Referral patterns of intraocular tumour patients to a dedicated Canadian ocular oncology department

Management of Uveal Melanoma: Updated Cancer Care Alberta Clinical Practice Guideline

OBJECTIVE

The purpose of this guideline update is to reassess and update recommendations in the prior guideline from 2016 on the appropriate management of patients with uveal melanoma.

METHODS

In 2021, a multidisciplinary working group from the Provincial Cutaneous Tumour Team, Cancer Care Alberta, Alberta Health Services was convened to update the guideline. A comprehensive review of new research evidence in PubMed as well as new clinical practice guidelines from prominent oncology groups informed the update. An enhancement in methodology included adding levels of evidence and strength of recommendations. The updated guideline was circulated to all members of the Provincial Cutaneous Tumour Team for review and endorsement.

RESULTS

New and modified recommendations address provider training requirements, diagnostic imaging for the detection of metastases, neo-adjuvant pre-enucleation radiotherapy, intravitreal anti-vascular endothelial growth factor agents for radiation retinopathy, genetic prognostic testing, surveillance following definitive local therapy, and systemic therapy for patients with metastatic uveal melanoma.

DISCUSSION

The recommendations represent evidence-based standards of care agreed to by a large multidisciplinary group of healthcare professionals.

Evaluating the Performance of ChatGPT in Ophthalmology: An Analysis of Its Successes and Shortcomings

Purpose

Foundation models are a novel type of artificial intelligence algorithms, in which models are pretrained at scale on unannotated data and fine-tuned for a myriad of downstream tasks, such as generating text. This study assessed the accuracy of ChatGPT, a large language model (LLM), in the ophthalmology question-answering space.

Design

Evaluation of diagnostic test or technology.

Participants

ChatGPT is a publicly available LLM.

Methods

We tested 2 versions of ChatGPT (January 9 "legacy" and ChatGPT Plus) on 2 popular multiple choice question banks commonly used to prepare for the high-stakes Ophthalmic Knowledge Assessment Program (OKAP) examination. We generated two 260-question simulated exams from the Basic and Clinical Science Course (BCSC) Self-Assessment Program and the OphthoQuestions online question bank. We carried out logistic regression to determine the effect of the examination section, cognitive level, and difficulty index on answer accuracy. We also performed a post hoc analysis using Tukey's test to decide if there were meaningful differences between the tested subspecialties.

Main Outcome Measures

We reported the accuracy of ChatGPT for each examination section in percentage correct by comparing ChatGPT's outputs with the answer key provided by the question banks. We presented logistic regression results with a likelihood ratio (LR) chi-square. We considered differences between examination sections statistically significant at a P value of < 0.05.

Results

The legacy model achieved 55.8% accuracy on the BCSC set and 42.7% on the OphthoQuestions set. With ChatGPT Plus, accuracy increased to 59.4% ± 0.6% and 49.2% ± 1.0%, respectively. Accuracy improved with easier questions when controlling for the examination section and cognitive level. Logistic regression analysis of the legacy model showed that the examination section (LR, 27.57; P = 0.006) followed by question difficulty (LR, 24.05; P < 0.001) were most predictive of ChatGPT's answer accuracy. Although the legacy model performed best in general medicine and worst in neuro-ophthalmology (P < 0.001) and ocular pathology (P = 0.029), similar post hoc findings were not seen with ChatGPT Plus, suggesting more consistent results across examination sections.

Conclusion

ChatGPT has encouraging performance on a simulated OKAP examination. Specializing LLMs through domain-specific pretraining may be necessary to improve their performance in ophthalmic subspecialties.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Survey of ophthalmic imaging use to assess risk of progression of choroidal nevus to melanoma

BACKGROUND/OBJECTIVES

The aim of this study was to ascertain the use of ocular imaging and the updated screening criteria in the evaluation of choroidal nevus across the United States.

METHODS

Sixty ophthalmologists completed an anonymous 21-question survey addressing their use of the screening criteria for evaluating choroidal nevi, as well as their use of ultrasonography (US), optical coherence tomography (OCT), and autofluorescence (AF) in daily practice.

RESULTS

The majority of respondents were from the Northeast (55%), worked in private practice (83%), and practiced general ophthalmology (42%). The 2009 criteria TFSOM-UHHD was used by 39 (65%) respondents, while the 2019 criteria TFSOM-DIM was used by 29 (48%) respondents. Compared to anterior segment ophthalmologists, posterior segment ophthalmologists were more likely to use the TFSOM-UHHD criteria (94% vs. 53%, OR = 13.9, p = 0.014), the TFSOM-DIM criteria (88% vs. 33%, OR = 15.5, p < 0.001), fundus AF (82% vs. 19%, OR = 20.4, p < 0.001), and US (94% vs. 42%, OR = 22.2, p = 0.004) in daily practice.

CONCLUSIONS

From the survey of current practice patterns, we learned that there is a general trend of underutilization of the proper imaging modalities - and thus the criteria - in evaluating choroidal nevus. More education about ocular cancer and its screening could improve patient outcomes in the future.

Multimodal imaging characteristics of congenital grouped hyper- and hypo-pigmented fundus lesions

BACKGROUND

The imaging characteristics of congenital grouped pigmentation of the retinal pigment epithelium (CGP-RPE) and its non-pigmented variant - grouped congenital albinotic retinal pigment epithelial spots (GCARPES) are poorly defined in the literature. Our case series reports their multimodal imaging characteristics across a spectrum of presentations.

METHODS

A retrospective review of patient records was conducted on patients seen at the Centre for Eye Health between January and December 2016. The multimodal imaging findings across four cases is described using optical coherence tomography (OCT), infrared imaging, ultra-widefield imaging, fundus photography and fundus autofluorescence (FAF).

RESULTS

Case 1 is a 55-year-old female with a bilateral presentation of CGP-RPE showing typical features. Case 2 is a 28-year-old male with a classical presentation of GCARPES in the left eye. Case 3 is a 33-year-old female with unilateral CGP-RPE and an atypical solitary congenital hypertrophy of the retinal pigment epithelium (CHRPE) in the same eye. Case 4 is a unilateral presentation in an 11-year-old female with unusual characteristics. Ocular imaging characteristics of CGP-RPE lesions varied between patients: OCT showed visible RPE changes in cases 3 and 4 but not case 1. The pattern of FAF and infrared imaging also varied with most lesions displaying a pattern of hypo-autofluorescence, but some central lesions in case 3 exhibited hyper-autofluorescence. All lesions were visible with fundus photography.

CONCLUSION

FAF can be helpful in alerting clinicians to the presence of lesions that may be difficult to visualise funduscopically and OCT can be helpful in differentiating between CGP-RPE and its variants from more sinister ocular conditions. All in all, these findings highlight the variable manifestation of CGP-RPE and its variants on multimodal imaging; the diagnosis of CGP-RPE and its variants should remain based on its characteristic funduscopic appearance.

Referral Patterns in Neuro-Ophthalmology

BACKGROUND

Neuro-ophthalmologists specialize in complex, urgent, vision- and life-threatening problems, diagnostic dilemmas, and management of complex work-ups. Access is currently limited by the relatively small number of neuro-ophthalmologists, and consequently, patients may be affected by incorrect or delayed diagnosis. The objective of this study is to analyze referral patterns to neuro-ophthalmologists, characterize rates of misdiagnoses and delayed diagnoses in patients ultimately referred, and delineate outcomes after neuro-ophthalmologic evaluation.

METHODS

Retrospective chart review of 300 new patients seen over 45 randomly chosen days between June 2011 and June 2015 in one tertiary care neuro-ophthalmology clinic. Demographics, distance traveled, time between onset and neuro-ophthalmology consultation (NOC), time between appointment request and NOC, number and types of providers seen before referral, unnecessary tests before referral, referral diagnoses, final diagnoses, and impact of the NOC on outcome were collected.

RESULTS

Patients traveled a median of 36.5 miles (interquartile range [IQR]: 20-85). Median time from symptom onset was 210 days (IQR: 70-1,100). Median time from referral to NOC was 34 days (IQR: 7-86), with peaks at one week (urgent requests) and 13 weeks (routine requests). Median number of previous providers seen was 2 (IQR: 2-4; range:0-10), and 102 patients (34%) had seen multiple providers within the same specialty before referral. Patients were most commonly referred for NOC by ophthalmologists (41% of referrals). Eighty-one percent (242/300) of referrals to neuro-ophthalmology were appropriate referrals. Of the 300 patients referred, 247 (82%) were complex or very complex; 119 (40%) were misdiagnosed; 147 (49%) were at least partially misdiagnosed; and 22 (7%) had unknown diagnoses. Women were more likely to be at least partially misdiagnosed-108 of 188 (57%) vs 39 of 112 (35%) of men (P < 0.001). Mismanagement or delay in care occurred in 85 (28%), unnecessary tests in 56 (19%), unnecessary consultations in 64 (22%), and imaging misinterpretation in 16 (5%). Neuro-ophthalmologists played a major role in directing treatment, such as preserving vision, preventing life-threatening complications, or avoiding harmful treatment in 62 (21%) patients.

CONCLUSIONS

Most referrals to neuro-ophthalmologists are appropriate, but many are delayed. Misdiagnosis before referral is common. Neuro-ophthalmologists often prevent vision- and life-threatening complications.

The advantages of intermediate-tier, inter-optometric referral of low risk pigmented lesions

Purpose

Pigmented ocular lesions are commonly encountered by eye‐care professionals, and range from benign to sight or life‐threatening. After identifying a lesion, the primary care professional must establish the likely diagnosis and decide either to reassure, to monitor or to refer. The increasing use of ocular imaging technologies has contributed to an increase in the detection rate of pigmented lesions and a higher number of referrals, which may challenge existing pathways of health‐care delivery. Specialist services may be over‐burdened by referring all patients with pigmented lesions for an opinion, while inter‐optometric referrals are underutilised. The aim of this study was to describe the referral patterns of pigmented lesions to an optometry led intermediate‐tier collaborative care clinic.

Methods

We performed a retrospective review of patient records using the list of patients examined at Centre for Eye Health (CFEH) for an initial or follow up pigmented lesion assessment between the 1/7/2013 and the 30/6/2016. Analysis was performed on: patient demographic characteristics, the referrer's tentative diagnosis, CFEH diagnosis and recommended management plan.

Results

Across 182 patient records, the primary lesion prompting referral was usually located in the posterior segment: choroidal naevus (105/182, 58%), congenital hypertrophy of the retinal pigment epithelium (CHRPE; 11/182, 6%), chorioretinal scarring (10/182, 5%) or not specified (52/182, 29%). Referrals described a specific request for ocular imaging in 25 instances (14%). The number of cases with a non‐specific diagnosis was reduced after intermediate‐tier care assessment (from 29% to 10%), while the number of diagnoses with less common conditions rose (from 2% to 21%). There was a 2% false positive referral rate to intermediate‐tier care and a first visit discharge rate of 35%. A minority required on‐referral to an ophthalmologist (22/182, 12%), either for unrelated incidental ocular findings, or suspicious choroidal naevi. Conditions most amenable to optometric follow up included: 1) chorioretinal scarring, 2) choroidal naevus, and 3) CHRPE.

Conclusions

Intermediate‐tier optometric eye‐care in pigmented lesions (following opportunistic primary care screening) has the potential to reduce the number of cases with non‐specific diagnoses and to increase those with less common diagnoses. The majority of cases seen under this intermediate‐tier model required only ongoing optometric surveillance.

Management of uveal melanoma: a consensus-based provincial clinical practice guideline

INTRODUCTION

Survival in uveal melanoma has remained unchanged since the early 1970s. Because outcomes are highly related to the size of the tumour, timely and accurate diagnosis can increase the chance for cure.

METHODS

A consensus-based guideline was developed to inform practitioners. PubMed was searched for publications related to this topic. Reference lists of key publications were hand-searched. The National Guidelines Clearinghouse and individual guideline organizations were searched for relevant guidelines. Consensus discussions by a group of content experts from medical, radiation, and surgical oncology were used to formulate the recommendations.

RESULTS

Eighty-four publications, including five existing guidelines, formed the evidence base.

SUMMARY

Key recommendations highlight that, for uveal melanoma and its indeterminate melanocytic lesions in the uveal tract, management is complex and requires experienced specialists with training in ophthalmologic oncology. Staging examinations include serum and radiologic investigations. Large lesions are still most often treated with enucleation, and yet radiotherapy is the most common treatment for tumours that qualify. Adjuvant therapy has yet to demonstrate efficacy in reducing the risk of metastasis, and no systemic therapy clearly improves outcomes in metastatic disease. Where available, enrolment in clinical trials is encouraged for patients with metastatic disease. Highly selected patients might benefit from surgical resection of liver metastases.

Pigmented Lesions of the Retinal Pigment Epithelium

: The primary eye care practitioner assumes an important role in clinical decisions involving the differentiation between malignant and nonmalignant pigmented lesions. A misdiagnosis may have profound consequences on patient management and visual or life prognosis. However, information on these lesions, particularly their appearance using advanced imaging, is fragmented throughout the literature. The purpose of this review is to describe these features in detail, so that the implications of this information on clinical practice are more readily apparent. Clinically relevant descriptions of pigmented lesions of the retinal pigment epithelium using traditional and advanced imaging modalities in the literature were collated and integrated with findings from patients seen at the Centre for Eye Health. The information was then organized and tabulated. Finally, a flow diagram was created to be used as a clinical reference in the differential diagnosis of pigmented lesions of the retinal pigment epithelium.