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Compared to many medical conditions, retinopathy of prematurity (ROP) lends itself relatively easily to screening, for it is treatable and affects a defined population of preterm babies who
are almost always resident in the hospital neonatal unit at the critical time. The report of an 11-year experience of ROP screening by Brennan _et al_ in this issue of _Eye_ is useful and
thought provoking as it reflects maintained solid experience, confirms some aspects of the clinical features of this condition, but even more important, it highlights a number of the
dilemmas of screening. The authors confirm the findings of other studies that ROP behaves in a relatively uniform manner, displays in its acute phase a high degree of interocular symmetry,
and that severe disease requiring treatment develops over a relatively defined period that is best defined by postmenstrual age.1,2,3 While this last point is recognised by the current UK
guidelines,4 the recommendation that screening starts at 6–7 weeks caused some pretty close shaves in the Newcastle study of Brennan _et al_ as five babies needed treatment at the 7th week.
No ophthalmologist wants the fright of diagnosing ROP at such an advanced stage on the first examination, especially as there is a distinct possibility that in the future treatment will be
undertaken at a slightly earlier stage. Brennan _et al_ support the current birthweight (BW) and gestational age (GA) inclusion criteria of the UK guidelines (⩽1500 g BW and <32 weeks
GA). They point out that if these were lowered to ⩽1250 g BW and ⩽29 weeks GA, as sometimes suggested to reduce the screening burden, then two babies included in their report would have been
denied the opportunity for treatment. Screening is currently performed by experienced ophthalmologists, who in the UK examine about 8200 babies to identify the 1.8% who require treatment.5
Brennan _et al_ point out that each baby requires an average of 2.3 examinations and it takes an average of 39 examinations to detect each case of threshold ROP—not very dissimilar from the
estimate of 55 examinations per threshold case obtained from a national audit.5 This low treatment yield represents a massive ‘funnel effect’, and it could be argued that this is not
optimising skilled and expensive ophthalmic expertise, which might be better utilised for other more fruitful tasks. So, now is the time to seriously explore alternatives to screening by
ophthalmologists. Transferring the screening role to the paediatrician falls into the category of passing the buck rather than real innovation, and cannot be robust using traditional
examination techniques. However, the recent development of contact wide-field digital retinal imaging (eg RetCam 120) opens up exciting new opportunities for ROP screening and can utilise
other staff such as a nurse or medical photographer.6,7 The images so obtained could either be subjected to full or partial grading (such as: no, mild or severe ROP) by the examiner, or
transmitted (telemedicine) without preliminary analysis to the ophthalmologist for primary grading or for confirmation. Also, images from babies suspected of harbouring serious diseases
could also be shipped remotely for expert opinion. Brennan _et al_ rightly point out that photographic screening must not result in deskilling ophthalmologists in the field. Clearly,
research is required, but this new technology is here and it is important that we fully explore its potential, not only in the UK and other high-income countries, but also in middle-income
countries where ROP-induced blindness is an even greater problem and ophthalmic expertise sparse.8 The recent report of a national UK audit showed that many ophthalmologists are making a
great contribution to ROP screening, and frequently without this being recognised in their job plans.5 The report by Brennan _et al_ in this edition of _Eye_ shows just how much work is
required to identify one baby that needs treatment. This same group has also recently shown9 that the regionalisation of ROP services improves compliance with guidelines. So, now is the time
to follow the excellent example of the Newcastle group to look hard at how we screen babies for ROP and to consider all aspects of service organisation, and promote concordance with
clinicians and families,10 so that it is really both effective and efficient. REFERENCES * Fielder AR, Shaw DE, Robinson J, Ng YK . Natural history of retinopathy of prematurity: a
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Download references AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Department of Ophthalmology Imperial College Faculty of Medicine 9th Floor Laboratory Block Charing Cross Hospital, Fulham
Palace Road, London, W6 7RF, UK A R Fielder Authors * A R Fielder View author publications You can also search for this author inPubMed Google Scholar CORRESPONDING AUTHOR Correspondence to
A R Fielder. RIGHTS AND PERMISSIONS Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Fielder, A. Time for a fresh look at ROP screening. _Eye_ 17, 117–118 (2003).
https://doi.org/10.1038/sj.eye.6700297 Download citation * Published: 14 March 2003 * Issue Date: 01 March 2003 * DOI: https://doi.org/10.1038/sj.eye.6700297 SHARE THIS ARTICLE Anyone you
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