|Year : 2017 | Volume
| Issue : 1 | Page : 13-16
Mobile unit for retinopathy of prematurity screening and management at urban Neonatal Intensive Care Units: Outcomes and impact assessment
Jai Kelkar1, Supriya Agashe1, Aditya Kelkar1, Rajiv Khandekar2
1 Department of Pediatric Ophthalmology, National Institute of Ophthalmology, Pune, Maharashtra, India
2 Department of Research, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
|Date of Web Publication||21-Feb-2017|
Department of Research, King Khaled Eye Specialist Hospital, P. O. Box: 7191, Aruba Road, Riyadh 41162
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Purpose: To study the outcomes and impact of a mobile unit for retinopathy of prematurity (ROP) screening and management at urban Neonatal Intensive Care Units (NICUs).
Study Design: Public health intervention study.
Methods: This study was conducted in 2012. Staff of a mobile unit assessed all infants aged 32 weeks or less and/or weight 1250 g or less admitted in five NICUs between 2009 and 2011. An ophthalmologist performed bedside ROP screening through dilated pupils using indirect ophthalmoscopy. ROP was graded and managed as per the International Classification of ROP treatment guidelines. Counseling and laser treatment were the interventions. The incidence, grade, and determinants of ROP were estimated. Direct and indirect costs were calculated to estimate the unit cost of screening and managing a child with ROP using the mobile unit.
Result: The study sample included 104 preterm/underweight infants. The prevalence of ROP of different grades in either eye was 32.7% (95% confidence intervals: 23.7–41.7). ROP Stage I was present in 75% of these eyes. The mobile unit could help in preventing/reducing visual disability in 5 infants with advanced stages of ROP. The unit cost of ROP screening, identifying one child with ROP, and addressing visual disability due to ROP was US $310, 950, and 6500, respectively.
Conclusion: A mobile screening is likely feasible and cost-effective method to detect ROP and offer timely intervention in urban areas with limited resources.
Keywords: Childhood blindness, health economics, retinopathy of prematurity, screening
|How to cite this article:|
Kelkar J, Agashe S, Kelkar A, Khandekar R. Mobile unit for retinopathy of prematurity screening and management at urban Neonatal Intensive Care Units: Outcomes and impact assessment. Oman J Ophthalmol 2017;10:13-6
|How to cite this URL:|
Kelkar J, Agashe S, Kelkar A, Khandekar R. Mobile unit for retinopathy of prematurity screening and management at urban Neonatal Intensive Care Units: Outcomes and impact assessment. Oman J Ophthalmol [serial online] 2017 [cited 2017 Aug 19];10:13-6. Available from: http://www.ojoonline.org/text.asp?2017/10/1/13/200684
| Introduction|| |
Retinopathy of prematurity (ROP) is an important cause of preventable blindness in children. In countries with rapidly evolving economies, there is an increasing incidence of ROP due to improved survival rates of preterm babies. Early detection of ROP and timely treatment are recommended health strategies to address childhood blindness in the VISION 2020 – the right to the sight initiative of the World Health Organization to eliminate avoidable blindness by the year 2020. This initiative focused on disease control, human resource development, provision of required resources, and adopt program approach both at national and supranational levels. Within the disease control, childhood blindness included all eye ailments that cause visual disabilities including ROP. This strategy required a better coordination of the national eye health-care and maternal and child health-care programs and millennium developmental goals. The criteria to screen and manage different stages of ROP are well established.,,, However, implementing these criteria in developing countries is a challenge. Poor accessibility and a lack of awareness among parents as well as health-care providers result in late presentation and irreversible damage.,
In the era of telemedicine, screening, and prompt management of eye diseases such as diabetic retinopathy and ROP have been performed using digital transfer of images from screening site to the experts at tertiary eye centers., Unfortunately, the high cost of infrastructure at the screening site prohibits the broad application of telemedicine. The cost-effectiveness of ROP screening had been evaluated in industrialized countries., However, to the best of our knowledge, the outcomes of ROP screening and management using mobile units to cover Neonatal Intensive Care Units (NICUs) in Western India have not been previously published.
The community ophthalmology department of the National Institute of Ophthalmology established a mobile unit for ROP screening in 2008. The team members of this unit periodically visit five small-sized NICUs, but with at least 15 beds in Pune, India. They screen premature infants for ROP, propose management, and counsel the parents accordingly. We present the outcomes and impact of ROP screening using this mobile unit in Pune, India.
| Methods|| |
The Institutional Ethical Committee approved this project. This study was conducted in 2012. Two ophthalmologists, an epidemiologist and paramedical staff were the field investigators. A mobile ROP screening unit consisted of a mobile van (Maruti Omni, Iridexlaser India) with a driver and two ophthalmologists trained in ROP screening and was equipped with a portable indirect ophthalmoscope (IDO) (Keeler, UK) and portable laser unit (Iridex laser, USA). Five NICUs catering to 15–30 beds were selected in Pune city to participate in this project. The aim was to reach out to smaller NICUs. These NICUs were well equipped to manage critical preterm babies. The staff was trained to inform the ROP screening unit when babies fulfilling the inclusion criteria were registered. NICU nurses and resident doctors catering to premature babies were briefed about the purpose and benefit of ROP screening. Members of the mobile unit visited each NICU twice a week.
Infants aged <33 weeks and/or birth weight 1250 g or less and were admitted in the NICUs between 2009 and 2011 were included in our study. Eye examination was performed at 4 weeks after birth or 31–33 weeks postconception age whichever was later. Informed consent of each parent was obtained before ROP screening. The pupils were dilated with 10% phenylephrine eye drops that were diluted with artificial tears in the ratio of 1:4. One drop was instilled in each eye and if the dilation was inadequate, an additional drop was instilled after 30 min. A detailed retinal examination was performed with IDO, infant speculum, and scleral indentation. ROP was graded into stages and zones based on the International Classification of ROP. All babies, with a normal retina on the 1st examination, were asked to follow-up at the referring hospital every 6 months for 1 year; and then, once yearly. Once vascularization of the temporal retina is completed or infant reaches gestational age of 40 weeks and weight of 2000 g, we did not follow them further. Infants who required laser therapy or surgery were followed every 3 months.
All eyes with threshold ROP were treated with laser at the gestational age of 32–34 weeks. The laser spot size was 200 µ, power of 150–200 mW, duration of 100 ms, and then, was followed every week till regression of vascularization was noted.
To calculate the cost of screening and management, we included the cost of capital investment of equipment and the recurrent cost that included an annual salary of eye team involved for the duration of screening, counseling, and management. Frequencies, percentage proportion, and 95% confidence intervals (CIs) of incidence of ROP were calculated.
| Results|| |
A total of 104 preterm infants were screened in this study. ROP in either eye was noted in 34 infants. The incidence of ROP was 32.7% (95% CI: 23.7–41.7). The grades of ROP are presented in [Table 1]. Twenty-nine infants were closely monitored without any intervention as their ROP was mild and regressed. Four infants (12%) were treated with laser and one infant (3%) was treated with pars plana vitrectomy. The mobile unit could help in preventing blindness in five eyes with advanced stage of ROP.
|Table 1: (a) Stages of retinopathy of prematurity in infants aged 32 weeks or less and/or weight 1250 g or less|
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The cost of mobile ROP screening unit was estimated in Indian Rupees and then was converted to US $ at a rate of 58 Indian Rupees = 1$. The costing was grouped into capital investment (fixed cost) and recurrent cost for a 3-year project [Table 2]. We reduced capital cost by 20% less in subsequent years to account for depreciation of the items. We also increased the cost of recurrent expenses by 5% every year to account for inflation. The total cost of ROP screening over 3 years of screening was Indian Rupees 1,872,486 (US $32,285).
|Table 2: Costing of retinopathy of prematurity screening and management project using a mobile unit|
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The unit cost of ROP screening in five NICU in our study was 32,285/104 = US $310. The unit cost of identifying one child with ROP was US $950. The unit cost of addressing visual disability due to ROP in our project was 32,285/5 = US $6500.
| Discussion|| |
The 37% incidence of ROP in our study was within the range for developing countries.,,,, More than one-sixth required active intervention. The parents of the rest were counseled and infants were monitored without intervention. The cost of screening one child was US $310. To identify a child with ROP, one needs to screen three preterm infants at NICU. The unit cost for identifying one true case of ROP was US $950. While the unit cost of management of positive ROP case was US $6,500.
In Latin America, the prevalence of ROP ranged from 7% to 82%. Among these cases, 1%–24% of the eyes with severe ROP required treatment. In Turkey, the prevalence of ROP among preterm infants was 56%. A study in Karnataka, India, the incidence of ROP in urban population was 16.5%. The incidence of ROP in a pediatric unit of hospital in Pune was 23%. Although the criteria for screening were similar, there was wide variation in the incidence of ROP. Even within India, the rate varied from 33% in the present study to 45% in a study from Chandigarh, India.
We used IDO for ROP screening in our study. Adhikari et al. in Nepal used similar equipment for ROP screening. The inability to verify the findings by experts is a significant limitation of screening in our study. Documenting of the retinal image using Retcam (Clarity Medical Systems Inc., Pleasanton, CA, USA) as well as IDO system are costly but perhaps better tools for ROP screening., Capturing retinal images using smart phone and telemedicine facilities is perhaps the best solution to overcome high cost of ROP screening. In this Karnataka Internet Assisted Diagnosis of ROP program for ROP screening, trained technicians used smartphones and retinal cameras to capture the images to interpret the images and decide the intervention strategy with the help of retina specialist by sending these images to tertiary center. The validity of such screening was very high and acceptable for a program approach.
ROP screening could be performed at NICU while the infant is receiving multidisciplinary care. However, the interventions for ROP, especially intravitreal bevacizumab injection should be performed in aseptic conditions preferably in ophthalmic operation theatres rather than in NICU or in mobile units.
The cost of our initiative to address visual disabilities due to ROP seems to be very high. Perhaps predictors of mild ROP will help in further reducing the cost of ROP screening and management of severe ROP cases. In the UK, the cost of ROP telescreening by a trained nurse was 176 pounds. However, at the time of reviewing the cost-effectiveness, one should note the societal burden of blindness that far exceeds the costs of treatment of ROP per child. Use of telemedicine and simple alternatives of using low-cost methods have further reduced the cost of ROP screening., Kemper et al. suggested that the evidence is not sufficient to recommend retinal imaging as a routine at NICUs to identify infants who have serious ROP.
ROP has recently been included as a priority blinding eye disease in VISION 2020 – India. Efforts of strengthening teamwork by neonatologists and ophthalmologists through clinical workshops will further enhance the need to adopt cost-effective and practical approach for ROP screening and timely interventions.
| Conclusion|| |
The present public health intervention type of study that provided solid evidence that has a value similar to a cohort study suggested that a mobile screening seems to be a feasible and cost-effective strategy to detect ROP and offer timely intervention in urban areas with limited resources.
We would like to thank staff of National Institute of Ophthalmology, Pune, and all neonatal intensive care units who collaborated in ROP screening and management project. The cooperation of parents was crucial for the success of this project. We thank them for permitting their wards to participate in this research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Azad R. Prevention of blindness due to retinopathy of prematurity: A national movement. Indian J Pediatr 2014;81:1373-5.
Niranjan HS, Benakappa N, Reddy KB, Nanda S, Kamath MV. Retinopathy of prematurity promising newer modalities of treatment. Indian Pediatr 2012;49:139-43.
World Health Organization. Childhood Blindness in VISION 2020 the Right to the Sight. Global Initiative for Elimination of Avoidable Blindness. Action Plan 2006-2013. Geneva, Switzerland: WHO; 2007. p. 22-5. Available from: http://www.who.int/blindness/Vision2020_report.pdf?ua=1
. [Last accessed on 2014 Jun 05].
Black MM, Pérez-Escamilla R, Rao SF. Integrating nutrition and child development interventions: Scientific basis, evidence of impact, and implementation considerations. Adv Nutr 2015;6:852-9.
Fierson WM, Saunders RA, Good W, Palmer EA, Phelps D, Reynolds J, et al
. Screening examination of premature infants for retinopathy of prematurity. Pediatrics 2013;131:189-95.
Chen J, Stahl A, Hellstrom A, Smith LE. Current update on retinopathy of prematurity: Screening and treatment. Curr Opin Pediatr 2011;23:173-8.
Mutlu FM, Sarici SU. Treatment of retinopathy of prematurity: A review of conventional and promising new therapeutic options. Int J Ophthalmol 2013;6:228-36.
Jalali S, Matalia J, Hussain A, Anand R. Modification of screening criteria for retinopathy of prematurity in India and other middle-income countries. Am J Ophthalmol 2006;141:966-8.
Sanghi G, Dogra MR, Katoch D, Gupta A. Demographic profile of infants with stage 5 retinopathy of prematurity in North India: Implications for screening. Ophthalmic Epidemiol 2011;18:72-4.
Hashmi FK, Chaudhry TA, Ahmad K. An evaluation of referral system for retinopathy of prematurity in leading health centers across Karachi, Pakistan. J Pak Med Assoc 2010;60:840-4.
Richter GM, Williams SL, Starren J, Flynn JT, Chiang MF. Telemedicine for retinopathy of prematurity diagnosis: Evaluation and challenges. Surv Ophthalmol 2009;54:671-85.
Surendran TS, Raman R. Teleophthalmology in diabetic retinopathy. J Diabetes Sci Technol 2014;8:262-6.
Au A, Gupta O. The economics of telemedicine for vitreoretinal diseases. Curr Opin Ophthalmol 2011;22:194-8.
Dunbar JA, Hsu V, Christensen M, Black B, Williams P, Beauchamp G. Cost-utility analysis of screening and laser treatment of retinopathy of prematurity. J AAPOS 2009;13:186-90.
Castillo-Riquelme MC, Lord J, Moseley MJ, Fielder AR, Haines L. Cost-effectiveness of digital photographic screening for retinopathy of prematurity in the United Kingdom. Int J Technol Assess Health Care 2004;20:201-13.
Jalali S, Anand R, Kumar H, Dogra MR, Azad R, Gopal L. Programme planning and screening strategy in retinopathy of prematurity. Indian J Ophthalmol 2003;51:89-99.
International Committee for the Classification of Retinopathy of Prematurity. The International Classification of Retinopathy of Prematurity revisited. Arch Ophthalmol 2005;123:991-9.
Carrion JZ, Fortes Filho JB, Tartarella MB, Zin A, Jornada ID Jr. Prevalence of retinopathy of prematurity in Latin America. Clin Ophthalmol 2011;5:1687-95.
Basmak H, Niyaz L, Sahin A, Erol N, Gürsoy HH. Retinopathy of prematurity: Screening guidelines need to be reevaluated for developing countries. Eur J Ophthalmol 2010;20:752-5.
Murthy KR, Murthy PR, Shah DA, Nandan MR, Niranjan HS, Benakappa N. Comparison of profile of retinopathy of prematurity in semiurban/rural and urban NICUs in Karnataka, India. British J Ophthalmol 2013;97:687-9.
Chaudhari S, Patwardhan V, Vaidya U, Kadam S, Kamat A. Retinopathy of prematurity in a tertiary care center – Incidence, risk factors and outcome. Indian Pediatr 2009;46:219-24.
Vinekar A, Dogra MR, Sangtam T, Narang A, Gupta A. Retinopathy of prematurity in Asian Indian babies weighing greater than 1250 grams at birth: Ten year data from a tertiary care center in a developing country. Indian J Ophthalmol 2007;55:331-6.
Adhikari S, Badhu BP, Bhatta NK, Rajbhandari RS, Kalakheti BK. Retinopathy of prematurity in a tertiary care hospital in Eastern Nepal. JNMA J Nepal Med Assoc 2008;47:24-7.
Weaver DT, Murdock TJ. Telemedicine detection of type 1 ROP in a distant neonatal intensive care unit. J AAPOS 2012;16:229-33.
Prakalapakorn SG, Freedman SF, Wallace DK. Evaluation of an indirect ophthalmoscopy digital photographic system as a retinopathy of prematurity screening tool. J AAPOS 2014;18:36-41.
Vinekar A, Gilbert C, Dogra M, Kurian M, Shainesh G, Shetty B, et al.
The KIDROP model of combining strategies for providing retinopathy of prematurity screening in underserved areas in India using wide-field imaging, tele-medicine, non-physician graders and smart phone reporting. Indian J Ophthalmol 2014;62:41-9.
Flavahan PW, Lavy TE, Wykes W. Intravitreal bevacizumab for the treatment of retinopathy of prematurity: A case report. Scott Med J 2013;58:130-2.
Dave HB, Gordillo L, Yang Z, Zhang MS, Hubbard GB 3rd
, Olsen TW. The societal burden of blindness secondary to retinopathy of prematurity in Lima, Peru. Am J Ophthalmol 2012;154:750-5.
Salcone EM, Johnston S, VanderVeen D. Review of the use of digital imaging in retinopathy of prematurity screening. Semin Ophthalmol 2010;25:214-7.
Vinekar A, Avadhani K, Dogra M, Sharma P, Gilbert C, Braganza S, et al.
A novel, low-cost method of enrolling infants at risk for retinopathy of prematurity in centers with no screening program: The REDROP study. Ophthalmic Epidemiol 2012;19:317-21.
Kemper AR, Wallace DK, Quinn GE. Systematic review of digital imaging screening strategies for retinopathy of prematurity. Pediatrics 2008;122:825-30.
[Table 1], [Table 2]