Test & Treatments

The most important aspect of your diagnostic evaluation is a thorough clinical examination, including slit lamp biomicroscopy and indirect ophthalmoscopy, by a physician with extensive experience with eye tumors. In addition, you will probably need additional diagnostic tests to help determine what type of eye tumor you have. These tests may include the following:

Tests

  • Ultrasound
  • Fluorescein Angiography
  • Indocyanine Green (ICG) Angiography
  • Magnetic Resonance Imaging (MRI)
  • Computed Tomography (CT)
  • Fine Needle Aspiration Biopsy
  • Molecular Testing

Treatments

  • Observation
  • Cryotherapy
  • Laser Photocoagulation
  • Transpupillary Thermotherapy (TTT)
  • Photodynamic Therapy (PDT)
  • Plaque Radiotherapy
  • External Beam Radiotherapy
  • Local Tumor Resection
  • Chemotherapy
  • Enucleation

Tests

Ultrasound

Ultrasound uses sound waves to image the inside of eye. This allows the dimensions, location and consistency of the tumor to be determined with great accuracy. Ultrasound is often the most useful diagnostic test for evaluating an eye tumor and is often performed in the initial workup and subsequent follow-up examinations. For an "A scan" exam, the eye is anesthetized with drops and a small probe is placed on the surface of the eye to measure the thickness and internal consistency of the tumor. For a "B scan" exam, a larger probe is placed on the eye to determine the shape, location and other features of the tumor. Occasionally, a special high-frequency ultrasound probe is used to examine the front, or anterior, part of the eye if the tumor involves the ciliary body, iris or anterior segment. An ultrasound examination usually takes no more than a couple of minutes in the doctor's office.

Fluorescein Angiography

A fluorescein angiogram is a study that evaluates the flow of blood through the tissues of the eye and through the tumor. This test can be helpful in certain circumstances to distinguish between different types of eye tumors. This study requires the injection of a non-radioactive, fluorescent dye into a vein in your hand, followed by a series of photographs of the eye for about five minutes using a special camera.

 

Indocyanine Green (ICG) Angiography.

An ICG angiogram is similar to, and is often done in conjunction with, a fluorescein angiogram. This study provides slightly different information than the fluorescein angiogram about the flow of blood through the eye and the tumor. Certain tumors, such as choroidal hemangiomas, often display a characteristic ICG angiographic pattern that can be helpful in confirming the diagnosis.

 

Magnetic Resonance Imaging (MRI)

This is a test that uses magnetic energy to image the eyes, eye sockets, optic nerves, and brain. Eye tumors often have characteristic features on MRI that can help in confirming the diagnosis. MRI can also be used to determine whether a tumor has invaded into the optic nerve or eye socket. This test is performed in a hospital or radiology center and requires a physician referral.

 

Computed Tomography (CT)

A CT scan is similar to an MRI scan, except that some radiation is required for this study. A CT scan may be necessary in some situations, for example, to identify bone or calcium associated with certain types of tumors. This test is performed in a hospital or radiology center and requires a physician referral.

 

Fine Needle Aspiration Biopsy

In some patients, a biopsy may be needed to confirm the diagnosis of melanoma. We perform biopsies in the operating room under sterile conditions using retinal surgery techniques. The biopsy usually consists of a small sample of tumor obtained through a small needle. Since fine needle aspiration specimens from the eye can be very difficult to interpret, these specimens should be read by a cytopathologist who has extensive experience with eye tumor specimens. Our biopies are interpreted by Dr. Rosa Davila, who is a highly experienced cytopathologist at Washington University Medical Center who has published in the medical literature on the interpretation of fine needle biopsies from the eye.

 
Molecular Testing

Ocular (uveal) melanoma is the most common cancer of the eye and leads to metastatic death in up to half of affected patients. Early identification of uveal melanoma patients at high risk of metastasis could allow these patients to receive preventative systemic therapy to delay or prevent the development of metastasis.  Washington University in St. Louis has developed a unique molecular prognostic test that can be performed on tumor tissue obtained by fine needle biopsy or at the time of eye removal. 
 

Treatments

Observation

For many patients, the best treatment is no treatment, at least initially. We often follow patients carefully to see if a tumor is growing before deciding whether treatment is necessary.

 

Cryotherapy

This is a treatment that causes local destruction of tissue by freezing. It can be used to treat certain small tumors, such as retinoblastomas and retinal capillary hemangiomas. In adults, this procedure can be performed in the office as an outpatient using local anesthesia. In children, the procedure is performed under general anesthesia in the operating room.

 

Laser Photocoagulation

In adults, most laser treatments are performed in the office as an outpatient under local anesthesia. In children, this treatment is usually performed under general anesthesia. Laser treatment typically takes from 5-30 minutes.

 

Transpupillary Thermotherapy (TTT)

TTT is a special form of laser for treating certain eye tumors by heating them to high temperatures. Our center and others around the world have acquired much experience with TTT, but the precise indications and long term outcomes after TTT are still being determined. TTT typically is performed in the office under local anesthesia as an outpatient, and it usually requires 15-45 minutes.

 

Photodynamic Therapy (PDT)

PDT is another specialized form of laser therapy that has been extensively studied for the treatment of age-related macular degeneration, but its indications in the treatment of eye tumors are still unclear. Early evidence suggests that it may have a role in treating certain eye tumors, such as choroidal hemangiomas. PDT requires the injection of a special, non-radioactive dye into a vein in the hand, and the laser is applied about 10 minutes later. A session of PDT typically requires less than a half hour and is performed as an outpatient.

 

Plaque Radiotherapy

Plaque radiotherapy is the most common treatment for patients with choroidal and ciliary body melanomas. This is a form of local radiation treatment that requires a surgical procedure. Occasionally, this treatment may also be used for other types of eye tumors, including iris melanomas, metastatic tumors, and choroidal hemangiomas. The "plaque" is a round cap made of gold that shields the body from radiation and keeps the radiation focused on the tumor. Radioactive seeds are placed on the inside of the plaque, which is surgically placed on the outside of the eye overlying the tumor. This surgery is performed in the operating room under anesthesia. The patient remains in the hospital for 4-5 days during the radiation treatment, and then the plaque is removed in a second, short surgical procedure. Although radiation complications to the other eye or other parts of the head are virtually eliminated with plaque radiotherapy, this treatment can cause significant vision loss to the treated eye due to radiation damage to the retina, optic nerve and other ocular structures.

Although failure rates for plaque radiotherapy have been reported as high as 20% in some centers, our failure rate has been under 5%. We believe that this improved success rate may be due, at least in part, to our use of intraoperative ultrasound to optimally place the radioactive plaque over the tumor. Several other leading centers around the country also use this technique, and there is growing evidence that intraoperative ultrasonography may lower the rate of treatment failure and reduce the risk of metastatic spread of tumor outside of the eye.

 

External Beam Radiotherapy

External beam radiotherapy is the tradition form of radiation treatment where the radiation is directed at the eye from an external source. Consequently, there is the potential for radiation-induced complications outside of the treated eye, such as lash loss, dry eye, hair loss, and arrest of bone growth in young children. In addition, children with hereditary retinoblastoma are at high risk of developing second cancers in the field of radiation. For these reasons, external beam radiotherapy is used sparingly for treating eye tumors and generally is reserved for a limited number of specific circumstances.

 

Local Tumor Resection

This is a surgical procedure to remove the tumor while leaving the eye intact. Depending on the location of the tumor, this surgery may involve removal of part of the iris (iridectomy), the iris and ciliary body (iridocyclectomy), the ciliary body and choroid (cyclochoroidectomy), or the choroid (choroidectomy). The indications of this technically demanding procedure have been controversial over the years. For best results, most surgeons believe that the surgery should be performed under hypotensive anesthesia, which can be risky in older patients with poor cardiovascular status. In addition, this surgery carries a significant risk of complications such as vitreous hemorrhage, retinal detachment and proliferative vitreoretinopathy (a severe scarring reaction involving the retina). In general, we reserve this procedure for certain types of tumors that involve the front part of the eye (i.e., the iris and ciliary body), and we generally use other treatment options for tumors that are located elsewhere.

 

Chemotherapy

The main use for chemotherapy in treating eye tumors is in the treatment of retinoblastoma. There has been a revolution in the management of retinoblastoma in the past decade, with the emergence of chemotherapy combined with local treatment modalities. Many retinoblastoma patients who once would have received external beam radiotherapy are now treated with chemotherapy. While the longterm results with chemotherapy are still not known, most ocular oncologists believe that chemotherapy will continue to play an important role in treating retinoblastoma into the foreseeable future. Chemotherapy may also be used in treating other eye tumors, such as metastatic tumors and lymphoma.

 

Enucleation

Enucleation, or removal of the eye, is performed less commonly today than in the past, due to the availability of other treatment options. However, in certain situations, enucleation is still the safest treatment option to try to prevent the spread of a tumor outside of the eye or to maximize the chance of local tumor control. In most situations, the eye is replaced by a round implant that is located in the eye socket and attached to the eye muscles. About six weeks after surgery, the patient is fit with prosthetic eye that closely matches the natural eye. This is performed by an ocularist. Most patients have an excellent cosmetic result and resume most of their normal activities.

 

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