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Original Investigation
July 3, 2019

A Quantitative Severity Scale for Retinopathy of Prematurity Using Deep Learning to Monitor Disease Regression After Treatment

Author Affiliations
  • 1Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland
  • 2Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown
  • 3Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago
  • 4Department of Electrical and Computer Engineering, Northeastern University, Boston, Massachusetts
  • 5Massachusetts General Hospital & Brigham and Women’s Hospital Center for Clinical Data Science, Boston
  • 6Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
  • 7Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
JAMA Ophthalmol. 2019;137(9):1029-1036. doi:10.1001/jamaophthalmol.2019.2442
Key Points

Question  Can a quantitative measurement of retinopathy of prematurity severity be used over time to monitor disease regression after treatment?

Findings  In this cohort study of at-risk infants using data collected for the Imaging and Informatics in Retinopathy of Prematurity study, the quantitative retinopathy of prematurity vascular severity score developed using an automated deep learning–based plus disease classifier consistently reflected clinical disease posttreatment regression in 46 included eyes with laser or bevacizumab treatment.

Meaning  Tracking quantitative measurements of retinopathy of prematurity severity may be an effective method of following disease regression and identifying patients at risk for recurrence after retinopathy of prematurity treatment.


Importance  Retinopathy of prematurity (ROP) is a leading cause of childhood blindness worldwide, but treatment failure and disease recurrence are important causes of adverse outcomes in patients with treatment-requiring ROP (TR-ROP).

Objectives  To apply an automated ROP vascular severity score obtained using a deep learning algorithm and to assess its utility for objectively monitoring ROP regression after treatment.

Design, Setting, and Participants  This retrospective cohort study used data from the Imaging and Informatics in ROP consortium, which comprises 9 tertiary referral centers in North America that screen high volumes of at-risk infants for ROP. Images of 5255 clinical eye examinations from 871 infants performed between July 2011 and December 2016 were assessed for eligibility in the present study. The disease course was assessed with time across the numerous examinations for patients with TR-ROP. Infants born prematurely meeting screening criteria for ROP who developed TR-ROP and who had images captured within 4 weeks before and after treatment as well as at the time of treatment were included.

Main Outcomes and Measures  The primary outcome was mean (SD) ROP vascular severity score before, at time of, and after treatment. A deep learning classifier was used to assign a continuous ROP vascular severity score, which ranged from 1 (normal) to 9 (most severe), at each examination. A secondary outcome was the difference in ROP vascular severity score among eyes treated with laser or the vascular endothelial growth factor antagonist bevacizumab. Differences between groups for both outcomes were assessed using unpaired 2-tailed t tests with Bonferroni correction.

Results  Of 5255 examined eyes, 91 developed TR-ROP, of which 46 eyes met the inclusion criteria based on the available images. The mean (SD) birth weight of those patients was 653 (185) g, with a mean (SD) gestational age of 24.9 (1.3) weeks. The mean (SD) ROP vascular severity scores significantly increased 2 weeks prior to treatment (4.19 [1.75]), peaked at treatment (7.43 [1.89]), and decreased for at least 2 weeks after treatment (4.00 [1.88]) (all P < .001). Eyes requiring retreatment with laser had higher ROP vascular severity scores at the time of initial treatment compared with eyes receiving a single treatment (P < .001).

Conclusions and Relevance  This quantitative ROP vascular severity score appears to consistently reflect clinical disease progression and posttreatment regression in eyes with TR-ROP. These study results may have implications for the monitoring of patients with ROP for treatment failure and disease recurrence and for determining the appropriate level of disease severity for primary treatment in eyes with aggressive disease.