Al Harby Lamis, Ali Zaria, Rajai Azita, Roberts Stephen A, Peto Tunde, Leung Irene, Gray Jane, Hay Gordon, Arora Amit K, Keane Pearse A, Cohen Victoria M L, Sagoo Mandeep, Balaskas Konstantinos
Ocular Oncology, Moorfields Eye Hospital NHS Foundation Trust, London, UK.
Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
Br J Ophthalmol. 2022 Jan;106(1):128-134. doi: 10.1136/bjophthalmol-2020-317371. Epub 2020 Oct 9.
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.
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.
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%.
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.
脉络膜痣是一种常见的偶然发现，常促使患者转诊至眼科肿瘤专科。此类病变很少具有足以诊断小黑色素瘤的可疑特征。本研究的目的是表明基于“虚拟”成像的途径是管理此类转诊的一种安全有效的选择。
2016年6月至2017年7月在曼彻斯特皇家眼科医院和摩尔菲尔德眼科医院进行了一项前瞻性队列研究，对400例患者的管理决策进行研究。这些患者由眼科医生进行面对面会诊（金标准），并辅以眼底摄影、光学相干断层扫描、自发荧光（AF）和B超检查。图像还由不知情的分级人员（非医学专业）和不知情的眼科医生独立读取，并仅基于图像审查做出管理决策（虚拟途径）。比较两种途径的安全性。
面对面途径和虚拟途径之间管理决策的一致性为83.1%（非医学专业）和82.6%（医学专业）。虚拟途径中的过度转诊更多（非医学专业为金标准出院的24.3%，医学专业为23.3%），只有两例转诊不足（占金标准转诊的10.5%），均为临床风险极小的临界病例。生长风险因素（橙色色素、视网膜下液、高自发荧光）的一致性在82.3%至97.3%之间。
我们前瞻性地验证了一种用于安全管理脉络膜痣的虚拟诊所模型。这种护理模式是可行的，转诊不足率较低。在设计此类途径时，需要考虑到虚拟途径近24%的过度转诊率及其成本效益证据。
