Telemedicine for Global ROP Screening
An initiative to remotely treat ROP is reaching more infants in Ghana and Ethiopia and revealing pathological distinctions.
Akwasi Ahmed, MD, MBA; Imoro Z. Braimah, MD; Sadik T. Sherief, MD; Sarthak V. Shah, MD; Arthur R. Brant, MD; Cindy S. Zhao, MD; and Darius M. Moshfeghi, MD
Retina Today 
KEY TAKEAWAYS Although many low- and middle-income countries have expanded neonatal intensive care unit capabilities and improved preterm infant survival rates, health care infrastructure and resources to screen premature infants at risk of retinopathy of prematurity (ROP) have lagged. A pilot telemedicine ROP (teleROP) screening program was launched in 2024 as a partnership between experts at Stanford University and the Komfo Anokye Teaching Hospital and was later expanded across Ghana and Ethiopia. The program has noted region-associated pathological distinctions in ROP; while only 7.5% of neonates at Standford University had treatment-warranted ROP driven by zone I stage 3 without plus disease, 40% of treated eyes in Ghana had treatment indications based on zone-driven disease. Retinopathy of prematurity (ROP) is a preventable condition that remains the leading cause of childhood blindness.1,2 In the 21st century, the third ROP epidemic has disproportionately affected low- and middle-income countries (LMICs), including many in sub-Saharan Africa. Many LMICs have expanded neonatal intensive care unit (NICU) capabilities and improved preterm infant survival rates, but health care infrastructure and resources to screen premature infants at risk of blindness from ROP have lagged.3 Particularly in NICUs in rural areas, premature infants are still exposed to unfractionated oxygen at high rates due to limited numbers of oxygen blenders and continuous positive airway pressure machines. Access to ophthalmologists who can screen and treat ROP is also limited; in Ghana and Ethiopia, ophthalmologists are already in short supply, much less specialists in pediatric ophthalmology or retina.4,5 TELEMEDICINE PROGRAM TO ENHANCE ROP SCREENING To bridge gaps in ROP screening, telemedicine-based ROP (teleROP) screening has been adopted and validated throughout LMICs and high-income settings alike, providing improved access within a country due to the concentration of specialists in major urban areas.6 In the United States, the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP) initiative began in 2005 and has been validated to have high sensitivity and specificity for treatment-warranted ROP (TW-ROP).7 Since 2007, the Karnataka Internet Assisted Diagnosis for Retinopathy of Prematurity model has successfully been screening infants throughout rural and semi-urban India with nonphysician imagers/graders who travel an average of 7,000 km each month.8 A pilot teleROP screening program was launched in 2024 as a partnership between quaternary teleROP experts at Stanford University and the Komfo Anokye Teaching Hospital. The model was then refined and scaled to three other metropolitan areas: Accra and Tamale in Ghana and Addis Ababa in Ethiopia. In the first 22 months of the program, more than 3,000 infants have been screened over nearly 13,000 visits, generating more than 185,000 images and treating 92 infants. Such a program has been accomplished through the diligence of a team that includes eight full-time, in-country ROP coordinators and imagers, two country-wide managers, a network of local physicians (neonatologists, vitreoretinal surgeons, and pediatric ophthalmologists), and a quaternary teleROP expert at Stanford University. After referral of infants meeting local ROP screening criteria (birth weight ≤ 2,000 g or gestational age ≤ 32 weeks in Ghana; birth weight ≤ 2,500 g or gestational age ≤ 34 weeks in Ethiopia; or medical course deemed high-risk by a local neonatologist), widefield fundus images are captured with a 120° or 130° camera.
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