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Original Investigation
November 2016

Analysis of Discrepancy Between Diagnostic Clinical Examination Findings and Corresponding Evaluation of Digital Images in the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity Study

Graham E. Quinn, MD, MSCE1,2; Anna Ells, MD3; Antonio Capone Jr, MD4; et al G. Baker Hubbard, MD6; Ebenezer Daniel, MD, PhD1; P. Lloyd Hildebrand, MD5; Gui-shuang Ying, PhD1; for the e-ROP (Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity) Cooperative Group
Author Affiliations
  • 1Department of Ophthalmology, University of Pennsylvania, Philadelphia
  • 2Division of Ophthalmology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 3Department of Ophthalmology, University of Calgary, Calgary, Alberta, Canada
  • 4Associated Retinal Consultants, Royal Oak, Michigan
  • 6Department of Ophthalmology, Emory University, Atlanta, Georgia
  • 5Dean McGee Eye Institute, University of Oklahoma, Oklahoma City
JAMA Ophthalmol. 2016;134(11):1263-1270. doi:10.1001/jamaophthalmol.2016.3502
Key Points

Question  What are the discrepancies between image grading and clinical examination findings in infants at risk for retinopathy of prematurity (ROP) in the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity study?

Findings  Consensus review of discrepant referral-warranted ROP findings (ie, eyes with zone I ROP, stage 3 ROP, or plus disease) by a panel of ROP experts found that nonphysician readers were less likely to detect stage 3 ROP than clinicians. However, trained readers were generally better than physicians at identifying the zone of ROP and presence of plus disease.

Meaning  This report highlights different strengths and weaknesses of both the grading of retinal images and the bedside examination of infants at risk for ROP.


Importance  As effective treatments for potentially blinding retinopathy of prematurity (ROP) have been introduced, the importance of consistency in findings has increased, especially with the shift toward retinal imaging in infants at risk of ROP.

Objective  To characterize discrepancies in findings of ROP between digital retinal image grading and examination results from the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity study, conducted from May 2011 to October 2013.

Design, Setting, and Participants  A poststudy consensus review of images was conducted by 4 experts, who examined discrepancies in findings between image grades by trained nonphysician readers and physician examination results in infants with referral-warranted ROP (RW-ROP). Images were obtained from 13 North American neonatal intensive care units from eyes of infants with birth weights less than 1251 g. For discrepancy categories with more than 100 cases, 40 were randomly selected; in total, 188 image sets were reviewed.

Main Outcomes and Measures  Consensus evaluation of discrepant image and examination findings for RW-ROP components.

Results  Among 5350 image set pairs, there were 161 instances in which image grading did not detect RW-ROP noted on clinical examination (G−/E+) and 854 instances in which grading noted RW-ROP when the examination did not (G+/E−). Among the sample of G−/E+ cases, 18 of 32 reviews (56.3%) agreed with clinical examination findings that ROP was present in zone I and 18 of 40 (45.0%) agreed stage 3 ROP was present, but only 1 of 20 (5.0%) agreed plus disease was present. Among the sample of G+/E− cases, 36 of 40 reviews (90.0%) agreed with readers that zone I ROP was present, 23 of 40 (57.5%) agreed with readers that stage 3 ROP was present, and 4 of 16 (25.0%) agreed that plus disease was present. Based on the consensus review results of the sampled cases, we estimated that review would agree with clinical examination findings in 46.5% of the 161 G−/E+ cases (95% CI, 41.6-51.6) and agree with trained reader grading in 70.0% of the 854 G+/E− cases (95% CI, 67.3-72.8) for the presence of RW-ROP.

Conclusions and Relevance  This report highlights limitations and strengths of both the remote evaluation of fundus images and bedside clinical examination of infants at risk for ROP. These findings highlight the need for standardized approaches as ROP telemedicine becomes more widespread.