Evaluation of an Artificial Intelligence System for Retinopathy of Prematurity Screening in Nepal and Mongolia

Emily Cole; Nita G Valikodath; Tala Al-Khaled; Sanyam Bajimaya; Sagun Kc; Tsengelmaa Chuluunbat; Bayalag Munkhuu; Karyn E Jonas; Chimgee Chuluunkhuu; Leslie D MacKeen; Vivien Yap; Joelle Hallak; Susan Ostmo; Wei-Chi Wu; Aaron S Coyner; Praveer Singh; Jayashree Kalpathy-Cramer; Michael F Chiang; J Peter Campbell; R V Paul Chan

doi:10.1016/j.xops.2022.100165

Evaluation of an Artificial Intelligence System for Retinopathy of Prematurity Screening in Nepal and Mongolia

Ophthalmol Sci. 2022 Apr 25;2(4):100165. doi: 10.1016/j.xops.2022.100165. eCollection 2022 Dec.

Authors

Emily Cole¹, Nita G Valikodath¹, Tala Al-Khaled¹, Sanyam Bajimaya², Sagun Kc³, Tsengelmaa Chuluunbat⁴, Bayalag Munkhuu⁴, Karyn E Jonas¹, Chimgee Chuluunkhuu⁵, Leslie D MacKeen^{6

7}, Vivien Yap⁸, Joelle Hallak¹, Susan Ostmo⁹, Wei-Chi Wu¹⁰, Aaron S Coyner⁹, Praveer Singh¹¹, Jayashree Kalpathy-Cramer¹¹, Michael F Chiang¹², J Peter Campbell⁹, R V Paul Chan¹

Affiliations

¹ Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, Illinois.
² Tilganga Institute of Ophthalmology, Kathmandu, Nepal.
³ Helen Keller International, Kathmandu, Nepal.
⁴ National Center for Maternal and Child Health, Ulaanbaatar, Mongolia.
⁵ Orbis International, New York, New York.
⁶ The Hospital for Sick Children, Toronto, Canada.
⁷ Phoenix Technology Group, Pleasanton, California.
⁸ Department of Pediatrics, Weill Cornell Medical College, New York, New York.
⁹ Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon.
¹⁰ Chang Gung Memorial Hospital, Taoyuan, Taiwan, and Chang Gung University, College of Medicine, Taoyuan, Taiwan.
¹¹ Harvard Medical School, Boston, Massachusetts.
¹² National Eye Institute, National Institutes of Health, Bethesda, Maryland.

Abstract

Purpose: To evaluate the performance of a deep learning (DL) algorithm for retinopathy of prematurity (ROP) screening in Nepal and Mongolia.

Design: Retrospective analysis of prospectively collected clinical data.

Participants: Clinical information and fundus images were obtained from infants in 2 ROP screening programs in Nepal and Mongolia.

Methods: Fundus images were obtained using the Forus 3nethra neo (Forus Health) in Nepal and the RetCam Portable (Natus Medical, Inc.) in Mongolia. The overall severity of ROP was determined from the medical record using the International Classification of ROP (ICROP). The presence of plus disease was determined independently in each image using a reference standard diagnosis. The Imaging and Informatics for ROP (i-ROP) DL algorithm was trained on images from the RetCam to classify plus disease and to assign a vascular severity score (VSS) from 1 through 9.

Main outcome measures: Area under the receiver operating characteristic curve and area under the precision-recall curve for the presence of plus disease or type 1 ROP and association between VSS and ICROP disease category.

Results: The prevalence of type 1 ROP was found to be higher in Mongolia (14.0%) than in Nepal (2.2%; P < 0.001) in these data sets. In Mongolia (RetCam images), the area under the receiver operating characteristic curve for examination-level plus disease detection was 0.968, and the area under the precision-recall curve was 0.823. In Nepal (Forus images), these values were 0.999 and 0.993, respectively. The ROP VSS was associated with ICROP classification in both datasets (P < 0.001). At the population level, the median VSS was found to be higher in Mongolia (2.7; interquartile range [IQR], 1.3-5.4]) as compared with Nepal (1.9; IQR, 1.2-3.4; P < 0.001).

Conclusions: These data provide preliminary evidence of the effectiveness of the i-ROP DL algorithm for ROP screening in neonatal populations in Nepal and Mongolia using multiple camera systems and are useful for consideration in future clinical implementation of artificial intelligence-based ROP screening in low- and middle-income countries.

Keywords: Artificial intelligence; BW, birth weight; DL, deep learning; Deep learning; GA, gestational age; ICROP, International Classification of Retinopathy of Prematurity; IQR, interquartile range; LMIC, low- and middle-income country; Mongolia; Nepal; ROP, retinopathy of prematurity; RSD, reference standard diagnosis; Retinopathy of prematurity; TR, treatment-requiring; VSS, vascular severity score; i-ROP, Imaging and Informatics for Retinopathy of Prematurity.