Retinopathy of prematurity (ROP) is a vasoproliferative disease of the retina that affects approximately 3 in every 1,000 newborns in the United States annually.1 Globally, approximately 2 of every 3 preterm infants affected by ROP are from middle-income countries in Asia, Africa, and Latin America.2 Worldwide, approximately 1 in every 1,000 premature infants develops blindness as a result of ROP.2 Because the rate of neonatal survival is increasing, a greater population of premature infants are susceptible to developing ROP and ultimately becoming blind.3 Although the Cryotherapy for Retinopathy of Prematurity (CRYO-ROP) and Early Treatment for Retinopathy of Prematurity (ETROP) studies demonstrated progress in the timely management of ROP, various factors continue to hinder the ability to provide adequate ROP care.4,5
In the United States, one-fifth of fellowship-trained ROP specialists are considering terminating ROP screening services.3 In a survey of ophthalmology fellows, 29% indicated that they conducted unsupervised screenings two-thirds of the time, and 7% reported that their skills in ROP diagnosis were formally assessed.3 Moreover, exposure to ROP diagnosis and treatment differs among trainees.6 Studies have demonstrated retina fellows achieving 75% sensitivity and 84% specificity in the identification of type 2 or worse ROP compared to pediatric ophthalmology fellows achieving 53% sensitivity and 94% specificity when performing an identical task.1,7 Such inconsistencies indicate a concern for missed ROP diagnoses or improper staging and management.1
On an international level, middle-income and developing countries face additional pressures to provide care for patients with ROP. These factors include higher birth rates, greater neonatal intensive care unit (NICU) admissions, and increasing survival among premature infants, coupled with inadequate screening guidelines, a shortage of ROP specialists, and insufficient resources.8,9
ROP training practices in three countries were explored in the current study. The purpose of this study was to characterize ROP training in international residency and fellowship programs based on responses from trainees, and attending ophthalmologists collected through a web-based survey.
Patients and Methods
This study was granted an exemption by the institutional review board of the University of Illinois at Chicago and conformed to the requirements of the U.S. Health Insurance Portability and Privacy Act of 1996.
Using a publicly available online-based platform ( http://www.SurveyMonkey.com), a multiple-choice survey was developed that included demographic items and questions that targeted ROP screening and treatment practices in training programs. For example, survey items were designed to elicit the number of ROP screenings performed in the NICU, the number of laser photocoagulation procedures performed during training, and the proportion of these activities that were directly supervised by an attending ophthalmologist. Demographic items elicited level of training and setting of clinical practice. Questions that were specifically designed for either trainees or attending ophthalmologists could be left unanswered if not applicable. Authors of the study reviewed the questions for face and content validity.
Residents, fellows, and affiliated attending ophthalmologists were recruited from training programs in the Philippines, Thailand, and Taiwan. To date, the economic statuses of these countries are classified as follows: the Philippines is a lower middle-income country, Thailand is an upper middle-income country, and Taiwan is a high-income country.10 E-mail addresses of residents, fellows, and attending ophthalmologists were provided on request. With permission from host country investigators, an invitation to complete the survey was sent via e-mail. Unique survey web links were created for each country. By following the link, participants were directed to a webpage requesting informed consent to participate in the survey, which was obtained via an electronic signature. Participants who had not completed the survey were sent a reminder after 7 months. Responses were collected between July 2016 and February 2017.
The survey responses were collected and categorized by country. To maintain confidentiality, we used alphabetic characters to represent each country (eg, Country A, Country B, and Country C). The data were analyzed in a similar fashion as previously described.3 The data collected on SurveyMonkey were analyzed by descriptive statistical methods and chi-square statistical significance testing using SPSS software (IBM Corporation, Armonk, NY). The responses were organized into tables and figures using a Microsoft Excel (Microsoft Corporation, Redmond, WA) spreadsheet.
Three countries were invited to participate in the survey, and a total of 95 surveys were included in the analysis. Throughout the current study, the countries were referred to as Country A, Country B, and Country C. The response rate by country was as follows: Country A had 31 participants (33% of total respondents), Country B had 56 participants (59% of total respondents), and Country C had 8 participants (8% of total respondents). Table 1 characterizes the participants by level of training (eg, attending ophthalmologists, fellows, and residents) and by country. Overall, 47 participants reported completing fellowship training, of whom 41 completed training in vitreoretinal disease. In regard to the setting of the institutions where the physicians trained or practiced, 82 participants indicated working in urban centers, 54 reported practicing at a university-affiliated teaching hospital, and 31 reported working in a large community or health ministry hospital. Furthermore, respondents reported the specialty of physicians who typically screened for ROP: 57 indicated vitreoretinal specialists, 34 reported general ophthalmologists, and 15 indicated pediatric ophthalmologists.
Reported Level of Training
Figure 1 shows the number of ROP screenings performed in the NICU by the participants during training. The number of laser photocoagulation procedures performed during training by country are summarized in Figure 2. Figure 3 characterizes responses by attending ophthalmologists, fellows, and residents who estimated the percentage of ROP examinations supervised by an attending ophthalmologist. Likewise, Figure 4 shows the combined responses of attending ophthalmologists, fellows, and residents estimating the percentage of laser treatments supervised by an attending ophthalmologist. Furthermore, the participants were asked to indicate whether or not formal evaluations that measured ROP competency were implemented into the curricula of training programs. For example, evaluations may include attending ophthalmologists verifying the trainees' fundus examinations and providing structured feedback. The results showed that 10 of 31 (32%) participants in Country A, 20 of 56 (36%) participants in Country B, and 5 of 8 (63%) participants in Country C indicated that competency was formally assessed.
Number of retinopathy of prematurity (ROP) screenings performed. Participants reported the total number of ROP screening examinations they performed in the neonatal intensive care unit (NICU) during their training (ie, residency and fellowship, if applicable).
Number of laser treatments performed. Participants reported the total number of laser treatments for retinopathy of prematurity they performed during their training (ie, residency and fellowship, if applicable).
Percentage of examinations supervised. Participants reported the percentage of retinopathy of prematurity examinations directly supervised by an attending ophthalmologist.
Percentage of laser treatments supervised. Participants reported the percentage of laser treatments for retinopathy of prematurity they performed that were supervised by an attending ophthalmologist.
Data regarding the proportion of cases in the respondents' practices that involved screening and management of ROP were reported. Notably, 73 participants (77%) estimated that 1% to 33% of their practice was spent screening for ROP, and 53 (56%) estimated that 1% to 33% of their practice was dedicated to managing ROP. The number of weekly ROP examinations performed during training are reported in Figure 5. Participants reported their preferences for treatment of ROP. Notably, 17 of 31 participants (55%) in Country A preferred anti-VEGF therapy. In contrast, 52 of 56 (93%) in Country B and 5 of 8 (63%) in Country C preferred laser treatment.
Number of weekly retinopathy of prematurity (ROP) examinations. Participants reported the number of weekly ROP examinations they performed.
The key findings of this study were as follows: (1) participants reported infrequent supervision by an attending ophthalmologist when performing ROP examinations, (2) trainees reported performing a limited number of laser photocoagulation procedures for ROP and were not routinely supervised, and (3) slightly more than one-third of the respondents reported receiving formal evaluations that assessed their competency in ROP.
Because a notable proportion of ROP examinations performed by trainees in the NICU were reportedly not supervised by an attending ophthalmologist, it remains unclear whether diagnoses were accurately made and whether treatment plans were appropriately devised. The issues that arise from a lack of supervision, reflected in the data from prior studies, demonstrated the limited accuracy of ROP diagnosis by U.S. retina and pediatric ophthalmology fellows.1,7 Misdiagnosis may lead to worsening of the disease and resultant visual morbidity. Similar concerns were noted by Wong et al.3 in their assessment of U.S. retina and pediatric ophthalmology fellowship training programs through a web-based survey. In the United States, 23 respondents (28%) reported that 67% to 99% of examinations were supervised and 26 (32%) reported 100% supervision.3 On an international level, our findings demonstrated that 46 participants (48%) reported 1% to 33% of screenings were performed in the presence of an attending ophthalmologist. We compared our results using the international dataset with the U.S.-based results from Wong et al. through a chi-square analysis using SPSS software.3 The difference in the number of examinations directly supervised in the U.S. versus internationally is statistically significant (P = .002). In other words, compared to the U.S. results from Wong et al., the number of ROP examinations performed under direct supervision was found to be lower among the international trainees and attending ophthalmologists surveyed.
Among international trainees and practicing ophthalmologists, 35 participants (37%) reported the use of formal evaluations. This proportion is fivefold greater than the percentage of U.S. ophthalmology trainees reportedly receiving evaluations.3 Perhaps this difference is due to the exigent demand for ROP screening in middle- and low-income countries, leading to greater attention directed toward ROP competency during training in these regions. However, there remains an absence of requirements for structured feedback to be provided to trainees in the U.S. and in other ophthalmology programs around the world.3 With the emergence of the “third epidemic” of ROP in middle- and low-income countries and a growing ROP population in sub-Saharan Africa, there is a shortage of trained specialists to screen patients for ROP.9 Given the overall limited exposure to ROP screening and treatment, international ophthalmologists, like their U.S. counterparts, would benefit from a standardization of the ROP curriculum and an assessment of the quality of the cases managed, paralleling the Residency Review Committee's means of enforcing core competencies.11 Official records of ROP screenings and surgical cases, along with formal clinical observation or digital fundus imaging for comparison with expert consensus, are among the recommendations that can be initially implemented by the Accreditation Council for Graduate Medical Education or the Association of University Professors and then adopted by international programs.9
Implementing a tele-education program can enhance trainees' diagnostic skills and aid in ensuring accuracy during screenings in the absence of direct supervision.7 A tele-education system was piloted in Mexico, where trainees who completed the program improved their diagnosis of plus disease, achieving 67% sensitivity compared to the control group that achieved 48% sensitivity.12
There are several potential limitations identified in our study. Responses recorded from every experience level were combined for each country during analysis. Although this allowed for a range of perspectives to be taken into account, it is possible that more junior trainees participated in a lower number of ROP cases and were less likely to partake in the treatment process that requires a skillset in intravitreal injections and laser photocoagulation. The survey was conducted in the English language, which may have been a barrier for some participants to reflect on their training experiences. However, the investigators of the study distributed the survey to programs where English is the common language for teaching. Participation in the survey was voluntary, and those who chose to answer the survey had the option to leave questions unanswered. This raises the possibility that individuals who did not fill out the questionnaire may not have received ROP training during their residency or fellowship, or they felt uncomfortable reporting on their experience. If this were the case, we may expect the results of the study to demonstrate less exposure to ROP training than what we found. Because three countries participated in this study, the analysis does not encompass all regions of the world. However, this study provided a global snapshot of ROP training practices.
The results of the study aid in identifying the strengths and shortcomings of current screening and treatment practices internationally and serve as a launching point for curricular enhancements. Further studies assessing ROP curriculum in international training programs would be beneficial with a focus to improve training for future and current ROP providers.
- Chan RVP, Williams SL, Yonekawa Y, Weissgold DJ, Lee TC, Chiang MF. Accuracy of retinopathy of prematurity diagnosis by retinal fellows. Retina. 2010;30:958–965. doi:10.1097/IAE.0b013e3181c9696a [CrossRef]
- Blencowe H, Lawn JE, Vazquez T, Fielder A, Gilbert C. Preterm-associated visual impairment and estimates of retinopathy of prematurity at regional and global levels for 2010. Pediatr Res. 2013;74Suppl 1:35–49. doi:10.1038/pr.2013.205 [CrossRef]24366462
- Wong RK, Ventura CV, Espirtu MJ, et al. Training fellows for retinopathy of prematurity care: a web-based survey. J AAPOS. 2012;16:177–181. doi:10.1016/j.jaapos.2011.12.154 [CrossRef]22525176
- Good WVEarly Treatment for Retinopathy of Prematurity Cooperative Group. Final results of the Early Treatment for Retinopathy of Prematurity (ETROP) randomized trial. Trans Am Ophthalmol Soc. 2004;102:233–248.
- Cryotherapy for Retinopathy of Prematurity Cooperative Group. Multicenter trial of cryotherapy for retinopathy of prematurity: ophthalmological outcomes at 10 years. Arch Ophthalmol. 2001;119:1110–1118. doi:10.1001/archopht.119.8.1110 [CrossRef]11483076
- Bakri SJ, Alniemi ST, Chan RV. Experiences of vitreoretinal surgery fellows in the United States. Retina. 2013;33:392–396. doi:10.1097/IAE.0b013e31826b6700 [CrossRef]
- Myung JS, Paul Chan RV, Espiritu MJ, et al. Accuracy of retinopathy of prematurity image-based diagnosis by pediatric ophthalmology fellows: implications for training. J AAPOS. 2011;15:573–578. doi:10.1016/j.jaapos.2011.06.011 [CrossRef]22153403
- Gilbert C. Retinopathy of prematurity: a global perspective of the epidemics, population of babies at risk and implications for control. Early Hum Dev. 2008;84:77–82. doi:10.1016/j.earlhumdev.2007.11.009 [CrossRef]18234457
- Chan RV, Patel SN, Ryan MC, et al. The Global Education Network for Retinopathy of Prematurity (GEN-ROP): development, implementation, and evaluation of a novel tele-education system (an American Ophthalmological Society Thesis). Trans Am Ophthalmol Soc. 2015;113:T2.26538772
- Countries and economies. The World Bank. https://data.world-bank.org/country. Accessed December 21, 2017.
- Williams GA. Vitreoretinal surgery fellowship training and the big disconnect: is it just a numbers game?Retina. 2013;33:263–264. doi:10.1097/IAE.0b013e31826b677b [CrossRef]
- Patel SN, Martinez-Castellanos MA, Berrones-Medina D, et al. GEN-ROP, i-ROP Research Consortium. Assessment of a tele-education system to enhance retinopathy of prematurity (ROP) training by international ophthalmologists-in-training in Mexico. Ophthalmology2017;124:953–961. doi:10.1016/j.ophtha.2017.02.014 [CrossRef]28385303
Reported Level of Training
|Country Code||Attending Ophthalmologists||Fellows||Residents||No. of Respondents|