For example, a telemedicine network involving five German neonatal intensive care units has been operational since 2001 [16]. In this program, all premature infants at risk for ROP are screened with wide-angle imaging and also examined by local ophthalmologists according to the German guidelines. In this particular study, all suspected treat- ment-requiring ROP stages were detected with 100% sensitivity, and the overall positive predictive value for treatment-requiring ROP was 88.2% after 6,460 examinations in 1,222 infants [16].

Similarly, a network involving four NICUs, in which nurses are trained to capture serial wideangle retinal images, has been routinely providing remote care for at-risk infants at Stanford University since 2005. With regard to detection of “referral-warranted” ROP, this program reported that telemedicine had 100% sensitivity, 99.4% specificity, 85.7% positivity predictive value, and 100% negative predictive value after 669 examinations in 160 infants [19, 20, 33].

There were no known cases of retinal detachments or other poor anatomical outcomes from missed diagnoses reported by these programs. In addition to these particular programs, the authors are aware of numerous other smaller operational ROP telemedicine systems around the world. Taken together, these programs suggest that it is possible to successfully incorporate image capture, remote telemedicine interpretation, and timely referral of high-risk infants into neonatal workflow.

17.2.4 Potential Barriers

Despite many technological advances to support telemedicine for ROP management, its widespread adoption has been limited by several factors, such as concerns about licensure, liability, confidentiality and acceptability to patients and providers, and lack of a consistent insurance coverage and reimbursement policy [3, 11]. Although many published studies and operational programs have shown that diagnostic performance may be good and that telemedicine might even be more accurate than ophthalmoscopy in some situations, it is difficult to rigorously assess accuracy because

there may be significant variability in the reference standard of binocular indirect ophthalmoscopy. The level of diagnostic accuracy required for implementation of real-world ROP telemedicine systems is not clear, particularly given concerns about medicolegal liability. Capturing images with sufficient diagnostic quality may not always be practical, particularly in the peripheral retinal tissue of more premature infants, warranting reevaluation either by repeat imaging or BIO [12]. Furthermore, the implementation of telemedicine for ROP also requires approval of physicians and financial investments to cover the costs of new equipment and utilization of telecommunication technologies.

17.3Closing Remarks

17.3.1 Future Directions

Telemedical systems have many potential benefits for ROP screening and management, including opportunities for improving accessibility, quality, and cost of health care. They may also support advances in medical education and research. However, careful attention must be given to the selection and training of members of the NICU team and nonphysicians, if they are to play a critical role in identifying high-risk preterm infants and capturing retinal images. In addition, physicians must undergo training to interpret images because studies have demonstrated significant variability in ROP diagnosis, even among experts [3, 37].

The feasibility and implementation of telemedicine for ROP will also depend on the resolution of challenges such as integration into existing neonatology workflow, reimbursement, medicolegal liability, and licensure. Future studies are needed for the development of standard protocols for retinal image capture and creation of training protocols for photographers and graders in order to support the applications of telemedicine for ROP diagnosis.

Financial Disclosure MFC is an unpaid member of the Scientific Advisory Board for Clarity Medical Systems (Pleasanton, CA).