Challenges and Future Directions in the Detection

and Treatment of Retinopathy of Prematurity

Graham E. Quinn, MD, MSCE*
*Division of Ophthalmology, The Children’s Hospital of Philadelphia, Philadelphia, PA

Practice Gaps
1. Preterm patients at risk for retinopathy of prematurity may sometimes
miss appropriately timed diagnostic examinations.
2. Some eligible preterm patients may not have ready access to an
ophthalmologist to receive eye exams.

AUTHOR DISCLOSURE Dr Quinn has
disclosed no financial relationships relevant to
this article. This commentary does contain a
discussion of an unapproved/investigative
use of a commercial product/device.
ABBREVIATIONS
CRYO-ROP Cryotherapy for Retinopathy
of Prematurity
CSROP clinically significant
retinopathy of prematurity
e-ROP Telemedicine Approaches to
Evaluating Acute-Phase
Retinopathy of Prematurity
ETROP Early Treatment for
Retinopathy of Prematurity
PMA postmenstrual age
ROP retinopathy of prematurity
RW-ROP referral-warranted
retinopathy of prematurity
TW-ROP treatment-warranted
retinopathy of prematurity
Abstract
Multicenter studies addressing screening and intervention for retinopathy of
prematurity (ROP) inform the management guidelines jointly recommended
by American pediatric and ophthalmology academies. Current research
focuses on improvements in the identification of ROP and in the treatment of
high-risk disease. The development of digital image technology may address
various challenges in the diagnosis of ROP, including availability of pediatric
ophthalmologic expertise, interobserver variation in diagnosis, and inherent
limitations in visual diagnosis. Improved clinical prediction models based on
nonophthalmologic data may complement examination-based ROP
diagnosis. Alternatives to retinal ablation therapy are being studied to
decrease the associated morbidities of such therapy.
Objectives After completing this article, readers should be
able to:
1. Describe the current approach to screening for retinopathy of prematurity.
2. Understand the potential impact of digital technology on screening for
and diagnosis of severe retinopathy of prematurity.
3. Describe the current concerns regarding the use of anti–vascular endothelial
growth factor inhibitors for treatment of retinopathy of prematurity.
INTRODUCTION
Programs for detection of retinopathy of prematurity (ROP) are well established
in the United States, but new approaches to detection and treatment may
require alteration of the current approach. In countries with well-developed

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 NICU systems like the United States, ROP is a disorder of
the developing retinal vasculature that is found largely in
low-birthweight premature infants, particularly in very-low-
birthweight infants. The retinal vasculature develops from
the optic nerve at about 12 weeks of gestation and reaches
the far periphery of the retina at about full term. In premature
infants, vascularization of the retina is usually arrested at
birth with slow progress toward the periphery. The extent of
vascularization is directly related to gestational age, with the
most immature infants having the least vascularization and
therefore the greatest risk for abnormal vascularization af-
ter birth. Still, only a small percentage of premature infants
develop sufficiently severe ROP to require treatment, with
an estimated 6% to 8% of infants with birthweights of less
than 1,251 g based on the results of the Early Treatment for
ROP (ETROP) randomized trial. (1)
CURRENT STATUS
Extensive knowledge is available on the timing of devel-
opment and progression of ROP. Onset of disease in most in-
fants is between 31 and 33 weeks’ postmenstrual age (PMA),
with the greatest severity noted between 35 and 38 weeks’
PMA. (2) Most infants who require treatment of 1 or both
eyes are still in the hospital and therefore available for struc-
tured screening programs. The use of the word “screening”
in the current context is misleading because what is actu-
ally performed is a diagnostic examination of the eye by an
ophthalmologist to determine the need for treatment and
also the need for follow-up examinations. The standard for
these examinations is a retinal examination by an ophthal-
mologist experienced in ROP and performed using a binoc-
ular indirect ophthalmoscope. Results should be recorded in
terms of the International Classification of ROP. (3) In brief,
the examination should record at least these 3 components:
the extent of retinal vascularization (zone I is most posterior
and zone III most peripheral), the extent of abnormality at
the junction between the vascularized and avascular retina (no
ROP or stage 1-5 ROP with worrisome disease usually greater
than stage 2 ROP), and the presence of plus disease (markedly
increased dilation and tortuosity of the posterior pole ves-
sels, especially around the disc) or preplus disease. (3) Effective
programs require careful timing of the initial examination
of at-risk infants, and the results of the examination are used
to determine the need for and timing of subsequent exam-
ination or treatment. Careful attention to these details is
an essential component of the program with all stakeholders
and care providers aware of the scheduled examinations. (4)
At present, the recommendations for detection of ROP in
premature infants in the United States are based largely on
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the birthweight and gestational age of the infant, that is,
retinal examinations are recommended for infants with
birthweights of less than or equal to 1,500 g or with a
gestational age of 30 weeks or less. An examination is also
recommended for those slightly larger (1,500 to <2,000 g
birthweight) or more mature (>30 weeks’ gestation) infants
who have an “unstable clinical course” in the opinion of the
attending neonatologist or pediatrician. (4)
The timing of the initial and subsequent retinal exam-
inations is critical for the detection of acute-phase disease
because the intervention in serious disease is time-sensitive.
The timing is based on onset of ROP noted in the large
datasets accumulated in the ETROP (5) and Cryotherapy for
ROP (CRYO-ROP) studies. (6) The present recommenda-
tion for initiating ROP examinations is based on the ges-
tational age of the infant, and in infants of up to 27 weeks’
gestation, the initial examination should be at 31 to 32 weeks’
PMA (recognizing that the most immature infants will be 8
or 9 weeks after birth). For the infants with gestations less
than 25 weeks, an earlier examination should be considered
if serious comorbidities are noted. For infants with more
than 27 weeks of gestation, the recommendation is to start
retinal examinations at 4 weeks after birth. (4)
To determine the timing of the initial examination, it is
equally important to determine when the next examination
should be. In the current system, the follow-up examination
is determined by the examining ophthalmologist based on
the examination findings. Based on ETROP findings, (1) for
the highest-risk eyes (eyes that have retinal vessels extend-
ing only into zone I, eyes that have low-stage ROP in zone I,
or eyes with any stage 3 ROP), an examination is recom-
mended in 1 week or less. Less frequent examinations, every
1 to 2 weeks, or at 2 weeks, are recommended for eyes with
mild ROP in zone II or eyes with no ROP but vessels
extending into zone II, with 2- to 3-week follow-up for eyes
with zone III ROP or retinal vascularization well into zone III.
Termination of surveillance for acute-phase ROP is more
complex, with “suggestions” for when to conclude that
acute-phase ROP examinations are no longer indicated.
They include zone III vascularization with no history
of ROP and a PMA of more than 35 weeks. Other criteria
include full retinal vascularization to or near the ora serrata,
an examination at 50 weeks’ PMA with no stage 3 or zone I
ROP, or regression of ROP well into zones II or III.
CHALLENGES: ALTERNATE DETECTION APPROACHES
BASED ON EYE FINDINGS
In addition to an examination performed by an ophthal-
mologist, a series of investigations in the United States
have examined the use of remote evaluation of digital
images to detect ROP that either requires treatment or needs
to be evaluated by an ophthalmologist to consider treatment.
(7)(8)(9)(10)(11) The largest of these studies is the Tele-
medicine Approaches to Evaluating Acute-Phase ROP (e-ROP)
study, which enrolled more than 1,200 infants with
birthweights of less than 1,251 g in 13 North American centers
from 2011 to 2013. (8)(9)(12)(13) The mean birthweight of
these infants was 864 g and mean gestational age was 27
weeks. In e-ROP, the infants had routine ophthalmologic
examinations by e-ROP–certified ophthalmologists and also
underwent digital imaging by nonphysicians using a wide-
field camera either just before or after the eye examination.
The standard 6-image set for an eye was then graded by 2
trained nonphysician readers for the presence of ROP in
zone I, stage 3, or worse ROP, or plus disease (termed
referral-warranted or RW-ROP). The readers were masked
to the eye examination findings at the time of imaging as
well as the gestational age and PMA of the infant, findings of
the fellow eye, or previous gradings. If the readers disagreed
on key components, the results of the 2 gradings were ad-
judicated by a masked ophthalmologist and the final results
were then compared with the eye examination results, which
was deemed the criterion standard. The results showed high
sensitivity (90.0%, 95% confidence interval [CI] 85.4-93.5) for
detecting RW-ROP when both eyes of an infant were consid-
ered, with a specificity of 87.0% (95% CI 84.0-89.4) and a
negative predictive value of 97.3%. When considering infants
who received ROP treatment by the examining ophthalmolo-
gist, the sensitivity for detecting RW-ROP increased to 98.4%
(95% CI 94.4-99.4) with a specificity of 80.2% (95% CI
77.0-83.0) and a negative predictive value of 99.6%. (9)
The Photographic Screening for ROP Study (14) compared
the validity of remote image interpretation by ROP experts with
indirect ophthalmoscopy in 51 infants of less than 31 weeks’
gestation and weighing less than 1,000 g at birth. The investi-
gators used the term “clinically significant ROP” (CSROP) to
indicate the need for an examination. Compared with the refer-
ence standard indirect ophthalmoscopic diagnosis, the sensitiv-
ity for detecting CSROP was 92%, with a specificity of 37.1%.
Some institutions have implemented ROP telemedicine
programs to provide ROP detection for neonatal units that
would otherwise have limited routine surveillance and poten-
tially extend ROP expertise into remote areas. In addition,
developing digital image sets of an infant’s eyes during the at-
risk period allows online consultation, provides retrospective
comparison with the previous session, and may provide the
opportunity for more objective assessments.
An example of the clinical application of ROP telemedi-
cine is the Stanford University Network for Diagnosis of
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ROP program initiated by D.M. Moshfeghi, MD. In a recent
report of the first 6 years of this program (7) in 6 northern
California NICUs, more than 600 preterm infants were
screened an average of 3.6 times with images submitted to a
central facility for evaluation. Imaging was performed by
trained nurses and repeated within 48 hours if the images
were inadequate. Infants who met ROP screening criteria
were included in this study with a mean birthweight of
1,261 g and mean gestational age of 28.8 weeks. Twenty-two
infants (3.6%) were noted to have treatment-warranted (TW)
ROP with 21 (95.5%) of 22 infants with TW-ROP having
birthweights of less than 1,000 g. In this project, indirect
ophthalmoscopic examinations were performed in the neo-
natal unit only if the digital images were noted to have:
1) zone I, any stage ROP with plus disease; 2) zone I, stage 3
ROP; 3) zone II, stage 2 or 3 with plus disease; 4) plus
disease; or 5) any retinal detachment. Laser photocoagula-
tion was undertaken if warranted. As a safety measure, at
least 1 examination was performed using indirect ophthal-
moscopy within 1 week after discharge, regardless of image
findings.
Weaver and Murdock (10) used telemedicine screening
for ROP to provide service for a distant hospital in a rural
region of Montana. Over a 4.5-year period, infants who were
suspected of needing treatment were transferred to a med-
ical center where treatment could be provided. Of the 137
infants screened, 13 were transferred, with 9 requiring laser
treatment.
Several projects have examined the issue of agreement
among experts in the evaluation of digital image sets.
Slidsborg et al (15) presented images of the posterior pole to
4 ROP experts to determine the presence of plus disease.
The inter-reader agreement was poor, and they suggested
that this was likely because of the “subjective nature” of the
assessments. In a similar study, Gschliesser et al (16) ex-
amined both inter- and intraobserver reliability in deter-
mining the severity of ROP (stage, zone, plus disease). They
found interexpert agreement was fair (k range 0.24–0.41)
and intraexpert agreement was moderate (k range 0.47–
0.63), indicating “that the grading process is subjective.”
In a larger, recent study by Campbell et al, (17) 2 experts
evaluated 1,553 image sets from 281 infants for the various
components of ROP. There was disagreement on the stage
of ROP in 620 image sets (40%), plus disease in 287 (18%),
and zone of ROP in 117 (8%). Still, agreement between the
2 experts in detecting ROP that required treatment, which
is essentially a composite of zone, stage, and plus disease,
was greater than 95%.
In a 2013 clinical report from the American Academy of
Pediatrics, (4) the authors examined the current state of
Vol. 18 No. 2 FEBRUARY 2017 e93
 knowledge about the use of telemedicine in ROP and re-
viewed 8 level I studies that demonstrated good to excel-
lent sensitivity for detecting ROP of concern (though it
was defined differently across the various studies). The
panel concluded that remote image evaluation is “a useful
adjunct but not a replacement for” binocular indirect
ophthalmoscopy.
One of the concerns about changing from the diagnos-
tic examination to the use of remote image evaluation is
“missing” serious disease that might require treatment.
There is an inherent variability across clinicians in the
diagnosis of ROP with, for example, 12% disagreement
in the CRYO-ROP study between the initial examiner’s
determination of TW-ROP and the confirming examiner’s
findings. (2) Other studies have examined this issue and
found some variability in ophthalmoscopic findings. (18)
(19)(20) A 2016 report from e-ROP (21) undertook a con-
sensus review by 5 ROP experts of digital images from the
e-ROP study and compared the result of the diagnostic
examinations performed by e-ROP ophthalmologists and
the result of grading of digital images at the same session
by masked nonphysician readers. Among the 5,350 image
sets evaluated for RW-ROP in e-ROP, there was agreement
between image grading and examination results in 4,335
(81.0%). In 161 sessions (3%), there was disagreement in
which image grading did not document findings consistent
with RW-ROP while the examination did (false-negative).
In 854 sessions (16.0%), image grading documented RW-
ROP when the examination did not (false-positive). The
former comparison (161 sessions, 3.0%) is more worrisome
because these eyes would not have been referred for an eye
examination to consider treatment. Based on the consensus
review of the images of discrepant cases by ROP experts,
the investigators estimated that the experts agreed with the
trained reader gradings in more than half of the false-
negative sets and almost 3 of 4 of the false-positive image
sets. Thus there are “limitations and strengths of both
remote evaluation of fundus images and bedside exam-
inations of infants at risk for ROP.” An editorial by I.E.
Zimmer-Galler accompanying this report (22) agreed with
the need for developing standard approaches for evaluating
eyes of at-risk infants to improve quality of care delivered
to these high-risk infants.
CHALLENGES: ALTERNATE DETECTION APPROACHES
BASED ON NEONATAL FINDINGS
It has long been acknowledged that the sickest and the
slowest growing infants are the most likely to develop
serious ROP, and increasing attention has been given to
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weight gain as a surrogate for measurement of growth
factors (eg, insulinlike growth factor 1) in premature
infants. (23)(24)(25) Several groups have suggested that
weight gain in the postnatal period could be used to
predict which infants were at highest risk. (26)(27)(28)
(29) Such an approach could target eye examinations
with increased frequency in the highest-risk infants
and decreased frequency in the lowest risk. By consid-
ering the traditional criteria of birthweight and gesta-
tional age in combination with some assessment of
weight gain, the number of examinations per infant and
overall could be significantly reduced. (24)(25)(26)(30)(31)
(32)(33)(34) Development of these algorithms is underway,
but validation in large samples in various populations are
needed before these approaches are used generally.
CHALLENGES: INCORPORATING NEW TREATMENTS
OF DISEASE
Although no large randomized treatment trials are under-
way at present, techniques for ROP treatment are not static
and need to be considered in monitoring the eyes of pre-
mature infants in the near-term period. In view of the
widespread use of anti–vascular endothelial growth factor
drugs for retinal diseases in adults, (35)(36)(37)(38) attention
was given to the use of these drugs in the eyes of infants with
serious ROP. Anecdotal reports emerged in the late 2010s
(39)(40) and a randomized trial was reported in 2011 by
Mintz-Hittner et al. (41) Termed the Bevacizumab Elimi-
nates the Angiogenic Threat of ROP Trial, this trial of 150
infants with birthweights of less than 1,501 g compared
intravitreal bevacizumab with conventional laser treatment.
This drug was being used off-label. Infants were random-
ized to one treatment or the other because of the known
systemic absorption of bevacizumab. The primary out-
come measure was recurrence requiring treatment at 54
weeks’ PMA. There are methodologic concerns about the
relatively small sample, the bevacizumab dosage used, and
surveillance of long-term ocular and systemic problems,
(42)(43)(44)(45)(46)(47)(48) but the issue of recurrence
has become important in the immediate post-term infant.
Recurrence is seen in fewer than 10% of conventional
treatments using laser photocoagulation, with recurrence
happening within a few weeks, usually around term. How-
ever, recurrence in bevacizumab eyes occurred on average
almost 20 weeks after treatment (mean 19 þ 8.6 weeks) (41)
leading to a recommendation for weekly observation of
bevacizumab-treated eyes until 50 weeks’ PMA and less
frequent checks required at least up until 70 weeks’ PMA.
The relevance of using these new treatment approaches
highlights the need for continued surveillance, which is
often required even while the infant is still in the hospital.
CHALLENGES: INCORPORATING NEW TECHNOLOGIES
INTO ASSESSMENT OF ACUTE-PHASE RETINOPATHY
OF PREMATURITY
Understanding of the abnormal pathophysiology associated
with ROP continues to evolve, with new techniques being
developed to move beyond the current standard of indirect
ophthalmoscopy to judge an eye’s risk for poor outcomes.
Quantitative rather than qualitative methods have been
developed to determine which eyes are at high risk for
developing serious disease. These efforts have largely quan-
tified, in series of digital images, the extent of abnormality
of posterior pole vessels, that is, the presence of plus dis-
ease, which is a major indicator for treatment at present.
Several analytic approaches have worked well to identify
eyes that required treatment, but none have been used yet
in clinical care. (49)(50) Such a quantitative approach has
promise in producing a less variable, more sensitive tool
than the current use of the indirect ophthalmoscope for
clinical examination. When such reliable programs are
available, it will likely change the surveillance paradigms
for ROP. (51)
In addition to digital images that capture photographic
images of retina, additional investigative techniques are
increasingly being used in NICUs to assess the presence
of potentially serious ROP. Fluorescein angiography
can now be safely used in the nursery to identify earlier
changes of ROP than might be visible on routine indi-
rect ophthalmoscopy. (52) In addition, the use of optic
coherence interferometry (53)(54)(55)(56) has allowed
cross-sectional analysis of the retinal layers to deter-
mine at which level abnormalities occur and which abnor-
malities might be predictive of ocular and systemic
problems.
SUMMARY
The current ROP surveillance guidelines in the United
States are likely to change over time as more quantifiable
assessments become widespread and new techniques are
implemented. It is important, however, to recall that the
guidelines developed for use in NICUs in the United States
and other regions with well-developed neonatal care are not
generalizable to other regions of the world as expertise in
neonatal care of infants at risk for ROP in these regions
develop. (57)(58)(59)
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American Board of Pediatrics
Neonatal—Perinatal Content
Specification
• Know the clinical features and course of retinopathy of
prematurity and the staging of severity according to the
international classification.
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38. Abdallah W, Fawzi AA. Anti-VEGF therapy in proliferative diabetic
retinopathy. Int Ophthalmol Clin. 2009;49(2):95–107
39. Mintz-Hittner HA, Kuffel RR Jr. Intravitreal injection of bevacizumab
(avastin) for treatment of stage 3 retinopathy of prematurity in zone I
or posterior zone II. Retina. 2008;28(6):831–838
40. Quiroz-Mercado H, Martinez-Castellanos MA, Hernandez-Rojas
ML, Salazar-Teran N, Chan RV. Antiangiogenic therapy with
intravitreal bevacizumab for retinopathy of prematurity. Retina.
2008;28(3 suppl):S19–S25
41. Mintz-Hittner HA, Kennedy KA, Chuang AZ; BEAT-ROP
Cooperative Group. Efficacy of intravitreal bevacizumab for stage
3þ retinopathy of prematurity. N Engl J Med. 2011;364(7):603–615
42. Lepore D, Quinn GE, Molle F, et al. Intravitreal bevacizumab versus
laser treatment in type 1 retinopathy of prematurity: report on
fluorescein angiographic findings. Ophthalmology. 2014;121
(11):2212–2219
43. Morin J, Luu TM, Superstein R, et al; Canadian Neonatal Network
and the Canadian Neonatal Follow-Up Network Investigators.
Neurodevelopmental outcomes following bevacizumab injections
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44. Avery RL. What is the evidence for systemic effects of intravitreal
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46. Lien R, Yu MH, Hsu KH, et al. Neurodevelopmental outcomes in
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47. Quinn GE, Darlow BA. Concerns for development after
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ranking disease severity and using quantitative image analysis.
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52. Lepore D, Molle F, Pagliara MM, et al. Atlas of fluorescein
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prematurity. Ophthalmology. 2011;118(1):168–175
53. Moreno TA, O’Connell RV, Chiu SJ, et al. Choroid development
and feasibility of choroidal imaging in the preterm and term
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54. Maldonado RS, Toth CA. Optical coherence tomography in
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Toth CA. Insights into advanced retinopathy of prematurity using
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implications for screening programs. Pediatrics. 2005;115(5):
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59. Blencowe H, Lawn JE, Vazquez T, Fielder A, Gilbert C. Preterm-
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Vol. 18 No. 2 FEBRUARY 2017 e97
 NeoReviews Quiz
There are two ways to access the journal CME quizzes:
1. Individual CME quizzes are available via a handy blue CME link in the Table of Contents of any issue.
2. To access all CME articles, click “Journal CME” from Gateway’s orange main menu or go directly to: http://www.
aappublications.org/content/journal-cme.

1. A male infant born at 27 weeks gestational age is now 4 weeks old. Although he required NOTE: Learners can take
continuous positive airway pressure during the first week, he is not in room air. Which of NeoReviews quizzes and
the following statements concerning ophthalmologic evaluation for this infant is correct? claim credit online only
A. The first examination should be performed between 35 to 38 weeks postmenstrual at: http://Neoreviews.org.
age.
B. If the infant no longer requires oxygen, the eye exam can be deferred until after To successfully complete
discharge to home. 2017 NeoReviews articles
C. An eye exam for this infant should include the extent of retinal vascularization, the for AMA PRA Category 1
extent of abnormality at the junction between vascularized and avascular retina, CreditTM, learners must
and the prevalence of plus disease or pre-plus disease. demonstrate a minimum
D. If this patient were to have retinopathy, it would likely have already started at 28 performance level of 60%
weeks postmenstrual age. or higher on this
E. At present, there are no recommendations by professional societies in regard to the assessment, which
eligibility and timing of eye exams for retinopathy. measures achievement of
2. The infant is now 5 weeks old (32 weeks postmenstrual age) and eye exam has revealed the educational purpose
low-stage retinopathy of prematurity in zone I. Which of the following time intervals would and/or objectives of this
be appropriate for next follow-up exam? activity. If you score less
A. One week or less. than 60% on the
B. Two weeks. assessment, you will be
C. Three weeks. given additional
D. Once more prior to discharge to home. opportunities to answer
E. After discharge at the ophthalmologist’s clinic. questions until an overall
60% or greater score is
3. Due to lack of availability of an ophthalmologist who can be routinely available for eye
achieved.
exams, your NICU is considering the use of remote evaluation strategies. In reviewing the
literature on this topic, you are considering several studies, including the largest
telemedicine study on this topic (e-ROP). Which of the following statements correctly This journal-based CME
describes this study? activity is available
A. This study enrolled more than 1,200 infants, all of whom were less than 27 weeks through Dec. 31, 2019,
gestational age. however, credit will be
B. Imaging, using wide-field camera at the time of the ophthalmologist’s eye exam, recorded in the year in
was graded by trained nonphysician readers. which the learner
C. The digital image obtained for comparison to an ophthalmologic evaluation completes the quiz.
consisted of 2 images per eye.
D. Although the sensitivity of digital imaging was high (90% to 95%), the specificity
was low at 50% to 60%.
E. The generalizability of this study to US NICUs is questioned, as the centers involved
were all from South America and Europe.
4. In reviewing the literature, you are considering who might review the images that may be
used for remote evaluation for retinopathy. Which of the following statements regarding
this topic is correct?
A. In the 2 largest studies that examined clinician interpretation of eye exam findings,
there has been 100% agreement in regard to treatment-warranted retinopathy when
2 pediatric ophthalmologists performed the review of digital images.
B. In the 6-year report of the SUNDROP program, imaging led to 20% of infants
receiving digital imaging requiring treatment for retinopathy during initial
hospitalization.
C. In the e-ROP cohort, the image grading was not considered referral warranted for
3% of cases in which the direct exam by ophthalmologist indicated that referral was
warranted.

e98 NeoReviews
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 D. In several studies of agreement on evaluation of digital images, when experts on
retinopathy of prematurity were the subjects involved, the agreement on whether
plus disease is present is 98% to 100%.
E. In their 2013 clinical report, the American Academy of Pediatrics has endorsed
telemedicine for retinopathy of prematurity exams to be superior to binocular
indirect ophthalmoscopy.
5. A 27-week gestational age male infant has received intravitreal bevacizumab for
retinopathy of prematurity. Which of the following statements regarding follow-up for this
patient is correct?
A. Follow-up evaluations are only warranted if the patient originally had plus disease
prior to treatment.
B. The main reason that the immediate follow-up evaluation should be delayed until 4
weeks posttreatment is that an ophthalmologic exam too soon can lead to lower
drug absorption.
C. Due to recurrence risk, the current recommendation is for weekly observation of
treated eyes until 50 weeks postmenstrual age and less frequent checks to at least
70 weeks postmenstrual age.
D. The mean time of recurrence in similar patients is within a few weeks after
treatment, usually before term.
E. The frequency of posttreatment eye exams can vary, but can end when the patient
is discharged to home.

Vol. 18 No. 2 FEBRUARY 2017 e99

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Challenges and Future Directions in the Detection and Treatment of Retinopathy
of Prematurity
Graham E. Quinn
NeoReviews 2017;18;e91
DOI: 10.1542/neo.18-2-e91

Updated Information & including high resolution figures, can be found at:
Services http://neoreviews.aappublications.org/content/18/2/e91
References This article cites 56 articles, 12 of which you can access for free at:
http://neoreviews.aappublications.org/content/18/2/e91#BIBL
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Challenges and Future Directions in the Detection and Treatment of Retinopathy
of Prematurity
Graham E. Quinn
NeoReviews 2017;18;e91
DOI: 10.1542/neo.18-2-e91

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://neoreviews.aappublications.org/content/18/2/e91

Neoreviews is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since . Neoreviews is owned, published, and trademarked by
the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2017 by the American Academy of Pediatrics. All rights reserved. Online
ISSN: 1526-9906.

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