Real-world experience of implementing the MOLES score in a virtual choroidal naevi clinic at a tertiary referral centre.

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.

Intravenous indocyanine green dye is insufficient for robust immune cell labelling in the human retina.

It is not currently possible to reliably visualise and track immune cells in the human central nervous system or eye. Previous work demonstrated that indocyanine green (ICG) dye could label immune cells and be imaged after a delay during disease in the mouse retina. We report a pilot study investigating if ICG can similarly label immune cells within the human retina. Twelve adult participants receiving ICG angiography as part of routine standard of care were recruited. Baseline retinal images were obtained prior to ICG administration then repeated over a period ranging from 2 hours to 9 days. Matched peripheral blood samples were obtained to examine systemic immune cell labelling and activation from ICG by flow cytometry with human macrophage cultures as positive controls. Differences between the delayed near infrared ICG imaging and 488 nm autofluorescence was observed across pathologies, likely arising from the retinal pigment epithelium (RPE). Only one subject demonstrated ICG signal on peripheral blood myeloid cells and only three distinct cell-sized signals appeared over time within the retina of three participants. No significant increase in immune cell activation markers were detected after ICG administration. ICG accumulated in the endosomes of macrophage cultures and was detectable above a minimum concentration, suggesting cell labelling is possible. ICG can label RPE and may be used as an additional biomarker for RPE health across a range of retinal disorders. Standard clinical doses of intravenous ICG do not lead to robust immune cell labelling in human blood or retina and further optimisation in dose and route are required.

Management of optic neuritis in Ireland: a survey comparing the management practices of acute demyelinating optic neuritis amongst ophthalmologists and neurologists in Ireland.

BACKGROUND: Acute optic neuritis (ON) is often the first manifestation of multiple sclerosis which is particularly common in Ireland. Despite the specific clinical details regarding investigations and management of ON provided by the Optic Neuritis Treatment Trial (ONTT), international surveys have shown that there are still notable differences in the management of ON between neurologists and ophthalmologists. AIM: To compare the investigation and treatment of acute optic neuritis between ophthalmologists and neurologists in Ireland METHOD: A survey consisting of a case scenario and questions regarding treatment and investigations of a patient with ON was emailed to ophthalmology consultants, trainees and medical ophthalmologists registered with the Irish College of Ophthalmologists and to neurology consultants and registrars registered with the Irish Institute of Clinical Neuroscience. RESULTS: One hundred sixty recipients responded out of 350 (46%). The majority of the neurologists would initiate steroid treatment regardless of the patient's vision (75%), treat with 1 g IV methylprednisolone (100%) for 5 days (57%), perform an MRI brain and orbits with contrast (92%) and multiple laboratory tests (96%). In contrast, the ophthalmologists tended to initiate treatment depending on the patient's vision (48%), treat with 1 g IV methylprednisolone (97%) for 3 days instead of 5 days (93%), perform MRI brain and orbits with contrast (73%) and favour electrophysiology testing (73%) over laboratory testing (68%). CONCLUSIONS: Overall, most respondents would follow the ONTT guidelines regarding IV methylprednisolone. There was a significant difference in responses between the ophthalmologists and neurologists regarding who to treat, duration of treatment and appropriate investigations.

'Teeth in the brain' - a case of giant intracranial mature cystic teratoma.

The authors describe a case of a giant intracranial mature cystic teratoma in a 16-year-old girl presenting acutely with a severe headache, vomiting and a complex generalised seizure with a background history of intermittent headaches for 3 years. CT and MRI brain demonstrated a ruptured large cystic teratoma encapsulating two large teeth within the diffusely dense fatty heterogeneous lesion. Surgical debulking of the cyst was performed and the calcific remnants were left behind owing to dense adhesion to the brain. The procedure was complicated by postoperative hydrocephalus and needed a ventricloperitoneal shunt. She is currently asymptomatic and undergoing rehabilitation.