moorfields adult ocular oncology Referral Form

Please e-mail this form to meh-tr.ocularoncology@nhs.net with any image(s) of lesion

Referral Date

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PATIENT DETAILS
Title	First name	Surname
Gender	DOB	NHS No (if known)
House & Street
Town/City	Post code
Mobile number	Landline	E-mail

REFERRING OPHTHALMOLOGIST’S DETAILS General practitioners should refer to optometrists, who should refer (directly) to the patient’s local hospital eye service (informing GP). (Supra-regional ocular oncology centres should receive only tertiary referrals from senior/consultant ophthalmologists.)
Consultant	Person referring	Dept
Address
Town/City	Post code
Phone No	E-mail

CLINICAL DETAILS
Clinical history
Tumour location (e.g., iris, conj, etc.)
Retinal findings	Haemorrhage	Exudates	Detachment
Images submitted with referral	Fundus photo	Slitlamp photo	FAF	OCT	US

(Please hover over text in MOLES scoresheet below for explanations and suggestions.)

If melanocytic choroidal tumour, please compute MOLES Score to estimate melanoma risk. Indicator Finding Score Mushroom shape Absent=0 Early tumour spread through RPE = 1 Present (i.e. definitive mushroom shape with overhang) = 2 Orange pigment Absent=0 Trace (i.e., fine hyper-auto-fluorescent specks)=1 Confluent (i.e. easily visible clumps of orange pigment)=2 Large size Flat (<1mm thick) and less than 3 disc-diameters (DD) wide=0 Subtle dome shape AND/OR 3-4 DD wide=1 Significant thickening (>2mm) AND/OR more than 4 DD wide=2 Enlargement* None (or no baseline photography)=0 Suspected change on comparing photographs=1 Definite growth confirmed by sequential imaging=2 Subretinal fluid Absent subretinal fluid on ophthalmoscopy=0 Trace (i.e., confirmed by optical coherence tomography)=1 Definite subretinal fluid visible with ophthalmoscopy=2 MOLES total score (0=common naevus; 1=low-risk naevus; 2=high-risk naevus; >2=probable melanoma): Note: *Assume growth and score ‘Enlargement’>0 if thickness>3 mm or diameter>5 DD.

SUGGESTED MANAGEMENT OF PATIENTS WITH MORE-COMMON TUMOURS

Conjunctival naevus: Self-monitoring if small and visible in mirror, with photograph. Otherwise, monitoring by ophthalmologist after 6-12 months. Urgent assessment by ocular oncologist if documented growth or if tumour is non-bulbar.

Papilloma: Treatment by ocular oncologist.

Primary acquired melanosis: Review by ophthalmologist after 6 months then annually. Referral to ocular oncologist if involving most of conjunctiva or if growth is documented photographically.

Complexion-associated melanosis: Reassurance and discharge.

Conjunctival squamous/sebaceous intra-epithelial neoplasia: Urgent referral to ocular oncologist.

Nodular conjunctival melanoma / carcinoma: Urgent referral to ocular oncologist. (Biopsy at local hospital is not advised because of high risk of seeding.)

Melanocytic iris tumour: Monitoring by optometrist if <3 mm wide and flat or by ophthalmologist if 3-5 mm wide and /or elevated. Urgent assessment by ocular oncologist if: (a) tumour involves angle; (b) if diffuse or (c) >5 mm wide.

Iridociliary cyst: Monitoring for glaucoma if known diagnosis. UBM by ocular oncologist if uncertain diagnosis.

Congenital ocular melanosis: Full eye exam with mydriasis (and IOP) by ophthalmologist every 12 months.

Disc/iris melanocytoma: Examination by ophthalmologist after 4-6 months and eventually every 12 months.

Congenital hypertrophy of RPE: Self-care (review by optometrist every 2 years or if seen for other reasons).

Common naevus: Review by optometrist every 2 years or if seen for other reasons.

Low-risk naevus: Non-urgent assessment by ophthalmologist, then long-term surveillance by optometrist at discretion of ophthalmologist.

High-risk naevus: Non-urgent assessment by ophthalmologist, then long-term monitoring, with intensity of surveillance adjusted according to melanoma risk.

Melanoma: Urgent assessment by ophthalmologist with urgent onward referral to ocular oncologist if diagnosis is confirmed.

Choroidal haemangioma: Assessment by ophthalmologist to confirm diagnosis. If subretinal fluid or symptoms, referral to ocular oncologist; otherwise, monitoring by ophthalmologist or optometrist.

Suspected vitreoretinal lymphoma: Urgent multimodal imaging by ophthalmologist with urgent onward referral to ocular oncology centre for vitreous biopsy and multidisciplinary management.

Metastasis: Urgent assessment by ophthalmologist with urgent onward referral to ocular oncologist or, if diagnosis is certain, to local medical oncologist/radiotherapist for treatment.

HOW TO REFER

If suspected cancer, refer urgently, following NHS 2-week-wait protocol for suspected cancer (see below).

Inform patient of differential diagnosis, need to keep appointment, and what to do if appointment letter is not received by specified date.

Optometrists and general pracitioners should refer only to the patient's local hospital eye service (not a supraregional ocular oncology service, which should receive only tertiary referrals from senior ophthalmologists).

Refer electronically and securely using NHS e-Referral Service (eRS) or 1st-class post,

Include in referral the following:

Patient’s name, date of birth, NHS number, address, phone number(s), and e-mail address,

Names, addresses and phone numbers of referrer, general practitioner and optometrist.

Clinical history, ophthalmic findings, and any relevant diagnostic reports

Recent images of lesion (e.g., colour photograph(s), optical coherence tomography, autofluorescence imaging, ultrasound) and, if tumour growth is suspected, the oldest available images. Patients presenting to a GP should therefore be directed to their local optometrist for imaging, tentative diagnosis and, if necessary, referral to an ophthalmologist.

Special needs and preferences of patient (e.g., interpreter)

Within 24 hours:

Send general practitioner and patient confirmation of referral (e.g., copy of referral letter)

Give patient a number to phone if appointment letter is not received in 2 weeks

Ensure that referral has been received by hospital

Royal College of Ophthalmologists guidelines: https://www.rcophth.ac.uk/wp-content/uploads/2021/01/Referral-Pathways-for-Adult-Ocular-Tumours-Feb-2021.pdf

College of Optometrists guidelines: https://www.college-optometrists.org/guidance/clinical-management-guidelines/pigmented-fundus-lesions.html

NHS: Delivering cancer waiting times. A good practice guide: https://www.england.nhs.uk/wp-content/uploads/2015/03/delivering-cancer-wait-times.pdf