Article

Tele-Education in Retinopathy of Prematurity

Facilitating standardization of, and access to, education.

Related

Tele-education has been described as the “delivery of education programs via telecommunication.”1 It can encompass web-based education, seminars, and web-based peer-to-peer mentorship. Tele-education has been applied in surgical subspecialties and medical education, with livestreaming of didactic material and real-time surgical telementoring. There has been significant growth of online resources and interest in developing tele-education programs for ophthalmology. Web-based education is particularly applicable in rural areas and low- to middle-income countries (LMIC) where specialists are often distant from their patients. One example is Cybersight, a tele-education platform for providers and trainees that provides educational content in collaboration with Orbis International.

Emily Cole, MD, MPH, is a second-year resident in the Department of Ophthalmology and Visual Sciences at the Illinois Eye and Ear Infirmary, University of Illinois at Chicago in Chicago, Illinois. Edward H. Wood, MD, is an assistant professor of ophthalmology in the Department of Ophthalmology at Stanford University in Palo Alto, California. Tala Al-Khaled, BA, is a fourth-year medical student in the Department of Ophthalmology and Visual Sciences at the Illinois Eye and Ear Infirmary, University of Illinois at Chicago in Chicago, Illinois. Michael F. Chiang, MD, is a professor of ophthalmology and medical informatics and clinical epidemiology in the Oregon Health & Science University School of Medicine and a pediatric ophthalmologist at Oregon Health & Science University Elks Children’s Eye Clinic in Portland, Oregon. Darius Moshfeghi, MD, is a professor of ophthalmology in the Department of Ophthalmology at Stanford University in Palo Alto, California. R.V. Paul Chan, MD, MSc, MBA, is interim chair and the John H. Panton, MD, professor of ophthalmology, director of pediatric retina and the ROP service, and co-director of the vitreoretinal fellowship at the University of Illinois College of Medicine in Chicago, Illinois. Dr. Cole and Dr. Wood report no related disclosures. Dr. Khaled reports grants from the National Center for Advancing Translational Sciences at the National Institutes of Health and Research to Prevent Blindness. Dr. Chiang reports consultancy to Novartis; equity in InTeleretina, LLC; and grant funding from the National Institutes of Health, the National Science Foundation, and Genentech. Dr. Moshfeghi reports advisory board membership with Akebia, consultancy to Bayer Pharma and Novartis, grants with Genentech, board of directors membership and equity with Pr3vent, consultancy to and research for Regeneron, consultancy to and equity in Versl Inc., and advisory board membership and equity in Visunex. Dr. Chan reports grants from Research to Prevent Blindness and the National Institutes of Health as well as consultancy to Novartis, Alcon, and Phoenix Technology Group. Reach Dr. Chan at rvpchan@uic.edu.

RATIONALE FOR TELE-EDUCATION IN ROP

There is a significant need for more health care providers who are skilled at managing retinopathy of prematurity (ROP). As advances in neonatal care have led to increased survival of younger and smaller infants, ROP remains a challenge to manage in the United States. Barriers to providing ROP care includes medicolegal liability, reimbursement, and complex coordination of care.2 Vartanian et al surveyed 847 neonatal intensive care unit medical directors who reported difficulties maintaining ophthalmic care for ROP, citing contract issues, liability risk, insufficient reimbursement, cost of malpractice, and lack of trained and qualified ophthalmologists. Only 56% of respondents agreed that there were enough ophthalmologists to screen for and treat ROP in their area.3

In middle-income countries, the “third epidemic” of ROP is leading to an increased burden of disease with relatively fewer trained local ROP experts.4 Many of these countries lack the infrastructure to adequately treat ROP with laser photocoagulation or anti-VEGF therapy. Improving ROP education is particularly important in LMIC because comprehensive ophthalmologists may be the only providers screening for ROP.

ROP TRAINING FOR TRAINEES

There is no standard for ROP training at either the residency or fellowship level in the United States. The Association of University Professors in Ophthalmology requirements for fellows in pediatric ophthalmology and retina do not have specific recommendations for ROP examinations and laser procedures.5 Tele-education platforms provide an opportunity for standardization of competency assessment.

Web-based surveys of training programs in the United States and internationally demonstrate variability in the number of ROP exams performed, diagnosis of treatment-requiring disease, and level of supervision of trainees.6-11 A survey of international ophthalmologists reported that between 1% and 33% of ROP screenings were performed under direct attending supervision, and 46% of respondents reported that they did not perform any laser photocoagulation procedures during training.8

Retina fellows were noted to have higher variability in diagnosis of type 2 pre-threshold ROP. Forty-seven percent of eyes were overcalled (treatment-requiring ROP) and 36% were undercalled (no/mild ROP).10 Other studies have demonstrated that pediatric ophthalmology fellows may also face challenges in ROP diagnosis for treatment-requiring disease.11

A web-based study that assessed classification of ROP based on widefield retinal images demonstrated that ROP was correctly diagnosed by international ophthalmology residents in less than half of the cases. Additionally, treatment-requiring ROP and type 2 ROP were commonly underdiagnosed due to low accuracy in identifying plus disease. There was no difference between trainees in higher income countries and lower income countries in the sensitivity or specificity of diagnosing clinically significant disease.12

TELE-EDUCATION PLATFORMS IN ROP

Tele-education and telementoring can provide improved access to ROP education and help ensure that ophthalmologists are adequately trained to recognize the relevant features of ROP. It has been shown that ROP tele-education programs can improve diagnostic accuracy of inexperienced ROP examiners and provide a foundation of image-based training that can be applied to retinal examinations under supervision. The Global Education Network for Retinopathy of Prematurity (GEN-ROP), in collaboration with the Imaging and Informatics for ROP (i-ROP) consortium, recently designed and implemented a web-based tele-education platform for ROP.13 This tele-education system consists of 65 cases that include images from 36 infants. A reference standard ROP diagnosis was established by combining the clinical diagnosis by indirect ophthalmoscopic examination and image-based diagnosis by multiple experts. With the expansion of internet access, these modules are widely accessible to ophthalmologists around the world.

Trainees are required to select the appropriate zone, stage, and category based on retinal images of various stages of ROP. Figure 1 demonstrates the learning interface in which trainees determine the presence or absence of plus disease, ROP, and aggressive posterior ROP. Each chapter is designed to emphasize a particular category of ROP (no/mild ROP, type 2 ROP, and treatment-requiring ROP). A pretest and post-test are administered to assess competency in image-based diagnosis. Following the pretest, trainees must complete a tutorial which introduces fundamental concepts that are needed to work through the subsequent cases.

Figure 1. Web-based retinopathy of prematurity learning interface.

Figure 2 shows an example of individualized feedback following completion of each chapter. Trainees are provided with (1) annotated images to compare to the images they selected in the case, (2) additional annotated images of the correct answer from different clinical cases, and (3) examples of the incorrect pathology chosen by the trainee. The introductory tutorial is also available for review between case chapters to clarify challenging concepts.

Figure 2. Individualized feedback following completion of each chapter of the retinopathy of prematurity learning system.

Retinopathy of prematurity tele-education has been applied in the United States, Mexico, Mongolia, Brazil, the Philippines, and a number of other countries. Tele-education has been shown to improve ophthalmology trainees’ competency in diagnosing zone, stage, and presence or absence of plus disease.14 In Mexico, trainees who completed the module had 94% specificity for diagnosing AP-ROP, 92% specificity for diagnosing type 2 or worse ROP, and 89% specificity for treatment-requiring ROP.

Trainees in the United States demonstrated similar improvement, with the largest increase in sensitivity noted for AP-ROP. PGY-3 and PGY-4 residents were noted to have greater improvement in diagnosing plus disease compared to PGY-2 residents. Ultimately, this platform can be used to train telemedicine graders, retinal imaging technicians, and other providers involved in ROP care.15

Other ROP training modules include the Widefield Imaging for Screening and Education for ROP (WISE-ROP) program, which is a 90-day ROP training module that incorporates self-assessment, video sessions scheduled with an assigned mentor, and exercises in image-based diagnosis. This module was developed for use in KID-ROP (Karnataka Internet Assisted Diagnosis of Retinopathy of Prematurity), which is one of the largest telemedicine screening programs for ROP in India. Participants are given a certificate for completion of the program.16

WEB-BASED RESOURCES FOR ROP

Web-based educational resources can supplement formal tele-education programs and bedside exams. The Ophthalmic Mutual Insurance Company provides a comprehensive set of resources entitled the OMIC ROP Safety Net Toolkit. These resources include specific operating procedures and standardized forms for screening, discharge, and coordination of care. There are also risk-analyses of ROP-related claims for providers to review.17

The Do No Harm technical briefs address ROP prevention and screening and are available in English, Spanish, and French. They provide a concise summary of evidence-based practices for primary, secondary, and tertiary prevention of ROP-related blindness. These resources are accessible and applicable to ophthalmologists and other providers, particularly those working in low-resource settings. The topics covered include oxygen management and infection prevention.18

The American Academy of Ophthalmology also provides both case-based learning and literature relevant to ROP care. Figure 3 demonstrates an example of the case-based learning available through the AAO website.19-20 The vitreoretinal section of the Knights Templar Eye Foundation Pediatric Ophthalmology and Strabismus Resource Center is an AAO resource that provides up-to-date resources on ROP care.

Figure 3. Case-based retinopathy of prematurity learning available through the American Academy of Ophthalmology website.
Image copyright the American Academy of Ophthalmology; reprinted with permission.

FUTURE DIRECTIONS

In other specialties of medicine, tele-education programs have been integrated into existing telemedicine systems.1,21 iTelegen is a web-based platform that aims to combine tele-education and telemedicine in ROP and diabetic retinopathy.22 FocusROP, now known as Phoenix CONNECT (Phoenix Technology Group) is a telemedicine platform that is compatible with all wide-angle retinal imaging systems and includes systems for documentation, tools for image review, and management of telescreening workflow.23

In the future, tele-education platforms may be able to aggregate trainee data to create a “smart” tele-education platform that can be tailored to an individual learner. There can be variation in educational material presented based on the learner’s progress and performance in the module.

Surgical telementoring has been used in general surgery, urology, neurosurgery, and gynecology. It has been demonstrated that utilization of such programs improves surgical competency and facilitates surgical mentorship across the world.24-25 This is relevant to providers in middle-income countries who may not have been trained in surgical interventions for ROP and management of associated complications.

Artificial intelligence (AI) algorithms have been developed to assess ROP severity and identification of plus disease. The i-ROP system was applied by Ataer-Cansizolgu et al and was demonstrated to perform with high accuracy for classifying ROP vs no ROP. This was assessed by applying the system to a set of widefield images and comparing the outcomes to clinical judgment as determined by indirect ophthalmoscopic examinations as well as manual grading of each image.26 This deep-learning algorithm has been demonstrated to monitor clinical regression of disease using a vascular severity score, ranging from 1 to 9. These algorithms have the potential to be used alongside clinical examination to improve ROP diagnosis. Tele-education programs targeted at ophthalmology trainees should integrate AI curriculum so that trainees are able to utilize AI-assisted diagnosis in clinical practice.26-29

CONCLUSION

Retinopathy of prematurity presents both diagnostic and clinical challenges to ophthalmologists around the world. There is no standardization of ROP training in current retina and pediatric fellowships, leading to variability in the accuracy of diagnosis by trainees. Tele-education modalities enable standardization of ROP education and are widely accessible through web-based platforms. RP

REFERENCES

  1. Zollo SA, Kienzle MG, Henshaw Z, Crist LG, Wakefield DS. Tele-education in a telemedicine environment: implications for rural health care and academic medical centers. J Med Syst. 1999;23(2):107-122.
  2. American Academy of Ophthalmology. Ophthalmologists warn of shortage in specialists who treat premature babies with blinding eye condition. http://www.aao.org/newsroom/release/20060713.cfm . Accessed August 25, 2008.
  3. Vartanian RJ, Besirli CG, Barks JD, Andrews CA, Musch DC. Trends in the screening and treatment of retinopathy of prematurity. Pediatrics. 2017;139(1).
  4. Gilbert C, Rahi J, Eckstein M, O’Sullivan J, Foster A. Retinopathy of prematurity in middle-income countries. Lancet. 1997;350(9070):12-14.
  5. Association of University Professors of Ophthalmology. Program requirements for fellowship education in pediatric ophthalmology and strabismus. https://aupofcc.org/system/files/resources/2017-08/peds_guidelines.pdf . Accessed October 7, 2019.
  6. Wong RK, Ventura CV, Espiritu MJ, et al. Training fellows for retinopathy of prematurity care: a Web-based survey. J AAPOS. 2012;16(2):177-181.
  7. Nagiel A, Espiritu MJ, Wong RK, et al. Retinopathy of prematurity residency training. Ophthalmology. 2012;119(12):2644-2645.
  8. Al-Khaled T, Mikhail M, Jonas KE, et al; Global Education Network for Retinopathy of Prematurity (GEN-ROP). Training of residents and fellows in retinopathy of prematurity (rop) around the world: an international web-based survey J AAPOS. 2019;22(4):e57.
  9. Swamy L, Patel S, Jonas KE, Ostmo S, Chiang M, Chan RP. Characterization of errors in retinopathy of prematurity (ROP) diagnosis by ophthalmology residents. J AAPOS. 2019;20(4):e44.
  10. Paul Chan RV, Williams SL, Yonekawa Y, Weissgold DJ, Lee TC, Chiang MF. Accuracy of retinopathy of prematurity diagnosis by retinal fellows. Retina. 2010;30(6):958-965.
  11. Myung JS, Paul Chan RV, Espiritu MJ, et al. Accuracy of retinopathy of prematurity image-based diagnosis by pediatric ophthalmology fellows: implications for training. J AAPOS. 2011;15(6):573-578.
  12. Kang KB, Swamy L, Patel SN, et al. Characterization of errors in retinopathy of prematu rity (ROP) diagnosis by international ophthalmology residents. Invest Ophthalmol Vis Sci. 2016;20(4)e44.
  13. Chan RV, Patel SN, Ryan MC, et al. The Global Education Network for Retinopathy of Prematurity (Gen-Rop): development, implementation, and evaluation of a novel tele-education system (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2015;113:T2.
  14. Patel SN, Martinez-Castellanos MA, Berrones-Medina D, Swan R, et al. Assessment of a tele-education system to enhance retinopathy of prematurity (ROP) training by international ophthalmologists-in-training in Mexico. Ophthalmology. 2017;124(7):953-961.
  15. Campbell JP, Swan R, Jonas K, et al. Implementation and evaluation of a tele-education system for the diagnosis of ophthalmic disease by international trainees. AMIA Annu Symp Proc. 2015;366-375.
  16. Vinekar A, Bhende P. Innovations in technology and service delivery to improve Retinopathy of Prematurity care. Community Eye Health. 2018;31(101):S20-S22.
  17. OMIC’s ROP Resources. https://www.omic.com/rop-resources/ . Accessed October 7, 2019.
  18. Chan RVP, Jonas KE, Litch JA, Campbell JP, Yap V. Prevention and screening of retinopathy of prematurity (ROP). Every Preemie—SCALE. April 2018. https://www.everypreemie.org/?smd_process_download=1&download_id=1363 . Accessed October 8, 2019.
  19. Chan RV, Chiang M, Jonas K. Retinopathy of prematurity: case-based training. https://www.aao.org/interactive-tool/retinopathy-of-prematurity-case-based-training . Accessed October 8, 2019.
  20. Knights Templar Eye Foundation Pediatric Ophthalmology Education Center. Vitreoretinal disease. https://www.aao.org/pediatric-ophthalmology-strabismus-listing?subspecialty=pediatric-ophthalmology-strabismus&subtopic=Vitreoretinal_Diseases . Accessed October 8, 2019.
  21. Geissbuhler A, Bagayoko CO, Ly O. The RAFT network: 5 years of distance continuing medical education and tele-consultations over the Internet in French-speaking Africa. Int J Med Inform . 2007;76(5-6):351-356.
  22. Cole E, Beca F, Gil GL, et al. iTeleGEN: development of a web-based diabetic retinopathy education module [ARVO abstract 5307]. Invest Ophthalmol Vis Sci. 2019;60(9):5307.
  23. Phoenix Technology Group. Phoenix Technology Group acquires FocusROP from InterVIEW Medical Systems. https://phoenixtech.com/press/focus-rop-phoenix-connect/ . Accessed October 7, 2019.
  24. Challacombe B, Wheatstone S. Telementoring and telerobotics in urological surgery. Curr Urol Rep. 2010;11(1):22-28.
  25. Gambadauro P, Magos A. NEST (network enhanced surgical training): a PC-based system for telementoring in gynaecological surgery. Eur J Obstet Gynecol Reprod Biol. 2008;139(2):222-225.
  26. Ataer-Cansizoglu E, Bolon-Canedo V, Campbell JP, et al; i-ROP Research Consortium. Computer-based image analysis for plus disease diagnosis in retinopathy of prematurity: performance of the “i-ROP” system and image features associated with expert diagnosis. Transl Vis Sci Technol. 2015;4(6):5.
  27. Campbell JP, Ataer-Cansizoglu E, Bolon-Canedo V, et al; Imaging and Informatics in ROP (i-ROP) Research Consortium. Expert diagnosis of plus disease in retinopathy of prematurity from computer-based image analysis. JAMA Ophthalmol. 2016;134(6):651-657.
  28. Brown JM, Campbell JP, Beers A, et al; Imaging and Informatics in Retinopathy of Prematurity (i-ROP) Research Consortium. Automated diagnosis of plus disease in retinopathy of prematurity using deep convolutional neural networks. JAMA Ophthalmol. 2018;136(7):803-810.
  29. Redd TK, Campbell JP, Brown JM, et al; Imaging and Informatics in Retinopathy of Prematurity (i-ROP) Research Consortium. Evaluation of a deep learning image assessment system for detecting severe retinopathy of prematurity. Br J Ophthalmol. 2018;103(5):580-584.