Background <p>The MOLES scoring system was developed to help non-experts estimate the likelihood of malignancy in melanocytic choroidal tumours according to mushroom shape, orange pigment, large size, enlargement, and subretinal fluid. If only imaging is assessed, as in telemedicine, a choroidal melanoma (CM) may be scored as a naevus if subretinal fluid and orange pigment are not evident and if sequential imaging is not available. In such a telemedicine environment it might be safest to modify the MOLES score to assume lesion enlargement has occurred if the thickness and/or diameter exceed 3 mm or 7.5 mm, respectively.</p> Methods <p>Clinical records and multimodal imaging of patients with clinically diagnosed small CM (with no histopathological analysis) treated with ruthenium-106 (Ru-106) plaque brachytherapy were retrospectively reviewed. Sensitivity of the original and revised MOLES in estimating likelihood of malignancy were evaluated.</p> Results <p>The cohort comprised 142 patients (mean age 60 ± 13.6 years) with small CM. Mean tumour thickness and largest basal diameter (LBD) were 1.9 ± 0.5 mm (range 0.4–2.5 mm) and 7.5 ± 1.9 mm (range 3.5–15 mm), respectively. The MOLES score was ≥3 in 97.9% and 100% of small CM according to the original and modified scoring systems, respectively. No cases had MOLES score &lt;2, indicating that 100% of patients would have been referred for specialist assessment.</p> Conclusions <p>The revised MOLES score increases sensitivity in diagnosing CM from 97.9% to 100% and is therefore a useful aid to patient management.</p>