A: Most studies have shown that the laser treatment just burns the surface of the melanoma. This can leave live cancer cells under the tumor’s laser scarred surface and in the wall of the eye. It may be just a matter of time before the cancer will grow again. If the cancer is not killed or removed, there is a chance that it might spread to the rest of your body.

Transpupillary Thermotherapy ( TTT ) is an investigational treatment currently used in addition to plaque radiation in treatment of choroidal melanoma. Due to the large amounts of laser energy required to treat a melanoma, there are significant risks (to vision) related to combined plaque - TTT therapy. Intraocular hemorrhages are common and in rare cases, the wall of eye (sclera) can be weakened. After TTT, tumors have been noted to grow into the tissues behind the eye.

Histopathology shows live choroidal melanoma beneath the TTT treated retina

Continued choroidal melanoma growth along the edge of a TTT laser scar

This melanoma has grown into the scleral wall of the eye. Lasers cannot reach these hidden areas.

Related Links
TTT - for Choroidal Melanoma

A Comparative Study of TTT versus Plaque Radiation Therapy

A: During this type of surgery the eye must be opened. This can allow tumor cells to float out of the eye and into the orbit (spaces around your eye). Though this is not a proven risk factor for metastatic melanoma, tumors found to have grown outside the eye (into the orbit) are known to be more likely to spread.

With lamellar (split thickness) eyewall resection, the wall of the eye (sclera) is sewn back in place. The COMS study showed that up to 50% of choroidal melanomas had invaded the wall of the eye (called the sclera). Therefore, with lamellar eye wall resection, the entire tumor is not always removed or treated. In order to prevent recurrence, eye cancer specialists are currently adding plaque therapy (to treat the eye wall). Lastly, many eyes do not tolerate eye wall resection. They suffer detachments of the retina, cataract, and intraocular hemorrhage.

A histopathological slide demonstrating choroidal melanoma cells which have invaded into the wall of the eye (sclera).

A: For the rest of your life. You must be followed by an eye-care specialist and may need a medical oncologist. You may want to consider this when choosing your doctors and their location.

Patients who receive plaque radiotherapy are typically seen by their eye care specialist every 3 to 4 months. Patients typically undergo twice-yearly blood tests, radiographic imaging studies and physical examinations.

Copies of your laboratory evaluations should be forwarded to your eye cancer specialist's office so that they can be double-checked for metastatic disease. In the United States, the law requires that you must request this in writing from your family doctor, internist, or oncologist.

A: Almost all patients who have been determined to have an ocular tumor (e.g. choroidal melanoma) are treated and then return to their normal activities.

The time between the diagnosis and the completion of treatment can be very stressful. Rely on your doctors and family for help. After you are treated they should encourage you to get back to your normal activities. Just remember to be periodically monitored by your eye care specialists and general medical doctors.

A: "Standard Treatments for Choroidal Melanoma" Are Enucleation and Radiation

Enucleation is the removal of the eye. In most cases, it is the only form of treatment that allows your doctor to completely remove the tumor from your body. Unfortunately, patients also lose their vision from that eye. With time, almost all patients are able to do all the things they used to before losing their eye. Since the COMS study found no difference in survival between enucleation and plaque radiation therapy (for medium-sized melanomas), few doctors will recommend enucleation if "eye-sparing" radiation therapy is possible.

The most common alternative to removal of the eye is radiation therapy, and the most commonly used radiation technique for intraocular melanoma is eye-plaque therapy.

Plaque technique involves placing a dish-shaped plaque-device (about 1 to 2 centimeters in diameter) on the outer surface of the eye, under the tumor. The plaque is implanted behind the eye, left in place for up to 7 days, and then removed. During treatment patients are likely to notice no more than occasional discomfort.

The effects of radiation on the tumor are typically measured 3 to 4 months after treatment. Eventually, eye melanomas shrink to about 40% of their pretreatment size. Though they rarely disappear, these tumors are considered to be dead. In most studies irradiated tumors will regrow (within the eye) in less than 8% of cases.

Note about radiation: More than 95% of patients have no problems associated with plaque surgery. As with any ocular surgery, there can be secondary retinal detachments, hemorrhages, or infections. There are also the regular risks of anesthesia. Most plaque patients do not develop these problems.

A: Around the world, researchers are working on new methods of diagnosis and treatment for choroidal melanoma, retinoblastoma and other ocular tumors. One only has to do a PubMed search (http://pubmed.gov) to find thousands of published articles.

It is important to point out two major research initiatives:

The first multicenter, multinational prospective randomized clinical study carried out for an eye cancer was called The Collaborative Ocular Melanoma Study (COMS). These types of studies offer the best evidence-based statistically significant information currently available. The National Eye Institute (NEI) and the National Institute of Health (NIH) supported the COMS.

The COMS had three Studies:

The Small Choroidal Melanoma Study confirmed that orange pigmentation, leakage of fluid and thickness are all correlated to tumor growth and metastatic potential. This study also found that there exists a risk (3% over 2 years) of metastatic melanoma from small choroidal melanomas.

The Medium-sized Choroidal Melanoma Study determined that plaque radiation was equal to removal of the eye for the prevention of metastatic choroidal melanoma.

Lastly, The Large-sized Choroidal Melanoma Study determined that 2000 cGy of external radiation prior to enucleation does not prevent the spread of choroidal melanoma.

The second major collaborative step forward was that The American Joint Committee on Cancer joined with the International Union Against Cancer to develop a Tumor-Node-Metastasis (TNM) grading system for most eye cancers. It is our hope that this common language will enable centers (around the world) to compare their results.

A: After enucleation (removal of the eye) there is no vision from that eye. The patient is considered monocular and sees from the remaining eye. Most patients see well from their remaining eye and live normal lives. Loss of one eye does affect depth perception, but with time, most patients are able to adjust. Consider that part of depth perception comes from the relative size of objects (distant objects appear smaller).

After plaque radiation therapy for choroidal melanoma, at least 44% of patients keep their central vision for up to 5 years, and their natural eye looks better than a prosthesis. Disadvantages include that you must see an ophthalmologist every 3 to 4 months after treatment for dilated ophthalmoscopy and ultrasound measurements of your tumor. This is because patients who have their eye irradiated (plaque or proton) develop radiation complications within the eye, and there is a small chance that tumor might regrow. These complications may eventually require additional laser therapy, radiation or in less than 10% of cases, the eye may have to be enucleated (removed).

The patients chance for functional vision after radiation is related to how close the tumor is to the functional center of the retina (macula), the type of radiation and dose delivered to normal ocular structures.

To learn more about radiation treatments, read the radiation therapy section of this web site.

A: Less than 4% of patients are found to have metastatic melanoma at the time of diagnosis. But, with time after treatment, a larger percentage are found to develop metastasis. This difference is thought to be due to undetectable microscopic melanoma cells present at the time of treatment. It is not helpful to dwell on percentages, but your doctor should be able to give your approximate chance of developing metastasis based on your tumor's size and location.

A: The eye is surrounded by bones; therefore, it is much easier to tolerate removal of an eye as compared to loss of a lung or kidney.

If you are young and healthy, you may want to have your surgery as an outpatient. Currently, most patients stay in the hospital or under observation for at least one night after surgery.

Since this surgery is usually performed under general anesthesia, the patient does not feel or see anything during surgery. Long-acting local anesthesia (6 hours) can be given during surgery allowing for the least amount of pain possible (when you wake up in the recovery room). Most patients, who have their eye removed, have a mild headache for 24-36 hours after surgery.

A: Enucleation is removal of the eye. It is the form of treatment that allows your eye cancer specialist to remove the tumor from your body. Unfortunately, patients also lose all the vision and the cosmetic use of the eye. With time, almost all patients are able to do most all the things they used to do before their eye was removed.

A: This is a patient who has completed cosmetic rehabilitation after enucleation surgery. Notice that he looks normal but the prosthetic eye does not move as well as a normal eye.

Patient Looking Forward

Patient Looking Left

A: Patients can usually have a temporary prosthesis (that looks like an eye) within 10 days of enucleation surgery. Besides the swelling and the "black-eye," you will look fairly normal. After a final prosthetic fitting 90% of Dr. Finger's patients are happy with the way they look, and 80% say others can’t even tell they are monocular.

Read the book "A Singular View" by Frank Brady. It will help in your transition. This book was written by an airplane pilot who lost one eye. We suggest that you wear unbreakable polycarbonate glasses to protect your good eye.

A: This is because the amount of radiation required to kill a large tumor which fills most of the eye, is just too much for the eye to stand. Within months to years, many patients who are treated with radiation for very large ocular melanomas lose vision, develop glaucoma, or have their eye removed anyway. Despite these risks, many patients with large intraocular tumors can be treated with eye and vision-sparing radiation therapy.

A: For the rest of your life. You must be followed by an eye-care specialist and may need a medical oncologist. You may want to take this into account in choosing your doctors and their location.

An eye care specialist examines patients who are enucleated twice a year. In addition, patients should have blood tests, radiographic imaging studies, and physical examinations. Copies of your laboratory evaluations should be forwarded to your eye-cancer specialist's office so that they can be double-checked for metastatic disease. The law requires that you must request this in writing from your family doctor, internist, or oncologist.

A: We recommend that you have an eye examination 1 week, 1 month, and at least every 6 months after surgery. This is because there is an extremely small chance the tumor will regrow behind your prosthesis, to monitor for inflammation or infection.

We recommend that you return for a complete ophthalmic oncology examination at least on a yearly basis. You should also have twice-yearly medical check-ups by your family doctor, internist, or medical oncologist.

A: You will advised to take topical antibiotic and steroid medications for one month. These medicines will help you heal more safely and quickly.

For the first week after surgery, you will tear a lot. These tears may contain a little blood. This is normal. Once a day, you should gently wash the outside of your eyelid with a warm, clean, soapy washcloth. Don’t let matter accumulate to form crust on your eyelids.

A: Enucleation means removal of the eye. It is a form of treatment that completely removes the primary tumor from the body, but the patient loses all vision and the cosmetic use of the eye.

It takes some time to adjust to using one eye, but almost all patients learn to compensate within the first year after surgery.

A: Patients can usually have a temporary prosthesis (that looks like an eye) within 10 days of enucleation surgery. Most patients are fitted with a permanent prosthesis 4 to 6 weeks later.

A: Do not lift, strain, or rub your eye for at least 14 days after surgery.

Do not take aspirin or other blood thinners unless your internist says it is required. The orbit should heal quickly and you should be able to return to school or work within 2 to 6 weeks after surgery.

Many patients can be fit with a temporary ocular prosthesis within two weeks of surgery.

A: You should gently clean your lids each day. You may use a clean wash cloth or sterile gauze. You should not rub your eyelids or run the shower at your operated eye for at least 10 days after surgery.

A: Eye tumors and cancers are rare conditions. That means that we need each and every patient to help us support research to find cures for their disease.

If you are interested in helping create and/or support the programs of The EyeCare Foundation please contact our office (212) 832-7297. We are targeting funds for teaching, research, support-groups, and infrastructure.

A: The EyeCare Foundation continues to develop an extensive patient-to-patient support network.

The Patient-to-Patient Network is made up of patients, family members, and friends who can deal with the issues involved in diagnosis, treatment, and living with macular degeneration and ocular tumors.

If you would like to volunteer to speak with someone who is facing the problem you have overcome, or if you need to speak with someone who has confronted your eye problem, please join our contact list by calling 212-832-7297.

A: The EyeCare Foundation funds a bulletin board for patients to ask questions, support one another and help others.

Related Links
The Eye Cancer Network Bulletin Board - Sponsored by The EyeCare Foundation

A: The EyeCare Foundation is a nonprofit charitable organization that provides the most up-to-date treatment information available to patients and their families, physicians, and other health-care providers. It has established family and patient support programs to ease emotional stress and real-life adjustment issues related to the severe forms of these conditions. The Foundation strives to empower patients to find the resources to improve their lives.

The EyeCare Foundation funds and directs research to find cures for patients with ocular tumors, macular degeneration, and related eye diseases. It also coordinates national and international prospective-randomized clinical trials to evaluate new methods of diagnosis and treatment.

Related Links
Learn more about The EyeCare Foundation at www.eyecarefoundation.org

A: Please join us in supporting eye cancer research.

Eye tumors are uncommon, so we need the support of each patient and their families.

The EyeCare Foundation, Inc., is a nonprofit charity certified by the Internal Revenue Service of the United States of America. Your contributions are tax deductible in the United States of America.

The EyeCare Foundation, Inc.
115 East 61st Street
New York City, New York, USA 10021
PHONE: 1-212-832-7297
EMAIL: contactus@eyecarefoundation.org

A: You should pick a doctor who has experience caring for eye cancer patients and with whom you are comfortable. You should be able to ask questions about your case and feel comfortable that your treatment decisions are not only based on available science but take into account your personal situation and medical problems. Since you may need to see your doctors for many years, consider that it is easier to be treated and followed with a doctor in your area.

Consider the following:

• You should be guaranteed to see the doctor with whom you are making the appointment (not a substitute doctor). Ask when making your appointment.

• Make sure that your surgeries will be performed by the doctor you want. Ask the doctor when signing your consent form.

• You should be able to ask questions about your case and treatment decisions. Ask how easy it is to speak with your doctor before and after surgery.

• Make sure your doctor has the expertise to manage any eye and/or systemic problems you may have in the future.

A: For the rest of your life. You must be followed by an eye cancer specialist and may need a medical oncologist. You may want to take this into account when choosing your doctors and their location. Patients who receive plaque radiotherapy are typically seen every 3-4 months. Patients who are enucleated are usually seen twice a year. Many eyelid and orbital tumor patients are advised to follow up with their eye cancer specialist, at least, on a yearly basis.

In any case, your eye care specialist should check to make sure that you have regularly scheduled medical workups including an evaluation for metastatic disease (as necessary). Copies of your laboratory evaluations should be forwarded to your eye-cancer specialist's office so that they can be double-checked. The law requires that you must request this in writing from your family doctor, internist, or oncologist.

A: No! Once the radiation plaque is removed, all the radioactivity is gone. There will be no radiation left in your body, your clothing, your glasses, or any of your personal belongings. However, the effects of the radiation delivered to your tumor and eye will continue to be observed for months and years after treatment.

A: We recommend that you be examined every 3-4 months after plaque radiation. This is because there is a small chance the tumor will regrow or that your eye may develop radiation-related problems (that may require treatment).

In addition to seeing your local eye care specialist, we recommend that you return for a complete ophthalmic oncology examination (at least) on a yearly basis.

You should also have twice-yearly medical check-ups by your family doctor, internist, or medical oncologist. Dr. Finger recommends that you have a medical checkup at least two times a year. This should include a physical examination, blood tests, radiographic imaging of the abdomen and an annual chest x-ray.

A: Tumors are usually measured to shrink after 3 months. We don’t measure a tumor before three months have passed because they can swell and become temporarily larger after radiation. Since the goal of radiation therapy is to prevent the tumor from growing, don’t be concerned if your tumor shrinks slowly. Most tumors eventually shrink to about 40% of their original size and rarely disappear. A residual lump of dark, shrunken tumor typically persists for years after treatment.

A: The eye should heal quickly. You should not lift any objects greater than 10 pounds or rub your eye for at least two weeks after surgery. Then you can return to normal activity. Patients usually return to school or work within 2-4 weeks after completion of treatment.

A: After ophthalmic plaque radiation therapy, the paitent is usually requested to take eye-drops daily for about a month. These drops contain antibiotics, steroids, and medicines to relax your eye. These drops help your eye heal more safely and quickly. For the first week after surgery, you will tear and the tears may contain a little blood. This is normal. You should gently wash the outside of your eyelid with a warm, clean, soapy wash cloth. Don’t let matter accumulate to form crust on your eyelids.

A: Proton Beam Radiotherapy is a form of external beam irradiation. It involves directing radiation through the front of the eye, lids, and orbit in order to reach the intraocular tumor. Eyelash loss, eyelid excoriation, corneal neovascularization and ulceration, dry eye, neovascular glaucoma, and cataract have been reported to be more common after proton beam radiation therapy.

Proton beam radiation therapy typically requires surgical clips to be sewn onto the eye (around the tumor) this helps the radiation therapist to direct the beam into the eye. Eye movements are monitored on a video screen because if the eye moves, the beam moves away from the tumor. If the eye is detected to move, the radiation technologist will temporarily turn off the beam until the eye is repositioned. In contrast, radiation eye plaques are sewn onto the eye as to cover the base of the intraocular tumor. So when the eye moves, so does the plaque.

When compared to low-energy eye-plaque radiation therapy, it is easier to treat tumors that are surrounding the optic nerve with protons. But, such treatment places the optic nerve within the targeted zone resulting in earlier radiation-related optic nerve damage and loss of vision. Special notched plaques can be used to treat certain tumors that touch the optic nerve.

Eye-Plaque Radiotherapy typically involves attaching a dish-shaped radiation source beneath the tumor and leaving it there for 5-7 days. With proton beam, once the marking clips are surgically placed, the patient visits the radiation center for 3-5 treatments. The marker-clips are not typically removed.

Compared with Proton-Beam, the front of the eye usually receives much less radiation with plaque radiation therapy, but parts of the retina may receive more. This is why anterior "front of the eye" complications are much less common after low-energy ophthalmic plaque radiation therapy. But, earlier radiation retinopathy may occur with plaques.

A: A radioactive eye-plaque is a device that can be used to deliver a high-dose of radiation to an intraocular tumor.

This is because when an eye-plaque contains radioactive iodine-125 or palladium-103 seeds, the gold of the plaque blocks more than 99% of radiation. Therefore, when the plaque is sewn to the outside of your eye (underneath the tumor), the radiation is directed into the eye. For an average-sized tumor, less than 10% of the radiation makes it out of the other side of the eye.

Plaques come in various sizes (typically between 10 and 22 mm). A plaque will be chosen to cover your entire tumor plus at least a 2-millimeter "safety margin". The extra area is included to make sure the entire tumor is within the targeted area. The plaque is implanted utilizing several standard techniques (transillumination, ophthalmoscopy and ultrasound). Intraoperative ultrasound and light-assisted plaque localization are techniques developed to make plaque-placement more accurate (see innovations).

Radiation treatment is continuous and will typically take up to 7 days. At the end of treatment, your tumor will have been given all the necessary radiation. Once your plaque is removed, there will be no radioactivity left in your body.

Radioactive plaques come in various sizes with suture eyelets so that it can be temporarily attached to the wall of the eye for treatment.

A: Radioactive plaque therapy is a form of treatment, which allows the eye-cancer specialist to destroy your tumor without removing the eye. Unfortunately, the radiation can also affect the normal parts of your eye and harm your vision. Your ophthalmic and radiation oncologists will work together to try to increase the effectiveness of radiation (to kill your cancer), while decreasing the chance that radiation will harm the normal parts of your eye.

A: Protons are charged nuclear particles that can be sent into the eye. These particles travel through and are somewhat absorbed by tissues on the way to your intraocular tumor. The targeted zone (the tumor and surrounding 2-3 mm) gets most of the radiation. The proton radiation field is in the shape of a tube, with little side-scatter or dose posterior to the eye. Like plaque radiotherapy, the amount of radiation to the normal parts of the eye depends of the size and location of the tumor.

A: While the radiation-plaque is sewn onto your eye, certain precautions must be observed. These rules will ensure that visitors and patients in surrounding areas do not receive radiation exposure in excess of the Nuclear Regulatory Commission (NRC) regulations. A list of rules are given to you before you go home with the plaque in place and can be disregarded after you have the radiation-plaque removed.

A: Radiation may cause eventual blurring, dimming, or rarely a total loss of vision (in the eye with the tumor). The amount of vision loss depends on what your vision was before treatment, how close the tumor is to the center of your retina (the fovea), and how sensitive your tissues are to radiation. Most plaque-irradiated eyes maintain some central vision, and almost all retain peripheral vision. Plaque radiation should not affect the vision in the other eye.

A: Plaque radiation therapy is delivered over to a dose known to destroy the cancer, and at a dose rate that will be tolerated by the eye. The rate at which the radiation is delivered is affected by both the radiation source and the size of the tumor.

In consultation with the radiation oncologists, eye plaques are individually designed and constructed for each patient. Specialized computer programs are used to calculate the total dosage and speed of radiation. The precise distribution of radiation throughout the eye is calculated and used to determine the risks of secondary radiation complications.

A: It is normal for patients to have fears about radiation.

The type of radiation used in most eye plaque therapy should not cause hair loss, nausea, brain damage, or affect your other eye.

Other forms of radiation therapy can cause hair loss within the field of irradiation. For example, proton beam radiation therapy is associated with eyelash loss. External beam therapy can also cause hair loss where it enters and exits the head.

A: Second opinions are great when all your doctors say the same thing. Unfortunately, differing opinions can make things even more confusing. Remember to ask the doctor:

1. What are the standard treatment options for my tumor?

2. If the proposed treatment is "new" or investigational?
If so, how many patients have been treated?
How long have they been followed for recurrent disease?

3. Is the proposed treatment FDA or CE approved?

4. Who will be the operating surgeon?
a) In the case of plaque therapy; who will put it in and who will take it out?

5. Does your center compare radiation plaque types (before surgery) to determine which one
would be best for my tumor?

6. Does your center keep plaque patients in the hospital or send them home during treatment?

7. Does your eye cancer specialist and center personally follow treated patients for recurrence
and metastatic disease?

8. How soon will you ask me to return after surgery?

9. What tests do you perform (over time) to monitor my body for metastatic disease?

10. What does your eye cancer specialist do if I am found to have metastatic disease?

A: Most retinoblastomas are diagnosed before the age of 3. Most eye cancer specialists agree that a child with retinoblastoma is not likely to develop a new tumor after 7 years of age.

A: Most children are found to have a white pupil "leukocoria," or a deviated eye "strabismus," or secondary painful glaucoma. In less developed countries patient more commonly present with orbital or optic nerve extension or metastasis.

A: Other than retinoblastoma, cataract, Coat's disease, persistent hyperplastic primary vitreous, and retinopathy of prematurity can cause the appearance of a white pupil.

A: There are typically 350 of new cases of retinoblastoma diagnosed each year in North America. Five thousand cases are estimated to occur throughout the world. Retinoblastoma occurs equally in boys and girls, different ethnic groups, and in either eye.

Retinoblastoma is a genetic cancer. Therefore, 10% of patients will have a family history of retinoblastoma, and 25% will affect both eyes. Forty percent of patients have the retinoblastoma gene throughout their body. The abnormal gene is 13q14.2, that is chromosome 13, long arm (q), band 14.2. Though it is the most common primary intraocular cancer in children, intraocular leukemia is more common.