“This experience has made me realise the importance of a thorough and experienced optician”
Optometrist at the Lancashire-based Broadhurst Optometrists, Jennifer Smith, and her patient June Williams, discuss how a routine check-up unveiled a choroidal melanoma
30 March 2020
Before you went for a sight test, had you experienced any symptoms?June Williams (JW): I attended Broadhurst Optometrists for a routine check-up. Leading up to the sight test I had no symptoms and was unaware that there was a problem.
JW: During the sight test, the optometrist found a possible melanoma. Jennifer told me she was referring me to my GP who would then refer me to my local hospital.
What did the optometrist find, and how did they explain the next steps to you?
Can you describe how you felt during the referral?JW: I was a little concerned initially when I was told I would be referred. But I became more concerned when they referred me on to St. Paul’s Eye Hospital in Liverpool.
JW: Following the referral, I had to have radiotherapy treatment in my right eye. This involved inserting a metal plaque in my eye and conducting the radiotherapy through it. This was then removed two days later.
Did you have to undergo further treatment and what has been the outcome?
The treatment has been successful in reducing the melanoma but has left me with some distortion in that eye. I also have to attend the hospital every six months for further cancer checks.
During the sight test, Jennifer found a possible melanoma. She told me she was referring me to my GP who would then refer me to my local hospital
Have your views on the importance of sight tests and eye care changed as a result of this experience?JW: I have always known that sight and eye health checks are important, but this experience has made me realise the importance of a thorough and experienced optician.
How has the experience changed your life?JW: The resulting distortion left behind from the treatment causes me some problems which I and the clinicians are dealing with as best we can. I am also glad of the six-monthly cancer checks. At the age of 73 I feel this is no bad thing.
I have always known that eye checks are important, but this experience has made me realise the importance of a thorough and experienced optician.
What did you identify during the sight test and what was your reaction?
Jennifer Smith (JS): During the retinal Volk exam I discovered a suspicious, large pigmented choroidal lesion inferior to the macula, which was approximately 4-5DD in size. Although the lesion was flat, the margins were poorly defined and rings of pigment within the lesion implied it was in fact increasing in size. I see numerous naevi as a minor eye conditions service (MECS)-accredited practitioner and was immediately concerned that it could be a melanoma.
How did you approach explaining what you had identified?
JS: We are fortunate to have Optomap widefield imaging technology at Broadhurst Optometrists, so I was able to show the patient the image and point out the features I was concerned about. I related the changes I had seen to those you would look for in a mole on the arm, including size, colour and shape. This helped the patient to understand my concerns and the need for a second opinion.
I was careful to avoid voicing my tentative diagnosis so as not to panic the patient but stressed the need for an urgent referral in order to get a specialist diagnosis.
What were the next steps that you took?
JS: As the patient was visiting from another area outside of our MECS pathway, we decided the best course of action was to ring the GP surgery and refer them using secure nhs.net email, including the images taken.
I then followed up immediately with a phone call to the medical secretary to ensure receipt of the email. I asked that they refer immediately to the local hospital for triage as suspected cancer.
When did you hear about the results of your referral and how have you been involved since?
JS: I followed up with the patient a few days later and was informed that they had been referred on to the local specialist ocular oncology centre for further investigation. I then liaised closely with the specialist centre providing further history and images.
It was with the aid of the historical images that they decided on a melanoma diagnosis and within six to eight weeks from the original sight test the patient underwent plaque-brachytherapy. I have since seen the patient in practice where I was amazed that the vision was stable at 6/6- and the lesion has significantly reduced in size.
What would be your three top tips to other practitioners when making a referral?
JS: 1. When referring suspicious naevi, always include historical images to help the triage and hospital teams look for progression. This allows the patient fast access to treatment as the hospital doesn't have to waste any further time monitoring for change
2. Own your referrals – follow up and liaise closely with hospital teams or GPs to minimise delay
3. Remain calm and ensure the patient understands why they are being referred. Tell them when they should expect to be seen and the importance of attending appointments. I always advise my patients to contact me if they have any concerns or queries.
*The patient’s name has been changed to respect their request for anonymity.