Understanding Eye Melanoma

The eye is like a camera, using light to make pictures. It has layers of tissues and is filled with a clear jelly.

When we look at someone’s eye, we see the clear front layer of the cornea, the dark centre called the pupil, and the coloured ring called the iris. All of these are protected by a layer called the conjunctiva.

Behind the white outer part of the eye (sclera) that you can see is a middle layer called the uvea. The uvea is made up of three parts:

• the iris
• the ciliary body, and
• the choroid (see the diagram below).

The front section (where the iris sits) is called the anterior uvea, and the back section is called the posterior uvea.

• The choroid or posterior uvea – The layer between the retina and white outer part (sclera). It contains melanocytes and blood vessels that deliver oxygen and nutrients to the retina. About 90% of ocular melanomas start here.
• The ciliary body – This part of the eye controls the shape of the lens. It makes the fluid the eye needs and maintains eye pressure. About 5–10% of ocular melanomas are found here.
• The iris – This is the coloured part of the eye that helps regulate the amount of light entering the eye. Fewer than 5% of eye melanomas are found in the iris.

Conjunctival melanoma is a rarer type of eye melanoma that starts in the conjunctiva.

These tests help doctors see inside your eye. A slit lamp is a microscope with a bright light that looks at the front section of the eye.

Eye drops may be used to make your pupil bigger so it’s easier to look inside your eye. The drops can cause blurry vision or light sensitivity for a few hours, so take sunglasses to your test.

You’ll need to wait until your eyesight returns to normal before driving.

These photography machines take detailed photos of large areas of the back of your eye (called the fundus). Drops may be used to widen (dilate) your pupil before the camera takes pictures.

This test may be compared to previous imaging and used to help track changes before and after treatment.

This scan uses sound waves to create pictures of the inside of the eye. It uses a small probe with ultrasound gel that is placed on the eye or eyelid and gently moved over the area. It can measure the size and shape of the tumour.

This test uses light to create pictures of the retina, uvea and blood vessels. A rest for your chin and forehead helps to move you into position for the scans, which take a few minutes. The machine does not touch your eye.

This test may be done before surgery to show exactly where the melanoma is. The lights in the room are dimmed and a very bright light is shone into your eye to look for abnormal areas.

This may be done at an eye hospital or by a specialist ophthalmologist in the eye clinic. Drops are put into the eye and a dye is injected into a vein in your arm.

The doctor then photographs the back of the eye to check the blood flow (circulation).

This removes a small sample of tissue with a needle to check for cancer cells. You will have either a local or general anaesthetic so you don’t feel any pain.

Doctors usually diagnose ocular melanoma using imaging tests, but a biopsy is sometimes also needed. Genetic tests may be done on a biopsy sample to find out the risk of the cancer spreading to other parts of the body.

The cancer may be classified as low, intermediate or high risk.

These scans are used to check the rest of the body for signs of cancer. You lie on a table that slides into a scanner. Sometimes a dye is injected into a vein in your arm to make the images clearer.

• Understand your options – Learn about all available treatments (e.g. surgery, chemotherapy, radiation therapy, targeted therapy or immunotherapy), including what they involve.
• Benefits vs side effects – Consider how each option may help control the cancer and what short- and long-term side effects might occur.
• Your values matter – Think about what’s most important to you – quality of life, length of treatment, recovery time, fertility, work or school, and family responsibilities.
• Ask questions – It’s okay to ask your doctor or health care team to repeat something or explain things in plain language
• Second opinions – Getting another medical opinion is common and can help you feel more confident.
• Time to decide – Some decisions are urgent, while others allow time to think. Ask how much time you have to think about it
• Written information – Use fact sheets and reputable websites to review information at your own pace.
• Shared decision-making – Decisions are usually made together with your health care team, respecting your preferences.
• Travel and costs – You may need to consider whether to travel away from home to have treatment. You may be able to claim some of your travel costs via a government scheme. To find out more, call Cancer Council 13 11 20.

This checklist may be helpful when thinking about the questions you want to ask your doctor.

• What type of eye melanoma do I have?
• Has the cancer spread? Is it early or advanced?
• Will I lose my eyesight?
• What tests will I need to have?
• What are the treatment options for me? What do you recommend and why?
• What are the possible risks and side effects of my treatment? How will these be managed?
• Have you treated this type of cancer before?
• How complex is the surgery and how long does the operation take?
• How long will other treatments I may have take?
• Am I able to speak with someone who has had this type of cancer and treatment? 
• Is this treatment covered by Medicare or private insurance? Will there be extra expenses?
• Are there any complementary therapies that might help me? 
• If the cancer comes back, how will I know? 
• If I am part of a clinical trial, what are the possible benefits and risks?

• iridectomy – Removal of part of the iris (the coloured part of the eye). May be done for a biopsy or to remove small melanomas.
• iridocyclectomy – Removal of part of the iris and the ciliary body. Used for certain small to medium melanomas.
• enucleation – Removal of the entire eyeball. This is done if the melanoma is large or if vision in the eye has already been lost. After surgery, an artificial eye is usually fitted to match the size and colour of your other eye.
• orbital exenteration – Removal of the eyeball and some surrounding tissue. This may include some or all of the eyelid, fat and muscles. Only used for advanced cancers, or cancers that have grown into the area that surrounds the eyeball.

A small disc (a plaque) containing radioactive material is put over the tumour during surgery. You may have a general anaesthetic (so you are asleep) or a local anaesthetic with sedation (so you are awake but relaxed and feel no pain).

You stay in hospital for 2–7 days with the disc in place. Then you have a short operation to remove the disc and go home.

Visit The Royal Victorian Eye and Ear Hospital to read their fact sheet, Plaque Radiotherapy.

This uses radiation in the form of x-ray beams. A large machine directs multiple small beams of radiation to precisely target the tumour in high doses.

You usually need five sessions given over 10 days. This is planned during your first appointment.

You will meet with a radiation oncologist and lie on an examination table for a CT scan (in the same position as during treatment). A mesh mask keeps your head still, but can make some people feel anxious.

The specialist will plan the treatment area, type of radiation and how to deliver the right dose. Radiation therapists then deliver the treatment sessions over a number of days.

A treatment session doesn’t take very long and you can usually go home after each one.

This uses proton beams rather than x-ray beams. Protons release most of their radiation within the cancer, protecting nearby tissue. Treatment is given in high doses over several days.

Proton therapy is most useful near very sensitive areas. It’s not currently operating in Australia but may be available in the future. Talk to your radiation oncologist your options. 

After treatment, you will have regular appointments to check that the cancer hasn’t come back and to monitor any side effects. You may have scans, eye tests and physical examinations.

You may have access to a care navigator who can assist with questions and appointments.

Some cancer centres will give you a survivorship care plan. This includes a summary of your treatment, sets out a schedule for follow-up care and lists any symptoms and long-term side effects to watch out for.

It also tells you about any medical or emotional problems that you may experience and suggests ways to live a healthy lifestyle. If you don’t have a survivorship care plan, ask your doctor for one and give a copy to your GP and your health team.

For some people, eye melanoma does come back after treatment, which is called a recurrence. Treatment will depend on where the cancer is in your body, but may include surgery, radiation therapy, laser therapy or immunotherapy.

A clinical trial may also be recommended.

In some cases of advanced cancer, the main focus of treatment will be on managing any symptoms, such as pain, and improving quality of life.

This is called palliative treatment and can be provided at home, in hospital, in a palliative care unit or hospice, or in a residential aged care facility.