Evaluating and optimizing retinal examination methods for diagnosing retinopathy of prematurity in premature infants

Purpose This study aims to evaluate and compare the effectiveness of the Binocular Indirect Ophthalmoscope (BIO) and the Wide-Field Fundus Imaging System (RetCam) in the diagnosis of Retinopathy of Prematurity (ROP).Methods We retrospectively reviewed routinely collected records from a standardized paired-screening workflow for preterm infants examined for ROP in outpatient and inpatient settings during 2020–2021. BIO was performed first by a senior pediatric ophthalmologist, followed within 10 min by RetCam3 imaging by another ophthalmologist. The paired BIO sketches and RetCam images were reviewed by three experienced ophthalmologists, and disagreements were resolved by consensus to establish an adjudicated reference standard for this study. The primary outcome was diagnostic accuracy for ROP zone, stage, plus/pre-plus disease, and lesion extent.Results A total of 796 eyes from 398 preterm infants (birth weight 1323.8 +/− 456.2 g; gestational age 29.8 +/− 2.9 weeks) were examined using both BIO and RetCam. Compared with the adjudicated reference standard, BIO and RetCam achieved AUCs of 0.997 and 0.995 for detecting any ROP, 0.983 and 0.982 for zone classification, and 0.999 and 0.959 for stage classification, respectively. RetCam misdiagnoses were most common in zone III and stage 1 disease. BIO showed lower agreement than RetCam for lesion extent (p < 0.001).Conclusion BIO and RetCam showed complementary strengths in ROP screening. BIO provided clearer peripheral three-dimensional assessment of subtle stage and plus/pre-plus findings, whereas RetCam provided objective wide-field documentation of lesion distribution. A combined strategy may improve diagnostic confidence and clinical management for ROP.