Dr. Harper on Ophthalmology Times EyePod Podcast
As one of only about 40 doctors in the world that specializes in retinopathy of prematurity (ROP), Dr. C. Armitage Harper has screened thousands of babies ROP, and saved hundreds from losing their eyesight.
Dr. Harper recently shared his experience in treating ROP cases and his passion and personal mission to eradicate childhood blindness from ROP around the globe on Ophthalmology Times EyePod podcast.
Read the entire interview below or listen to the podcast here.
Tell us about yourself and your practice.
I’ve been with Austin Retina Associates for 26 years. I was trained in ROP in Oregon when I did my fellowship from 1993 to 1995 and have been doing ROP ever since. When I was a resident at LSU in New Orleans, my wife was in preterm labor with both of our kids and I decided if they came out okay, then I would take care of these little guys for the rest of my practice. And that's what I've done.
Can you speak more on your personal focus and what drew you to the field of ROP?
I think that it's changed a lot since I've started. We didn't have as many tools as we do now to treat ROP, but I think the main thing that drives me is that we have in our hands these babies with 80 years of potential vision, if they're going to live to be 80 years old. ROP is something that is really a preventable disease process, largely, especially in the United States with the tools we have. Now, if the babies are followed appropriately, we can really do a good job of both limiting vision loss, limiting refractive errors, and giving them something that they might not have had, you know, 15 years ago. In addition, babies now are being born as early as 22 weeks and those babies have a much higher propensity to have retinopathy of prematurity. So, it's our job to really follow those babies more closely than ever.
My personal approach to this and the thing that I try to educate the residents I teach at the University of Texas San Antonio and the University of Texas Austin, is the practical approach to treating these children and how to look at it from a practical standpoint so then that can be translated out to the general public. We've done stuff like written papers on smaller needles that we have drawn for babies, or we've developed what we call the safer protocol, which is the safe way to inject babies with anti-VEGF and how to follow them.
Should all ophthalmologist screen infants for ROP?
I think it's tough because there's not enough of us that do it and really you need to be trained in your fellowship, whether you're a pediatric ophthalmologist or a retinologist, to do ROP screening and not all retina fellowships train people to do retinopathy of prematurity and not all pediatric ophthalmology fellowships have enough volume to really be good at it. One of our primary focuses is to try to educate as much as we can to get people aware of when to screen and how to do it, and then also promote telemedicine. Because again, there just aren't enough of us to go around.
How prevalent is ROP in low-income countries?
In my practice in Central Texas, I screen about 550 new babies a year and only about 3% of them require treatment. The average birth weight baby that we ended up treating is about 550 to 600 grams. And if you look in other countries, for instance, our nearest neighbor, Mexico, the average birth weight baby that they treat is 1,750 grams. In some studies, in these countries, the rate of treatable retinopathy of prematurity is in the range of 50 to 70% of these small babies. There is a big disparity and it’s my belief that it's one of the largest healthcare inequities in the world that's not looked at very well.
Are there any developing countries that are making advancements in treating ROP?
I think they're all trying to change things. For instance, my colleagues in Mexico passed a law, which indicates that all babies under a certain weight are required to be screened by the practitioners in those areas. It doesn't always happen because they just don't have the right people in place to be able to do that. In addition, in these rural areas and other countries the neonatologists are focused simply on saving the babies, not necessarily the retinopathy of prematurity. We’re also trying to educate them that if retinopathy of prematurity is treated appropriately and systemically with proper oxygen, then all the comorbidities like bronchopulmonary dysplasia (which is a lung disease), gut disease, and cardiac disease and brain bleeds will all go down.
What kind of impact has the pandemic had in the efforts to treat ROP or has it hampered any efforts in low-income countries?
I think it has. I usually travel with different organizations, Project Orbis Flying Eye Hospital, Stop Infant Blindness in Africa (SIBA), and Small World Vision to try to assess and help get them the tools they need and education they need, but we've been unable to do it. I know that they're struggling to find people to screen and the difficulty in treatment is a huge burden as well.
I understand you're currently working on a project to prevent blindness in preterm babies.
Yes. One of the things that happens in preterm babies in the United States is we control the oxygen amount that the babies get very well. We use a pulse oximeter, which is a little device that you stick on your finger. If we can keep the oxygen at a consistent level, in the U.S. most of the time between 88% and 92%, we can both preserve the baby's life because there's enough oxygen, but not hyper-oxygenate them, which is the problem in most developing countries. They don't have that control and they don't have a device called an oxygen blender that blends the air with oxygen to provide them a specific percentage. The oxygen blenders are very expensive. They run anywhere from $2,200 to $5,000, and each baby would have to have one of those. If you had 30 baby units, you'd have 30 of those blenders. A lot of the countries don't have those. So, we are delivering those blenders to them and also working on a new blender that would use ambient air using Venturi flow with either wall or bottled oxygen to give them the proper amount of oxygen. Along with that, we're setting up an educational program to educate the nurses and neonatologists to be able to help them.
We're probably a third of our way through the development of those. We almost have our first prototype and we've been working with engineers in Israel, through another company called O2 Science, in order to develop that. We're not to the clinical trial phase yet, but we're rapidly approaching that.
Are you targeting specific countries for that?
Our closest neighbor and my good friends in Mexico is where we'd like to begin because it's easy access for us. I know that Project Orbis is interested in Mongolia. Then of course Africa, which is going to be the largest country population wise and growth wise in the future, is where we're really going to be focused eventually. Again, most of the time in our NICU here we have wall air and wall oxygen, and most of these countries don't have the wall air so it’s not forced air, so we have to use ambient air. We're trying to design a system that works with that ambient air (the bottled oxygen you see) and the wall oxygen. A lot of these countries are also running out of oxygen because of COVID, and the lack of supply chain and the supply chain issues that go along with it.
What technologies do you visualize as necessary to resolve the gross healthcare inequity and ROP treatment across the globe?
A lot of it has to do with just what I'm talking about, that oxygen, but also the systemic health of the baby. One of the things that's super important for these children is to have the babies grow and there's a standard growth curve when a baby is born prematurely that the baby needs to follow. If the baby falls off that growth curve, they're almost guaranteed to develop severe retinopathy of prematurity. So nutrition, oxygen, and health are all the things that go together. In addition, there's a severe nursing shortage. There are not enough nurses to help with these babies and they are a precious, precious resource. Our foundation is trying to help to develop an educational process where we can help them and provide funding for that as well.
What other comorbidities can be reduced concomitant with a more widespread systemic prevention of ROP?
The primary ones are going to be lung disease, bronchopulmonary dysplasia, where the lungs develop poorly, necrotizing enterocolitis, which involves the blood vessels in the gut, head bleeds and then cardiovascular problems as well. If that oxygen is controlled, all those things will start to dissipate and go away over time. If I can encourage people to go down this route, we can also help prevent those other comorbidities and keep these children alive and healthy in a developing country. And not that Mexico is a poor country, but in any country where children are blind, it's a very difficult problem economically for both the country, because they have to support that child throughout its life, which is very expensive. But oftentimes the parents, usually the mom, has to stay home and is unable to work. So therefore, the other children may have to go to work and then not go to school. It’s a big cascading process where the whole family, population and economy suffers. And if that can be fixed, all those dominoes won't have to fall like they do now.
What is your outlook for the future of ROP treatment?
We're very excited for the treatment of ROP. I think that the more people that become educated in this process and the more people that we can reach out to the better off we're going to be, I mean, Stevie Wonder is blind because of retinopathy of prematurity. And if we can get more people on board to recognize that we can really impact this. This is largely preventable as my colleague Mike Tracy would say. And I think that if we can do that, we can really prevent and reduce blindness worldwide because the leading cause of infant blindness and childhood blindness right now is retinopathy of prematurity. Premature births are only going to increase in volume. Therefore, this problem is only going to get magnified, and we can really make a huge impact if we can all just work together towards the same goal.