Armenian ROP EyeCare Project: Agreement Between Ophthalmoscopic Diagnosis by Newly Trained Local Ophthalmologists vs. Remote Image-Based Diagnosis by Experts

Abstract

Purpose: Retinopathy of prematurity (ROP) incidence in developing countries is rising due to improvements in neonatal care. In 2010 the Armenian EyeCare Project trained Armenian ophthalmologists with no prior ROP experience to manage this disease. Images of all infants were taken using a wide angle camera (RetCam; Clarity Medical Systems, Pleasanton, CA) and reviewed remotely by experts in the United States (US), with the goal of improving diagnostic skills. This study intended to measure diagnostic agreement between ophthalmoscopic exams by Armenian ophthalmologists with remote image interpretations by US experts.

Methods: All infants who received ophthalmoscopic exam by an Armenian ophthalmologist between 6/1/2010 and 4/30/2012, with paired image-based diagnosis by a remote US expert were included in the study if documentation was complete. Trained Armenian screeners recorded ROP examination results in a database and uploaded images. Remote US experts (RVPC, MFC, TCL) reviewed images, and uploaded findings to the database. All ophthalmoscopic and image-based diagnoses were recorded using the international classification of ROP (zone, stage, plus disease). Overall diagnoses were converted to a four-level scale: (1) no ROP, (2) mild ROP (defined as less than type-2), (3) type-2 ROP (defined by the ETROP study), and (4) treatment-requiring ROP (defined as type-1 or worse). Absolute agreement between Armenian exams and corresponding remote US interpretations was calculated.

Results: A total of 151 infants from 5 NICUs received paired exams. Trained Armenian screeners and remote experts performed 983 and 492 individual eye exams, respectively. After exclusion of exams ineligible for agreement analysis, 336 corresponding exams were compared. Analysis revealed 68% agreement for ROP level, 80% agreement for diagnosis of any ROP, 91% agreement for diagnosis of type-2 or worse ROP, and 95% agreement for diagnosis of treatment-requiring ROP. Of 151 study infants, laser therapy was performed in 78 eyes.

Conclusions: Newly-trained Armenian ophthalmologists had good agreement with expert US ophthalmologists for diagnosis of clinically-significant ROP, but had less agreement for diagnosis of mild ROP. This suggests that in-country training, followed by remote mentorship, is effective for education and monitoring expertise in developing countries.

Keywords: 706 retinopathy of prematurity