Tele-ophthalmology model for ROP management

Dr Anand Vinekar descibes how tele-ophthalmology models for ROP can be used in developing countries, using a successful Indian programme as a case study.

Retinopathy of Prematurity (ROP) is a potentially blinding disease that affects premature infants when normal blood vessels fail to complete their growth cycle to the edges of the retina. In its advanced stages, the untreated disease can result in permanent and complete blindness. ROP is the leading cause of childhood and infant blindness in the developed world.

The magnitude of the problem in India can be gauged by looking at the government's census report. Incidence of ROP in India is reported to vary between 38–51.9 % in low birth weight infants.2-4 In 2007, roughly 27 million live births were recorded in India with approximately 8.7% believed to be below 2000 g at birth5 and 1-2% estimated to be premature and at ROP risk. If it were to be assumed that only 50% survive and 50% reach neonatal care centres, the number of babies requiring screening would amount to 65,000 to 130,000 infants each year. Ten to fifteen percent of these have the potential of going blind if untreated.

ROP screening must be completed within a very small window of time. The disease usually manifests within 3-4 weeks of birth and progresses within the subsequent 6-8 weeks to complete retinal detachment. Appropriate screening and timely treatment using the ETROP guidelines7 will result in > 90% success of vision preservation. Even aggressive posterior ROP (APROP) in Asian Indian babies show a satisfactory outcome if treated early.8

This data coincides with a study by Gilbert et al10 which shows that the mean birth weights of infants with severe ROP in highly developed countries are lower than in moderately and poorly developed countries. In the three highly developed countries, the mean birth weight values all were <800 g, whereas the mean values for the other countries all were >1000 g. The mean gestational age (GA) values of infants with severe ROP in highly developed countries all were <26 weeks, which was lower than the values for the other countries, which ranged from 26.3 weeks in Lithuania to 33.5 weeks in Ecuador. Overall, 142 (13%) of 1091 infants in this study with severe ROP from moderately and poorly developed countries had birth weights and GAs exceeding those recommended for screening by the Royal College of Ophthalmologists of the United Kingdom.

With less than 400 trained retinal surgeons (2008) and less than 20 centres capable of comprehensive ROP screening and management services in all of India, the challenge lies in using these limited resources to provide screening (and treatment) to the underserved areas of the country.