It is an irony of medicine that sometimes a treatment or drug that cures one problem causes another that was unforeseen. In neonatology the paradox is this: As neonatal care continues to improve and ever-younger preemies survive, increasing numbers of survivors are losing their sight from a common condition in premature infants, retinopathy of prematurity (ROP).
Michael Chiang and Osode Coki look for signs that can cause blindness in preemies.
The ultimate irony is that at a time when the need for early detection and treatment is growing (one out of every eight babies in the United States is born prematurely), hospitals are struggling to find doctors to care for the eyes of preemies. Michael Chiang, M.D., assistant professor of ophthalmology and biomedical informatics at Columbia, not only has chosen to undertake this task, but is also developing a method to train others to care for these babies.
"Not many ophthalmologists are trained to perform ROP exams and of those trained, many are unable to do it because of logistical difficulties or concerns about medico-legal liability," Dr. Chiang says. So at least once a week, Dr. Chiang packs a few instruments, leaves his practice, and walks over to the neonatal intensive care unit at Morgan Stanley Children's Hospital of New York to spend the day peering inside the eyes of preemies.
With an ophthalmoscope strapped to his head like a miner's headlamp, Dr. Chiang carefully examines the infants' retinas. As he examines a tiny baby boy, born 15 weeks prematurely, Dr. Chiang painstakingly searches for the irregular blood vessels that cause ROP. With what looks like a little metal lasso in one hand, Dr. Chiang gingerly moves the boy's eyeball to get as complete a view of the retina as possible. The baby squirms and whimpers and his electronic heart monitor begins to beep. After several minutes, Dr. Chiang finishes examining the second eye and declares that both eyes look good.
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Thousands Diagnosed Each Year
About half of all preemies weighing less than three pounds at birth display some signs of ROP. Among these 15,000 babies diagnosed with ROP in the United States each year, most cases simply clear up on their own. But in some, the irregular vessels coalesce into a jumbled mass that can peel the retina away from the eye. If spotted early by a skilled ophthalmologist, laser treatment can shrink the mass and greatly reduce the chance of blindness.
Of the 400 to 600 preemies who become blind from ROP each year in the U.S., the sight of many could have been preserved if their condition was caught and treated early enough. Rural hospitals have the most trouble finding doctors, but even some large hospitals in urban areas such as New York City have had difficulty finding ophthalmologists willing to perform the exams.
"The shortage of doctors is a real problem," Dr. Chiang says. "Also, a few hundred cases of blindness each year may not sound like a lot, but the costs to society of lifelong blindness in these children is estimated at between $40 million and $60 million per year in the United States alone. And, of course, the emotional and economic impact of vision loss at such a young age is enormous both to the child and his or her family."
To help eradicate blindness caused by ROP, Dr. Chiang, John Flynn, M.D., the Anne S. Cohen Professor of Pediatric Ophthalmology, and Justin Starren, M.D., Ph.D., associate professor of clinical biomedical informatics and radiology, have turned to the Internet. The high speed and reliability of Internet connections today coupled with the introduction of the Retcam, a digital camera designed to take pictures of the infant retina now make it possible for a small number of trained ophthalmologists in reading centers to screen patients at any hospital in the country.
So far, a few published studies by Drs. Chiang, Flynn, Starren, and others have shown that expert readers viewing Retcam pictures may be able to arrive at the same diagnosis as standard examinations performed by ophthalmologists. But the pictures used in those studies were taken by trained ophthalmologists or ophthalmic photographers. Hospitals are still left with the problem of finding doctors to take pictures to send to reading centers.
To deal with this challenge, Drs. Chiang and Flynn asked themselves what would happen if a neonatal intensive care unit (NICU) nurse took the pictures. They are now answering that question in an NIH-funded trial involving babies at both New York-Presbyterian and the hospital of the University of Miami.
Babies in the trial undergo two exams: a standard exam conducted by an ophthalmologist and a Retcam exam conducted by an NICU nurse. Osode Coki, the trial's research nurse, begins the exam by dabbing anesthetic gel onto the baby's eyes. A few moments later, she places the lens of the handheld video camera onto the clear gel. The camera transmits images of the retina to a nearby computer monitor and when the image looks good, Osode snaps the photo by pressing a footpad. A set of photos covering the entire retina is then sent to CUMC's reading center where an expert ophthalmologist will make a diagnosis from the images.
"If our results show that remote screening works just as well as the standard exam, we could bring the diagnostic expertise of a major eye institute to isolated locations, vastly extending our ability to catch and treat ROP before it causes blindness," Dr. Chiang says.
The Retcam telemedicine system has the potential to reach every baby at risk of ROP in the United States, and also in developing countries that are increasingly saving younger and younger preemies. "ROP is probably the leading cause of preventable blindness in both developed and developing countries, but we don't have enough ophthalmologists to examine every baby in the world," Dr. Flynn says. "With this network, nurses in Lithuania can interact with experts at Columbia and there's the possibility of transferring these babies to local doctors who can treat them to prevent blindness."