Original article
Color Fundus Photography Versus Fluorescein Angiography in Identification of the Macular Center and Zone in Retinopathy of Prematurity

https://doi.org/10.1016/j.ajo.2015.01.027Get rights and content

Purpose

To examine the usefulness of fluorescein angiography (FA) in identifying the macular center and diagnosis of zone in patients with retinopathy of prematurity (ROP).

Design

Validity and reliability analysis of diagnostic tools.

Methods

Thirty-two sets (16 color fundus photographs and 16 color fundus photographs paired with the corresponding FA images) of wide-angle retinal images obtained from 16 eyes of 8 infants with ROP were compiled on a secure web site. Nine ROP experts (3 pediatric ophthalmologists and 6 vitreoretinal surgeons) participated in the study. For each image set, experts identified the macular center and provided a diagnosis of zone. main outcome measures: (1) Sensitivity and specificity of zone diagnosis and (2) computer-facilitated diagnosis of zone, based on precise measurement of the macular center, optic disc center, and peripheral ROP.

Results

Computer-facilitated diagnosis of zone agreed with the expert's diagnosis of zone in 28 (62%) of 45 cases using color fundus photographs and in 31 (69%) of 45 cases using FA images. Mean (95% confidence interval) sensitivity for detection of zone I by experts compared with a consensus reference standard diagnosis when interpreting the color fundus images alone versus interpreting the color fundus photographs and FA images was 47% (range, 35.3% to 59.3%) and 61.1% (range, 48.9% to 72.4%), respectively (t(9) ≥ (2.063); P = .073).

Conclusions

There is a marginally significant difference in zone diagnosis when using color fundus photographs compared with using color fundus photographs and the corresponding FA images. There is inconsistency between traditional zone diagnosis (based on ophthalmoscopic examination and image review) compared with a computer-facilitated diagnosis of zone.

Section snippets

Methods

This study was approved as a prospective study by the Institutional Review Board at Weill Cornell Medical College. Informed consent was obtained from all study participants before participation, and waiver of consent was obtained for use of de-identified retinal images. This study was conducted in accordance with Health Insurance Portability and Accountability Act guidelines.

Study Experts

Among the 9 experts who consented to participate in the study, 6 (67%) were retina specialists and 3 (33%) were pediatric ophthalmologists. The experts have been practicing ophthalmology for a mean of 19 years (standard deviation, 8.6 years; range, 10 to 33 years). When asked if FA is safe in neonates and infants, all (9/9) responded “yes.” Each expert graded 32 images (16 color fundus photographs, 16 FA images) from 16 eyes, for a total of 288 readings of the macular center. Figure 2 reveals

Discussion

The key findings from this study are as follows. (1) There does not seem to be a statistically significant difference by ROP experts in identification of the macular center using color fundus photographs versus FA images. (2) There is a marginally significant improvement in sensitivity of zone diagnosis and no statistically significant difference in specificity of zone diagnosis when using color fundus photographs compared with using color fundus photographs with the corresponding FA images.

Samir N. Patel is a medical student at Weill Cornell Medical College. He received his BS in Biology and Economics from Pennsylvania State University. He is expecting his MD degree in May 2016.

References (19)

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    Zone I ROP was correctly identified only half the time by two readers, whereas TR3 had a much higher sensitivity, identifying zone I ROP correctly two-thirds of the time. Locating the foveal center on color images of preterm infants is challenging and extremely variable, even among ROP specialists.16,17 In our study, even when two independent grading results agreed on the presence of zone I ROP, only half of such results agreed with the clinical examination.

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    It is well established that inter-expert agreement in ROP classification is imperfect. However, most previous work has focused on plus disease8,9,11,12,16 and zone classification.7,19,20 In this study, the majority of discrepancies in stage classification were at the very mild ends of the disease spectrum (stage 0 vs. 1).

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Samir N. Patel is a medical student at Weill Cornell Medical College. He received his BS in Biology and Economics from Pennsylvania State University. He is expecting his MD degree in May 2016.

R.V. Paul Chan, MD, FACS is the St. Giles Associate Professor of Pediatric Retina, Associate Professor of Ophthalmology, and Director of the Retina Service at Weill Cornell Medical College. Dr Chan's clinical practice is in adult and pediatric retina. His research focuses on utilizing new technology and imaging techniques to better evaluate and manage pediatric retinal disease.

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