Facilitated versus self-guided training of non-ophthalmologists for grading pre-plus and plus disease using fundus images for retinopathy of prematurity screening

Nikolas N. Raufi, Caleb K. Morris, Sharon F. Freedman, David K. Wallace, S. Grace Prakalapakorn

Research output: Contribution to journalArticle


Purpose: Retinopathy of prematurity (ROP) is an important cause of preventable blindness; barriers to screening necessitate novel approaches. Although trained non-ophthalmologists can accurately grade retinal images for ROP, effective training protocols are not established. This study compares the effectiveness of facilitated versus self-guided training of non-ophthalmologists for grading retinal images for pre-plus or plus disease in ROP. Methods: Forty-eight undergraduate and graduate students were trained to grade retinal images for the presence of pre-plus or plus disease. Students were randomly assigned to one of two training protocols. Both used identical electronic slideshows: one was guided by an in-person facilitator and the other was self-guided. After completing their respective training, students proficient in grading pre-plus and plus disease graded images in a telemedicine screening scenario. Accuracy of grading was compared to the reference standard of clinical examination. Results: Eighty-three percent (40 of 48) of trained students (91% in the facilitated vs 77% in the self-guided group, P = .26) were proficient and qualified to grade the ROP telemedicine screening scenario. Median accuracy for grading normal, pre-plus, or plus disease was 69% (70% in the facilitated vs 68% in the self-guided group, P = .91). When considering the designation of pre-plus or plus disease by graders as a screening test for detecting plus disease (confirmed on clinical examination), the median sensitivity and specificity of all students were 95% and 64%, respectively. Conclusions: Both facilitated and self-guided teaching protocols yielded similar performance in ROP image grading for pre-plus or plus disease. Self-guided training protocols may be adequate to train non-ophthalmologists to grade retinal images for pre-plus and plus disease with high sensitivity.

Original languageEnglish (US)
Pages (from-to)179-185
Number of pages7
JournalJournal of Pediatric Ophthalmology and Strabismus
Issue number3
StatePublished - Jan 1 2016
Externally publishedYes


ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Ophthalmology

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