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Rees NOT, Schimansky S, Bizley G, Kobayter L. Real-world experience of implementing the MOLES score in a virtual choroidal naevi clinic at a tertiary referral centre. Eye (Lond) 2024; 38:1183-1188. [PMID: 38057559 PMCID: PMC11009328 DOI: 10.1038/s41433-023-02864-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/08/2023] Open
Abstract
INTRODUCTION The MOLES score has been validated to clinically differentiate choroidal naevi from melanomas by ocular oncologists and community optometrists. However, its utility in a virtual choroidal naevi clinic at a tertiary eye hospital without specialist ocular oncology services has not yet been evaluated. METHODS A retrospective case review of 385 choroidal lesions in the virtual choroidal naevus clinic at Bristol Eye Hospital during January-March 2020 and April-August 2021 was performed. Choroidal lesions were assessed using the TFSOM-UHHD risk factor index and MOLES score, respectively. For both study periods, clinical outcome and adherence data were analysed. RESULTS Choroidal lesions scored higher with the TFSOM-UHHD index (median 2) compared to the MOLES score (median 0; p < 0.001). Median required follow-up duration was 2 years for lesions assessed with the TFSOM-UHHD index, and 0 years for those graded with the MOLES score. Overall, 215 patients were appropriately discharged to community optometrists based on their MOLES score. Imaging requirements for the TFSOM-UHHD index and MOLES score protocols were met in 69.1% and 94.8% of cases, respectively. CONCLUSION The MOLES score was easily implemented in a virtual choroidal naevus clinic, with good adherence. It increased clinic capacity by facilitating appropriate discharges of low-risk naevi to community monitoring, allowing finite and specialist hospital-based services to monitor higher-risk naevi more closely.
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Affiliation(s)
- Nicholas O T Rees
- Medical Retina Service, Bristol Eye Hospital, Lower Maudlin Street, Bristol, BS1 2LX, United Kingdom.
| | - Sarah Schimansky
- Medical Retina Service, Bristol Eye Hospital, Lower Maudlin Street, Bristol, BS1 2LX, United Kingdom
| | - Gemma Bizley
- Medical Retina Service, Bristol Eye Hospital, Lower Maudlin Street, Bristol, BS1 2LX, United Kingdom
| | - Lina Kobayter
- Medical Retina Service, Bristol Eye Hospital, Lower Maudlin Street, Bristol, BS1 2LX, United Kingdom
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Churchill RA, Pecoraro TYC, Tooley AA, Houghton OM, Mashayekhi A, Dalvin LA. Multimodal imaging risk factors predictive of small choroidal melanocytic lesion growth to melanoma: An educational study and pictorial guide. Eye (Lond) 2024; 38:798-805. [PMID: 37880451 PMCID: PMC10920886 DOI: 10.1038/s41433-023-02782-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Risk factors for small choroidal melanocytic lesion growth to melanoma have been redefined using multimodal imaging. We explored provider ability to recognize risk factors for small choroidal melanocytic lesion growth to melanoma before and after image-based education and with and without multimodal imaging. METHODS Providers were invited to participate in a survey assessing ability to identify risk factors for small choroidal melanocytic lesion growth to melanoma using either fundus imaging or multimodal imaging. Risk factors included thickness >2 mm on ultrasonography, subretinal fluid on optical coherence tomography, presence of orange pigment by autofluorescence, acoustic hollowness by ultrasonography, and diameter >5 mm by fundus imaging. Performance was assessed before and after reviewing an educational PowerPoint providing pictorial examples of risk factors. Comparison between groups was conducted using two-tailed Fisher's exact test. RESULTS Thirty and 26 providers completed the pre-education and post-education assessments, respectively. Post-education participants were more accurate within ±1 risk factor for lesions with zero risk factors (77% vs. 100%, p = 0.01) or two risk factors (79% vs. 91%, p = 0.03). Following education, participants presented with multimodal imaging more often correctly identified lesions with four (12% vs. 42%, p = 0.03) or five (4% vs. 39%, p = 0.004) risk factors, demonstrated lower mean level of concern for lesions with zero risk factors (2.0 vs. 1.4, p < 0.001), and expressed higher level of concern for lesions with 5 risk factors (2.4 vs. 3.6, p < 0.001). CONCLUSION Use of multimodal imaging may be more beneficial than education itself to improve accuracy of risk factor identification for small choroidal melanocytic lesions.
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Affiliation(s)
| | | | - Andrea A Tooley
- Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Lauren A Dalvin
- Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA.
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Qureshi MB, Lentz PC, Xu TT, White LJ, Olsen TW, Pulido JS, Dalvin LA. Choroidal Nevus Features Associated with Subspecialty Referral. Ophthalmol Retina 2023; 7:1097-1108. [PMID: 37517800 PMCID: PMC10823039 DOI: 10.1016/j.oret.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To identify choroidal nevus features associated with referral to a retina or ocular oncology subspecialist. DESIGN Population-based retrospective cohort study. SUBJECTS Patients diagnosed with choroidal nevus. METHODS Population-based retrospective cohort study of residents of Olmsted County, Minnesota, with an incident diagnosis of choroidal nevus from January 1, 2006, to December 31, 2015 using the Rochester Epidemiology Project, a medical record linkage system. Tumor features and patient demographics associated with referral to a retina or ocular oncology subspecialist were assessed. Wilcoxon rank sum test, chi-square test, and Fisher exact test were used for statistical analysis. MAIN OUTCOME MEASURES Tumor features and patient demographics associated with referral to subspecialty care. RESULTS There were 826 incident diagnoses of choroidal nevus, of which 88 cases (11%) were referred, with highest level of referral being retina in 29 cases (33%) and ocular oncology in 59 cases (67%). None of the analyzed demographic features were associated with choroidal nevus referral to subspecialty care. Tumor features associated with referral (vs. not referred) included greater mean basal diameter (4.6 mm vs. 2.4 mm, P < 0.001), greater mean tumor thickness (0.7 mm vs. 0.1 mm, P < 0.001), greater distance to optic disc (6.9 mm vs. 3.4 mm, P = 0.02), halo around nevus (5.7% vs. 0.4%, P < 0.001), and drusen on OCT (51% vs. 25%, P = 0.002). Presence of orange pigment (8% vs. 0%, P = 0.14), subretinal fluid (9% vs. 2.5%, P = 0.09), and low internal reflectivity on A-scan (7.7% vs. 0%, P = 1.00) were not found more frequently in the subspecialty referral group. CONCLUSIONS Greater basal diameter and mean tumor thickness of choroidal nevus were associated with referral to retina or ocular oncology. However, several features associated with increased risk of malignant transformation were not associated with subspecialty referral. These findings highlight the importance of educating eye care providers about high-risk tumor features associated with choroidal nevus transformation to melanoma. In the primary eye care setting where not all multimodal imaging may be available, we encourage color photography and OCT with referral for any features of basal diameter > 5 mm, presence of subretinal fluid, or thickness too large for capture by enhanced-depth imaging OCT. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
| | - Paul C Lentz
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona
| | - Timothy T Xu
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | - Launia J White
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Timothy W Olsen
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | - Jose S Pulido
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota; Wills Eye Hospital, Department of Translational Ophthalmology, Philadelphia, Pennsylvania
| | - Lauren A Dalvin
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota.
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Ong AY, Naughton A, Hornby S, Shwe-Tin A. Impact of an email advice service on filtering and refining ophthalmology referrals in England. Int Ophthalmol 2023; 43:4019-4025. [PMID: 37420128 DOI: 10.1007/s10792-023-02806-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/29/2023] [Indexed: 07/09/2023]
Abstract
PURPOSE The growing capacity-demand imbalance has necessitated the accelerated digital transformation of eye care services. The role of Oxford Eye Hospital's (OEH) email advice service has become even more relevant in the post-Covid era. We sought to evaluate its impact on referrals to secondary care. METHODS The consultant-led OEH email advice service primarily targets primary eye care personnel (optometrists and GPs) requiring clinical advice on patient referral. Emails received between September and November 2020 were analysed for demographic data, contents, characteristics, and outcomes. Thematic analysis was performed. A user feedback survey was conducted. RESULTS A total of 828 emails were received over the 3-month study period (mean 9.1/day). They were predominantly from optometrists (77.9%) and general practitioners (16.1%). Of the 81.0% (671) relating to clinical advice, over half (54.8%) included images from a variety of modalities, and following review, over half (55.5%) were deemed suitable for management in the community, while 36.5% were referred directly to appropriate subspecialty clinics. Only 8.1% required urgent assessment in eye casualty. Thematic analysis showed that this service was most useful for retinal lesions, optical coherence tomography abnormalities, and borderline abnormal optic discs. No adverse events were identified. User feedback was very positive. CONCLUSION A secure email advice service is a safe and low-maintenance modality that provides direct and efficient two-way communication between primary and secondary eye care professionals. It allows rapid response to clinical queries, referral filtering and refinement, and streamlining of patient referral pathways. Users (predominantly optometrists) were overwhelmingly positive about its usefulness in clinical practice.
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Affiliation(s)
- Ariel Yuhan Ong
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK.
| | - Aoife Naughton
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Stella Hornby
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Audrey Shwe-Tin
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
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Ching J, AlHarby L, Sagoo MS, Damato B. Is Tumour Thickness Measurement Required for MOLES Scoring of Melanocytic Choroidal Tumours? Ocul Oncol Pathol 2023; 9:40-47. [PMID: 38376089 PMCID: PMC10821789 DOI: 10.1159/000529862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/10/2023] [Indexed: 02/21/2024] Open
Abstract
Introduction It can be challenging to distinguish between choroidal naevi and melanomas in the community setting, particularly without access to ultrasonography (US), required to measure the thickness of melanocytic choroidal tumours. We aimed to determine whether thickness measurement is required for MOLES scoring of melanocytic choroidal tumours. Methods The dataset of a recent MOLES evaluation was reviewed. Patients were selected for the present study if their MOLES tumour size category was determined by tumour thickness measured with US. The largest basal tumour diameter and tumour thickness were then measured from ultra-widefield fundus images and optical coherence tomography (OCT) images, respectively. Results The tumour size category was determined by tumour diameter in 203/222 (91.4%) with no influence of tumour thickness. The tumour thickness influenced the MOLES score in 19/222 (8.6%) patients. In 11/19 patients with OCT measurements of tumour thickness, the US measurement exceeded the OCT by more than 25% in 5 patients, more than 50% in 2 patients, and more than 75% in 1 patient. As a result, the revised tumour thickness based on OCT determined the size category in 4/216 (1.8%) patients. The ultra-widefield fundus images measurements increased the diameter score by 1 in 5 patients. As a result, the revised tumour thickness determined the size category in 4/216 (1.8%) patients. If both the revised diameter and thickness scores were considered, the MOLES score reduced in 4 patients. If both the diameter and thickness scores were considered, the MOLES score reduced in 5 and increased in 1. Only 0.94% (2/211) of melanocytic choroidal tumours assessed with MOLES when using Optos ultra-widefield fundus images diameter and OCT to measure tumour diameter and thickness, respectively, required a change in management from a reduction in MOLES score from 1 to 0. Discussion/Conclusion This study suggests that the MOLES category for size is influenced more by the tumour diameter, if it can be measured accurately, than by the thickness. This study suggests ignoring tumour thickness if this cannot be measured accurately with OCT, unless the tumour has a mushroom shape.
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Affiliation(s)
- Jared Ching
- Ocular Oncology Service, Moorfields Eye Hospital, London, UK
- John van Geest Centre for Brain Repair, University of Cambridge, Cambridge, UK
| | - Lamis AlHarby
- Ocular Oncology Service, Moorfields Eye Hospital, London, UK
- NIHR Biomedical Research Centre for Ophthalmology, University College London Institute of Ophthalmology, London, UK
| | - Mandeep S. Sagoo
- Ocular Oncology Service, Moorfields Eye Hospital, London, UK
- NIHR Biomedical Research Centre for Ophthalmology, University College London Institute of Ophthalmology, London, UK
| | - Bertil Damato
- Ocular Oncology Service, Moorfields Eye Hospital, London, UK
- NIHR Biomedical Research Centre for Ophthalmology, University College London Institute of Ophthalmology, London, UK
- Nuffield Laboratory of Ophthalmology, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Sodhi GS, Singh N, Wrenn J, Singh AD. Peripheral Hemorrhagic Chorioretinopathy: Differentiating Features from Choroidal Melanoma. Ocul Oncol Pathol 2023; 9:1-8. [PMID: 37600851 PMCID: PMC10433100 DOI: 10.1159/000528663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/22/2022] [Indexed: 08/22/2023] Open
Abstract
Introduction Peripheral exudative hemorrhagic chorioretinopathy (PEHCR) is one of the leading mimickers of choroidal melanoma because of overlapping features with choroidal melanoma that make the distinction between these two entities difficult. Methods To identify nonoverlapping diagnostic features between PEHCR and choroidal melanoma, a retrospective study of 80 patients (80 eyes); 40 patients (40 eyes) with PEHCR; and 40 patients (40 eyes) with choroidal melanoma was conducted. Ophthalmoscopic and imaging features of PEHCR and choroidal melanoma were compared. Sensitivity and specificity for identifying PEHCR and choroidal melanoma were calculated. Youden's J statistic was assessed for each diagnostic feature. Results The most frequent clinical features of PEHCR were presence of druse (100%), hemorrhagic PED (93%), dome-shaped mass (B-scan) (90%), and subretinal/intraretinal hemorrhage (78%). Statistical analysis confirmed high sensitivity of hemorrhagic PED (0.93; 95% CI 0.80-0.98) and high specificity of clot retraction cleft, presence of lipid exudation, and bilaterality (1.00; 95% CI 0.91-1.00) as diagnostic features of PEHCR. Statistical analysis revealed presence of subretinal fluid 0.80 (95% CI 0.54-0.91) was most sensitive and presence of orange pigment, mushroom shape on B-scan, ciliary body extension, and choroidal excavation were most specific (1.00; 95% CI 0.91-1.00) for choroidal melanoma. Nonoverlapping diagnostic features of PEHCR were hemorrhagic PED, clot retraction cleft, presence of lipid exudation, and bilaterality. All PEHCR patients (100%) had at least one of these nonoverlapping diagnostic features. Nonoverlapping diagnostic features of choroidal melanoma were the presence of orange pigment, choroidal excavation, mushroom-shaped mass, and ciliary body extension (the latter 3 detected on B-scan). Youden's J statistic was highest for hemorrhagic PED and lowest for dome-shape appearance on B-scan (0.075). Conclusion PEHCR and choroidal melanoma can be differentiated by identifying diagnostic features that are exclusive to each entity. The presence of hemorrhagic PED strongly supports a diagnosis of PEHCR. B-scan ultrasonography is required to detect a mushroom-shaped mass, choroidal excavation, or ciliary body extension to exclude underlying choroidal melanoma.
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Affiliation(s)
- Guneet S. Sodhi
- Cleveland Clinic, Department of Ophthalmic Oncology, Cole Eye Institute, Cleveland, Ohio, USA
| | - Nakul Singh
- Mass Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Jacquelyn Wrenn
- Cleveland Clinic, Department of Ophthalmic Oncology, Cole Eye Institute, Cleveland, Ohio, USA
| | - Arun D. Singh
- Cleveland Clinic, Department of Ophthalmic Oncology, Cole Eye Institute, Cleveland, Ohio, USA
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Jaarsma-Coes MG, Klaassen L, Marinkovic M, Luyten GPM, Vu THK, Ferreira TA, Beenakker JWM. Magnetic Resonance Imaging in the Clinical Care for Uveal Melanoma Patients-A Systematic Review from an Ophthalmic Perspective. Cancers (Basel) 2023; 15:cancers15112995. [PMID: 37296958 DOI: 10.3390/cancers15112995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
Conversely to most tumour types, magnetic resonance imaging (MRI) was rarely used for eye tumours. As recent technical advances have increased ocular MRI's diagnostic value, various clinical applications have been proposed. This systematic review provides an overview of the current status of MRI in the clinical care of uveal melanoma (UM) patients, the most common eye tumour in adults. In total, 158 articles were included. Two- and three-dimensional anatomical scans and functional scans, which assess the tumour micro-biology, can be obtained in routine clinical setting. The radiological characteristics of the most common intra-ocular masses have been described extensively, enabling MRI to contribute to diagnoses. Additionally, MRI's ability to non-invasively probe the tissue's biological properties enables early detection of therapy response and potentially differentiates between high- and low-risk UM. MRI-based tumour dimensions are generally in agreement with conventional ultrasound (median absolute difference 0.5 mm), but MRI is considered more accurate in a subgroup of anteriorly located tumours. Although multiple studies propose that MRI's 3D tumour visualisation can improve therapy planning, an evaluation of its clinical benefit is lacking. In conclusion, MRI is a complementary imaging modality for UM of which the clinical benefit has been shown by multiple studies.
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Affiliation(s)
- Myriam G Jaarsma-Coes
- Department of Ophthalmology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Lisa Klaassen
- Department of Ophthalmology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department of Radiation Oncology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Marina Marinkovic
- Department of Ophthalmology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Gregorius P M Luyten
- Department of Ophthalmology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - T H Khanh Vu
- Department of Ophthalmology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Teresa A Ferreira
- Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Jan-Willem M Beenakker
- Department of Ophthalmology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Department of Radiation Oncology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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Damato BE. Can the MOLES acronym and scoring system improve the management of patients with melanocytic choroidal tumours? Eye (Lond) 2022; 37:830-836. [PMID: 35764877 PMCID: PMC9244298 DOI: 10.1038/s41433-022-02143-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/05/2022] [Accepted: 06/13/2022] [Indexed: 11/16/2022] Open
Abstract
It can be difficult for practitioners to determine the likelihood of malignancy in melanocytic choroidal tumours. This author has therefore devised the MOLES acronym to highlight the most informative clinical features, which comprise mushroom shape, orange pigment, large size, enlargement, and subretinal fluid. Each of these is scored 0 if absent, 1 if subtle or uncertain, and 2 if present. Tumours are categorised as ‘common naevus’, ‘low-risk naevus’, ‘high-risk naevus’ and ‘probable melanoma’ according to whether the sum of these five scores is 0, 1, 2 or 3 or more, respectively. Tentative recommendations, subject to future studies, include: review of ‘common naevi’ by a community optometrist whenever the patient attends for another reason, such as a two-yearly ‘check-up’ (i.e., ‘self-care’); non-urgent referral of patients with ‘low-risk naevi’ or ‘high-risk naevi’ to an ophthalmologist to plan long-term surveillance (i.e., determining the frequency of assessments and whether these should be undertaken by an ophthalmologist or a community optometrist); and urgent referral of patients with a MOLES score >2 (i.e., ‘probable melanoma’) to an ophthalmologist for immediate referral to an ocular oncologist if a suspicion of malignancy is confirmed. The MOLES system does not require assessment of internal acoustic reflectivity by ultrasonography. MOLES scores correlate well with diagnosis of choroidal naevi and melanomas by ocular oncologists; however, further evaluation of this aid in routine optometric practice and other situations is needed. MOLES should prevent unnecessary referral of patients with naevi for second opinion and non-essential monitoring of these patients at hospital eye services.
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Affiliation(s)
- Bertil E Damato
- Nuffield Laboratory of Ophthalmology, Department of Clinical Neurosciences, University of Oxford, and Ocular Oncology Service, Moorfields Eye Hospital, London, UK.
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Salmon B, Schalenbourg A. "De novo" Appearance of a Choroidal Melanoma During 5 Years' Follow-up for CHRPE. Klin Monbl Augenheilkd 2022; 239:590-592. [PMID: 35472812 DOI: 10.1055/a-1785-5349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Basile Salmon
- Ophthalmology, Hôpital ophtalmique Jules-Gonin, University of Lausanne, Lausanne, Switzerland
| | - Ann Schalenbourg
- Ophthalmology, Hôpital ophtalmique Jules-Gonin, University of Lausanne, Lausanne, Switzerland
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Al Harby L, Sagoo MS, O'Day R, Hay G, Arora AK, Keane PA, Cohen VML, Damato B. Distinguishing Choroidal Nevi from Melanomas Using the MOLES Algorithm: Evaluation in an Ocular Nevus Clinic. Ocul Oncol Pathol 2021; 7:294-302. [PMID: 34604203 PMCID: PMC8443944 DOI: 10.1159/000511363] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/02/2020] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE The aim of this study was to determine the sensitivity and specificity of the MOLES scoring system in differentiating choroidal melanomas from nevi according to Mushroom shape, Orange pigment, Large tumor size, Enlarging tumor, and Subretinal fluid (SRF). METHODS Color photographs, fundus-autofluorescence images, and optical coherence tomography of 222 melanocytic choroidal tumors were reviewed. Each MOLES feature was retrospectively scored between 0 and 2 and tumors categorized as "common nevus," "low-risk nevus," "high-risk nevus," and "probable melanoma" according to the total score. MOLES scores were compared with the experts' diagnosis of melanoma. RESULTS The MOLES scoring system indicated melanoma in all 81 tumors diagnosed as such by ocular oncologists (100% sensitivity) and nevus in 135 of 141 tumors given this diagnosis by these experts (95.7% specificity). Of the 6 tumors with discordant diagnoses, 4 had basal diameters exceeding 6 mm, all with SRF and/or orange pigment, and 2 small tumors showed either significant SRF with traces of orange pigment, or vice versa. CONCLUSIONS The MOLES system for diagnosing melanocytic choroidal tumors compares well with expert diagnosis but needs to be evaluated when deployed by ophthalmologists and community optometrists in a wide variety of working environments.
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Affiliation(s)
- Lamis Al Harby
- Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom
- University College London Institute of Ophthalmology, London, United Kingdom
| | - Mandeep S. Sagoo
- Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom
- University College London Institute of Ophthalmology, London, United Kingdom
| | - Roderick O'Day
- Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom
| | - Gordon Hay
- Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom
- University College London Institute of Ophthalmology, London, United Kingdom
| | - Amit K. Arora
- Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom
| | - Pearse A. Keane
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom
- University College London Institute of Ophthalmology, London, United Kingdom
| | - Victoria M.-L. Cohen
- Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom
- NIHR Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, United Kingdom
| | - Bertil Damato
- Ocular Oncology Service, Moorfields Eye Hospital, London, United Kingdom
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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11
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Singh AD, Grossniklaus HE. What's in a Name? Large Choroidal Nevus, Small Choroidal Melanoma, or Indeterminate Melanocytic Tumor. Ocul Oncol Pathol 2021; 7:235-238. [PMID: 34604194 PMCID: PMC8443921 DOI: 10.1159/000516536] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/01/2021] [Indexed: 01/23/2023] Open
Affiliation(s)
- Arun D. Singh
- Department of Ophthalmic Oncology, Cleveland Clinic Cole Eye Institute, Cleveland, Ohio, USA
| | - Hans E. Grossniklaus
- Departments of Ophthalmology and Pathology, Emory University School of Medicine, Atlanta, Georgia, USA
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Tanke LB, Leske DA, Dalvin LA. Conversion Factor for B-Scan Ultrasound Measurement of Intraocular Tumors With and Without the Sclera. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:1911-1917. [PMID: 33274784 DOI: 10.1002/jum.15575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/13/2020] [Accepted: 10/25/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To investigate the relationship between choroidal nevus and melanoma thickness measured with or without the sclera included by B-scan ultrasound and to present a simple conversion formula. METHODS Medical records were retrospectively reviewed for choroidal nevus or melanoma evaluated at the Mayo Clinic in Rochester, Minnesota, with B-scan ultrasound between February 4, 2004, and April 23, 2020. Charts were retrospectively reviewed for high-quality B-scan images in which the ultrasound transducer was perpendicular to the lesion, measuring the tumor thickness without the sclera included. Measurements were repeated with the sclera included for each patient. Univariate and multiple linear regression analyses were performed to identify factors correlated with scleral thickness. RESULTS There were 201 tumors included in the study, with a mean patient age ± SD of 61 ± 14 years, largest tumor basal diameter of 11.8 ± 4.8 mm, tumor thickness without the sclera included of 3.72 ± 2.7 mm, and thickness with the sclera included of 4.54 ± SD 2.8 mm. On the univariate analysis, factors associated with perceived scleral thickness by B-scan ultrasound included age (P < .001), tumor thickness (P < .001), and basal diameter (P = .06). On the multivariate analysis, factors associated with perceived scleral thickness included age and tumor thickness (P < .001) for all tumors and for the subset of 141 tumors with a thickness of 2 mm or greater (P < .001). For tumors of 2 mm or greater in thickness, perceived scleral thickness by ultrasound can be estimated by the formula 0.00495(patient age) + 0.02451(tumor thickness without the sclera) + 0.42549. CONCLUSIONS We present a simple formula for converting between B-scan ultrasound measurements of choroidal nevus and melanoma measuring 2 mm or greater in thickness with and without the sclera included.
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Affiliation(s)
- Laurel B Tanke
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA
| | - David A Leske
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lauren A Dalvin
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA
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Al Harby L, Ali Z, Rajai A, Roberts SA, Peto T, Leung I, Gray J, Hay G, Arora AK, Keane PA, Cohen VML, Sagoo M, Balaskas K. Prospective validation of a virtual clinic pathway in the management of choroidal naevi: the NAEVUS study Report no. 1: safety assessment. Br J Ophthalmol 2020; 106:128-134. [PMID: 33037007 DOI: 10.1136/bjophthalmol-2020-317371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Choroidal 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. METHODS A 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. RESULTS The 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%. CONCLUSIONS We 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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Affiliation(s)
- Lamis Al Harby
- Ocular Oncology, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Zaria Ali
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Azita Rajai
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester, UK
| | - Stephen A Roberts
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester, UK
| | - Tunde Peto
- Centre for Public Health, Blackwell's Queen's University Belfast, Belfast, UK
| | - Irene Leung
- Moorfields Ophthalmic Reading Centre, NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | - Jane Gray
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Gordon Hay
- Medical Retina, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Amit K Arora
- Ocular Oncology, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Pearse A Keane
- Moorfields Ophthalmic Reading Centre, NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK.,Medical Retina, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | | | - Mandeep Sagoo
- Moorfields Ophthalmic Reading Centre, NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK.,Barts Health NHS Trust, London, UK
| | - Konstantinos Balaskas
- Moorfields Ophthalmic Reading Centre, NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK .,Medical Retina, Moorfields Eye Hospital NHS Foundation Trust, London, UK
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Detecting Progression of Melanocytic Choroidal Tumors by Sequential Imaging: Is Ultrasonography Necessary? Cancers (Basel) 2020; 12:cancers12071856. [PMID: 32664236 PMCID: PMC7408899 DOI: 10.3390/cancers12071856] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/20/2020] [Accepted: 07/07/2020] [Indexed: 02/03/2023] Open
Abstract
Purpose: To determine if ultrasonography is necessary to detect progression of choroidal melanocytic tumors undergoing sequential multi-modal imaging with color photography, autofluorescence (AF) and optical coherence tomography (OCT). Methods: All patients with choroidal melanoma undergoing treatment at Moorfields Eye Hospital between January 2016 and March 2020 were reviewed to identify those with treatment deferred by ≥2 months. Tumors that showed progression prior to treatment, defined as an increase in (a) basal dimensions (b) thickness (c) orange pigment and/or (d) sub-retinal fluid, were included. Mushroom shape, Orange pigment, Large size, Enlargement and Sub-retinal fluid (MOLES) scores were assigned to all tumors at earliest date and date of treatment. Results: A total of 99 patients with a mean age of 66 years (range: 26-90) were included. The initial MOLES score was 1 in 2 cases, 2 in 23 cases, and ≥3 in 74 cases. Progression was detected with sequential color photography alone in 100% of MOLES 1/2 and 97% of lesions with a MOLES score of ≥3. When findings on AF and OCT were included, sensitivity for detecting subtle change without ultrasonography improved to 100% for MOLES 3 and 97% for MOLES 4/5. Only one patient included in this study had an isolated increase in thickness that may have been missed had sequential ultrasonography not been performed. Overall, the sensitivity for detecting progression with color photographs alone was 97% (95% CI 93-100%) and increased to 99% (95% CI 97-100%) by including autofluorescence and OCT. Conclusions: Monitoring of choroidal nevi, particularly those classified as MOLES 1 or 2 (i.e., low-risk or high-risk naevi), can be accomplished safely without the need for ultrasonography. The findings of this study may remove barriers to the implementation of tele-oncology clinics for the monitoring of choroidal melanocytic tumors.
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