Choroidal naevi is common incidental finding prompting specialist referrals to ocular oncology. Lesions sometimes have sufficient features to diagnose a small melanoma. The study aimed to show that ‘virtual’ imaging-based pathways are safe.
Management decisions of 400 patients reviewed by an ophthalmologist in consultation 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 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%.
The study validated a virtual clinic model for the safe management of choroidal naevi. Such a model of care is feasible with a low rate of under-referral. An over-referral rate of almost 24% from the virtual pathway needs to be factored into designing such pathways in conjunction with evidence on their cost-effectiveness.