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Original Investigation
April 5, 2018

Diagnostic Accuracy of Ophthalmoscopy vs Telemedicine in Examinations for Retinopathy of Prematurity

Author Affiliations
  • 1Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland
  • 2Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago
  • 3Center for Global Health, College of Medicine, University of Illinois at Chicago
  • 4Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
JAMA Ophthalmol. Published online April 5, 2018. doi:10.1001/jamaophthalmol.2018.0649
Key Points

Question  Is ophthalmoscopy or telemedicine more accurate in diagnosing clinically significant retinopathy of prematurity (ROP) when compared with a reference standard diagnosis?

Findings  In this multicenter study, each method was slightly more accurate for different components of retinopathy of prematurity (zone, stage, and plus disease), but there was no statistically significant difference in their ability to detect clinically significant retinopathy of prematurity. Both methods demonstrate high interexaminer variability.

Meaning  Telemedicine is as effective as ophthalmoscopy in identifying clinically significant retinopathy of prematurity, but both methods demonstrate high interexaminer variability; future studies should use a consensus reference rather than ophthalmoscopy as the criterion standard.


Importance  Examinations for retinopathy of prematurity (ROP) are typically performed using binocular indirect ophthalmoscopy. Telemedicine studies have traditionally assessed the accuracy of telemedicine compared with ophthalmoscopy as a criterion standard. However, it is not known whether ophthalmoscopy is truly more accurate than telemedicine.

Objective  To directly compare the accuracy and sensitivity of ophthalmoscopy vs telemedicine in diagnosing ROP using a consensus reference standard.

Design, Setting, and Participants  This multicenter prospective study conducted between July 1, 2011, and November 30, 2014, at 7 neonatal intensive care units and academic ophthalmology departments in the United States and Mexico included 281 premature infants who met the screening criteria for ROP.

Exposures  Each examination consisted of 1 eye undergoing binocular indirect ophthalmoscopy by an experienced clinician followed by remote image review of wide-angle fundus photographs by 3 independent telemedicine graders.

Main Outcomes and Measures  Results of both examination methods were combined into a consensus reference standard diagnosis. The agreement of both ophthalmoscopy and telemedicine was compared with this standard, using percentage agreement and weighted κ statistics.

Results  Among the 281 infants in the study (127 girls and 154 boys; mean [SD] gestational age, 27.1 [2.4] weeks), a total of 1553 eye examinations were classified using both ophthalmoscopy and telemedicine. Ophthalmoscopy and telemedicine each had similar sensitivity for zone I disease (78% [95% CI, 71%-84%] vs 78% [95% CI, 73%-83%]; P > .99 [n = 165]), plus disease (74% [95% CI, 61%-87%] vs 79% [95% CI, 72%-86%]; P = .41 [n = 50]), and type 2 ROP (stage 3, zone I, or plus disease: 86% [95% CI, 80%-92%] vs 79% [95% CI, 75%-83%]; P = .10 [n = 251]), but ophthalmoscopy was slightly more sensitive in identifying stage 3 disease (85% [95% CI, 79%-91%] vs 73% [95% CI, 67%-78%]; P = .004 [n = 136]).

Conclusions and Relevance  No difference was found in overall accuracy between ophthalmoscopy and telemedicine for the detection of clinically significant ROP, although, on average, ophthalmoscopy had slightly higher accuracy for the diagnosis of zone III and stage 3 ROP. With the caveat that there was variable accuracy between examiners using both modalities, these results support the use of telemedicine for the diagnosis of clinically significant ROP.