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Experts do not agree when to treat retinopathy of prematurity based on plus disease
Carina Slidsborg1, Julie Lyng Forman, Alistair R Fielder
1Department of Ophthalmology, Copenhagen University Hospital, Glostrup Hospital, Glostrup, Denmark. carinaslidsborg@hotmail.com
Insights
Inter-reader agreement on retinopathy of prematurity (ROP) vascular changes is poor, leading to inconsistent treatment indications. This subjectivity may explain earlier treatment of preterm infants and a shift in treatment recommendations over time.
Area of Science:
- Ophthalmology
- Neonatology
- Medical Imaging Analysis
Background:
- Retinopathy of prematurity (ROP) is a leading cause of blindness in preterm infants.
- Accurate grading of vascular changes is crucial for timely treatment decisions.
- Previous studies have highlighted variability in ROP assessment.
Purpose of the Study:
- To evaluate inter-reader agreement on ROP severity grading, including central vascular changes and aggressive posterior ROP.
- To determine if there was an unintended shift in the criteria for initiating treatment.
- To assess the impact of subjective interpretation on ROP management.
Main Methods:
- Four international ROP experts graded 243 photographs from 136 infants.
- Grading included five severity levels for vascular changes and presence of aggressive posterior ROP.
- Statistical analyses (permutation test, Rasch analysis, Mann-Whitney U test) were used to assess agreement and shifts in treatment indication.
Main Results:
- Poor inter-reader agreement was observed for central vascular changes (7.38% quadrant score agreement).
- No agreement was reached on the presence of aggressive posterior ROP among all readers.
- A significant shift in treatment indication occurred between 2000-2002 and 2003-2006, with treatment recommended in only 7.4% of eyes despite 80.2% agreement on scoring.
Conclusions:
- Inter-reader agreement on ROP vascular changes is inadequate, particularly with multiple rating categories.
- Subjective assessment of vascular changes may lead to earlier treatment of preterm infants.
- A significant shift in treatment indication has contributed to the increased incidence of treated infants.
Objectives:
To investigate inter-reader agreement on five severity levels of central vascular changes (none, mild, moderate, severe pre-plus disease, plus disease) and aggressive posterior retinopathy of prematurity (ROP), and to see whether an unintended shift in indication for treatment occurred.
Methods:
Four international ROP readers participated. Before the grading of the photographs, the readers were informed that a high proportion of advanced ROP cases were included. In total, 243 photographs/948 quadrants were available from 136 infants. As a standard series of photographs was available, grading was performed under optimised conditions.
Results:
The four readers agreed on the quadrant scores of only 70 (7.38%) of the 948 quadrants--that is, on 1, 5, 15, 4 and 45 quadrants for scores 0, 1, 2, 3 and 4, respectively. The mean scores differed systematically between the readers (permutation test, p<0.0001). Agreement on presence of aggressive posterior ROP from all four readers was not obtained for any of the photographs. Readers scored plus disease in at least two quadrants in 95.5% of the eyes for which treatment was indicated. All four readers agreed on the scoring of indication for treatment for 195 eyes (80.2%); however, treatment was only recommended in 18 (7.4%) eyes. One reader was found to differ systematically from the others in indicating treatment (Rasch analysis; p=0.0001). Finally, a significant shift in indication for treatment occurred between birth period 2000-2002 and 2003-2006 (Mann-Whitney rank sum test, p<0.001).
Conclusions:
Inter-reader agreement on central vascular changes is poor, especially when based on more than two rating categories. The subjective nature of diagnosing such vascular changes possibly resulted in earlier treatment of preterm infants in Denmark over the entire study period (1997-2006). The recent increased incidence of treated infants in Denmark is, at least in part, explained by a significant shift in indication for treatment.
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