OXFORD OCULAR ONCOLOGY Referral Form

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To refer a patient, e-mail this form to ouh-tr.ocularmoles.oxon@nhs.net Please attach image(s) of the lesion, which may avert a hospital visit. If no images are available, please let us know.
We will review the images within two weeks and send a report to the patient as well as the referring optometrist and general practitioner. If no images are received, we will contact the referring practitioner to request images. This may delay the referral. If images are not available or if they are inadequate, we will organise imaging at OEH. Please advise patients that they will NOT have a face-to-face meeting with an ophthalmologist at this visit. If no further hospital visits are necessary, we will send the patient a colour photograph of the lesion to take to their optometrist at every visit. If monitoring is needed, we will organise an OEH Photography Clinic visit after 4-6 months. If malignancy is suspected, we will see the patient in the Ocular Oncology Clinic at OEH within 2 weeks. Please advise the patient to visit the Ocular MOLES Service page on the Oxford University Hospitals website, which they can find by googling ‘OUH Ocular MOLES Service’ and where they can download an information leaflet.

Referral Date

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

Carer / Key Worker Details (if applicable)
Name	Phone
Relationship to patient

Cognitive, Sensory or Mobility Impairment (if applicable)
Sensory	Mobility	Cognitive	Comments

General Practitioner Details
Usual GP
Practice	Practice Code (if known)
Address	Town/City
Postcode	Phone	E-mail

Referring Optometrist Details
Name
Practice	GOC Number
Address	Town/City
Post code	Phone	E-mail

Suspected diagnosis:
Affected eye	Findings
Please complete the MOLES scoresheet if referring a patient with a pigmented fundus lesion Risk Factor Finding Score Mushroom shape Absent = 0 Incipient (erosion through RPE) / uncertain) = 1 Present (i.e. definitive mushroom shape with overhang) = 2 Orange pigment Absent = 0 Dusting / unsure = 1 Confluent (i.e. easily visible clumps of orange pigment) = 2 0 Large size Flat (<1mm thick) and less than 3 disc diameters (DD) wide = 0 Subtle dome shape (1-2mm thick) AND/OR 3-4DD wide = 1 Significant thickening (>2mm) AND/OR more than 4DD wide = 2 Enlargement None (or no baseline photography) = 0 Suspected change on comparing photographs = 1 Definite growth confirmed by sequential imaging = 2 Subretinal fluid Nil = 0 Trace (limited retinal detachment seen only with OCT) = 1 Definite subretinal fluid visible with ophthalmoscopy = 2 Moles total score = 0 Proximity to disc is no longer considered a risk for malignancy. Drusen on the surface of the lesion are NOT signs of malignancy. Patients with melanocytoma or congenital ocular melanosis need monitoring and can be referred non-urgently using this form, completing the Comment section below: If SUSPECTED EYE CANCER: If probable melanoma (i.e., MOLES score >2) or other suspected cancer (e.g., conjunctival melanoma or carcinoma, iris melanoma, choroidal metastasis) e-mail this form to PCC2wwOxford@nhs.net Encourage patient to accept first available clinic Give patient a FastTrack Patient Information Sheet
DO NOT REFER the following with this form
Common naevus (i.e., MOLES score = 0)	Inform the patient, advising self-care (i.e., visit to optometrist every 1-2 years according to guidelines college-optometrists.org Ideally provide patient with a fundus photograph to take to optometrist at every visit.
Patient symptomatic or diagnosis in doubt	Consider Minor Eye Conditions (MECS), or E-mail for advice at: oxon.eyes@nhs.net or Follow Guidelines of the Oxfordshire CCG.
Congenital hypertrophy of RPE (CHRPE)	Inform the patient, advising self-care (see above)

Does the patient have a history of cancer?	Ocular/systemic history:
Comment

I have discussed the possible diagnosis of melanoma with the patient
The patient/guardian consents to sharing information/images with the Oxford Eye Hospital via email
Please type your name to indicate your signature

(Save and rename file with patient identifier then e-mail to: OEH MOLES Clinic)

This form and the MOLES Information Sheet can be downloaded from the OEH website.