Prospective validation of a virtual clinic pathway in the management of choroidal naevi: the NAEVUS study Report no. 1: safety assessment

BackgroundChoroidal naevi are a common incidental finding prompting specialist referrals to ocular oncology. Rarely, such lesions have sufficient suspicious features to diagnose a small melanoma. The aim of the study is to show that ‘virtual’ imaging-based pathways are a safe and efficient option to manage such referrals.MethodsA prospective cohort study at the Manchester Royal Eye Hospital and Moorfields Eye Hospital between June 2016 and July 2017 of the management decision of 400 patients reviewed by an ophthalmologist in a face-to-face consultation (gold standard) supported by fundus photography, optical coherence tomography, autofluorescence (AF) and B-mode ultrasound. The images were also read independently by blinded graders (non-medical) and blinded ophthalmologists, and a management decision was made based on image review alone (virtual pathway). The two pathways were compared for safety.ResultsThe agreement for management decisions between face-to-face and virtual pathways was 83.1% (non-medical) and 82.6% (medical). There were more over-referrals in the virtual pathway (non-medical 24.3%, medical 23.3% of gold standard discharge) and only two under-referrals (10.5% of gold standard referrals), both borderline cases with minimal clinical risk. The agreement for risk factors of growth (orange pigment, subretinal fluid, hyper-AF) ranged between 82.3% and 97.3%.ConclusionsWe prospectively validated a virtual clinic model for the safe management of choroidal naevi. Such a model of care is feasible with low rate of under-referral. An over-referral rate of almost 24% from the vitrual pathway needs to be factored into designing such pathways in conjunction with evidence on their cost-effectiveness.

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The MOLES System for Planning Management of Melanocytic Choroidal Tumors: Is It Safe?

Cancers ◽

10.3390/cancers12051311 ◽

2020 ◽

Vol 12 (5) ◽

pp. 1311 ◽

Cited By ~ 2

Author(s):

Kelsey A. Roelofs ◽

Roderick O’Day ◽

Lamis Al Harby ◽

Amit K. Arora ◽

Victoria M.L. Cohen ◽

...

Keyword(s):

Optical Coherence Tomography ◽

Ciliary Body ◽

Demographic Data ◽

Choroidal Melanoma ◽

Subretinal Fluid ◽

Fundus Photography ◽

Tumor Diameter ◽

Specialist Care ◽

Orange Pigment ◽

Large Size

Purpose: To evaluate the MOLES system for identifying malignancy in melanocytic choroidal tumors in patients treated for choroidal melanoma. Methods: Records of 615 patients treated for choroidal melanoma between January 2017 and December 2019 were reviewed. Patients were excluded if iris and/or ciliary body involvement (106 patients), inadequate fundus photography (26 patients), no images available for review (21 patients) and/or treatment was not primary (11 patients). Demographic data and AJCC TNM Stage were collected. Color fundus and autofluorescence photographs (FAF), optical coherence tomography (OCT) and B-scan ultrasounds were prospectively reviewed. MOLES scores were assigned according to five criteria: mushroom shape, orange pigment, large size, enlarging tumor and subretinal fluid. Results: A total of 451 patients (mean age, 63.9 ± 13.9 years) were included. At treatment, mean largest basal tumor diameter (LBD) and thickness were 10.3 ± 2.8 mm (range, 3.0–23.0) and 4.3 mm (range, 1.0–17.0). All but one (0.2%) had MOLES scores of ≥3. Eighty-two patients were treated after surveillance lasting a mean of 1.5 years. Initially, most (63/82; 76.8%) had a MOLES score ≥ 3. Importantly, none of the 451 tumors had a score of <2, and as such, the MOLES protocol would have indicated referral to an ocular oncologist for 100% of patients. Conclusion: The MOLES scoring system is a sensitive (99.8%) tool for indicating malignancy in melanocytic choroidal tumors (MOLES ≥ 3). If the examining practitioner can recognize the five features suggestive of malignancy, MOLES is a safe tool to optimize referral of melanocytic choroidal tumors for specialist care.

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Small Choroidal Melanoma: Correlation of Growth Rate with Pathology

Ocular Oncology and Pathology ◽

10.1159/000517203 ◽

2021 ◽

pp. 1-10

Author(s):

Vishal Raval ◽

Shiming Luo ◽

Emily C. Zabor ◽

Arun D. Singh

Keyword(s):

Growth Rate ◽

Retinal Pigment ◽

Choroidal Melanoma ◽

Case Series ◽

Subretinal Fluid ◽

Categorical Variables ◽

Continuous Variables ◽

Basal Diameter ◽

Orange Pigment ◽

Rpe Atrophy

Purpose: The aim of the study was to evaluate equivalence of growth rate and pathologic confirmation in small choroidal melanoma (SCM). Design: This study is a case series. Subjects, Participants, and Controls: A total of 61 patients with a choroidal melanocytic tumor of size 5.0–16.0 mm in the largest basal diameter and 1.0–2.5 mm in thickness were classified into the pathology-confirmed group (n = 19), growth-confirmed group (n = 30), and with combined observations (n = 12). Methods: Distribution of clinical variables (age, gender, laterality, tumor dimensions, tumor location, and presence of orange pigment, subretinal fluid, drusen, and retinal pigment epithelial [RPE] atrophy) between the groups was analyzed. Patient and disease characteristics were summarized as the median and interquartile range for continuous variables and the frequency and percentage for categorical variables. Comparisons were made using the Wilcoxon rank sum test for continuous variables and either Fisher’s exact test or the χ2 test for categorical variables with a p value threshold of 0.05 for statistical significance. Growth rate (change in basal dimension/12 months) diagnostic of SCM was quantified. Main Outcome Measures: The primary aim of this study was to test the hypothesis that “growth” was diagnostic of SCM with the secondary aim of quantifying the malignant “growth rate” (growth rate of SCM). Results: The clinical characteristics among all 3 groups were similar except more patients with symptoms (68 vs. 20 vs. 42%, p = 0.004) and juxtapapillary location (p = 0.03) were in the pathology group than in the growth-confirmed group. Those in the combined and growth-confirmed groups had more patients with drusen (11 vs. 60 vs. 50%, p = 0.003) and RPE atrophy (11 vs. 23 vs. 67%, p = 0.003), respectively, than in the pathology group. The median time to detect growth was 9 months (range 3–26 months). The mean growth rate in basal dimension was 1.8 mm/12 months (range, 0.0–7.4 mm; [95% CI: 1.32–2.28]). Conclusions and Relevance: Choroidal melanocytic lesions exhibiting a defined growth rate can be clinically diagnosed as SCM without a need for biopsy.

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923 Accuracy of Assessment in Hand Trauma; Pre COVID-19 Face to Face Assessment Compared to Virtual Assessment During COVID-19 Lockdown

British Journal of Surgery ◽

10.1093/bjs/znab134.030 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

S Westley ◽

H Creasy ◽

R Mistry

Keyword(s):

Telephone Call ◽

Initial Assessment ◽

Accurate Assessment ◽

Hand Trauma ◽

Face To Face ◽

Queen Victoria ◽

Set Up ◽

Operation Note ◽

Similar Accuracy ◽

Virtual Clinic

Abstract Introduction The Queen Victoria Hospital (QVH) was designated a cancer and trauma hub during the COVID-19 pandemic. With this, a new virtual hand trauma clinic was set up. We assess accuracy of assessment within this virtual set-up with comparison to pre COVID-19 face-to-face assessment. Method Two weeks of clinic sessions during and pre lockdown were analysed. Initial assessment was compared with the patient's operation note. Results In the pre COVID-19 two-week period 129 face-to-face appointments were analysed. Of 99 patients that required surgery 77 (78%) had an accurate assessment. 6 were overestimated, 12 were underestimated. 189 patients were seen over two weeks during lockdown via telephone or video call. Accuracy of assessment increased with seniority of the clinician. Of 126 patients that required an operation 109 (87%) had an accurate assessment; all structures injured were correctly predicted. 12 were overestimated, 5 had their injury underestimated. Conclusions The new virtual clinic allowed patients to be remotely assessed during lockdown, reducing footfall and unnecessary journeys. We found that virtual clinic assessments are accurate, and no patient underwent an unnecessary procedure. Using a telephone call plus photo gave similar accuracy as a video call. Virtual assessment was more accurate than face-to-face assessment.

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Could a low-cost audio-visual link be useful in rheumatology?

Journal of Telemedicine and Telecare ◽

10.1258/1357633001934078 ◽

2000 ◽

Vol 6 (1_suppl) ◽

pp. 35-37 ◽

Cited By ~ 9

Author(s):

L E Graham ◽

S Mcgimpsey ◽

S Wright ◽

G Mcclean ◽

J Carser ◽

...

Keyword(s):

Diagnostic Accuracy ◽

Gold Standard ◽

Junior Doctor ◽

Low Cost ◽

Clinical Signs ◽

Final Diagnosis ◽

Provisional Diagnosis ◽

Face To Face ◽

Significant Difference ◽

Small Joint

We have investigated prospectively the diagnostic accuracy, specialist satisfaction and patient–specialist rapport of a low-cost audio-visual link between a junior doctor with a patient and a consultant rheumatologist. Using a telephone link and subsequently a video-phone link, 20 patients, with various rheumatological problems, were presented by a junior doctor to the consultant rheumatologist for provisional diagnosis. All patients were then seen face to face by the consultant, when a final diagnosis was made. An independent consultant rheumatologist made a ‘gold standard’ diagnosis. Thirty-five per cent of diagnoses were made correctly over the telephone and 40% over the video-phone – there was no significant difference in the diagnostic accuracy between these two methods of communication. Rapport over the video-phone was universally poor. Where it was important, clinical signs could not be visualized over the video-phone and in more than 85% of cases small joint swellings could not be seen clearly.

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Modeling a Telemedicine Screening Program for Diabetic Retinopathy in Iran and Implementing a Pilot Project in Tehran Suburb

Journal of Ophthalmology ◽

10.1155/2019/2073679 ◽

2019 ◽

Vol 2019 ◽

pp. 1-8 ◽

Cited By ~ 1

Author(s):

Sare Safi ◽

Hamid Ahmadieh ◽

Marzieh Katibeh ◽

Mehdi Yaseri ◽

Homayoun Nikkhah ◽

...

Keyword(s):

Diabetic Retinopathy ◽

Gold Standard ◽

Web Application ◽

Mixed Model ◽

Screening Program ◽

National Level ◽

Pilot Project ◽

Fundus Photography ◽

Care Services ◽

Model Study

Purpose. To model a community-based telescreening program for diabetic retinopathy (DR) in Iran and to implement a pilot project at the Iranian Diabetes Society (IDS) branch in a Tehran suburb. Methods. In this mixed model study, a web application called the “Iranian Retinopathy Teleophthalmology Screening (IRTOS)” was launched. The educational course for DR screening was established for general practitioners (GPs). Registered patients in IDS branch were recalled for fundus photography; images were transferred to the reading center via IRTOS to be graded by GPs, and patients were informed about the results via mobile messaging. All images were independently reviewed by a retina specialist as the gold standard. Patients who required further assessment were referred to an eye hospital. Results. Overall, 604 subjects with diabetes were screened; of these, 50% required referral. The sensitivity and specificity for diagnosis of any stage of DR by trained GPs were 82.8% and 86.2%, respectively, in comparison to the gold standard. The corresponding values for detecting any stage of diabetic macular edema (DME) were 63.5% and 96.6%, respectively. Conclusions. Telescreening was an effective method for detecting DR in a Tehran suburb. This screening model demonstrated its capacity for promoting diabetic eye care services at the national level. However, the sensitivity for detecting DME needs to be improved by modifying the referral pathway and promoting the skill of GPs.

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Is a virtual clinic model a safe and effective way for assessing patients referred with suspiciously blurred optic discs? The blurred disc clinic

European Journal of Ophthalmology ◽

10.1177/1120672120976043 ◽

2020 ◽

pp. 112067212097604

Author(s):

Joanna M Jefferis ◽

Nigel Griffith ◽

Daniel Blackwell ◽

Ruth Batty ◽

Simon J Hickman ◽

...

Keyword(s):

Optic Nerve ◽

Optic Disc ◽

Direct Contact ◽

Visual Fields ◽

Referral Letter ◽

Face To Face ◽

The Face ◽

Optic Discs ◽

Eye Clinic ◽

Virtual Clinic

Background: There are increasing numbers of referrals to ophthalmology departments due to blurred optic disc margins. In light of this and the COVID-19 pandemic we aimed to assess whether these patients could be safely assessed without direct contact between the clinician and patient. Methods: We retrospectively reviewed the records of consecutive patients seen in our ‘blurred disc clinic’ between August 2018 and October 2019. We then presented anonymous information from their referral letter, their visual fields and optic nerve images to two consultant neuro-ophthalmologists blinded to the outcome of the face-to-face consultation. In the simulated virtual clinic, the two consultants were asked to choose an outcome for each patient from discharge, investigate or bring in for a face-to-face assessment. Results: Out of 133 patients seen in the blurred disc clinic, six (4.5%) were found to have papilloedema. All six were identified by both neuro-ophthalmologists as needing a face-to-face clinic consultation from the simulated virtual clinic. One hundred and twenty (90%) patients were discharged from the face-to-face clinic at the first consultation. The two neuro-ophthalmologists chose to discharge 114 (95%) and 99 (83%) of these respectively from the simulated virtual clinic. The virtual clinic would have potentially missed serious pathology in only one patient who had normal optic discs but reported diplopia at the previous face-to-face consultation. Conclusions: A virtual clinic model is an effective way of screening for papilloedema in patients referred to the eye clinic with suspicious optic discs. Unrelated or incidental pathology may be missed in a virtual clinic.

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Combined OCT and colour fundus photography in virtual clinic assessments of wet AMD patients

Eye ◽

10.1038/eye.2011.345 ◽

2012 ◽

Vol 26 (4) ◽

pp. 619-619 ◽

Cited By ~ 4

Author(s):

M Mookhtiar ◽

L Downey

Keyword(s):

Fundus Photography ◽

Wet Amd ◽

Virtual Clinic

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Implementation of medical retina virtual clinics in a tertiary eye care referral centre

British Journal of Ophthalmology ◽

10.1136/bjophthalmol-2017-311494 ◽

2018 ◽

Vol 102 (10) ◽

pp. 1391-1395 ◽

Cited By ~ 23

Author(s):

Karsten Kortuem ◽

Katrin Fasler ◽

Amanda Charnley ◽

Hussain Khambati ◽

Sandro Fasolo ◽

...

Keyword(s):

Fundus Photography ◽

Retinal Diseases ◽

First Line ◽

Face To Face ◽

Visual Acuity Testing ◽

Timely Fashion ◽

Promising Solution ◽

Increasing Demand ◽

Rapid Access Clinic ◽

Medical Retina

BackgroundThe increasing incidence of medical retinal diseases has created capacity issues across UK. In this study, we describe the implementation and outcomes of virtual medical retina clinics (VMRCs) at Moorfields Eye Hospital, South Division, London. It represents a promising solution to ensure that patients are seen and treated in a timely fashionMethodsFirst attendances in the VMRC (September 2016–May 2017) were included. It was open to non-urgent external referrals and to existing patients in a face-to-face clinic (F2FC). All patients received visual acuity testing, dilated fundus photography and optical coherence tomography scans. Grading was performed by consultants, fellows and allied healthcare professionals. Outcomes of these virtual consultations and reasons for F2FC referrals were assessed.ResultsA total number of 1729 patients were included (1543 were internal and 186 external referrals). The majority were diagnosed with diabetic retinopathy (75.1% of internal and 46.8% of external referrals). Of the internal referrals, 14.6% were discharged, 54.5% continued in VMRC and 30.9% were brought to a F2FC. Of the external referrals, 45.5% were discharged, 37.1% continued in VMRC and 17.4% were brought to a F2FC. The main reason for F2FC referrals was image quality (34.7%), followed by detection of potentially treatable disease (20.2%).ConclusionVMRC can be implemented successfully using existing resources within a hospital eye service. It may also serve as a first-line rapid-access clinic for low-risk referrals. This would enable medical retinal services to cope with increasing demand and efficiently allocate resources to those who require treatment.

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A pilot trial of tele-ophthalmology for diagnosis of chronic blurred vision

Journal of Telemedicine and Telecare ◽

10.1177/1357633x13476233 ◽

2013 ◽

Vol 19 (2) ◽

pp. 65-69 ◽

Cited By ~ 17

Author(s):

Hwai Tan Johnson Choon ◽

Ting Poh Eugenie Wei ◽

Srinivasan Sanjay ◽

Han Tim Tock

Keyword(s):

Pilot Trial ◽

Anterior Segment ◽

Care Facility ◽

Tertiary Hospital ◽

Fundus Photography ◽

Digital Information ◽

Blurred Vision ◽

Face To Face ◽

Video Recordings ◽

Experience Questionnaire

We evaluated the accuracy of tele-ophthalmology in diagnosing the major causes of chronic blurring of vision. Thirty consecutive patients attending a primary eye-care facility in Singapore (the Ang Mo Kio Polyclinic, AMKP) with the symptom of chronic blurred vision were recruited. An ophthalmic technician was trained to perform Snellen acuity; auto-refraction; intraocular pressure measurement; red-colour perimetry; video recordings of extraocular movement, cover tests and pupillary reactions; and anterior segment and fundus photography. Digital information was transmitted to a tertiary hospital in Singapore (the Tan Tock Seng Hospital) via a tele-ophthalmology system for teleconsultation with an ophthalmologist. The diagnoses were compared with face-to-face consultation by another ophthalmologist at the AMKP. A user experience questionnaire was administered at the end of the consultation. Using face-to-face consultation as the gold standard, tele-ophthalmology achieved 100% sensitivity and specificity in diagnosing media opacity (n = 29), maculopathy (n = 23) and keratopathy (n = 30) of any type; and 100% sensitivity and 92% specificity in diagnosing optic neuropathy of any type (n = 24). The majority of the patients (97%) were satisfied with the tele-ophthalmology workflow and consultation. The tele-ophthalmology system was able to detect causes of chronic blurred vision accurately. It has the potential to deliver high-accuracy diagnostic eye support to remote areas if suitably trained ophthalmic technicians are available.

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Regression patterns of choroidal melanoma: After palladium-103 (103Pd) plaque brachytherapy

European Journal of Ophthalmology ◽

10.1177/1120672118776146 ◽

2018 ◽

Vol 28 (6) ◽

pp. 722-730 ◽

Cited By ~ 3

Author(s):

Abhilasha Maheshwari ◽

Paul T Finger

Keyword(s):

Complete Resolution ◽

Retinal Pigment Epithelial ◽

Retinal Pigment ◽

Choroidal Melanoma ◽

Subretinal Fluid ◽

Tumor Thickness ◽

Tumor Vascularity ◽

Orange Pigment ◽

Pigment Epithelial ◽

Plaque Brachytherapy

Purpose: To describe the patterns of regression of choroidal melanoma after treatment with plaque brachytherapy. Methods: Retrospective interventional case series including 170 consecutive patients treated with 103Pd eye plaque radiation for choroidal melanoma. Outcome measures were changes in tumor thickness, surface characteristics, tumor vascularity, ultrasonography, fluorescein angiography, optical coherence tomography, and histopathology. Results: The mean initial tumor thickness was 3.9 mm (median 2.8 mm; range 2–11.3 mm) that decreased to 1.7 mm (median 1.2 mm; range 0–7.1 mm) after plaque brachytherapy. On imaging, tumors were pigmented in 51% ( n = 86/170), amelanotic in 10% ( n = 17/170), and variably pigmented in 39% ( n = 67/170). Tumor pigmentation increased in 64% ( n = 106/166), decreased in 18% ( n = 30/166), and was unchanged in 18% ( n = 30/166). Of the 120 that demonstrated intrinsic vascularity, 10% ( n = 12/120) had decreased tumor-related vascularity and 90% ( n = 108/120) showed complete resolution. Subretinal fluid was present in 34% ( n = 58/170) of eyes at presentation. Of them, 15% (9; n = 9/58) had persistent SRF at last follow-up. On ultrasound imaging, 88% ( n = 149/170) tumors presented with low to moderate internal reflectivity of which 61% ( n = 91/149) showed increased reflectivity on regression. We noted a crescendo–decrescendo fluctuation in the presence of orange pigment lipofuscin along with complete resolution of drusenoid retinal pigment epithelial detachments. In the entire series of 170 patients, there was 0.5% (1) failure of local control, 2% (4) secondary enucleations, and 6% (10) patients developing metastasis. Conclusion: Findings related to choroidal melanoma regression after 103Pd plaque brachytherapy included decreased intrinsic tumor vascularity, decreased tumor-related subretinal fluid, increased pigmentation, specific changes in orange pigment lipofuscin and resolution of drusenoid retinal pigment epithelial detachments, as well as decreased tumor thickness with an increase in internal reflectivity on ultrasound.

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