By Kapil G. Kapoor, MD, Wagner Macula & Retina Center
Being able to determine how someone’s health is when that someone is far away requires knowing what to measure, how to measure it, and how to get that information where it needs to go.
When we think of melanoma, we think primarily of melanoma affecting the skin. To be sure, cutaneous melanoma remains the most serious type of skin cancer and can be lethal if it progresses undetected. Even though cancer affecting the eye is much less common, melanoma still remains the most common type of primary intraocular cancer. With early detection, both cutaneous melanoma and ocular melanoma have great cure rates. However, early detection of ocular melanoma has unique challenges. Cutaneous melanoma permits self-monitoring and detection through the basic “ABCDE” principles (asymmetry, border, color, diameter, and evolution). The same is not achievable for ocular melanoma – there is no way to self-monitor. In fact, many patients have absolutely no symptoms despite having a melanoma growing inside their eye. This is because just like melanocytes are present in the entire external skin layer and plainly visible to us, these same cells also line the uvea, or middle layer of the entire inside of the eye. If a melanoma develops within the uveal layer away from the central vision area of the macula, patients may have no vision changes, or may have only subtle or vague symptoms of floaters or flashes of light.
By collaborating together, we can achieve our mutual goals for patients in our community by saving sight and enhancing lives.
Further, while suspicious moles are easily biopsied or excised with cutaneous melanoma, biopsy or excision of a suspicious nevus in the eye can present significant risks that include threatening the patient’s sight or allowing a pathway for extraocular spread of the tumor.
Thus the realm of screening and detection of ocular tumors is entirely in the wheelhouse of the team of physicians. Clinicians need to keep their ears to the ground for symptoms in at-risk patients, particularly those of the Caucasian race with light-colored irises, history of previous skin cancers or other inherited skin disorders, and history of significant ultraviolet light or tanning bed exposure. Dermatologists need to insist patients with cutaneous melanoma or other skin cancers pursue baseline screening to rule out the presence of suspicious choroidal nevi that may require monitoring. Oncologists need to ensure that all cancer patients who have any visual symptoms are screened for metastatic spread, since the uveal tract is at high risk for metastasis for cancers that spread hematogenously, given the high amount of blood flow per surface area required to maintain sight.
While uveal malignant melanoma continues to increase in incidence, treatment methods have become progressively more sophisticated, with high success rates in the setting of early detection. Years ago, detection of a uveal melanoma spelled removal of the eye by enucleation. Today, we typically employ a sight-saving centered approach using radioactive plaque brachytherapy with I-125 plaques, often coupled with biopsy and genetic testing at the time of treatment to understand a patient’s risk of metastatic spread. Some smaller tumors are amenable to laser treatments with transpupillary thermotherapy, photodynamic therapy, or cryotherapy. Our regionally unique ocular oncology team includes an assembly of two ocular oncologists, a team of radiation oncologists, and a clinical team that coordinates digital imaging, surgical planning, and systemic evaluation. We remain focused on creating individualized patient-centered treatment paradigms and welcome your partnership as part of our extended ocular oncology team. By collaborating together, we can achieve our mutual goals for patients in our community by saving sight and enhancing lives.
Kapil G. Kapoor, MD completed medical school at Ohio State University, residency at the University of Texas Medical Branch-Galveston and a fellowship at The Mayo Clinic. Dr. Kapoor is a Board certified ophthalmologist specializing in vitreoretinal surgery. wagnerretina.com
