AA melanoma is a primary tumor of the skin and also the eye. In the eye it arises from the pigmented cells of the uvea (choroid, ciliary body or iris) of the eye and is not a tumor that started somewhere else and spread to the eye. Malignancy means that the tumor is a cancer, which may spread to another part of the body (metastasis means cancer spread). Not all tumors metastasize. Although some choroidal melanomas are more life-threatening than others, all should be treated as if they were malignant.
Melanoma of the eye occurs in about 6 people per million people per year. It almost always occurs in one eye and your other eye is usually at no higher risk to develop this tumor. There is usually no inheritance so your family is at no higher risk to develop this tumor. Ocular melanoma is rarely seen in dark skinned individuals and is more common in fair skinned, blue- or green-eyed people.
Learn more about ocular melanoma:
Contact the UCLA Stein Eye Institute Westwood for more information at (310) 825-5000
Sometimes, even a large tumor may not cause any symptoms. As the cancer grows larger your symptoms may include:
If you experience these symptoms, your eye doctor may also see the tumor while examining your eye.
Melanoma within the eye is diagnosed during an examination of the eye by an ophthalmologist. Eye doctors are able to recognize a melanoma by the typical color, shape and location of the tumor and by other features observed in an eye examination.
The diagnosis is suspected as the eye is examined with the slit lamp machine and the headlight. A detailed drawing of the melanoma is done as we map out the characteristics of the tumor. Sometimes transillumination is used in the office. Transillumination allows us to see the tumor on the eye wall by directing a beam of light to the inside of the eye.
Some special tests enable us to be more certain of the size of the tumor and support the diagnosis of melanoma. These tests will be done by us at your first visit and at your follow-up visits. These tests, which usually cause no discomfort, include:
There is NO radiation involved in these tests.
Photography tests
A bright flash will be used to photograph the back of the eye. In some cases, a special lens is necessary to place on the numbed eye to get high quality angled pictures of the tumor.
Ultrasonography test
Sound waves are directed towards the tumor by a small probe placed over jelly on the surface of the eye. The pattern made by the reflection of the sound waves helps your doctor judge the thickness and internal qualities of the tumor. This is important in planning treatment.
Fluorescein angiography test
This test is useful in studying the blood vessels of the melanoma and to assess the health of the circulation in the rest of the eye. In this test, a tiny amount of vegetable dye is injected into a vein in your arm. As the dye passes through the blood vessels in the back of the eye, a rapid sequence of photographs is taken through your pupil. The dye is harmless to the body, but some people may be allergic to it.
In the past it was almost always necessary to surgically remove the eye which contained an ocular melanoma. In recent years, new methods of treatment have been developed which may be used to save the eye. There are now several ways to treat melanoma of the eye depending on several findings – the age and health of the patient and the size, location, thickness and growth of the tumor. The goal of treatment is to stop the growth of the tumor in the eye.
Treatment Options:
Observation
Observation of suspicious-appearing flat or elevated lesions, may be advised. Photography and ultrasonographic imaging studies may be used to check the lesion every few months. If the tumor grows, then an ocular melanoma is suspected, and definitive treatment with radiotherapy will be recommended.
Laser
Laser treatment is rarely used for melanoma of the eye, but may be used for other small benign tumors in the back of the eye.
Radiation (Plaque Radiotherapy)
Radiation treatment is a common form of treatment of the eye melanoma. It is used for all sized tumors. The method of giving the radiation at the UCLA Stein Eye Institute is as follows: a radioactive plaque (about the size of a coin) is applied in the operating room to the eye. The plaque is made of gold and it looks like a button with radioactive seeds on one side. The gold plaque provides a platform for attaching the radioactive seeds and also functions as a radiation shield to prevent radiation from leaving the eye. The ophthalmologist surgically secures the radioactive plaque to the eye over the area of the tumor. The side of the plaque with the radiation is placed directly over the tumor. The plaque radiation remains directly over the involved eye and does not affect the opposite eye, the brain or the rest of your body. It is left in place for an exact number of days to provide adequate radiation to the entire tumor. Usually, the patient receives 4 to 6 days of treatment. The radiation plaque may then removed in the office or in the operation room and you may be discharged the same day. Once the plaque is removed, you are not radioactive and none of your body is radioactive.
The radiation plaque causes gradual shrinkage of the tumor but the area where the tumor was remains a scar in the back of the eye and will be seen on our examination. The goal of radiation is to sterilize the tumor of its malignant cells and the remaining cells are slowing eliminated by the body over months. In a small percentage of patients (< 0.5% at the Stein Eye Institute) the tumor may regrow after radiation treatment and in some of these cases, a second plaque may be necessary or the eye may need to be removed (enucleation).
Radiation may cause a decline of vision as a side effect of the treatment, but a majority of patients do well with fair vision in the affected eye and excellent vision in the unaffected eye. Radiation may damage some healthy parts of the eye. Damage to the blood vessels of the retina (radiation retinopathy) or to the optic nerve often causes a gradual loss of vision. In some cases, hemorrhage into the inner part of the eye (vitreous cavity) may occur and may cause a loss of vision. Radiation damage to the lens may cause a cataract, which may require removal by surgery sometime later.
At UCLA, you may also have a silicone oil bubble placed in the eye to help limit the radiation from reaching the non-tumor parts of the eye. The vitreous humor is removed in a procedure called ‘vitrectomy’ and the oil bubble is placed inside the eye. The oil bubble may be removed at the time the plaque is removed or some time later when retinal detachment caused by the melanoma has resolved.
After radioactive plaque treatment, some patients note some dryness or irritation of the eye which usually can be relieved by the use of the eye drops called “artificial tears.” It is not uncommon for the patient to have double vision after surgery. In the majority of cases, single vision returns gradually over several months.
Radiation can also be delivered by Proton Beam Therapy. In most cases the results of the tumor treatment are no different than with plaque radiotherapy, but Proton Beam radiation may cause more irritation and discomfort of the surface of the eye.
Biopsy of the tumor
At the time of the plaque surgery, a biopsy of the tumor will be performed. This not only confirms the diagnosis, but also provides prognostic information about the tumor itself. In tumors that have a loss of chromosomes 3 (monosomy 3), the risk of developing metastasis is higher than a tumor with a normal chromosome 3. This genetic abnormality is only found in the ocular melanoma, and not in the rest of your body. Therefore, this abnormality cannot be transmitted to your offspring. You will be informed of this result after your treatment.
Enucleation
Prior to the 1960’s, the usual treatment for choroidal melanoma was enucleation (removal of the eye). Enucleation is still used to treat large melanomas when the vision is poor.
The surgery for enucleation is done in the operation room. The eye is removed and a hard plastic non-reactive ball impact (about the size of the eye) is placed in the gap where the eye was removed. The patient is discharged from the hospital with a patch over the operated eye. In 2 to 4 weeks, a prosthetic eye (glass or plastic eye) is fitted. It is sometimes difficult to tell which eye is the plastic eye and which eye is real. There is no surgery at the present to transplant an entire eye and this futuristic surgery will not be available in our lifetime.
After enucleation, there is a reduced field of vision on that side of the body when looking straight ahead and one’s depth perception may be altered as well. You can imagine what enucleation would be like by closing or patching one eye. Many of the skills of depth perception may be relearned with time and most patients continue with their same jobs and activities without any problems whatsoever. Protective glasses or goggles are needed to protect the remaining eye during dangerous activities or sports. We have treated hundreds of people who have lost one eye and who continue to live normal, productive lives.
Resection
Resection of the eye melanoma means to cut out the tumor from the eye and leave the rest of the eye intact. This is used for only certain types of tumors, and may be combined with radioactive plaque placement.
The surgery for resection is done in the operating room and may require at least 2 to 4 hours to complete the surgery. However, resection of the tumor often results in a higher rate of treatment failure compared to using radiation to treat the tumor.
After developing a melanoma of the eye, your life prognosis depends on several factors. These factors include the location and size of the tumor, the type of cells within the tumor as seen under a microscope and the presence or absence of monosomy 3 (a loss of one pair of chromosome 3) in the tumor tissue. Your prognosis is dependent on whether the cancer spreads (metastasizes) to other important organs. The risk of spreading of the tumor does not seem to depend on the type of treatment. Even if the eye is removed, you are still at risk to develop spreading of the tumor. In general, patients with eye melanoma do better than patients with many other malignancies. However, the tumor does have the capacity to spread. Once metastases are detected, survival rates decrease. When eye melanoma spreads, it usually goes to the liver first and then to the lungs. Treatment by a medical oncologist is necessary.
If you are diagnosed with ocular melanoma, a team of specialists will help you get the best treatment, follow-up and resources necessary to facilitate your quality of life. Education, information and reassurance are important throughout this process. We want you to be aware of the team members that may be helping you and their role in your care.
Team of specialist include:
