Roundtable addresses ROP screening, fellowship training efforts

Roundtable Participants

Gold: We are updating how we will credential OMIC-insured doctors to be qualified to do ROP screenings and treatments. Dr. Chan and the American Academy of Ophthalmology (AAO) have been instrumental in that.

Chan: Another interesting thing is what Gil Binenbaum, MD, MSCE, discussed at the 2024 American Association for Pediatric Ophthalmology and Strabismus meeting, something he calls the “P-score.” This is rooted out of the International Classification of Retinopathy of Prematurity (ICROP) discussion and is based on how we think about plus disease. Now, with the revised ICROP, we are thinking about plus disease as a continuum of vascular changes; it is more of a spectrum as opposed to just a binary, “You either have plus or no plus.” And, of course, there is pre-plus.

With the P-score they developed a nine-photograph image set for grading plus-like changes and compared intergrader agreement of the set with standard grading with no plus, pre-plus and plus disease.

This work demonstrated that, using the P-score, there was an improved agreement, so it is an interesting discussion: How do you define plus disease now?

And then, as we transition into an increased use of imaging and all the new developments that are coming out, we are still discussing the AI question. How do these new tools factor into taking better care of kids?

I believe that the P-score and the revised ICROP are going to be impactful in how we talk about treatment for plus disease and manage ROP going forward.

Gold: It was an interesting paper that he presented, and it has directed our ROP care to be much more focused than it ever has been. Would you agree with that?

Chan: It is timely because it is taking into account how everything has evolved in terms of what is available to us regarding technology and imaging. It is interesting, too, because I worry a little bit about our dependence on technology and that we may potentially be losing basic skills in our training. Dependency on technology can create questions such as, “Can you do indirect ophthalmoscopy?” This is still an incredibly important skill for examination and performing indirect laser to the retina.

In the adult retina world, we very much depend on the OCT or an image in helping us with making our diagnosis. In the pediatric retina community, we are starting to use these digital imaging systems more frequently. So, are we going to become more dependent on imaging, and will younger ophthalmologists who are going to manage ROP have the basic skills to do procedures like indirect laser? We still need to know how to perform laser and we have to be skilled at indirect ophthalmoscopy.

I do believe that as we move toward using new technology, we need to be thoughtful about what we are doing and how to make sure that we train doctors appropriately to adopt technology while still maintaining our fundamental examination skills.

Douglas R. Fredrick, MD: That was a great comment. By extension, it ties back to OMIC. It reminds me of what we are seeing with remote screening. For those around the country who are peripherally involved, it is always the same thing: The screening can be remote, but there always has to be a human at the end of that exam.

When it comes to OMIC, it is not the machine that is going to be liable. It is the person who fails at the end of that chain, and I don’t think we are paying enough attention to that as we roll out new algorithms to let machines help us do the screening, which is important to decrease the number of unnecessary screens. But at the end of the day, there is a workforce shortage in both the pediatric retina world as well as pediatric ophthalmology. We should be talking more about that.

Gold: The medical and legal risks if things are not done appropriately are certainly relevant. You are following a safety net, which are the protocols that have been written and suggested. They are suggestions, not the standard of care.

The telescreening aspect, like Dr. Fredrick said, is important. Someone sooner or later has to see that child. And then if there is a major problem, someone has to see the child in the hospital. So that is certainly an aspect of this that we have to deal with.

Rudolph S. Wagner, MD: Dr. Chan brought up an excellent point about training. Ensuring future pediatric ophthalmologists have the expertise to perform a precise exam and administer laser treatment is going to be an issue. I don’t know this for a fact, but I would assume that there are more injections being done as additional treatment than there have been in the past. On top of that, I see a lot of kids who are injected who end up needing an additional laser procedure done when they are not vascularizing as expected.

I don’t know if most of the pediatric fellowships are training pediatric ophthalmologists in the treatment of ROP as far as both laser and anti-VEGF injection. This is a legitimate concern because there is a benefit to seeing a number of these patients and treating them over time. You develop the expertise and as a result feel better about making your treatment decision.

You cannot become totally dependent on the imaging and the technology that we are discussing.

Gold: You are correct. There is a variability of the expertise in the training programs. That is reflected in the fellows who are trained to come out doing ROP screenings. Depending on their training, some of the fellows are not even comfortable going in and performing ROP screenings. A lot of them will receive training with retina physicians to do treatments for macular degeneration, for example. But it is a little different in an infant who is intubated in a neonatal intensive care unit (NICU).

M. Edward Wilson, MD: As a fellowship director, I can tell you that we feel a strong responsibility to train those who are going to screen. We are training the foot soldiers who are out there in the nurseries, and the technology may take a little bit of the load off by refining who needs to be screened by an actual ophthalmologist. But the pediatric ophthalmologists are going to do the screenings. There are currently not enough pediatric retina doctors to do that, and we make sure that our fellows are in there every single week performing hundreds of exams. They know that part of their contract when they get employed is going to depend on their ability to feel comfortable doing ROP screenings and taking on some of that liability. That is what the hospitals pay for. We train them to treat as well, but I know that some programs call in retina for treatment.

Either way, every fellowship program must take the responsibility to have competent screeners when the fellows graduate. If you cannot do that, you had better not train fellows or you must partner with somebody who can provide that. You cannot have a fellowship training without graduating a competent screener. That is the foot soldier.

Chan: Dr. Wilson, I would double down on what you just commented. Because of the workforce issues that we are seeing in pediatric ophthalmology in general, you need to not only have the pediatric ophthalmology fellows know how to screen and treat, but you also need to have the retina fellows know how to screen and treat.

Wilson: Adult retina fellows, certainly.

Chan: At our program, the retina fellows are the ones who perform the screening and treatment with our faculty.

Universally, we have to make it part of our core curriculum for all retina fellows and all pediatric ophthalmology fellows in the country because otherwise we are going to have a significant workforce issue.

Gold: In an academic institution, there are some fellows who either do not have that type of experience or do not want to have that type of experience. Some are afraid to go into a NICU.

Wilson: We offer 63 slots in the country in pediatric ophthalmology fellowship — way more than we have candidates. This is one of the things that needs to be policed maybe a little more strictly. That way, if you start a fellowship, you must attest to the competency of the graduate. There is a little bit of this that we can correct ourselves.

Fredrick: I had a quick question: On the Association of University Professors of Ophthalmology (AUPO) Fellowship Compliance Committee surgical log for fellows, you have all the strabismus, cataract and glaucoma data. But is there a minimum requirement for ROP either screening and/or treatment as well as injections?

Wilson: They keep track of injections and lasers, but the only requirement is that you have ROP experience. That needs to be written in more detail. It is loose right now, and there are not minimum numbers. Fellows are asked to write down how many lasers and injections they did, but that is just in the log. They are not necessarily going to lose their AUPO Fellowship Compliance Committee approval because of it.

Chan: That is why we built out these training modules for ROP. In addition, K. David Epley, MD, Faruk Orge, MD, and a team at the AAO are building out virtual reality trainers, which is a terrific initiative with the Knights Templar Eye Foundation.

As a profession, we can provide early career training or continuing medical education for ROP through simulators and web-based training. This could be through OMIC or with the AAO. We have a responsibility to figure out how to train in a responsible way.

Gold: With Dr. Chan and his colleagues, we have restructured the OMIC ROP module, which is good not only for current residents and fellows but also in continuing education down the road.

For example, for OMIC, every 5 years these modules can be updated to address current situations so that people are up-to-date on what is going on. That is certainly one of the positive things that has been done with ROP education.

Wilson: Hospital credentialing committees may get a hold of that because they rely on the fellowship director. If I say that a graduate is competent in ROP screening and treatment, they are going to take my word for it. But as these things become available, they may have more stringent requirements to continue to be credentialed to do this. You could provide the avenue to make sure they can maintain competence.

Wagner: I have a question for Dr. Chan. Do you think many fellows who you train are interested in treating ROP and dealing with ROP? A lot of the people in private practice who are in retina groups are not.

Chan: When people know that they have to manage ROP when they graduate from fellowship, there is definitely a greater motivation to learn how to screen and treat for ROP. We recently graduated two fellows in the same class who, when they first started, were not necessarily interested in pediatric retina and ROP. But one was asked during job interviews to do ROP screening as part of their future job, and then it was clear to them that they had to learn the skills. The other fellow went into a private practice, and I believe that part of the job posting was to treat some pediatric retina cases. There is a need for pediatric retina, and still not enough people are doing it. Whether there is an interest or not, we need skilled retina surgeons who are able to care for children.

And for the two retina fellows I mentioned, they were in a program where there are faculty who focus on pediatric retina and ROP. We provide them with exposure to it. However, some ophthalmology residents and fellows do not want to pursue ROP screening and treatment when they go into practice. There are a lot of considerations that we haven’t discussed today regarding the ROP workforce and it is certainly an issue that needs to be addressed.

• References:
• Bhatnagar A, et al. JAMA Ophthalmol. 2023;doi:10.1001/jamaophthalmol.2023.0809.
• Binenbaum G, et a. Ophthalmology. 2024;doi:10.1016/j.ophtha.2024.05.019.
• Chiang MF, et al. Ophthalmology. 2021;doi:10.1016/j.ophtha.2021.05.031.

• For more information:
• R.V. Paul Chan, MD, MSc, MBA, FACS, of Illinois Eye and Ear Infirmary, University of Illinois at Chicago, can be reached at rvpchan@uic.edu.
• Douglas R. Fredrick, MD, of Kaiser Permanente South San Francisco, can be reached at douglas.r.fredrick@kp.org.
• Robert S. Gold, MD, of Eye Physicians of Central Florida, can be reached at rsgeye@gmail.com.
• Rudolph S. Wagner, MD, of Rutgers New Jersey Medical School, can be reached at r.s.wagner@rutgers.edu.
• M. Edward Wilson, MD, of Storm Eye Institute, Medical University of South Carolina, can be reached at wilsonme@musc.edu.

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