title: Telemedical diagnosis of retinopathy of prematurity intraphysician agreement between ophthalmoscopic examination and image-based interpretation.
abstract: OBJECTIVE
  To evaluate the intraphysician agreement between ophthalmoscopic examination and image-based telemedical interpretation for retinopathy of prematurity (ROP) diagnosis, when performed by the same expert physician grader.
  
  
  METHODS
  Prospective, nonrandomized, comparative study.
  
  
  METHODS
  Sixty-seven consecutive premature infants who underwent ROP examination at a major university medical center whose parents consented for participation.
  
  
  METHODS
  Infants underwent standard dilated ophthalmoscopy by one of two pediatric ophthalmologists, followed by retinal imaging with a commercially available wide-angle fundus camera by a trained neonatal nurse. Study examinations were performed at 31 to 33 weeks postmenstrual age (PMA) and/or 35 to 37 weeks PMA. Images were uploaded to a Web-based telemedicine system developed by the authors. After a 4- to 12-month period, telemedical interpretations were performed in which each physician graded images from infants upon whom he had initially performed ophthalmoscopic examinations. Diagnoses were classified using an ordinal scale: no ROP, mild ROP, type 2 prethreshold ROP, and treatment-requiring ROP.
  
  
  METHODS
  Absolute intraphysician agreement and kappa statistic between ophthalmoscopic examination and telemedical interpretation were calculated by eye. All intraphysician discrepancies were reviewed, and underlying causes were classified by eye as no ROP identified by ophthalmoscopic examination, no ROP identified by telemedical interpretation, discrepancy about presence of zone 1 ROP, discrepancy about presence of plus disease, or other discrepancy in classification of ROP stage.
  
  
  RESULTS
  Absolute intraphysician agreement between ophthalmoscopic examination and telemedical interpretation was 86.3%. The kappa statistic for intraphysician agreement between examinations ranged from 0.657 (substantial agreement) for diagnosis of treatment-requiring ROP to 0.854 (near-perfect agreement) for diagnosis of mild or worse ROP. Among 206 eye examinations (103 infant examinations), there were 28 (13.6%) intraphysician discrepancies in diagnosis, 8 of which resulted from uncertainty about presence of zone 1 disease and 4 from uncertainty about presence of plus disease.
  
  
  CONCLUSIONS
  Intraphysician agreement between ophthalmoscopic examination and telemedical interpretation for ROP was very high. Neither examination modality appeared to have a systematic tendency to overdiagnose or underdiagnose ROP. Diagnosis of zone 1 disease and plus disease were major sources of clinically significant discrepancies.
authors.affiliation: Department of Ophthalmology, Division of Neonatology, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA.
authors.forename: Karen E
authors.initials: KE
authors.lastname: Scott
authors.forename: David Y
authors.initials: DY
authors.lastname: Kim
authors.forename: Lu
authors.initials: L
authors.lastname: Wang
authors.forename: Steven A
authors.initials: SA
authors.lastname: Kane
authors.forename: Osode
authors.initials: O
authors.lastname: Coki
authors.forename: Justin
authors.initials: J
authors.lastname: Starren
authors.forename: John T
authors.initials: JT
authors.lastname: Flynn
authors.forename: Michael F
authors.initials: MF
authors.lastname: Chiang
mesh_terms: D001724:Birth Weight; D005865:Gestational Age; D006801:Humans; D007090:Image Interpretation, Computer-Assisted / Q000379:methods*; D052577:Infant, Extremely Low Birth Weight; D007231:Infant, Newborn; D007234:Infant, Premature; D019102:Infant, Very Low Birth Weight; D015588:Observer Variation; D009887:Ophthalmoscopy / Q000379:methods*; D011446:Prospective Studies; D015203:Reproducibility of Results; D012178:Retinopathy of Prematurity / Q000175:diagnosis*; D012680:Sensitivity and Specificity; D019113:Telepathology / Q000379:methods*