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Ocular Oncology
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Eye Cancer

My doctor says I have a nevus in my eye. Will it become a cancer?
Just like a raised freckle on the skin, a nevus can occur inside your eye. And, like a nevus on the skin, a choroidal nevus can grow into a melanoma. This is why your ophthalmologist will examine your eyes on a regular basis (at least every six months) and use photography and echography to check if the nevus has changed in size.

Is ocular melanoma the same as skin melanoma?
Melanoma is the term used to describe a cancer that develops from cells called melanocytes. Melanocytes are the cells that produce a dark colored pigment called melanin and this pigment is responsible for the color of our skin. These cells are found in many places in our body including the skin, hair and lining of the internal organs. Although, most melanomas develop within the tissue of the skin, it is possible for it to arise in other parts of the body, such as the eye.

What causes ocular melanoma?
Unlike skin melanoma, there is no convincing evidence to show that sunlight causes choroidal melanomas. Like many other forms of cancer, the exact cause is unknown. Ocular melanoma is more common in people with lighter skin and in those over sixty years of age (although a significant number of patients are thirty or younger). Other predisposing factors that have been identified include exposure to ultraviolet radiation, genetics, or having a nevus (freckle). It occurs equally in men and women, and in left and right eyes. As far as we know, there is nothing you could have done to prevent ocular melanoma.

Will a biopsy be performed to make sure that the tumor is a cancer?
Biopsies are performed with some types of eye cancers, for example eyelid tumors, but are not recommended for choroidal melanomas. Fine-needle biopsy of a suspected melanoma is rarely done because the risks far outweigh the benefits. Tumor seeding (spread of the cancer cells) has been reported with fine-needle biopsy. Experienced ocular oncologists can diagnosis ocular melanoma without a biopsy.

Can the laser be used to treat ocular melanoma?
Studies show that the laser just burns the surface of the melanoma, which can leave cancer cells under the surface and in the wall of the eye. If the cancer is not killed or removed, there is a possibility that it will spread to the rest of your body.

Can an ocular melanoma tumor be surgically removed without radiation therapy or removing my eye?
Surgery to remove just the tumor could allow tumor cells to float into the spaces around the eye. Furthermore, studies have shown that up to 50% of choroidal melanomas already have invaded the sclera, therefore the entire tumor would not always be removed or treated. Lastly, many eyes do not tolerate this procedure and will suffer detachments of the retina, hemorrhages, and end up having to be removed anyway.

Will the cancer spread to other parts of my body?
Only about 2% of patients are found to have the cancer spread (metastasize) at the time they are diagnosed with a choroidal melanoma. Before surgery, you may be seen by a radiation oncologist and have medical testing to see if there are any signs of cancer elsewhere in your body. Unfortunately however, after treatment some people do develop metastasis. This is thought to be due to undetectable microscopic cancer cells present at the time of treatment that cannot be detected by current testing. While your doctor may be able to give you an approximate chance of developing metastasis based on your tumor's size and location, no one can give you an absolute guarantee that the cancer will not spread.

I just had a physical examination a few months ago. Why do I need to see a radiation oncologist before plaque surgery?
A radiation oncologist can give you a thorough physical examination and, in coordination with your eye doctor, specify the amount of radiation you will receive and the total number of treatment days.

Radiation Plaque Therapy

What can I expect during radiation plaque surgery?
Procedures differ from hospital to hospital, but usually you will be asked to arrive at the hospital several hours before the time of your scheduled surgery. A member of the surgical team will meet with you to answer any questions and prepare you for your operation. After changing into a hospital gown, the anesthesiologist will meet with you and begin to administer the anesthetic.

Anesthesia is used so that surgery can be performed without unnecessary pain. Local anesthesia selectively numbs only a part of your body. During general anesthesia you will be unconscious during the entire surgery. Because general anesthesia is associated with a higher risk for patients both during and after surgery, in most cases, local anesthesia is recommended for radiation plaque surgery. Under local anesthesia you are "awake" during the surgery, but will be given medication to relax and you will not be in pain. While you may be aware of sounds in the operating room, your "good" eye will be covered so you will not see what is happening during surgery.

What will it be like during my hospital stay after radiation plaque therapy?
Again, hospital procedures vary, but usually after close post-surgery monitoring, you will return to your hospital room. Many patients are tired and hungry after surgery, and after eating typically rest for several hours while the anesthesia wears off.

Most patients report that they have some discomfort the first night after surgery. Your doctor will leave orders for appropriate pain medication to keep you as comfortable as possible. There will be a patch over the operated eye and the nurse will administer eye medication to prevent infection. The day after surgery you probably will be encouraged to get out of bed and sit up for a while.

Some patients suggest bringing a Walkman and listening to audiobooks (available at bookstores or your local library) is more comfortable than reading or watching television. Most hospitals permit visitors during hospital visiting hours If you have a radiation plaque, visitors may be requested not to come into close contact with you for any length of time. Young children and expectant mothers should not visit. You will need to arrange for transportation home, since you will be unable to drive immediately following surgery.

What are the side effects of the radiation therapy?
The type of radiation used in eye-plaque therapy should not cause hair loss, nausea, brain damage, or affect your other eye. Once the radiation plaque is removed, there will be no radiation left in your body, on your clothing, or on any of your personal belongings.

The effects of the radiation delivered to your tumor and eye will continue to be observed for months and years after treatment. Radiation plaque therapy may cause eventual blurring, dimming, or rarely a total loss of vision in the treated eye. Plaque radiation does not affect the vision in the other eye. The amount of vision loss depends on what your vision was before treatment, how close the tumor is to the center of your eye, and how sensitive your tissues are to radiation. Most people maintain some central vision, and almost all retain peripheral vision.

What happens after I leave the hospital?
Your doctor will probably prescribe eye drops to help your eye heal more safely and quickly. For the first week after surgery, your eye may tear and the tears may contain a little blood. This is normal. Your doctor will give you detailed instructions before you are discharged from the hospital. These may include instructions to gently wash the outside of your eyelid with a warm, clean, soapy wash cloth. Most doctors recommend that you should not lift any objects greater than 10 pounds or rub your eye for the first two weeks after surgery. You may wear a protective eye patch for the first week or so after surgery. In most cases you can resume normal activities and return to school or work 2 to 4 weeks after you leave the hospital.

When will the doctor know if the radiation plaque treatment has been successful?
Since the goal of radiation therapy is to prevent the tumor from growing, don't be concerned if your tumor shrinks slowly. A tumor can swell and become temporarily larger after radiation. Most tumors shrink to about 40% of their original size but rarely disappear. A residual lump of dark, shrunken tumor often persists for years after treatment.

How often will I need to see my eye doctor after surgery?
You will need to be followed closely in case of a recurrence or metastasis from this primary cancer. Most physicians recommend that patients be seen at least every four to six months by an ocular oncologist (eye surgeon). These examinations may include repeat fundus photography and ultrasound examinations. In addition, most doctors recommend that you have a liver function blood test, chest X-rays and a systems evaluation by a medical oncologist at least once a year.


What should I expect during surgery to remove my eye?
The enucleation procedure is usually performed under local anesthesia, which involves numbing the entire eye and socket tissues prior to surgery. The operation is relatively simple to perform. Immediately after the eyeball is removed, an orbital implant, only slightly smaller than the natural eye, is inserted deep in the socket. In some instances a plastic shell called a conformer is placed over the implant to preserve the shape of the eye. The conformer would later be replaced by a permanent prosthesis.

After enucleation, a pressure patch is applied over the eyelid. This patch is intended to minimize the swelling of the socket tissues. The pressure patch is generally kept in place for about 12 hours after the surgery. While the pressure patch is in place, you may have difficulty opening the lids of the unoperated eye. Fortunately, the difficulty in opening the eyelids generally resolves itself after the first post-operative day. It may hurt when you jerk your good eye to one side or another because the muscles of both eyes always move together and although your eye has been removed, your eye muscles move as if your eye was still there. Moderate post-enucleation pain in the socket generally occurs during the first 24 hours; pain relievers are prescribed as needed to reduce this discomfort.

What will I look like after my eye is removed?
Keep in mind that your eyeball helps to keep the eyelid up. Therefore, when the eye is removed the eyelid simply stays shut as if you are winking. This should not cause you any discomfort, although you may be self-conscious about it and may want to wear an eye patch or sunglasses until you get your prothesis. The eyelid may be swollen and bruised for a few days.

Initially if you open your eyelid, you will see the moist, pink socket lined with conjunctiva. It will look like the inside of your mouth. If there is a conformer (shell) in place, you will see the clear plastic with a hole in the center. The shell is only there temporarily until the socket heals and an artificial eye can be fitted.

What will my prosthesis look like?
An ocular prosthesis is an artificial eye that is made and fitted by a specialist in artificial eyes (an Ocularist). At first, you will be fitted with a temporary prosthesis (that looks similar to, but not exactly like, your remaining eye) while your prosthetic eye is being custom-made. The prosthesis looks somewhat like a giant contact lens. It will match the shade of the sclera (white part of the eye), the iris color, veins, and the shape of your eyes as much as possible.

Your prosthesis is custom-made to match your remaining eye exactly.

What's involved in taking care of a prosthesis?
In most cases, the prosthesis can be left in place for months at a time. Artificial eyes can be cleaned with mild soap and water, but should be professionally cleaned and polished by the Ocularist about every 4 to 6 months and should be replaced every 3 to 5 years.

How soon after enucleation surgery can I return to normal activity?
Check with your doctor but usually you should not lift, strain, or rub your eye for at least 2 weeks after surgery. The orbit should heal quickly and you should be able to return to school or work within 2 to 4 weeks after surgery.

Will I be able to lead a normal life with only one eye?
It will take some time to adjust to using one eye, but almost everyone learns to compensate during the first year after surgery. After enucleation, there is reduced visual field on the side of the body when looking straight ahead, and there is a loss of depth perception. Many of the skills of depth perception can be re-learned and with time, almost all patients are able to do all the things they used to do before losing their eye. If the vision in your remaining eye is good, you will still be able to drive, read, play sports, and perform all your usual daily activities.

Visual Impairment

Will I be blind or visually impaired from my eye cancer?
Most people who have an eye cancer do NOT become blind or significantly visually impaired. Our visual function usually is described in terms of visual acuity and visual fields in BOTH eyes.

Visual acuity is expressed as a fraction; the top number refers to the distance you are from the eye chart (usually 20 feet). The bottom number indicates the distance at which a person with normal eyesight could read the line. For example, 20/40 means that the line you correctly read at 20 feet could be read by a person with normal vision at 40 feet. Normal visual acuity is 20/20.

Visual fields, or fields of vision, refers to the full extent of the area visible to an eye that is looking straight ahead. A normal visual field is 170 degrees.

A person is considered LEGALLY blind when the best corrected vision in BOTH eyes is 20/200 or more or if the visual field is 20 degrees or less. Low vision usually refers to those who have a visual acuity of 20/70 or worse in the better eye with correction. Many people with vision problems benefit from an evaluation at a Low Vision Center to learn about magnification aids, electronic reading technology, and print enhancing computer software.

My vision is 20/50 in my better eye. Is it okay for me to drive?
Driving laws vary from state to state and from country to country. In the State of Florida, drivers must have at least 20/40 vision in both eyes, with or without corrective lenses. If vision is 20/200 or worse in one eye, drivers must have 20/40 vision or better in the other eye. A doctor's referral may be required.

Remember, just because you can legally drive doesn't mean that it is safe for you to drive.

Coping with Cancer

I have been so worried since I was diagnosed with cancer that I haven't been able to think about anything else. Is this normal?
For most people, diagnosis of cancer creates emotional distress. Fear of treatment and fear of the future can produce apprehension, anxiety, confusion and depression.

Some degree of depression is common in people diagnosed with cancer. About a fourth of those with cancer suffer from a clinical depression that interferes with day-to-day activities. Feelings of sadness that interfere with normal functioning, a change in eating or sleep patterns, difficulty concentrating, or a loss of interest in ordinary activities, may be symptoms of clinical depression. You should consult a physician about treatment options, including counseling and/or medication to improve your quality of life. Clinical anxiety also can interfere with daily functioning. Symptoms of clinical anxiety include uncontrollable worrying, difficulty concentrating, feelings of restlessness, racing heart, shortness of breath, sweating, dry mouth, irritability and changes in eating and sleeping. Counseling and/or medication can be helpful for clinical anxiety.

My spouse has just been diagnosed with ocular melanoma. I keep trying to reassure him that he's going to be fine, but nothing I say seems to help. Is this normal?
When someone you care about is dealing with emotional distress, it's important to remember that you can't "fix" someone else's feelings. However, you can listen carefully to your loved one's feelings and provide reassurance and support. Encourage, but do not force, communication. You may want to encourage your loved one to consult a doctor about counseling or using medications if there is no improvement. Moreover, it's just as important to recognize and deal with your own feelings of sadness, fear or frustration.