Retinopathy of prematurity (ROP) is a pathologic process that occurs in the immature retinal tissue of preterm infants. It can progress to tractional retinal detachment which, without proper management, can progress to functional or complete blindness.1 In a recent study in the United States, the overall incidence of ROP among all live births was 0.12%, but the incidence in premature infants hospitalized for more than 14 days was 7.35%.2

With proper management, including the use of peripheral retinal ablative therapy as defined in a series of landmark clinical trials over the past 20 years, the incidence of poor visual outcome has been markedly decreased.1 To ensure that these improved outcomes continue, however, effective systems for screening and treatment must be in place, and pediatric ophthalmologists and retina specialists must work together to ensure that these tiny infants receive the proper sequence of examinations, follow-ups, and treatments.

Pediatric ophthalmologists must be aware of multiple practical issues when they enter into arrangements with a hospital’s neonatal intensive care unit (NICU) to provide screening for ROP in preterm infants. Considerations include what level of training is needed to perform these screenings, which infants should be screened, and how one negotiates a contract that ensures fair compensation for the pediatric ophthalmologist. This article explores some of these issues from the perspective of a pediatric ophthalmologist who has provided ROP screening services to 2 area NICUs for many years.

It is worth saying at the outset that a wealth of information on “Creating a Safety Net” for ROP is available from the Ophthalmic Mutual Insurance Company. It can be accessed by searching for “safety net” on the OMIC website (omic.com). The safety net information has been available since 2006, and it was revised in 2013 to reflect changes in the clinical guidelines set forth in the Policy Statement issued by the American Academy of Pediatrics (AAP) Section on Ophthalmology, the American Association of Pediatric Ophthalmology and Strabismus (AAPOS), and the American Academy of Ophthalmology (AAO).1

As the OMIC ROP Task Force notes, claims for mismanagement of ROP are relatively infrequent, but the indemnity payments for these claims can be high—in fact, among the highest in ophthalmology—because of the young age of the plaintiffs and the fact that essentially a lifetime of vision loss can result, even with treatment. The OMIC documents include sample protocols to help pediatric ophthalmologists establish standardized care at the hospitals where they provide ROP screening services.

WHO SHOULD PERFORM ROP SCREENING?

What level of knowledge is needed to perform ROP screening? This has become an important question over the years. Experience is critical in screening premature babies. Those who have been trained in pediatric ophthalmology in residencies and fellowships—if that training included sufficient volume of examining ROP babies—should be experienced enough to do so in the hospital NICU.

In a premature infant, it is not enough to have the cognitive knowledge to know what to look for. There is also a degree of art in examining the premature baby— being able to make out details in these small eyes with hazy media, and making sure that one gets an accurate look to make a diagnosis.

Even given adequate residency and fellowship training in pediatrics and retina, there is still a learning curve. Unfortunately, in pediatric ophthalmology and retina training today, people do not acquire as much experience with ROP as they might have years ago. As a result, some doctors coming out of their training are comfortable with ROP, and some not. Each new pediatric ophthalmologist and retina specialist must make a personal decision whether or not to become involved in screening for and treating ROP. Thus, those who are comfortable with it will do ROP screening and treatment, and those who are not will likely not seek to perform these types of examinations and treatments.

Our practice includes 4 pediatric ophthalmologists, all of whom perform ROP screening. Experience levels vary from a few years to 30 years, and we all work together to make sure that everyone is comfortable in all aspects of the screening process.

We work with retina specialists who perform retinal treatment when necessary, whether laser or injection of an anti-VEGF agent. Although these retina specialists are not in our practice, we have been working with them for many years. We are comfortable relying on them for treatment, and vice versa. Personally I have no desire to be involved in treating ROP because I know I have competent colleagues who are comfortable with that role.

TRACKING BABIES

Aside from training and comfort level, another reason many pediatric ophthalmologists and retina specialists choose not to be involved in ROP is the high medicolegal risk, as noted above. The most common reason for litigation is that babies become lost during follow-up. Parents fail to show up for visits, and the ophthalmologist is cited as at fault.

Therefore, it is important to have a strong program in place for tracking these patients. There must be a system in place, a “safety net,” to ensure proper documentation, proper tracking, and proper follow-up.

Our practice covers 2 area NICUs. Each hospital has its own ROP coordinator, and my office also has an ROP coordinator—a dedicated person who helps with organizing all the information on ROP babies. We have our own database to track the patients, and every time a baby is seen, that encounter is entered into the system. Currently we are not using electronic health records in our NICUs. When that will change will depend on the availability of software that will be amenable to all parties.

Telemedicine screening of ROP is a growing field that definitely has a place, particularly for rural NICUs that may not have a pediatric ophthalmologist on staff. We have not yet become involved in this area, and it is discussed elsewhere in this issue.

The OMIC safety net documents include excellent, detailed information on all the steps and components needed for tracking these tiny patients, including letters to the parents and communications with the neonatologist

NEGOTIATING A CONTRACT

Negotiating a contract for ROP screening or treatment is important for pediatric ophthalmologists and retina specialists alike. When you contract to provide ROP screening services, you are basically on call for the NICU. In general, reimbursement is low and risk is high. Additionally, the ophthalmologist is incurring expenses away from his or her practice, including time and travel, and he or she relies heavily on the efforts of the ROP coordinator.

There is no set pattern for negotiating a contract for ROP services rendered. It should involve discussion with the neonatologist and the financial officers of the hospital, so that you can become an important member of the NICU team.

The contract with the NICU, with its implied recognition that you are part of the team, is one of the stimuli for pediatric ophthalmologists and retina specialists to continue with the screening and treatment of premature babies. We have contracts with both of our NICUs, and we certainly feel that we are an important part of their teams.

In our contracts, we stipulate the retina specialists we want to work with. We are not in the same practice as the retina surgeons, so they and we have separate contracts. It is important for the pediatric ophthalmologist, who is only doing screening, to have input on who does the treatment. But it is ultimately up to the retina doctors to say yes, as well as the neonatologist.

DOING THE WORK

Although liability is high, the feeling in our practice is that part of our charge as pediatric ophthalmologists is to care for children of all ages. Premature babies are very frail children, and they need their eyes examined like any other child.

The ramifications of medicolegal issues are there, but we can have the same issues any day with any patient who walks into our office. This is just another patient. We want to do good work and do it completely. We have a protocol to follow these babies, and we set it up as best we can to do our jobs as pediatric eye doctors. We all worry about the litigation, but if we do our jobs the way we are supposed to, hopefully that will not be an issue.

Finally, it is important to note that ROP care continues to evolve. Classification and screening protocols are frequently updated, as with the Policy Statement update last year.1 There is an excellent online education tool that can help pediatric ophthalmologists and retina specialists stay current with changes in ROP care: the ROP Education Module from Focus ROP (focusrop.com). In fact, those who are OMIC insured are required to take and pass the exam at the end of the module, which keeps their knowledge of ROP current.

As the OMIC ROP Task Force observes in its Safety Net documents, “Screening and treating premature infants for [ROP] is an important aspect of pediatric ophthalmic care that provides a valuable service to not only the individual baby but also to society as a whole.”3 Attention to the practical aspects of providing ROP care can make this a rewarding part of what we do as pediatric ophthalmologists.

Robert S. Gold, MD, FAAP, is a pediatric ophthalmologist with Eye Physicians of Central Florida in Maitland, FL. He states that he has no financial relationships to disclose. Dr. Gold may be reached at rsgeye@gmail.com.

  1. Fierson WM; American Academy of Pediatrics Section on Ophthalmology; American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; American Association of Certified Orthoptists. Screening examination of premature infants for retinopathy of prematurity. Pediatrics. 2013;131(1):189-195.
  2. Lad EM, Nguyen TC, Morton JM, Moshfeghi DM. Retinopathy of prematurity in the United States. Br J Ophthalmol. 2008;92(3):320-325.
  3. Ophthalmic Mutual Insurance Company. ROP: Creating a safety net. http://www.omic.com/rop-creating-a-safety-net/
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