About DOTS

The DemDx Ophthalmology Triage System suggests a triage priority and the conditions to consider for adults attending an ophthalmic emergency department. It was developed at Moorfields Eye Hospital, validated in the UK and Brazil, and published in peer-reviewed journals.

Designed to support the triage nurse, not to replace them

The problem

Ophthalmic emergency departments see many patients who could be cared for elsewhere, while true emergencies must never be missed.

55.8%

of Moorfields A&E attendances were not emergencies

12,584 attendances

71.8%

of patients who needed elective care were still booked into A&E

Moorfields Eye Hospital A&E

≈ 1 in 2

attendances were not emergencies in eye emergency services in three countries

London 55.8% · Belo Horizonte 48.5% · Boston 49.4%

Sources: Brandao-de-Resende et al., eClinicalMedicine 2023 [1]; Mass Eye and Ear chart review 2015–16 (Digital Journal of Ophthalmology).

How DOTS works

The nurse enters the presentation and makes their own decision first. DOTS then suggests a priority and the conditions to consider, and suggests questions that could change it.

1 · Nurse enters

Age group
Affected eye and duration
Red flags
Signs and symptoms
Relevant history

No names or hospital numbers. A date of birth is turned into an age band on your device and is not sent.

2 · DOTS

A machine-learning model (gradient-boosted trees) trained on 11,315 Moorfields A&E attendances, with a second model ranking the likely conditions.

3 · Suggestion

EMERGENCYsee immediately

URGENTsee within a week

ROUTINEadvice, GP or optometrist

Plus more urgent conditions to consider or rule out, less urgent conditions to consider, and up to 5 questions that could change the result [3].

What it covers

93 condition groups, each prioritised by three consultant ophthalmologists. Any red flag means emergency.

EMERGENCY36 groups

Acute angle closure
Retinal detachment or tear
Retinal artery occlusion
Giant cell arteritis
Open globe injury
Keratitis

and 30 more

URGENT20 groups

Posterior vitreous detachment
Retinal vein occlusion
Proliferative diabetic retinopathy
Neovascular membrane
Proptosis
Dislocated IOL

and 14 more

ROUTINE37 groups

Dry eyes
Blepharitis
Chalazion
Infective conjunctivitis
Allergic conjunctivitis
Subconjunctival haemorrhage

and 31 more

Red flags

Rapid change in VAComplete visual lossDiplopiaChange in pupilsSevere painRecent traumaPost-opSystemically unwell

Published evidence

Development and validation study [1]: DOTS on its own compared with triage nurses on their own, on Moorfields cases held out from training.

Equivalent

sensitivity for emergencies, similar to triage nurses

25.1% → 42.4%

specificity for emergencies, nurses vs DOTS (+70% relative)

84.4% → 73.9%

cases triaged as emergency, nurses vs DOTS (−12% relative)

Published

Validated in two countries

11,315 attendances to develop DOTS, 1,269 for internal validation at Moorfields (London) and 761 for external validation at UFMG (Belo Horizonte, Brazil) [1].

Published

Usable and trusted by clinicians

In a mixed-methods study with 20 clinicians, over 90% found it easy to use, 85% found it safe and 95% said they would use it in their clinical workflow [2].

Emergency class. Moorfields temporal validation; differences from nurses significant at p < 0.05. Source: eClinicalMedicine 2023, Table 3 [1].

Clinical evaluation

DOTS is being evaluated with triage nurses in routine care.

Preliminary results · manuscript in preparation

Evaluation of DOTS in the Moorfields Eye Hospital A&E

Registration: ISRCTN25862260
Design: Single-centre pre-post evaluation: triage with DOTS compared with matched cases from the previous year
Funding: NIHR Artificial Intelligence in Health and Care Award
Status: Results are preliminary and not yet peer reviewed. They will be added here once published.

Publications

A machine learning system to optimise triage in an adult ophthalmic emergency department: a model development and validation study
Brandao-de-Resende C, Melo M, Lee E, Jindal A, Neo YN, Sanghi P, Freitas JR, Castro PVIP, Rosa VOM, Valentim GFS, Higino MLO, Hay GR, Keane PA, Vasconcelos-Santos DV, Day AC
eClinicalMedicine 2023;66:102331 · doi:10.1016/j.eclinm.2023.102331
Usability of an artificially intelligence-powered triage platform for adult ophthalmic emergencies: a mixed methods study
Jindal A, Sumodhee D, Brandao-de-Resende C, Melo M, Neo YN, Lee E, Day AC
Scientific Reports 2023;13:22490 · doi:10.1038/s41598-023-49213-y
Enhancing ophthalmic triage: identification of new clinical features to support healthcare professionals in triage
Jindal A, Brandao-de-Resende C, Neo YN, Melo M, Day AC
Eye 2024;38(13):2536–2544 · doi:10.1038/s41433-024-03070-9

DOTS is a clinical decision support tool for triage nurses in adult ophthalmic emergency departments. It suggests a priority and conditions to consider; it does not diagnose and does not replace clinical judgement. Do not enter names, hospital numbers or other patient identifiers.