|Year : 2019 | Volume
| Issue : 6 | Page : 723-724
Imaging the pediatric retina – Where are we headed?
Future Vision Eye Care and Research Centre, Mumbai, Maharashtra, India
|Date of Web Publication||24-May-2019|
Dr. Sabyasachi Sengupta
Future Vision Eye Care and Research Centre, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sengupta S. Imaging the pediatric retina – Where are we headed?. Indian J Ophthalmol 2019;67:723-4
This special issue of the Indian Journal of Ophthalmolog y on pediatric retina has been carefully curated to bring you the hot topics in this niche field of ophthalmology. By far the most common etiology that comes to mind when we imagine the pediatric retina is retinopathy of prematurity (ROP) which has been dealt with in great detail in this issue, including its epidemiology, pathogenesis, risk factors, imaging, screening, treatment, and outcomes by some of the masters in this field. In addition, pediatric tumors such as retinoblastoma, medulloepithelioma, and diseases inherently common in children such as Coats disease have been covered in some detail.
The third epidemic of ROP is upon us, with increasing incidence being reported form the developing world, and has been attributed to the development of high-class neonatal intensive care units (NICUs) with resultant heightened survival of very premature infants. It is imperative that these babies be screened timely to detect ROP and be treated at the first instance of vision-threatening disease. However, screening is easier said than done simply due to the increasing burden of disease, with thousands of babies requiring periodic screening till complete vascularization and the lack of specially trained vitreoretina specialists capable of performing widespread screening. To overcome these obstacles, innovative screening models have been built using tele-ophthalmology, such that ophthalmic technicians are trained to use retinal imaging devices and transmit images to a nodal center where an ophthalmologist can interpret images and advise the next course of action in real time. The Indian Twin-City ROP project  and the Karnataka Internet Assisted Diagnosis of ROP (KIDROP) are two such examples of very successful models from India that have made a tremendous impact and have been honored by international agencies for their work. Although binocular indirect ophthalmoscopy by an ROP specialist is the current standard of care, the burden of screening for vision-threatening disease may soon be transferred to wide-field digital imaging in the near future. With imaging possible, the world is also moving toward automated image analysis in ROP to reduce the burden of manual image interpretation.
The key ingredient for the success of these tele-ophthalmology-based screening models is the quality of the retinal images obtained by the technicians. There are many challenges in imaging the pediatric retina, including the need for a wide-field image to capture as far of the peripheral retina as possible, often requiring a contact system to stabilize the globe, a supine patient in a NICU setting with little space to work with, and poor mydriasis especially in the setting of advanced disease. The ideal system will be one which gives ultra-wide-field images (i.e., allowing visualization up to the ora serrate 360°) through a relatively small pupil, noncontact with eye tracking, portable, lightweight, preferably handheld, with Internet connectivity to seamlessly transfer images and is easy to operate with little training. In addition, fluorescein angiography and optical coherence tomography (OCT) including OCT angiography accompaniments will make for an ideal system.
RetCam (Natus Medical Systems, Inc., Pleasanton, CA, USA) is the most established imaging device till date and has been used for ROP imaging for over two decades. Although it satisfies many of the above-mentioned criteria for an ideal system, it is cost-prohibitive and hence, a large part of the developing world has found it difficult to use. Several other systems exist to image the retina. The handheld PICTOR camera has been studied most widely for the purpose of ROP screening. However, its limited field of view (45°) and difficult alignment issues are limiting factors which have reduced its popularity and wider adoption. Several other options such as ICON (Phoenix Clinical, Inc., Pleasanton, CA, USA), 3nethra Neo (Forus Health, Bangalore, India), Panocam (Visunex Medical Systems, Inc., Fremont, CA, USA), MII RetCam (Coimbatore, India), and the Optos California and 200-TX Optomap (Optos, Marlborough, MA, USA) exist for wide-field imaging of the retina in patients with ROP. This special issue of the Indian Journal of Ophthalmolog y has an article on the usefulness of the MII RetCam for ROP imaging. However, most of these devices remain largely untested in the real world, and the sensitivity and specificity to accurately detect ROP against indirect ophthalmoscopy are not available.
With the growing burden of ROP and tele-ophthalmology-based screening models offering a solution to tackle this disease effectively and help tease out babies that need urgent intervention, we need better imaging devices that are cost-effective, close to having ideal requirements, and are affordable for most ophthalmologists. We also need better studies adhering to the Standards for Reporting Diagnostic Accuracy Studies (STARD) to evaluate how good these imaging systems are compared with indirect ophthalmoscopy by an ROP expert. With some of the above-mentioned devices being made in India, the onus is on us to validate their sensitivity, specificity, and diagnostic accuracy in detecting vision-threatening ROP. All ROP specialists in India need to get together and form a consortium so that collaborative research can be performed across the country to validate the existing and newer devices on a large scale. Robust data generated from such studies will bring out unparalleled results and will help ophthalmologists adopt new and emerging technologies for ROP screening with confidence the world over. The Indian ROP society, constituted recently, is a step in this direction and brings together ROP specialists in India to work together and bring in advances in ROP management with special focus on ROP in India. With a high disease prevalence and a committed research group willing to invest time and energy in collaborative studies, we can pave the way for testing all emerging technologies on ROP imaging. It is our hope that with such collaborative research, the developing world, lead by India, shall do justice to its tremendous intellectual potential by making meaningful contributions to global scientific literature.
About the author
Dr Sabyasachi Sengupta is a consultant vitreoretinal surgeon at Future Vision Eye Care, Mumbai. He completed his Diploma in Ophthalmology from JIPMER, Pondicherry followed by DNB at Aravind Eye Hospital, Pondicherry. He then completed a research – cum – clinical fellowship in surgical vitreoretinal disorders at the prestigious Sankara Nethralaya, Chennai, and went on to pursue a research fellowship at Wilmer Eye Institute, Johns Hopkins University School of Medicine, USA. He was awarded the Mc Cartney prize by the Royal College of Ophthalmologist's in London for securing the highest marks in Ocular Pathology in FRCOphth in 2010 and had the distinction of being the first ever non-British national to receive this award. He was the recipient of Dr G. Venkataswamy Gold Medal in DNB Ophthalmology in 2009. He was awarded the best research fellow as well as the best outgoing fellow 2010 – 2012 at Sankara Nethralaya. He was recently awarded the “Young Achievers Award” by the Vidarbha Ophthalmic Society for his outstanding achievements and contribution to ophthalmic research in India. He has published 80 articles in peer-reviewed journals and presented more than 50 papers and posters in national and international conferences. He is the current associate editor of the Indian journal of Ophthalmology and a regular reviewer for many journals including JAMA Ophthalmology and Ophthalmology. He is the founder and director of Senguptas Research Academy, offering E-learning lectures on research methodology, with over 700 students enrolled from 66 countries. The academy also provides services for manuscript preparation.
| References|| |
Sai Kiranmayee P, Kalluri V. India to gear up to the challenge of “third epidemic” of retinopathy of prematurity in the world. Indian J Ophthalmol 2019;67:726-31. [Full text]
Jalali S, Kesarwani S, Hussain A. Outcomes of a protocol-based management for zone 1 retinopathy of prematurity: The Indian Twin Cities ROP Screening Program report number 2. Am J Ophthalmol 2011;151:719-24.e2.
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.
] [Full text]
Wittenberg LA, Jonsson NJ, Chan RP, Chiang MF. Computer-based image analysis for plus disease diagnosis in retinopathy of prematurity. J Pediatr Ophthalmol Strabismus 2012;49:11-20.
Prakalapakorn SG, Wallace DK, Freedman SF. Retinal imaging in premature infants using the Pictor noncontact digital camera. J AAPOS 2014;18:321-6.
Vinekar A, Rao SV, Murthy S, Jayadev C, Dogra MR, Verma A, et al
. A Novel, Low-Cost, Wide-Field, Infant Retinal Camera, “Neo”: Technical and Safety Report for the Use on Premature Infants. Transl Vis Sci Technol 2019;8:2.
Lekha T, Ramesh S, Sharma A, Abinaya G. MII RetCam assisted smartphone based fundus imaging for retinopathy of prematurity. Indian J Ophthalmol 2019;67:834-9. [Full text]