The next generation of pediatric ocular imaging – from  the  experts’  points of view

Screening neonatal and pediatric patients for eye disease can be challenging. When timely intervention can make all the difference, it is crucial to capture quality images that can lead to earlier detection of eye diseases, especially those that can lead to infant blindness. It is the reason why Natus engineers and clinical experts have worked to revolutionize the benefits of RetCam® with the newest launch of our Envision product.


This work is backed by clinical studies that show how retinal imaging is important for overall eye health and general well-being later in life. Explore a range of studies and articles that better explain the benefits of advanced digital screening, how nurse-led ROP programs offer an advantage in the NICU and how telemedicine is more readily available when working with detailed digital images.

Topic: The benefits of Wide-field Digital Eye Imaging vs. Binocular Indirect Ophthalmoscopy


The Accuracy of Digital Imaging in Diagnosis of Retinopathy of Prematurity in Iran: A Pilot Study1

Digital imaging provides many benefits compared to that of Binocular Indirect Ophthalmoscopy (BIO). BIO requires an ophthalmologist to travel to NICU’s (which can be both time consuming and costly) to provide subjective documentation of clinical findings through hand drawings.

A number of benefits are highlighted in this study including:

  • Digital imaging can be performed by other medical personnel such as nurses
  • Imaging has been reported to cause less physiological stress to neonates
  • Imaging provides the ability to compare images over time and is superior to hand drawings that have great variability even among experts.
  • Imaging offers an excellent screening option for ROP and can improve the management of patients. It also aids in facilitating telemedicine and research.

Read the full article here


Efficacy of wide-field digital retinal imaging for retinopathy of prematurity screening2

Wide-Field Digital Retinal Imaging (WFDRI) has been utilized successfully for many years. Studies show that WFDRI has a high sensitivity and a specificity in detecting infants requiring treatment for retinopathy of prematurity (ROP). Regional shortages in the availability of ophthalmologists for ROP screening has become a problem worldwide. Binocular indirect ophthalmoscopy (BIO) is laborious and time intensive for ophthalmologists. Scleral depression required with BIO can cause systemic complications such as bradycardia secondary to oculocardiac reflex.

BIO and WFDRI are known to cause transient changes in cardiorespiratory indices (bradycardia, tachycardia, tachypnoea, reduced oxygen saturation and raised blood pressure) during examination; however, WFDRI has been demonstrated to potentially cause less tachycardia and tachypnea than BIO. ROP screening with WFDRI can safely operate at a level that minimizes over referrals. Wide-field digital retinal imaging-based ROP screening, when applied to telemedicine, can improve delivery, accessibility, quality, and cost of ROP care, with potential to alleviate the manpower challenge. WFDRI-based telemedicine screening can increase access to ROP screening in medically under-resourced hospitals and is potentially more cost-effective than BIO.

Read the full article here


The Role of Telemedicine to Alleviate an increasingly Burdened Healthcare System: Retinopathy of Prematurity3

With many Retinopathy of Prematurity (ROP) screening programs already validated, such as the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP), Karnataka Internet Assisted Diagnosis of ROP (KIDROP) program and the Evaluating Acute-Phase Retinopathy of Prematurity (e-ROP) program, this article demonstrates that remote digital fundus imaging (RDFI-TM) partnered with telemedicine for the screening of ROP, helps address challenges faced by ophthalmologists in examining this disease.

Some of the challenges include: the number of ophthalmolodist wanting to screen, increased liablity and geographic limitations. The main benefit of RDFI-TM is increasing the accessibility of screening in both in high- and low-income countries. Telemedicine screening systems can reach infants in settings where in-person examination might not be readily accessible both in high- and low-income countries.

Read the full abstract here


Topic: Reducing Healthcare Costs and Improving outcomes

Cost analysis of remote telemedicine screening for retinopathy of prematurity4  

Wide-Field digital Retinal Imaging in conjunction with telemedicine appears to be an economically attractive option depending on the location and number of infants screened.

This paper details a cost analysis comparison from the perspective of the Canadian Ministry of Health, where 102 and 72 infants were screened from two existing telemedicine screening programs at two cities in Ontario, Canada, Sudbury and Barrie respectively.

The average total cost per eye examination was $ 4855 ± $ 5616 and $ 4540 ± $ 3129 for the telemedicine group and $ 19 834 ± $ 13 814 and $ 2429 ± $ 1664 for the control group from Sudbury and Barrie, respectively ( p <0.001).
Interhospital transfer cost for the control group was $ 19,489 ± $ 13,605 and $ 2055 ± $ 1471 compared to $ 635 ± $ 3968 and $ 30 ± $ 197 for the telemedicine group ( p <0.001) in Sudbury and Barrie, respectively.

This information is useful for planning a cost-effective model for future screening programs for ROP.

Read full abstract here


A cost-minimization analysis comparing alternative telemedicine screening approaches for retinopathy of prematurity5 

Screening for retinopathy of prematurity (ROP) is an important procedure in the prevention of blindness in high-risk preterm infants.   Many preterm infants are cared for in special care nurseries (SCNs), and when necessary, infants in these nurseries who are at risk of ROP are transferred to tertiary hospitals for ROP screening by pediatric ophthalmologists. The transport of preterm infants for eye examinations adds risk and incurs significant costs to the health system.

The article compares the costs of a traditional model of transporting infants to a tertiary center screening program, with two alternative telemedicine approaches for screening ROP. It demonstrates that Telemedicine programs that facilitate non-physician screening may improve the cost efficiency of the health system while maintaining the health outcomes for children, and reducing the risk associated with infant transport

Read the abstract here


Pain and stress assessment after retinopathy of prematurity screening examination: Indirect ophthalmoscopy versus digital retinal imaging6  

Fundoscopy performed by use of a binocular indirect ophthalmoscope (BIO) is the reference examination technique for screening for ROP. However, it is associated with pain and stress for premature infants. This comparative evaluation of two screening procedures (BIO and WFDRI with RetCam) demonstrated that PIPP and CRIES scores were lower in the WFDRI group vs. BIO examination. In conclusion they demonstrated that screening of ROP with digital imaging presents less pain and stress following completion of the exam when compared with binocular indirect ophthalmoscopy.

Read the full article here


Topic: Who can be trained to perform digital eye imaging?   

Comparison of wide field imaging by nurses with indirect ophthalmoscopy by ophthalmologists for retinopathy of prematurity: a diagnostic accuracy study7

Neonatal nurses trained in wide field digital retinal photography (WFDRP) for screening may provide a safe and effective strategy to reduce the burden of ophthalmologists in performing binocular indirect ophthalmoscopy (BIO). The objective of the study was to determine the diagnostic accuracy of WFDRP in the diagnosis of referral warranting ROP (RWROP).

This article hypothesizes that with an appropriate screening protocol in place, and proper training a standardized set of images can be acquired during an ROP exam. Neonatal nurses trained in wide-field digital retinal photography for ROP screening may provide a safe, feasible and effective strategy to reduce the burden of ophthalmologists in performing binocular indirect ophthalmoscopy.

Read the full article here


Validity of a Telemedicine System for the Evaluation of Acute-Phase Retinopathy of Prematurity8

Currently, identifying infants needing treatment for retinopathy of prematurity (ROP) requires repeated examinations of at-risk infants by physicians. However, ROP screening imaging exams can be carried out by trained non-physician personnel including NICU nurses, neonatal nurse practitioners and ophthalmic photographers. In addition, image interpretation by non-physicians may provide a more efficient strategy and still yield positive results/outcomes.

The results of this multi-center study provides important information about the validity of the e-ROP telemedicine system in managing ROP, as we move forward to address the broader use of digital retinal imaging in NICUs in the United States and other regions in the world.

Read the full article here


Specialist Nurse Screening for Retinopathy of Prematurity – Pilot Study9

ROP screening is traditionally conducted by the ophthalmologist using a binocular indirect ophthalmoscope. There is a shortage of trained ophthalmologists conducting ROP screening and less willingness to undertake ROP management by experienced ophthalmologists due to the increasingly hazardous nature of litigation, which has negatively affected screening programs worldwide.

The goal of this study was to compare ROP nurses that that have extensive experience in ROP screening who would perform the imaging exam and thus provided an ideal and safe setting in which to evaluate the accuracy of this alternative model of screening and ROP Grading to that of and an expert pediatric ophthalmologist.

Preliminary findings of the study demonstrated good agreement between ROP nurses and the ROP expert ophthalmologist.

Read the full article here


Training Retinal Imagers for ROP screening10

Screening for ROP has traditionally been the responsibility of an ROP-trained ophthalmologist. With the mismatch between the limited number of ophthalmologists and the large number of at-risk infants, other methods, such as using retinal digital imaging for remote evaluation, are gaining currency for efficiently, effectively, and safely evaluating infants at risk for ROP.

This article reports the training/certification process of non-physician imagers, image quality, and factors that affected image quality in the National Eye Institute sponsored multicentered e-ROP study and concluded that non-physicians successfully obtained acceptable quality images for ROP evaluation. Skills improved with experience.

Read the full article here


Topic: Telemedicine – Benefits with Digital Imaging   

Screening and treatments using telemedicine in retinopathy of prematurity11   

There is an increasing discordance between the number of premature infants requiring ROP screening and the number of ophthalmologists available to perform it. Numerous studies have shown that photographic screening using contact wide-field cameras can detect treatment and/or referral-warranted ROP at a rate that is safe and comparable to live screening with Binocular Indirect Ophthalmoscopy.

In one study, 43% of severe ROP cases were identified by telemedicine before they were detected by an ophthalmologist which was, on average, two weeks earlier. This is likely due to being able to objectively track the progression of the fundus appearance – one of the largest advantages of photographic screening. Photographic screening combined with telemedicine provides better documentation of disease severity and progression and appears to have several advantages over traditional bedside examination by providing objective data by reducing subjectivity and potentially human error.

Read the full article here


Telemedicine making ROP screening and monitoring a viable reality12   

The article finds that 44% of medical directors at 393 level III neonatal intensive care units did not think there were enough ophthalmologists to screen and/or treat ROP in their local area. Digital fundus imaging, performed weekly, enhances the safety net for eyes where aggressive disease can be missed after initial screening. Numerous studies have demonstrated the validity of the telemedicine paradigm for ROP surveillance.

Digital imaging is more cost effective and significantly more time efficient for physicians. A further advantage is that digital data are available for objective review, dissemination and second-opinion consultation. Digital health technology can reduce healthcare costs and improve access and outcomes for infants at risk for ROP.

Read the full article here


Evaluation of a Remote Telemedicine Screening System for Severe Retinopathy of Prematurity13  

The purpose of this study was to evaluate the validity of remote telemedicine screening for retinopathy of prematurity (ROP) in a population of at-risk preterm infants. A total of 124 telemedicine examinations using RetCam were performed on 35 infants during the study to capture retinal images for this evaluation, which were then sent to a secure server for evaluation by a pediatric ophthalmologist.

Remote telemedicine screening for referral-warranted ROP had a sensitivity of 100%, specificity of 97%, positive predictive value of 66.7%, and negative predictive value of 100%. Good outcomes were noted in all cases, and no patients progressed beyond stage 3 ROP.

This study of telemedicine screening demonstrates the reliably of detected referral-warranted ROP in at-risk premature infants with no poor outcomes during the 11-month period. These results demonstrate the validity and utility of remote telemedicine screening for ROP

Read the full abstract here


Telemedicine Applications in Pediatric Retinal Disease14   

Teleophthalmology is a developing field and one of its most successful applications to date has been in pediatric retinal disease, particularly in screening for ROP. Telemedicine for ROP screening allows a remote ophthalmologist to review images, identify abnormal findings and implement early interventions.

Trained NICU technicians can use a wide-angle, fiber optic fundus camera to obtain retinal images and send them to a specialist via remote digital fundus imaging (RDFI). The specialist can then review the images for ROP.  In some respects, wide-angle photography is even superior to BIO. ROP screening via telemedicine required less time than BIO. Digital imaging allows for analysis and documentation of the progression of ROP over time.

Pediatric retinal disease is particularly well suited to telemedicine because the existing health care delivery system struggles to screen for these diseases, and digital imaging tools allow us to address that need; and once a condition is identified, there are often therapeutic interventions available that benefit the patient.

In summary, telemedicine has been successfully used in pediatric retinal disease. It has been mostly used in the screening of ROP but has already shown promise as a universal newborn screening tool.

Read the full article here

To learn more about the importance of pediatric digital ocular imaging and how the RetCam Envision can benefit you and your patients, we invite you to visit our product website.


1. Karkhaneh R, Ahmadraji A, Riazi Esfahani M, Roohipour R, Farahani Dastjani A, Imani M, Khodabande A, Ebrahimiadib N, Ahmadabadi MN.  The Accuracy of Digital Imaging in Diagnosis of Retinopathy of Prematurity in Iran: A Pilot Study. J Ophthalmic Vis Res. 2019 Jan-Mar;14(1):38-41. doi: 10.4103/jovr.jovr_187_17. PMID: 30820285; PMCID: PMC6388530. 

2. Dai, Shuan & Chow, Kent & Vincent, Andrea. (2011). Efficacy of wide-field digital retinal imaging for retinopathy of prematurity screening. Clinical & experimental ophthalmology. 39. 23-9. 10.1111/j.1442-9071.2010.02399.x. 

3. Fares Antaki, Kenan Bachour, Tyson N. Kim & Cynthia X. Qian Published: 19 June 2020  Ophthalmology and Therapy volume 9, pages 449–464 (2020) 

4. Maram Isaac, MBBS, MHA,Wanrudee Isaranuwatchai, PhD, Nasrin Tehrani, MBBCh, FRCSC. Canadian Journal of Ophthalmology: vol 53, Issue 2, pp162-167. Published: November 14, 2017 DOI: https://doi.org/10.1016/j.jcjo.2017.08.018 

5. Kim E, Nguyen K-H, Donovan T, Edirippulige S, Armfield NR.   A cost-minimisation analysis comparing alternative telemedicine screening approaches for retinopathy of prematurity. Journal of Telemedicine and Telecare. January 2021. doi:10.1177/1357633X20976028 

6. Moral-Pumarega, M.T., Caserío-Carbonero, S., De-La-Cruz-Bértolo, J. et al. Pain and stress assessment after retinopathy of prematurity screening examination: Indirect ophthalmoscopy versus digital retinal imaging. BMC Pediatr 12, 132 (2012). https://doi.org/10.1186/1471-2431-12-132 

7. Athikarisamy SE, et al. BMJ Open 2020;10:e036483. doi:10.1136/bmjopen-2019-036483  

8. Quinn GE, Ying GS, Daniel E, Hildebrand PL, Ells A, Baumritter A, Kemper AR, Schron EB, Wade K; e-ROP Cooperative Group. Validity of a telemedicine system for the evaluation of acute-phase retinopathy of prematurity. JAMA Ophthalmol. 2014 Oct;132(10):1178-84. doi: 10.1001/jamaophthalmol.2014.1604. PMID: 24970095; PMCID: PMC4861044.  

9. Shah SP, Wu Z, Iverson S, Dai S. Specialist Nurse Screening for Retinopathy of Prematurity-A Pilot Study. Asia Pac J Ophthalmol (Phila). 2013 Sep-Oct;2(5):300-4. doi: 10.1097/APO.0b013e31829dc72b. PMID: 26107033 

10. Karp, K. A., Baumritter, A., Pearson, D. J., Pistilli, M., Nyquist, D., Huynh, M., Satnes, K., Keith, R., Ying, G. S., Quinn, G. E., & e-ROP Cooperative Group (2016). Training retinal imagers for retinopathy of prematurity (ROP) screening. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus, 20(3), 214–219. https://doi.org/10.1016/j.jaapos.2016.01.016 

11. Thanos A, Yonekawa Y, Todorich B, Moshfeghi D, Trese MT. Screening and treatments using telemedicine in retinopathy of prematurity. Eye Brain. 2016;8:147-151 https://doi.org/10.2147/EB.S94440  

12. Telemedicine making ROP screening and monitoring a viable reality https://www.modernretina.com/view/telemedicine-making-rop-screening-and-monitoring-viable-reality  

13. Brett A. Begley, BA, Joseph Martin, CO, COMT, Geoffrey T. Tufty, MD, and Donny W. Suh, MD.  Journal of Pediatric Ophthalmology & Strabismus Vol. 56, No. 3. Published Online: February 15, 2019 https://doi.org/10.3928/01913913-20190215-0

14. Pathipati AS, Moshfeghi DM. Telemedicine Applications in Pediatric Retinal Disease. Journal of Clinical Medicine. 2017; 6(4):36. https://doi.org/10.3390/jcm6040036