October 2008




Eye on ocular melanoma

by Maxine Lipner Senior EyeWorld Contributing Editor


Practitioner offers heads up on prevention and treatment

Example of ocular melanoma Source: Anand Sudhalkar, M.D.

Yet another example of melanoma Source: Ricardo Amin, M.D.

Classic choroidal melanoma with associated retinal detachment Source: Warren Hill, M.D.

The “Finger-trip Cryoprobe” firmly attached to the globe after enucleation Source: Paul T. Finger, M.D.

The large-sized cryoprobe treating a conjunctival tumor with corneal extension Source: Paul T. Finger, M.D.

For sun worshippers and others, skin melanoma is an all too common risk. But what are the chances that this may metastasize to the eye, of all places? This is a worry for many patients, according to Paul T. Finger, M.D., medical professor of ophthalmology, New York University, New York, and director of ocular cancer services, New York Eye and Ear Infirmary, New York. In a recent study, published in the May/June 2008 issue of Survey of Ophthalmology, Dr. Finger reported that fortunately, skin melanoma usually does not metastasize first to the eye.

“I’ve been an ocular oncologist for a long time now. One of the things that comes up over and over again is that a patient will come in with a history of skin melanoma, and he was told that he has a nevus or a freckle in his eye, and he’s really panicked that this is a metastatic lesion,” Dr. Finger said. “What we find, however, is that typically the eye melanomas occur when there are also other sites of melanoma metastasis.”

Spotting metastatic lesions

While the first site of metastasis can be the eye, most commonly Dr. Finger finds this is not the case. “This is actually pretty reassuring to most people,” he said. Also, when melanoma does metastasize to the eye there are typically some distinct signs. “There are certain things that happen in the eye when it’s a metastasis versus a primary eye melanoma that would tip you off to thinking that it’s from somewhere else and that you might want to look other places to see that it’s metastatic,” Dr. Finger said. For example, if the lesion in the eye originated from the skin it’s much more likely to be multifocal. “If you look in the eye and see a bunch of dark spots, maybe you should start thinking that it’s not a primary eye melanoma but actually a skin melanoma that has gone to the eye,” Dr. Finger said. “Also, if there are little bits that are floating around in the eye, that’s another sign that it’s more likely to be skin melanoma to the eye versus a primary eye melanoma.” Unfortunately, these metastasized tumors are usually more aggressive than their primary counterparts. “They tend to be much more rapidly growing than a primary eye melanoma,” Dr. Finger said. “They are also more difficult to treat.” The fact is that many of these patients unfortunately do not have a great life expectancy, Dr. Finger finds.

“When patients have skin melanomas to the eye, most of the time we just try to keep them comfortable, keep them seeing, and try to control the tumor,” he said. “There are some cases where you can control the eye metastasis and that might be the only site that shows up, but that’s really rare.”

Coping with choroidal melanoma

Patients with ocular primary melanoma, also known as choroidal melanoma, usually fare far better. This condition occurs in the United States at a rate of about six cases per million per year. It is far more common in Australia, where it occurs at a rate of 10 per million per year. “One of the reasons for the disparity is that there is an ozone hole in Australia, and they have a lot of fair-skinned people with light irises,” Dr. Finger said. While the actual etiology has yet to be proven, there is a lot of evidence that this is related to the sun. “It’s more common in blue-eyed people and fair-skinned people. It’s more common in people with outdoor occupations,” Dr. Finger said. These tumors are also much more common in the lower half of the iris which gets more sun than the upper half.

Treatment for primary choroidal melanoma is more hopeful than for metastasized tumors. “Before the 70s, the most common treatment [for choroidal melanoma] was to remove the eye,” Dr. Finger said. “Since that time we’ve developed various sight and eye saving treatments that allow us to kill the tumor and keep the patient’s eye and vision.” The typical treatment today is radiation therapy known as eye plaques. “The most common eye plaque is called Iodine 125,” Dr. Finger said. “I always compare Iodine versus palladium 103 before I do the surgery to figure out which one is going to give me the best radiation dose to the normal parts of the eye to try to maximize my patient’s ability to see over the long run.” Two other commonly used treatments include another plaque known as ruthenium 106, used mostly in Europe, and charged particles called protons.

“The difference between the protons and the ruthenium, the iodine, and the palladium is not so much in the ability to kill the tumor because the rate is high in all, but in the ability of the patient to see five years later,” Dr. Finger said. “The mean visual acuity is 20/200 or better in about 45% of patients using protons, iodine, and ruthenium.” Dr. Finger finds that this is significantly better with palladium and plans to report his findings soon in the literature.

Dr. Finger also pegs prevention as very important in saving sight. “Think of sunglasses as sun block for your eyes,” he said. “Almost preferentially people don’t have sun block on their eyelids or over their eyes, so the only way to complete your sunscreen is to put on sunglasses.”

Overall, he urges practitioners to be alert for ocular melanomas, which will unfortunately likely become more prevalent. “The problem is that with the skin melanomas, the incidence is going up radically,” Dr. Finger said. “People ought to realize that the ozone layer is thinning.” In the end, early detection ultimately offers patients the best hope. “Once the general ophthalmologist or the retina specialist thinks that the patient might have a metastatic lesion, prompt treatment offers the best chance for control,” Dr. Finger said.

Editors’ note: Dr. Finger has no financial interests related to his comments.

Contact information

Finger: 917-650-7186, pfinger@eyecancer.com

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