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Ocular Melanoma

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, therein lies no small task, as detection presents unique challenges with ocular melanoma.

 Whereas 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 a melanoma growing inside their eye. This is because just as melanocytes are present in the entire external skin layer 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 but is not aligned with the visual axis directly, patients may have no vision changes, or may have only subtle or vague symptoms of floaters or flashes of light.

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 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, a history of previous skin cancers or other inherited skin disorders, and a 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 patients with all cancers 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 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 or cryotherapy.  Our 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, enhancing lives.

Kapil G. Kapoor, M.D.

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