New Technology Update: RetCam II

RENÉ, LUTHE SENIOR ASSOCIATE EDITOR

The RetCam II (Clarity Medical Systems, Pleasanton, Calif) offers relief in the current crisis for screening retinopathy of prematurity (ROP). With doctors increasingly reluctant to screen premature infants due to fear of malpractice suits, and a rising number of premature babies, the camera’s ability to transmit images electronically and its design specifically for the eyes of infants, provide a way out of the impasse. According to retinal specialists who screen for ROP, the RetCam II’s images are clear and reliable. Its mobility and range of features make RetCam II a valuable tool for diagnosis and teaching, not only of ROP, but also Shaken Baby Syndrome and retinoblastoma, in hospitals or private practices.

USING THE RETCAM II

Using coupling gel, the contact retinal camera is placed on the cornea and images the retina with a choice of 5 lenses (130°, 120°, 80°, 30° and Portrait). The wide-field image is captured instantly and made into a digital, high-resolution color photograph with the 3 CCD (charged coupled device) medical-grade digital camera. Robert Gordon, MD, director of Pediatric Ophthalmology & Adult Strabismus, and an associate professor in both the ophthalmology and pediatrics departments at Tulane University Medical School in New Orleans, says that he has been using the RetCam II to image the retinas of babies in neonatal intensive care units in 2 hospitals on a telemedicine basis. “So far, it’s worked extremely well,” he says. “I’ve always used my own indirect ophthalmoscope, but there are so many babies now who require this screening procedure that the RetCam II helps with the manpower and time problems that physicians experience.”

Roger Novack, MD, of the Retina Vitreous Association Medical Group in Los Angeles, also says the camera allows him to perform many ROP screenings via telemedicine. He set up a screening network approximately 7 years ago. He now has cameras in 2 hospitals, institutions that either could not find a doctor willing to undertake the perceived legal risk of screening, or that didn’t have coverage. Both situations are common, according to both Dr. Gordon and Dr. Novack. Dr. Novack says the quality optics the camera provides make his telemedicine network viable. “In the old days, we would do drawings on a piece of paper, but now we have the ability to image the retina, and it’s much more accurate,” he says.

TELEMEDICINE CAPABILITIES

Telemedicine, of course, involves another party in obtaining patient images, and both physicians say that selecting and training the appropriate people to take the images is crucial to successful screening with the RetCam II. Dr. Gordon says that user training for imaging technology is an important part of managing a telemedicine program for ROP. “You need to choose the right people for the job and most of the time, it involves a highly-motivated nurse,” he says.

While the learning curve for RetCam II is short — Dr. Novack reports having a person performing imaging after only 10 minutes of training — he agrees that motivation is paramount. He has a neonatalogist and nurse practitioners taking the images to send him via the Internet, or alternatively, on a zip drive that they have rush-delivered to him at his home, where he has a “reading station.”

Dr. Novack feels confident about screening and diagnosing from Ret Cam II images. “There was a study at ARVO I presented a couple of years ago, and we had very high sensitivity and specificity,” he says. A feature that makes it easier to obtain good images, Dr. Gordon thinks, is the real-time, full resolution video, which captures up to 20 seconds. So even if the image-taker has trouble getting the focus exactly right at first, he or she can go over the video and capture only the best images. Moreover, the RetCam II offers side-by-side image comparison.

Dr. Gordon also expressed confidence in reading the RetCam’s images online. When Hurricane Katrina hit New Orleans, he took refuge in Wichita, Kan — where he found himself doing screenings for a nursery with RetCam images on his laptop computer. “I was not sure how well this would work out,” he says. But the hospital that asked me to do this had lost its ophthalmologist and no one else wanted to do it. I wouldn’t drive 4 hours to them, and I don’t like to fly on small private planes, so the hospital elected to use telemedicine and the RetCam. It turned out quite well.”

COMPARISON WITH OPHTHALMOSCOPY

Because accurate and timely diagnosis is particularly crucial in detecting ROP, doctors performing screenings must be aware of any distinctions between viewing the retina with the RetCam II and with the traditional method, indirect ophthalmoscopy. There are pros and cons to each method of screening. According to Dr. Gordon, while the RetCam’s images are “very good,” they are not as good as seeing it yourself with an indirect ophthalmoscope. However, RetCam II is easier to use. “The images are not as good as an indirect ophthalmoscope — assuming you know how to use that tool and you’re good at it,” he says. “And not everybody is good at it.” Additionally, he says, “A lot of the communities that require screening in nurseries may not have ophthalmologists who are particularly interested in, or expert at, looking at retinas, particularly in babies.”

While Dr. Novack concedes that “There are always some doubts, you’re always going to believe your own exam over the RetCam,” he praises the RetCam’s wide viewing range as compared with ophthalmoscopy. It provides a 130° view (out to the periphery), he points out, while regular fundus cameras provide only 30 or 45°. “You can see all the way out to the edge of the retina with the RetCam,” he says.

According to Audina Berrocal, MD, assistant professor of clinical ophthalmology at Bascom Palmer Eye Institute, the images RetCam II provides are sometimes better than ophthalmoscopy. She cites the quality of the images as one of the features of RetCam II that she likes best.

MORE FEATURES

In addition to the RetCam’s ability to take high-resolution images and store and transmit them digitally, the system offers other useful features for the hospitals and pediatric practices that typically purchase it. Dr. Novack says the system’s mobility is another plus. “You can roll it around, take it down to the ER for taking images of Shaken Baby Syndrome,” he explains. “The hemorrhages in the retina are imaged and sometimes they are the only way you can make the diagnosis. These hemorrhages go away in a few days, so with the camera, you can document this before that happens.”

Additionally, the video camera is lightweight, with a long cable for easy patient access. A large LCD displays real-time video, the control panel is lighted and the system comes with an Inkjet color printer, with real-time patient data report. The system offers the ability to print a single image from the video clip to the printer, and the RC II OS software provides multi-image data recall and display. Dual DVD-RAM facilitates backup. Options include an FA Light Box for fluorescein angiography and a dye sublimation color printer that produces instant photo-quality image prints with or without patient data, and prints side-by-side image comparisons.

Finally, all the doctors agree that the RetCam II is a valuable teaching tool. They use it to teach the assisting nurses about ROP, as well as the parents of the infants they screen. “Parents sometimes finds it very difficult to understand eye disease, and a photograph is the perfect visual tool to educate them,” says Dr. Berrocal. “Once a parent sees disease, I think that the rest of the relationship between doctor and parent becomes easier.”

THE EXPERIENCE FACTOR

While the RetCam II cannot offer additional “insurance” to the doctors who screen for ROP — it provides no earlier diagnosis than indirect ophthalmoscopy — it does provide some relief for the manpower shortage for screeners. “In this litigious society, everyone is just afraid to screen,” says Dr. Novack. “The RetCam can fill the gap and let doctors see more patients. We can reach reach areas that wouldn’t have had proper coverage.” Both he and Dr. Gordon screen for several hospitals with the system. “The first place that contacted me was Desert Region Medical Center in the Palm Springs area,” Dr. Novack reports. “They had one retinal group in town that wouldn’t screen. So I started doing it and then if there was a problem, I arranged for the retinal group there to see the baby and do the treatments. It worked out beautifully.”

Dr. Gordon cautions that for all the advanced technology RetCam II offers, “There’s no getting around the experience factor for doctors in reading these images. The RetCam won’t do that job for you.” Training the imagers, he says, is another important consideration. “If you choose the right people for this [screenings] — and that’s a big ‘if’ — and so far I’ve been very fortunate, it can work very well.” RP

None of the physicians interviewed for this article have a financial interest in the product discussed.