, Tang H, Chen H, Feng Z. A Prospective Study of the Incidence of Retinopathy of Prematurity in China: Evaluation of Different Screening Criteria. J Ophthalmol. 2016;2016:5918736.
4. Sen P, Rao C, Bansal N. Retinopathy of Prematurity: An Update. Med Vis Res Found. 2015;33(2):93.
5. Sitorus RS, Abidin MS, Prihartono J. Causes and temporal trends of childhood blindness in Indonesia: study at schools for the blind in Java. Br J Ophthalmol. 2007;91(9):1109-13.
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Management 4

 CRYO-ROP study*:
Peripheral retinal ablation reduced the occurrence of Retinal
detachment by 50 % (43.0% vs 21.8%)* in Threshold ROP

 ETROP study: Treatment at pre-threshold ROP**

 Reduced unfavorable visual outcome : 19.5% vs 14.5% (P=0.01)
 Reduced unfavorable structural outcome : 15.6% vs 9.2 %(P=0.001)

* Arch Ophthalmol. 1988;106(4):471-479.

** Trans Am Ophthalmol Soc 2004;102:233-250
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Examine premature infants at risk of

ROP, treat those with severe disease
and promote oxygen monitoring

3 Specific Ensure availability of ophthalmologists

experienced in indirect
Strategi ophthalmoscopy to identify premature
infants in intensive neonatal care who
es require treatment for ROP

Ensure that infants at risk have fundus

examinations starting at 4 to 6 weeks after
birth and that infants with severe disease are
treated immediately by laser or cryotherapy

Wilson et.al., Clin Perinatol 40 (2013) 241–259

http://dx.doi.org/10.1016/j.clp.2013.02.003
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The goal of ROP Screening* 6

1. To identify the infants who could benefit from treatment

2. Make appropriate recommendations on the timing for future
screening
3. Make recommendation for treatment intervention

*Pediatrics 2013;131:189–195
 Current indication for treatment 7

(Type I ROP)*

 Zone I : Any stage ROP with plus disease

 Zone I : Stage 3 ROP without plus disease
 Zine II : Stage 2 or 3 with plus disease

 * Early Treatment for Retinopathy of Prematurity Cooperative Group. Revised Indication for treatment of
Retinopathy of Prematurity :Results of the Early Treatment for Retinopathy of Prematurity randomized trial .
Arch Ophthalmol 2003;121(12): 1684-1694
 8
Zone and Plus disease
 9

Stage 1 Stage 2 Stage 3

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SCREENING IN ROP

1) Which babies should

be screened ???

2) How the babies

should be screened ???

3) When screening can

be safely terminated ???
 Screening Criteria 11
11
US1 Indonesia2

Infants with BW of ≤1500 gram or GA ≤ 30 weeks Infants with BW of ≤1500 gram or GA < 34 weeks

Infants with BW 1500-2000 gram or GA of >30 Infants with BW >1500 gram or GA of 34 weeks
weeks with an unstable clinical course with risk factor

GA <27 weeks first screening on post menstrual GA ≤30 weeks first screening on 4 weeks after
age 31 weeks birth

GA 27 weeks first screening on 4 weeks after GA >30 weeks first screening on 2-4 weeks after
birth birth

1. Ophthalmology AAOPS on, Ophthalmology AAO, Strabismus AA for POA, Orthoptists AA of C. Screening Examination of Premature Infants for Retinopathy of
Prematurity. Pediatrics. 2013 Jan 1;131(1):189–95
2. Sitorus RS, Andayani G, Djatikusumo A, Barliana JD, Yulia DE. Pedoman Nasional Skrining dan Terapi Retinopathy of Prematurity (ROP) Pada Bayi Prematur di
Indonesia. Jakarta: PERDAMI; 2011.
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12
How the baby should be screened ?
Standard examination for ROP Screening*
Pupilary dilation
Binocular Indirect Ophthalmoscope (BIO)
Lid speculum & scleral depression
Topical anesthetic drop
Pacifier : oral sucrose

*Policy statement of American Pediatric Association, Pediatric 2013 ;13(1).

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Indirect ophthalmoscope:

 In cooperative infant’s eye

 Inaccurate documentation :
Transcription from physician’s memory to the drawing

* Trese MT, What is the Real Gold Standard for ROP Screening ? Ed . Retina 2008 (28);3:s1-s2
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Digital Photo:

 Practical Consideration:
 Can be taken by hospital personnel
 Second opinion can be done electronically
 Allow the neonatologists to observe changes in the infants’
eye
 Accurate documentation
 Need proper training

Trese MT, What is the Real Gold Standard for ROP Screening ? Ed . Retina 2008 (28);3:s1-s2
The Level of Distress Caused by ROP
15

Screening using 3 different Methods

Mehta et al; Early Human Development (2005) 81,335 -360

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Using onsite indirect

ophthalmoscopy
diagnosis as the
reference standard
CSROP was identified by
digital images:
Sensitivity
92% (94% OD;
89% OS) and specificity
37.21% (40% OD; 35% OS)
ETROP prethreshold Type
I:
Sensitivity
92% (86% OD;
100% OS) and specificity
67.39% (67% OD; 68% OS)
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THE PHOTOGRAPHIC SCREENING FOR

RETINOPATHY OF PREMATURITY STUDY
(PHOTO-ROP): Primary Outcomes

PHOTOGRAPHIC SCREENING FOR

RETINOPATHY OF PREMATURITY (PHOTO-
ROP) COOPERATIVE GROUP
RETINA. 28(3):S47-S54, March 2008.
doi: 10.1097/IAE.0b013e31815e987f

A standard image set for each eye consisted of the iris, followed by disk
centered in the image, followed by images of temporal, nasal, superior,
and inferior retinal fields
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Comparison of RetCam II examination findings with Remote interpretation of

clinical assessment findings for detection of treatment- RetCam II/III images for the
war- ranted retinopathy of prematurity
detection of treatment-
Clinical Examination warranted (TW-ROP) :
RetCam II Examination
Positive Negative Total
Sensitivity 100%
Positive 21 1 22
Specificity 99.8%
Negative 0 586 586
PPV 95.5%,
Total 21 587 608
NPV 100%
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Detection of any stage of retinopathy of prematurity

(Number of eyes)
WFDRI
Binocular Indirect  Any stage of ROP : sensitivity
Ophthalmoscopy (BIO) Total 58.6%, specificity 100%
ROP (+) ROP (-)
 Treatment-requiring ROP
Wide-field digital retinal sensitivity 100%, specificity 100%
imaging (WFDRI)
ROP (+) 34 0 34  Plus disease sensitivity 100%,
ROP (-) 24 190 214
specificity 100%
Total 58 190 248
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Detection of zones of retinopathy of prematurity (Number of eyes)

Binocular Indirect Ophthalmoscopy (BIO)
Total
Zone I Zone II Zone III ROP (-)
Wide-field digital retinal
imaging (WFDRI)
Zone I 4 0 0 0 4
Zone II 0 26 0 0 26
Zone III 0 0 4 0 4
ROP (-) 0 0 24 190 214
Total 4 26 28 190 248
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Retinal photographic documentation of infants at risk for ROP using the

RetCam camera with remote interpretation of digital images has been
favorably assessed in many studies of babies, but there has yet to be a
large multicenter study published to confirm its ability to produce the
same accuracy of ROP disease detection in comparison with the clinical
gold standard of indirect ophthalmoscopy
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22

 A transient short-term pain

and stress response occurs
with both BIO and WFDRI
 Infants examined for
screening of ROP with
digital retinal imaging
present less pain and stress
at 30 seconds following
completion of the exam
when compared with
binocular indirect
ophthalmoscopy.
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23

Discontinuation of Screening:
1.Vascularization in zone III without previous zone I or II ROP
2.Full retinal vascularization in close proximity to the ora
serrata for 360°
3.Postmenstrual age of 50 weeks and no prethreshold or
worse ROP
4.Regression of ROP (no abnormal vascular tissue capable of
reactivation and progression present in zone II or III)
Advantages
Binocular Indirect Ophthalmoscopy Wide Field Digital Retinal Imaging

• Better visualization of fundus • Less pain and stress

details by a well-trained • Greater protection against
ophthalmologist medicolegal problems since
• Better visualization of retinal more accurate documentation
periphery • Can be done by trained reader,
• Easier to decide when to stop not only ophthalmologist
ROP screening since
visualization of normal
vascularization in zone 3
periphery was much more
easily

Eye (2013) 27, 1053–1057

Disadvantages
Binocular Indirect Ophthalmoscopy
• Technical difficulty and time
constraints of the
ophthalmologist
• Scleral depression required
during BIO may cause
systemic complications
such as bradycardia
secondary to oculocardiac
reflex
Wide Field Digital Retinal Imaging
• Difficult to capture the
exact stage and number
of clock hours
photographically that are
in peripheral zone 2 and
zone 3
• High initial cost of the
equipment
Eye (2013) 27, 1053–1057
 Conclusion

 Binocular Indirect Ophthalmology (BIO) is still a gold standard in diagnosis

of ROP
 Staging requires binocular indirect ophthalmoscopy to precisely define
peripheral retinal findings
 Screening determines when the next photographic or BIO examination is
needed
 Staging is needed for clinical trials. Screening provides good clinical care
 Wide Field Digital Retina Imaging (WFDRI) cannot completely replace BIO.
Instead, WFDRI can be used as an adjunctive method to BIO
 We still need large multicenter study to compare WFDRI with the clinical
gold standard of BIO
THANK YOU