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Eye tumours - Improving our Differential Diagnosis
At the recent Optometry Tomorrow conference hosted by the College of Optometrists in Newcastle last month, I had the pleasure of listening to Professor Bertil Damato, Director of the Ocular Oncology Service at the Royal Liverpool University Hospital, give the annual George Giles Memorial Lecture, ‘Prospects for change in the treatment of uveal melanoma.’
Professor Damato explained that changing attitudes to the influence of ocular treatment on survival have altered the way in which uveal melanomas are now being treated in Liverpool. He stated, ‘small melanomas which were previously observed or treated by phototherapy are now treated aggressively, with radiotherapy. Large uveal melanomas, which were previously treated radically by enucleation are also treated by radiotherapy, in the hope of conserving the eye with as much useful vision as possible.’
In addition, Professor Damato conducted a audit to determine the main referral source of uveal tumours into ocular oncology departments. The audit revealed that most uveal melanomas are detected by optometrists with many patients being asymptomatic at the time of tumour detection.
As optometrists, being able to differentiate between the benign and the malignant is made more complicated by the lack of exposure to either on a regular basis. In fact the number of melanomas we tend to come across during our careers is relatively few.
Despite this, differential diagnosis requires us to be aware of the full range of ocular tumours. We need good skills at recognising the clinical features of each if we are to make the most appropriate management decision for the patient.
With this in mind Professor Damato and fellow consultant ophthalmologist, Mr Carl Groenewald, also of the Royal Liverpool University Hospital, together have created an online internet atlas to assist practitioners in differentiating between the ocular tumours and as importanly, between the benign and the malignant.
As this site further develops, which I am sure it will, it will provide us with a valuable online tool to improve the quality of referrals from optometrist to ocular oncologist and thus further improve our ongoing commitment to improving patient care.
The atlas may be accessed at http://www.eyetumours.com/
bertildamato // Apr 7, 2007 at 10:13 am
There are many different ocular tumours, most of which have a wide variety of manifestations. Several are harmless but many are life-threatening or associated with lethal systemic syndromes. For these reasons, it can be difficult for the optometrist to decide how to manage a patient.
Texts on ocular oncology are conventionally organized according to tumour pathology. This layout assumes that the reader knows enough about the subject to refer to the relevant part of the textbook. A non-specialist consulting such a text, however, needs to scan most of the book to find the required information and this is not practical in a busy working environment.
Mr Carl Groenewald and I have created an atlas that organizes ocular tumours according to their location and colour. The user first selects the section according to whether the tumour is located extraocularly or in the anterior segment or the posterior segment of the eye. Next, the practitioner chooses the chapter according to whether the tumour is black-grey, yellow-white, brown-tan or red-pink. An array of thumbnail images then appears. Clicking on the selected tumour produces a magnified image together with the name of the tumour and a legend mentioning the key signs and summarizing the history.
A special section helps a practitioner to decide how to manage a patient with a melanocytic choroidal tumour of indeterminate malignancy (i.e. differentiate naevus from melanoma). The tumour is scored according to its diameter, height, shape, contact with optic disc, drusen, orange pigment, retinal detachment and symptoms. Depending on the score, the practitioner is advised to reassure, observe, refer non-urgently or refer urgently.
The atlas is available on the internet, free of charge. There is no downloadable version because we wish to evaluate the program and develop it further, according to the feedback we receive. Any suggestions, images or anecdotes would be welcome. Bertil Damato
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