What is the real gold standard for ROP screening?

What Is the Real Gold Standard for ROP Screening? Retinopathy of prematurity (ROP) screening is a hot topic for several reasons. The most important reason is that the child’s clinical care depends in large part on the timing of screening examinations and treatment. In addition, ROP screening can be a cause of medical malpractice actions. The goal of screening is to determine the appropriate management of the child’s eyes. The current gold standard of this screening is binocular indirect ophthalmoscopy (BIO) with scleral depression of the often uncooperative infant’s eye and transcription from the physician’s memory to a drawing. These drawings and notes are a constant source of controversy in depositions and trials for ROP malpractice cases. These arguments customarily involve one expert claiming that the examiner’s findings were wrong based on the drawings in the chart, the age of child, and the physiologic timeline of developing ROP. Although medical malpractice risks are higher in ROP than in diabetes or macular degeneration, the gold standard for documentation of both of these adult retinovascular diseases is clearly photography. The findings in a photograph can be argued as in a drawing, but photographs do give excellent documentation of the features of ROP. The Photo-ROP Study (reported in this issue of RETINA), as well as a study by Ells et al, showed that by using wide-angle photography of the posterior pole it was possible to reliably grade “referral-merited” ROP.1,2 Referral-merited ROP means ROP that either needs binocular indirect ophthalmoscopy or treatment. It has recently been reported that reviewers of fundus photographs of ROP can differ in their opinions on the presence or absence of plus disease.3 Whether screened photographically or at the bedside, equivocal plus disease eyes are followed sequentially until a clear picture evolves. This difference of opinion is also seen in interpretation of fluorescein angiography.4 Yet fluorescein angiography is still clinically helpful. Most ROP early treatment is based on the presence of plus disease or zone 1 findings, both of which are easily seen with wide angle photography, usually with only one image of the posterior pole.1,5 Photographic screening allows the physician to study the images and make appropriate decisions based on what is actually there or to seek advice if the examiner is not sure how to interpret the findings using a real image as a discussion point. Poor images can be reshot and there is no possibility of completing a drawing of something that is not actually there. Why is photography not currently the gold standard? Due to the peripheral nature of ROP, it can be difficult to capture the exact stage and number of clock hours photographically that are in peripheral zone 2 and zone 3. Again, in reference to referralmeriting disease, the camera is very reliable. Practical considerations are that the photographs can be taken by hospital personnel and read by hospital physicians. These photographs can be stored for a second opinion electronically allowing rapid interpretation. These photographs also allow the neonatologist to observe changes in the infant’s eyes. There is a difference between staging and screening. Staging requires binocular indirect ophthalmoscopy to precisely define peripheral retinal findings. Screening determines when the next photographic or BIO examination is needed. Staging is needed for clinical trials. Screening provides good clinical care. These photographs can also be used to accurately present findings in medical malpractice suits. This type of accurate documentation can also be helpful Dr. Trese is a member of the Scientific Advisory Board of Clarity Medical Systems. Reprint requests: Michael T. Trese, MD, Associated Retinal Consultants, 3535 W. 13 Mile Road, Suite 344, Royal Oak, MI 48073; e-mail: mgjt46@aol.com.