Abstract

PurposePigmented 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.MethodsWe 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.ResultsAcross 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.ConclusionsIntermediate‐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.

Highlights

  • Pigmented ocular lesions may be defined as any melanocytic abnormality of the eye or associated tissues and includes intraocular tumours, metastases, scarring or hyperplasia associated with degenerative, inflammatory or neovascular disease

  • The aim of this study was to describe pigmented lesion referral patterns to this optometry-ophthalmology collaborative care clinic and to quantify the level of diagnostic congruency between primary, community care optometrists and intermediate-tier Centre for Eye Health (CFEH) care, providing an evidence base regarding the role of optometry in the collaborative care of pigmented lesions

  • This report demonstrates that the use of intermediate-tier care optometry may aid in the appropriate referral of pigmented lesions

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Summary

Introduction

Pigmented ocular lesions may be defined as any melanocytic abnormality of the eye or associated tissues and includes intraocular tumours (benign, indeterminate or malignant lesions of the uvea, retina, retinal pigment epithelium or optic nerve), metastases, scarring or hyperplasia associated with degenerative, inflammatory or neovascular disease.Intermediate-tier care of pigmented lesionsFailure to distinguish benign pigmented lesions from potentially malignant conditions, such as choroidal melanoma, can result in delays in care, suboptimal treatment outcomes and a greater need for enucleation.[1]. Specialist care may be overburdened by false positive referrals of benign lesions, and inter-optometric referrals are uncommon.[9,10] Chronic and/or well controlled conditions may not require ophthalmological management.[11] core competencies for entry level into the optometric profession stipulate that optometrists should have the ability to assess and evaluate the various ocular tissues for the purpose of screening for health or disease.[12] optometrists are trained to recognise clinical situations which do not require intervention and those that necessitate periodic review due to risk of visual or systemic morbidity. Efficiency might be improved via referral refinement schemes integrating optometrists with a special interest.[15]

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