Features of choroidal naevi on swept source optical coherence tomography angiography and structural reverse flow optical coherence tomography.

PURPOSE: The purpose of our study was to describe features of choroidal naevi as seen on swept source optical coherence tomography angiography (OCTA) and also on en face images derived from structural data from OCTA. METHODS: A prospective observational cohort study was carried out. Patients attending a specialised choroidal naevomelanocytic with known naevi were imaged with swept source OCTA. RESULTS: Seventy-one eyes of 70 patients were imaged. Forty-three patients and 44 eyes were included. Mean age was 57.7 years (SD 14.9), range 29-81 years. Male to female ratio was 20:23. On OCTA after manual segmentation, naevi could be seen in 47.6% of cases, whereas in the en face images, naevi could be clearly visualised in 79.5% of cases. In OCTA, the superficial and deep capillary plexuses appeared undisturbed as did the outer retinal layer appeared in all cases of flat naevi. In choroidal naevi with mild elevation, the outer retinal layer appeared more susceptible to projection artefacts from overlying retinal vasculature. The choriocapillaris layer showed a fading of the normal homogenous vascular mosaic corresponding to the area of the naevus. In the en face images, even the faintest and thinnest naevi could be visualised in striking detail, and naevi greater than 120 µm thickness appeared darker (p = 0.0034). CONCLUSIONS: OCTA presents characteristic changes in the choriocapillaris layers in cases of choroidal naevi. The association of naevus substance appearing darker with increasing thickness may offer a novel prognostic clue. En face structural OCT may allow accurate, detailed measurement of lateral dimensions which could be of value in the monitoring of suspicious naevi.

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.

Colour imaging in the monitoring and documentation of choroidal naevi. Are Optomap colour images adequate for this purpose?

An audit project to evaluate and compare three different imaging systems used to photograph choroidal naevi and to determine whether the Optos Optomap(®) can be used as the only colour image capture system for monitoring and documenting choroidal naevi. A further aim was to assess whether existing protocols could be improved to accurately document position and appearance of choroidal naevi. Twenty patients with choroidal naevi were photographed on three different colour image capture systems. Colour images were taken on the Optomap(®) wide field P200MA camera; the Zeiss FF450plus(®) mydriatic camera and the Topcon TRC-NW6S(®). All images were reviewed retrospectively by a medical retina consultant (SD) who completed a questionnaire to determine the most effective photographic system(s) in demonstrating the location of the naevi and the features of the condition. The Optomap(®) was the most effective in pinpointing the location of the naevus and the Zeiss FF450plus mydriatic camera best captured the features of the naevus. The non-mydriatic camera was rated the least satisfactory for both tasks. The location of the naevus on the retina should determine the choice of modality. If it is possible to photograph the lesion and include the optic disc or central macula, then the mydriatic camera is considered the best modality for recording both the position and features of the pathology. However, if it is not possible, because of the location, to include both the disc or central macula with the lesion in the same frame, then the Optomap(®) should be used to photograph the naevus to record its position and ideally a colour image on the mydriatic camera should also be taken to record the appearance of the lesion.

The MOLES system to guide the management of melanocytic choroidal tumours: can optometrists apply it?

CLINICAL RELEVANCE: Although melanocytic choroidal tumours of the choroid are a common eye pathology, no standardised protocol exists for their management in the community. BACKGROUND: Choroidal naevi are found in approximately 6% of the adult White population, whereas choroidal melanomas are rare, with an annual incidence of 5-10/million/year. Multimodal imaging has advanced the understanding of malignancy imaging biomarkers, but distinguishing between a small melanoma and naevus remains difficult and an algorithm for their management by community practitioners has not been uniformly adopted. One of the authors (BD) devised the MOLES scoring system, which indicates malignancy likelihood according to mushroom shape, orange pigment, large size, enlargement, and subretinal fluid. When applied by ocular oncologists, the system accurately distinguishes choroidal naevi from melanomas. The aim of this study was to evaluate whether community optometrists can appropriately manage patients with melanocytic choroidal tumours using this system. METHODS: Clinical images of 25 melanocytic choroidal tumours were presented in an online survey, including colour fundus photographs, fundus autofluorescence, optical coherence tomography, and B-scan ultrasound images. Using the MOLES system, 39 optometrists diagnosed tumours as naevus or probable melanoma and decided between community monitoring and ophthalmologist referral. Responses were compared to MOLES grading of the same clinical images by ocular oncologists. RESULTS: Using MOLES, optometrists correctly identified 389/406 probable melanomas (95.8% sensitivity) and 331/516 choroidal naevi (64.1% specificity); correctly referred 773/778 tumours to an ophthalmologist (99.4% sensitivity); and correctly managed 80/144 lesions (55.6% specificity) in the community. CONCLUSION: Optometrists safely applied the MOLES scoring system in this survey. Further measures are indicated to reduce choroidal naevi over-referral and evaluate MOLES system usage in clinical optometric practice, where some imaging modalities may not be readily available.

Is Tumour Thickness Measurement Required for MOLES Scoring of Melanocytic Choroidal Tumours?

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.

Expanding the role of medical retina virtual clinics using multimodal ultra-widefield and optical coherence tomography imaging.

BACKGROUND: An increasingly elderly population with a corresponding increase in ophthalmic conditions has led to increased pressure on hospital eye services (HES). In this study, we evaluated the use of a medical retina virtual clinic (MRVC), which has expanded into assessing all new medical retina referrals, where the need for urgent treatment was not clear. METHODS: Retrospective analysis of all new patients who were seen in the MRVC between April 2016 and May 2018. Pro forma sheets were used in the MRVC to record the patient history, visual acuity, and type of imaging required. Two consultants reviewed the completed pro formas and images and provided a final diagnosis and management plan. These results and reasons for face-to-face (F2F) clinic appointment requests were analyzed. RESULTS: Six hundred ten new referrals were enrolled in the virtual clinic. The most common diagnosis was diabetic eye disease (59.9%). In the virtual clinic 44.1% were followed up, 28.1% were discharged, and 27.8% were booked an F2F clinic appointment (urgent/routine). The main reason for F2F clinic was to offer treatment. Urgent F2F appointments took place on average 11.9 days after virtual clinic attendance. In only two cases was the image quality felt to be inadequate to assess the retina. CONCLUSIONS: MRVC is an effective way of triaging medical retina referrals to allow those patients needing treatment to be seen promptly in the medical retinal service. The use of multimodal ultra-widefield and optical coherence tomography imaging allows assessment of a wide range of retinal pathologies and is a promising solution to alleviate the burden on HES.

Multimodal imaging of suspicious choroidal neoplasms in a primary eye-care clinic.

Small suspicious choroidal neoplasms commonly present a diagnostic challenge in primary eye-care clinics, where they are most likely to present. Differentiating benign from malignant choroidal neoplasms is essential for facilitating early diagnosis and treatment, potentially decreasing the risk of metastasis and vision loss in some cases. The purpose of this review is to describe the clinical, spectral-domain optical coherence tomography and fundus autofluorescence features of suspicious choroidal neoplasms in a case series of patients presenting to a primary eye-care clinic at the Veterans Health Administration, Cleveland, Ohio, USA.

Transient cystoid macular oedema in multiple choroidal naevi.

Choroidal Naevi are generally thought to be trivial. However, sometimes they cause visual loss, visual filed defect and rarely transform into malignant melanoma. We report the first case of unilateral numerous choroidal naevi in a healthy female associated with transient cystoid macular oedema and postulate about its pathogenesis.