Follow-up at home hospital
You should be examined by an ophthalmologist about one week after local resection or endoresection and about one month after other procedures (ie, plaque radiotherapy, enucleation).

Unless you live very close to Liverpool, this examination will be performed at your own hospital. Despite our best efforts, the discharge letter may not have arrived at your hospital by the time of your examination, in which case you should be prepared to explain to your ophthalmologist what has been done.

Some general ophthalmologists seem to get worried when they have to look after a patient who has undergone treatment for a tumour, because, quite understandably, they may not be very familiar with the surgical techniques involved. Nevertheless, all your ophthalmologist needs to do at this early stage is ensure that there is no infection, no raised intraocular pressure and, indeed, no sign of any other complication that would be common to any eye operation.

After radiotherapy or phototherapy, the tumour does not usually begin to regress for several weeks or months. This is why follow-up assessments at our Centre are delayed for six or nine months after such treatments.

If it is likely that treatment is required before this time, for example, after local resection or endoresection, then arrangements will be made for you to attend our Centre as necessary.

Ocular examination is recommended every six months for the first six years then once a year for several years and eventually once every 18 months to two years for the rest of your life.

Initially, arrangements are made for these examinations to alternate between your local hospital and our Centre. This system of alternating examinations is designed to:

• Ensure that the ophthalmologists at your hospital keep in touch with your progress and become familiar with your condition;
• Make it easier for the ophthalmologists at your hospital to take over full responsibility for your care once the time comes for you to stop attending our Centre;
• Reduce the need for you to travel long distances between your home and our hospital, if you live far from Liverpool;
• Reduce the number of patients attending our follow-up clinics, making it possible for our consultant to see every patient at every clinic visit.

Follow-up at the Oncology Centre
The procedure at our follow-up clinic is similar to your first consultation.

You will be registered at the reception desk. Next, the sift nurse will check your vision and, if necessary, dilate your pupils.

An SHO or specialist registrar (SPR) will first ask you a number of questions, using a structured questionnaire. These questions are designed to cover all possible symptoms and to get some idea of how worried you might be about tumour recurrence, tumour spread and metastatic disease. These questions are asked so that we can alleviate symptoms and discuss any of your fears. This is so that appropriate reassurance can be given if such fears are groundless (as they often are) or so that advice can be given if there is genuine cause for concern.

You will next have your photographs taken.

After your photography, you will be asked to wait until the consultant sees you. Unfortunately, this can be quite a long wait because the consultant routinely sees all patients at every clinic, which means that the clinic rarely finishes before 1.30 to 2.00 pm. We have tried to reduce waiting times by spreading appointment times more evenly across the clinic session but this tended to result in very slack periods in the early part of the clinic and a great rush to catch up later in the clinic. It only needed one or two patients to arrive late, because of a train delay or congestion on the motorways, to disrupt the whole clinic.

The consultant will review the casenotes with you, discuss any symptoms you might have, and examine your eye, if necessary also performing ultrasonography. If appropriate, he will compare the clinical findings with previous photographs. Next, he will discuss your results with you, dictate a letter to your ophthalmologist with a copy to your general practitioner, computerize any relevant information, and give you an appointment sheet to hand to the clerk at the reception desk.

The specialist ocular oncology nurse may speak to you in a quiet room if there are any important matters you wish to discuss with her.

The letters to your Ophthalmologist and General Practitioner are usually posted within one or two working days. Delays can sometimes occur if our secretary is on leave or if there are any typographical errors that need to be corrected.

Any oncologist or radiotherapist involved in your care will receive a copy of your report, but it is not our current policy to send copies of letters from follow-up clinics to optometrists.

Discharge from our Centre
You will be discharged from our Centre when:

• We feel that it is safe for you to stop attending;
• You are happy to stop coming to our clinic;
• Your ophthalmologist feels able to take over responsibility for your further care.

Screening for metastatic melanoma
After treatment of the primary tumour, the value of screening is disputed. Some authorities believe that there is little scope for screening unless better treatments are developed. Others recommend a blood test and a liver scan every six or twelve months in all patients, in the hope of detecting any tumours at an early stage, when chemotherapy or surgery may prolong life.

We feel that indiscriminate screening causes unnecessary distress and inconvenience to many patients. We suggest that screening has greatest scope in patients with a high risk of tumour spread (see Chapter 4). However, we believe that the ultimate decision should be taken by the by the patient and the specialist who would be responsible for caring for that patient, should tumour spread ever develop.

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