Winter 2012 Update

Casey Eye Institute: A Message from Dr. Wilson

Dr. David Wilson, OHSU Casey Eye InstitutePerhaps the most challenging eye disease is one called Retinopathy of Prematurity (ROP) that afflicts the most vulnerable of patients – premature babies.

A pioneering study centered at the Casey Eye Institute, and coordinated by Earl Palmer, M.D., demonstrated that the vision loss from ROP could be reduced if the condition was identified and treated at an early stage. But it is no simple task to safely identify and treat this disease in such fragile neonates. In fact few eye doctors receive sufficient training in ROP during residency or fellowship, so very few physicians are available to care for these vulnerable patients.

Michael Chiang, M.D. has pioneered the use of a specialized camera system that can be used by a neonatal nurse. Images from this camera can be sent to a reading center he has developed so that those babies needing treatment can be identified. Please see the Q&A with Dr. Chiang below for more insight into his exciting work.

The informatics based screening system for ROP that Dr. Chiang is developing will potentially save millions of dollars in eye care costs, but more importantly will save the vision of babies that might otherwise face a lifetime of blindness.

Your support of Casey Eye Institute gives hope. Everyone deserves a chance at a full and independent life. During this season of giving please renew your support of the Casey Eye Institute and help prevent one of the leading causes of blindness.

With deepest gratitude,

David J. Wilson, M.D.
Director, Casey Eye Institute

Q&A with Dr. Chiang

The following is from an interview with Michael F. Chiang, M.D., Professor of Ophthalmology & Medical Informatics and Clinical Epidemiology, Oregon Health & Science University.

Michael F. Chiang, M.D.Q: Why did you choose Casey Eye Institute to continue your research?
A: There are not that many places that you can do both great ophthalmology and great biomedical informatics. OHSU is one out of perhaps five or six such places in the country. I started my work at Columbia University with Ted Shortliffe (an internationally-known biomedical informatics expert), Justin Starren (a telemedicine specialist), and John Flynn (a foremost expert in retinopathy of prematurity).

Q: What problem(s) does telemedicine solve for retinopathy of prematurity?
A: Blood vessels in the eye begin developing at four months and complete development by full term. In a baby born several months early, the blood vessels are not fully developed yet. The exposure to the extrauterine environment – birth, oxygen exposure, and illness – can cause the blood vessels to grow irregularly and eventually detach the retina, resulting in blindness.

To diagnose ROP, you use an ophthalmoscope to look at the retina; based on what you see, you decide how to manage the disease which is no easy task. When ROP first became common during the 1950s, there was no treatment available, we could only examine and watch as some of these babies went blind.  For over 20 years, experts such as Earl Palmer (right here at OHSU) and John Flynn could only examine these babies and watch some of them go blind. Today, because of the pioneering work of Drs. Palmer and Flynn, and others, we can cure ROP using laser or freeze treatment when warranted.

But diagnosing ROP is a challenge which is why it continues to be a leading cause of childhood blindness in Oregon and throughout the world. There are enormous problems with access to healthcare, especially in rural areas so I spent seven years working out the system so that a telemedicine diagnosis would be as accurate as diagnosis in person. If we can get the data, we can classify the disease correctly – as long as experienced ophthalmologists can review the images.

Q: What are some of the complexities surrounding diagnosis and treatment of ROP?
A: Infancy-acquired childhood blindness is an enormous problem. As study found that in 1993, it cost to the US $40-60 million dollars for 400 to 600 babies blinded by ROP per year.

These babies are all hospitalized in the neonatal intensive care unit (NICU). But ophthalmologists work in offices and clinics, and it is often difficult and time intensive to travel to NICUs regularly to perform ROP screening exams. The coordination among ophthalmologists, neonatologists, nurses, and other NICU staff is extremely difficult. Sometimes babies are unavailable for regularly-scheduled ROP exams because they need tests from other physicians. So, these logistics are extremely challenging.

Even a lot of major hospitals cannot find people to do ROP exams often due to the enormous medico-legal liability for physicians (worse than for any other ophthalmic disease). There are also major gaps in ROP education. We’ve performed national surveys showing that fellows are often receiving inadequate training in this area, yet at many other institutions ROP exams are being performed by fellows without supervision by an experienced attending ophthalmologist.

Additionally, the incidence of ROP is increasing as improvements in neonatal care are increasing the survival rate of these premature babies. At the same time there are fewer ophthalmologists willing to diagnose. Demand is going up, supply is going down.  

Q: How is this work you are doing with infants going to help people with age-related macular degeneration?
A: A major cause of ROP, age-related macular degeneration, diabetic retinopathy, and other diseases is uncontrolled growth of blood vessels. It appears to be the exact same process that occurs in all of these diseases, yet why it occurs is not completely understood. In premature infants, the process of abnormal blood development in ROP occurs within weeks-to-months. In those other diseases, it can take decades to occur.  By studying what happens with ROP in premature infants, we can learn important lessons that may be applied to many other diseases.

We are actively studying the genetics of ROP to understand the causes of ROP more clearly, in collaboration with genetic analysis specialists.  We are also actively studying ways to diagnose ROP more accurately using computer-based image analysis using pattern recognition algorithms, in collaboration with several computer science and engineering groups. These are difficult problems, but we are working hard and the solutions are not far off.