Nearsightedness

Introduction

Nearsightedness (myopia) is a common vision condition in which you can see objects near to you clearly, but objects farther away are blurry.

The degree of your nearsightedness determines your focusing ability. People with severe nearsightedness can see clearly only objects just a few inches away, while those with mild nearsightedness may clearly see objects several yards away.

Nearsightedness may develop gradually or rapidly, often worsening during childhood and adolescence. Nearsightedness tends to run in families.

A basic eye exam can confirm nearsightedness. You can easily correct the condition with eyeglasses or contact lenses. Another treatment option for nearsightedness is surgery.

Signs and symptoms

Being nearsighted may mean:

• Distant objects appear blurry
• You need to squint to see clearly
• You have headaches caused by excessive eyestrain

Nearsightedness is often first detected during childhood, from early school years through the later teens. A child with nearsightedness may:

• Persistently squint
• Sit very close to the television, movie screen or chalkboard
• Hold books very close while reading
• Seem to be unaware of distant objects

Causes

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	Anatomy of the eye
	Nearsightedness (myopia)

Your eye has two parts that focus images:

• The cornea, the clear front surface of your eye
• The lens, a clear structure inside your eye that changes shape to help focus objects

In a perfectly shaped eye, each of these focusing elements has a perfectly smooth curvature like the surface of a rubber ball. A cornea and lens with such curvature bend (refract) all incoming light in such a way as to make a sharply focused image on the retina, at the back of your eye.

A refractive error
However, if your cornea or lens isn’t evenly and smoothly curved, light rays aren’t refracted properly, and you have a refractive error. Nearsightedness is one type of refractive error. Nearsightedness can occur when your cornea is curved too much or when your eye is longer than normal. Instead of being focused precisely on your retina, light is focused in front of your retina, resulting in a blurry appearance for distant objects.

Other refractive errors
In addition to nearsightedness, other refractive errors include:

• Farsightedness (hyperopia). This occurs when your cornea is curved too little or your eye is shorter from front to back than normal. The effect is the opposite of nearsightedness. Light is focused beyond the back of your eye, making nearby objects blurry. You’re usually able to see faraway objects clearly.
• Astigmatism. This occurs when your cornea is curved more steeply in one direction than in another. Uncorrected astigmatism blurs your vision. Typically, the images you see will be blurred more in one direction than another. For example, horizontal images may be more out of focus than are vertical or diagonal images.

When to seek medical advice

If your degree of nearsightedness is pronounced enough that you can’t perform a task as well as you wish, or if your quality of vision detracts from your enjoyment of activities, see an eye doctor. He or she can determine the degree of your nearsightedness and advise you of your options to correct your vision.

Screening and diagnosis

Nearsightedness is diagnosed by a basic eye exam. Three kinds of eye specialists, each with different training and experience, can provide routine eye care:

• Ophthalmologists. An ophthalmologist is an eye specialist with a doctor of medicine (M.D.) degree who provides full eye care, including performing complete eye evaluations, prescribing corrective lenses, diagnosing and treating common and complex eye disorders, and performing eye surgery when it’s necessary.
• Optometrists. An optometrist has a doctor of optometry (O.D.) degree. Optometrists are trained to evaluate vision, prescribe corrective lenses and diagnose common eye disorders. Complicated eye conditions, including those requiring surgery, must be treated by an ophthalmologist.
• Opticians. An optician is an eye specialist who fills prescriptions for eyeglasses — assembling, fitting and selling them. In some states, opticians are also allowed to sell and fit contact lenses.

A complete eye examination involves a series of tests. Your eye doctor may use odd-looking instruments, aim bright lights directly at your eyes and request that you look through an array of lenses. Each test allows your doctor to examine a different aspect of your vision.

According to the American Academy of Ophthalmology, recommendations for regular eye exams include:

Adults
If you don’t wear glasses or contacts, have no symptoms of eye trouble and are at a low risk of developing eye disease, it’s recommended that you have an eye exam at the following intervals.

• At least once between ages 20 and 39
• Every three to five years between the ages of 20 and 29 if you’re at high risk of certain eye diseases, such as glaucoma
• Every two to four years between ages 40 and 64
• Every one to two years beginning at age 65

However, if you wear glasses or contacts, have your eyes checked every year. And if you notice any problems with your vision, schedule an appointment with your eye doctor as soon as possible, even if you’ve recently had an eye exam. Blurred vision, for example, may suggest you need a prescription change.

Children and adolescents
Children need to be screened for eye disease and have their vision tested by a pediatrician, an ophthalmologist or another trained screener at the following ages and intervals.

• Between birth and 3 months
• Between 6 months and 1 year
• Around 3 years
• Around 5 years

Additionally, it’s recommended that school-aged children be screened at school or through community programs approximately every two years to check for vision problems.

Your child or adolescent may need more frequent visits if he or she experiences any problems with vision or has symptoms of eye trouble. In addition, children and adolescents who have a disease that puts their eyes at risk, such as diabetes, may need more frequent eye exams.

Complications

Nearsightedness may be associated with several complications, such as:

• Reduced quality of life. Uncorrected nearsightedness can affect your quality of life. You might not be able to perform a task as well as you wish, and your limited vision may detract from your enjoyment of day-to-day activities.
• Eyestrain. Squinting to see in the distance can cause eyestrain and headaches.
• Impaired safety. For your own safety and that of others, don’t drive or operate heavy equipment if you have an uncorrected vision problem.
• Glaucoma. Severe nearsightedness increases your risk of developing glaucoma, a potentially serious eye disease.
• Retinal tear and detachment. If you’re significantly nearsighted, it’s possible that the retina of your eye is thin. The thinner your retina, the higher your risk of developing a retinal tear or retinal detachment. If you experience a sudden onset of flashes, floaters or a dark curtain or shadow across part of your eye, seek medical assistance immediately. Retinal detachment is a medical emergency, and time is critical. Unless the detached retina is promptly surgically reattached, this condition can cause permanent loss of vision in the affected eye.

Treatment

The goal of treating nearsightedness is to help focus light on your retina through the use of corrective lenses or refractive surgery.

Corrective lenses
Wearing corrective lenses treats nearsightedness by counteracting the increased curvature of your cornea or the increased length of your eye. Types of corrective lenses include:

• Eyeglasses. Also called spectacles, eyeglasses come in a wide variety of styles and are easy to use. Eyeglasses can correct a number of vision problems at once, such as myopia and astigmatism. Eyeglasses may be the most economical correction alternative.
• Contact lenses. A wide variety of contact lenses are available — hard, soft, extended wear, disposable, rigid gas permeable (RGP) and bifocal. Ask your eye doctor about their pros and cons and what might be best for you.

Refractive surgery
This treatment corrects nearsightedness by reshaping the curvature of your cornea. Refractive surgery methods include:

• Laser-assisted in-situ keratomileusis (LASIK). LASIK is a procedure in which an ophthalmologist uses an instrument called a keratome or a special laser called a femtosecond laser to make a thin, circular hinged cut into your cornea. Your eye surgeon then uses a different type of laser, called an excimer laser, to remove layers from the center of your cornea to flatten its domed shape.
• Laser-assisted subepithelial keratomileusis (LASEK). Instead of creating a flap in the cornea, the surgeon creates a flap only in the cornea’s thin protective cover (epithelium). Your surgeon will use an excimer laser to reshape the cornea’s outer layers and flatten its curvature and then reposition the epithelial flap. To encourage healing, a bandage contact lens is worn for several days after this procedure.
• Photorefractive keratectomy (PRK). This procedure is similar to LASEK, except the surgeon removes the epithelium. It will grow back naturally, conforming to your cornea’s new shape. Like LASEK, PRK requires the use of a bandage contact lens following the procedure.
• Anterior chamber intraocular lens (IOL) implant. These lenses are surgically implanted into the eye, in front of the eye’s natural lens. They may be an option for people with moderate to severe myopia, although their use is controversial and they aren’t widely used.

All eye surgeries have some degree of risk, and possible complications from these eye procedures include infection, corneal scarring, vision loss and visual aberrations, such as seeing halos around lights at night. Discuss the potential risks with your doctor.

Prevention

Although a number of scientific attempts have been made to halt or slow the progression of nearsightedness, there are no proven ways to prevent the condition from occurring or progressing.

Self-care

Although you can’t prevent nearsightedness, you can help protect your eyes and your vision. Follow these steps:

• Have your eyes checked. Regardless of how well you see, have your eyes checked regularly for problems.
• Control chronic health conditions. Certain conditions, such as diabetes and high blood pressure, can affect your vision if you don’t receive proper treatment.
• Recognize symptoms. Sudden loss of vision in one eye, sudden hazy or blurred vision, flashes of light, black spots, or halos or rainbows around lights may signal a serious eye problem, such as retinal tear or detachment, requiring urgent medical attention. Similar symptoms can be caused by other serious medical problems, such as acute glaucoma or a stroke. Talk to your doctor immediately if you experience any of these symptoms.
• Protect your eyes from the sun. Wear sunglasses that block ultraviolet (UV) radiation. This is especially important if you spend long hours in the sun or are taking a prescription medication that increases your sensitivity to UV radiation.
• Eat healthy foods. Maintain a healthy diet that includes plenty of fruits and vegetables, which have shown to enhance eye health. Try foods that contain vitamin A and beta carotene, such as carrots, yams and cantaloupe.
• Don’t smoke. Just as smoking isn’t good for the rest of your body, it can affect your eye health as well.
• Use the right glasses. The right glasses optimize your vision. Having regular exams will ensure that your eyeglass prescription is correct.
• Use good lighting. Use adequate light for optimal vision.

You may associate melanoma with skin cancer and the growth or spread of moles on the surface of your skin. However, melanoma doesn’t occur just on your skin. It can also occur in your eyes and, rarely, in internal organs.

Melanoma develops in the cells that produce melanin — the pigment that gives your skin its color. Your eyes also have melanin-producing cells. Eye melanoma most commonly develops in the uvea, the vascular layer of your eye sandwiched between the retina and the white of the eye (sclera). Also called ocular melanoma, eye melanoma can occur in the front part of the uvea (iris and ciliary body) or in the back part of the uvea (choroid layer).

Melanoma that originates in your eye is termed a primary eye cancer. Eye melanoma is the most common type of primary eye cancer in adults, but it’s rare. If the melanoma begins elsewhere and then spreads to your eye, it’s called a secondary eye cancer; this also is rare.

Treatment is available for eye melanoma. The earlier it’s detected, the better your chance for successful treatment. Getting regular eye exams can help detect eye melanoma at an earlier stage.

Signs and symptoms

You may experience no symptoms at all for melanoma of the eye. On the other hand, eye melanomas may cause light flashes, blurring or a dark spot in your vision.

What to watch for

• A change in the color of the iris
• A growing dark spot on the iris
• A sensation of flashing lights
• Poor or blurry vision in one eye
• Loss of side (peripheral) vision in the affected eye
• Floaters (spots or squiggles drifting in your field of vision)
• A red and painful eye

Melanomas in the back portion of the eye usually are detected only during eye exams.

Causes

The exact cause of eye melanoma isn’t known; however, it’s not typically inherited. In recent years, scientists have developed a better understanding about the role that DNA plays in causing cells to become cancerous. DNA instructs the behavior of cells and therefore influences the risk of developing certain diseases, including some cancers.

Genetics can play a role
Some genes have the instructions for how cells should grow and divide. Defects (mutations) in DNA can cause these genes to malfunction, sometimes resulting in cancer. Sometimes these mutations are inherited, but usually they are acquired during life.

Definitive reasons about why these changes occur in some people, how the changes occur, and how the changes cause or promote the development of cancer are still not understood.

Risk factors

Risk factors for primary melanoma of the eye include:

• Eye color. Just as people with fair skin are more likely to develop melanoma of the skin, people with blue eyes are somewhat more likely to develop melanoma of the eye. Eye melanoma occurs less often in people with brown eyes.
• Genetic disposition. A rare condition called dysplastic nevus syndrome, which leads to abnormal moles of the skin and increased risk of skin melanoma, may increase your risk of developing melanoma of the eye. In addition, people with abnormal skin pigmentation involving the eyelids and adjacent tissues and increased pigmentation on their uvea — known as oculodermal melanocytosis or nevus of Ota — also have an increased risk of developing eye melanoma. Studies also have shown an association between certain abnormalities on chromosome 3 and increased risk that melanoma may spread from the eye to distant parts of the body.

Sun exposure
Although excessive exposure to sunlight has been proposed as a possible risk factor for melanoma of the eye, it has never been proved.

When to seek medical advice

Some types of eye melanomas can be detected only by a doctor, so it’s a good idea to have regular, routine eye examinations. Because this type of cancer is rare, there’s no screening test other than an eye examination.

If you find a dark spot on your iris that is enlarging, have a doctor examine it. Many doctors believe that skin and eye melanomas start from a mole (nevus), which is a noncancerous tumor of pigment cells. If you have a nevus or a freckle in your eye, have it checked regularly by an eye doctor.

Screening and diagnosis

Having a regular examination of your eyes by a doctor specializing in diseases of the eye (ophthalmologist) is the first and most important step in early detection and diagnosis of eye melanoma.

Your doctor will examine the outside of your eye, looking for enlarged blood vessels that can indicate a tumor inside your eye. Then, with the help of instruments, your doctor will look inside your eye. One method, called ophthalmoscopy, uses lenses and a bright light mounted on your doctor’s forehead — a bit like a miner’s lamp. Another method, called slit-lamp biomicroscopy, uses a microscope that produces an intense beam or line of light to illuminate the interior of your eye.

In most cases, looking inside your eye alone will be enough to detect and diagnose any tumors or other abnormalities.

Further evaluation of suspected melanoma
If your doctor suspects you may have eye melanoma, you may undergo one of a number of imaging tests:

• Ultrasound. This painless procedure uses high-frequency sound waves from a hand-held, wand-like apparatus called a transducer, which can produce precise images of structures within your body. It’s an important test for diagnosing and evaluating eye tumors. Eye melanomas often have a characteristic appearance on the ultrasound. Your doctor also uses ultrasound to measure the thickness of the tumor to help determine the most appropriate treatment. The initial ultrasound further provides a baseline measurement for comparison as you go through your treatment plan.In this test you sit in a chair in your doctor’s office. The transducer is placed against either your eyelid or the front surface of your eye, in which case your eye is numbed with anesthetizing drops. A lubricant placed on the transducer may run down your cheek, but there’s no discomfort or pain. The test takes about 15 minutes.

• Angiography. Angiography is a process that uses dyes to help your doctor better visualize parts of your body. In a procedure called fluorescein angiography, your doctor injects a yellow dye into a vein in your arm. The dye circulates in your eyes, highlighting the blood vessels in your retina and providing information about the characteristics of the tumor. A camera with special filters takes flash pictures every few seconds for several minutes, providing your doctor with useful images. Another procedure called indocyanine green angiography involves injecting a green dye. Again, using special filters, your doctor can obtain useful images that may help define the characteristics of a tumor.

Determining further spread of the cancer
Your doctor may also recommend additional diagnostic procedures to determine whether the cancer has spread (metastasized) to other parts of your body. Eye melanoma can spread through your bloodstream. The liver and lungs are the organs most often affected. Tests may include:

• Blood tests. Blood tests to measure the function of your liver are common at the time an eye melanoma is first discovered, as well as during follow-up visits. Abnormalities may indicate whether the melanoma has spread to your liver.
• Chest X-ray. Your doctor may use this procedure to determine whether your eye cancer has spread to your lungs. This is unlikely unless the cancer is in advanced stages.
• Computerized tomography (CT). Computerized tomography is an X-ray technique that produces images of your internal organs that are more detailed than are those produced by conventional X-ray exams. Conventional X-ray exams use a stationary X-ray machine to focus beams of radiation on a particular area of your body to produce two-dimensional images. CT scans use an X-ray-generating device that rotates around your body and a powerful computer to create cross-sectional images, like slices, of the inside of your body.Often, after the first set of X-rays is taken, a contrast dye is injected intravenously and a second set of pictures is taken. The dye helps better outline structures in your body.

  If you have an eye melanoma, the CT scan will concentrate on your liver and lungs because they are the most common locations to which an eye melanoma is likely to spread.

• Ultrasonography. Your doctor may have you undergo ultrasonography to generate images of your liver and help determine whether the cancer has spread to your liver.
• Magnetic resonance imaging. Magnetic resonance imaging (MRI) is a technique that uses a magnetic field and radio waves to create cross-sectional images of your head and body. Your doctor uses these detailed, clear images to identify and diagnose a wide range of conditions. MRI is a noninvasive way for your doctor to examine your body. The exam is painless and lasts between 30 and 90 minutes. In some cases, contrast agents are injected into your veins to enhance the appearance of certain tissues or blood vessels in the images. Doctors don’t routinely use MRI to assess eye melanomas because they can obtain the information they need by other, less expensive, methods above.

Tissue sample
If your doctor isn’t sure whether a tumor is a melanoma, he or she may obtain a tissue sample (biopsy). This is usually done by placing a small needle into your eye and removing a sample of tumor cells. These cells are then evaluated in the laboratory. However, doctors usually can make a confident diagnosis of eye melanoma using methods other than biopsy.

Treatment

After eye melanoma is diagnosed, you and your doctor will review your treatment options. Factors to be considered are the location and size of the melanoma, as well as your overall physical health.

Melanomas of the eye are rare, so it’s a good idea to find a doctor with experience in treating these cancers. In addition, a second opinion can provide more information and help you feel more confident about your treatment plan.

Sometimes, doctors suggest observing a small lesion rather than treating it right away. But your doctor will generally recommend treatment for a medium-sized or large-sized melanoma.

Treatment designed to destroy a melanoma often will cause some loss of vision, even though every effort is made to preserve vision. But because cancers of the eye can be fatal, in some cases you’ll need treatment even if it means loss of vision or loss of your eye.

Surgery is the foundation for most cancer treatments. If an eye melanoma is of a certain size and in a favorable location, treatment can sometimes be accomplished with surgery alone. Treatment for other eye melanomas may be done with radiation alone, or radiation combined with a therapy such as infrared laser.

Surgery
Depending on the characteristics of the tumor, your doctor may choose from a variety of surgical procedures to remove the melanoma:

• Iridectomy. This procedure removes only a part of the iris. It’s used for small iris melanomas that have not invaded other structures of your eye.
• Iridotrabeculectomy. This procedure removes parts of the iris and the supporting tissues around the cornea at the base of the iris for small iris melanomas that have invaded those tissues.
• Iridocyclectomy. This is another treatment for small melanomas of the iris and ciliary body. It involves removing part of the iris and the ciliary body.
• Choroidectomy. Part of the choroid is removed during this surgery, with or without removing part of the wall of the eye (sclerouvectomy). This complicated procedure may be followed by supplementary radiation.
• Enucleation. This surgery removes the entire eye. This procedure is used for large eye tumors when alternative treatments would destroy most of the eye anyway. It’s also commonly used if the eye has developed pain because of the tumor. An implant is inserted into the position where the eye was previously located, and the muscles are attached to it to provide normal movement for an artificial eye (prosthesis). The prosthesis is inserted later, between the lids, after the tissues have healed. Movement of the implant transmits motion to the artificial eye.

Radiation therapy
Carefully targeted and regulated doses of high-energy radiation — radiation therapy — can destroy ocular melanoma and be lifesaving.

Radiation therapy damages cells by destroying the genetic material that controls how cells grow and divide. And although both healthy and cancerous cells are damaged by radiation, the goal of treatment is to hurt as few normal, healthy cells as possible.

Doctors generally reserve radiation treatment for eye melanomas to medium-sized and large-sized melanomas. The radiation dose can be delivered with charged particles such as proton beams, which are generated from outside of your body and directed into your eye ( teletherapy ). Or, the radiation can come from small radioactive seeds that are temporarily anchored to your eye ( brachytherapy ).

In brachytherapy, a small implant (plaque) similar to a bottle cap and containing several radioactive seeds (usually iodine-125 seeds) is sutured to the wall of your eye at a site overlying the tumor. The plaque remains in place for several days until it has delivered an optimal amount of radiation for the characteristics of your tumor. The device is then removed, and your doctor will monitor the tumor at regular intervals to watch for tumor shrinkage.

Small eye melanomas
There has been a recent trend toward treating small eye melanomas with either radiation therapy or transpupillary thermotherapy (TTT) — a type of infrared laser therapy — or both. Destroying the cancerous tissue by freezing it (cryotherapy) also has been used for some small eye melanomas.

Prevention

A clear association between sunlight and melanomas of the skin has been established. This same association has not been established for melanomas of the eye.

Coping skills

Eye melanoma may result in partial or complete loss of vision and, in some cases, removal of the eye (enucleation). Although these outcomes are traumatic, you can overcome them with the support of friends and family, adequate time to heal and adjust, and modern technology.

If your cancer treatment leaves you with vision in only one eye (monocular vision), it’s still possible to do practically everything you were able to do with two working eyes. But you’ll need to make adjustments, primarily regarding your ability to judge distance, and it may be more difficult to be aware of things around you, especially things occurring on the side without vision.

If your eye must be removed, it will be replaced by a round implant and then covered by your own tissue. Your eye muscles will be attached to the implant so that the implant will move.

After several weeks, an artificial eye (prosthesis) is made. The front surface of your new eye will be custom-painted to match your existing eye, and the back surface will be custom-molded so it fits comfortably. Motion from the implant is transferred through the healed tissue to the prosthetic eye, in most cases providing a satisfactory cosmetic appearance.

You’ll be able to sleep with this new eye, but you’ll have to remove it occasionally for cleaning. In most cases, these artificial eyes last for decades.

You may associate melanoma with skin cancer and the growth or spread of moles on the surface of your skin. However, melanoma doesn’t occur just on your skin. It can also occur in your eyes and, rarely, in internal organs.

Melanoma develops in the cells that produce melanin — the pigment that gives your skin its color. Your eyes also have melanin-producing cells. Eye melanoma most commonly develops in the uvea, the vascular layer of your eye sandwiched between the retina and the white of the eye (sclera). Also called ocular melanoma, eye melanoma can occur in the front part of the uvea (iris and ciliary body) or in the back part of the uvea (choroid layer).

Melanoma that originates in your eye is termed a primary eye cancer. Eye melanoma is the most common type of primary eye cancer in adults, but it’s rare. If the melanoma begins elsewhere and then spreads to your eye, it’s called a secondary eye cancer; this also is rare.

Treatment is available for eye melanoma. The earlier it’s detected, the better your chance for successful treatment. Getting regular eye exams can help detect eye melanoma at an earlier stage.

Signs and symptoms

You may experience no symptoms at all for melanoma of the eye. On the other hand, eye melanomas may cause light flashes, blurring or a dark spot in your vision.

What to watch for

• A change in the color of the iris
• A growing dark spot on the iris
• A sensation of flashing lights
• Poor or blurry vision in one eye
• Loss of side (peripheral) vision in the affected eye
• Floaters (spots or squiggles drifting in your field of vision)
• A red and painful eye

Melanomas in the back portion of the eye usually are detected only during eye exams.

Causes

The exact cause of eye melanoma isn’t known; however, it’s not typically inherited. In recent years, scientists have developed a better understanding about the role that DNA plays in causing cells to become cancerous. DNA instructs the behavior of cells and therefore influences the risk of developing certain diseases, including some cancers.

Genetics can play a role
Some genes have the instructions for how cells should grow and divide. Defects (mutations) in DNA can cause these genes to malfunction, sometimes resulting in cancer. Sometimes these mutations are inherited, but usually they are acquired during life.

Definitive reasons about why these changes occur in some people, how the changes occur, and how the changes cause or promote the development of cancer are still not understood.

Risk factors

Risk factors for primary melanoma of the eye include:

• Eye color. Just as people with fair skin are more likely to develop melanoma of the skin, people with blue eyes are somewhat more likely to develop melanoma of the eye. Eye melanoma occurs less often in people with brown eyes.
• Genetic disposition. A rare condition called dysplastic nevus syndrome, which leads to abnormal moles of the skin and increased risk of skin melanoma, may increase your risk of developing melanoma of the eye. In addition, people with abnormal skin pigmentation involving the eyelids and adjacent tissues and increased pigmentation on their uvea — known as oculodermal melanocytosis or nevus of Ota — also have an increased risk of developing eye melanoma. Studies also have shown an association between certain abnormalities on chromosome 3 and increased risk that melanoma may spread from the eye to distant parts of the body.

Sun exposure
Although excessive exposure to sunlight has been proposed as a possible risk factor for melanoma of the eye, it has never been proved.

When to seek medical advice

Some types of eye melanomas can be detected only by a doctor, so it’s a good idea to have regular, routine eye examinations. Because this type of cancer is rare, there’s no screening test other than an eye examination.

If you find a dark spot on your iris that is enlarging, have a doctor examine it. Many doctors believe that skin and eye melanomas start from a mole (nevus), which is a noncancerous tumor of pigment cells. If you have a nevus or a freckle in your eye, have it checked regularly by an eye doctor.

Screening and diagnosis

Having a regular examination of your eyes by a doctor specializing in diseases of the eye (ophthalmologist) is the first and most important step in early detection and diagnosis of eye melanoma.

Your doctor will examine the outside of your eye, looking for enlarged blood vessels that can indicate a tumor inside your eye. Then, with the help of instruments, your doctor will look inside your eye. One method, called ophthalmoscopy, uses lenses and a bright light mounted on your doctor’s forehead — a bit like a miner’s lamp. Another method, called slit-lamp biomicroscopy, uses a microscope that produces an intense beam or line of light to illuminate the interior of your eye.

In most cases, looking inside your eye alone will be enough to detect and diagnose any tumors or other abnormalities.

Further evaluation of suspected melanoma
If your doctor suspects you may have eye melanoma, you may undergo one of a number of imaging tests:

• Ultrasound. This painless procedure uses high-frequency sound waves from a hand-held, wand-like apparatus called a transducer, which can produce precise images of structures within your body. It’s an important test for diagnosing and evaluating eye tumors. Eye melanomas often have a characteristic appearance on the ultrasound. Your doctor also uses ultrasound to measure the thickness of the tumor to help determine the most appropriate treatment. The initial ultrasound further provides a baseline measurement for comparison as you go through your treatment plan.In this test you sit in a chair in your doctor’s office. The transducer is placed against either your eyelid or the front surface of your eye, in which case your eye is numbed with anesthetizing drops. A lubricant placed on the transducer may run down your cheek, but there’s no discomfort or pain. The test takes about 15 minutes.

• Angiography. Angiography is a process that uses dyes to help your doctor better visualize parts of your body. In a procedure called fluorescein angiography, your doctor injects a yellow dye into a vein in your arm. The dye circulates in your eyes, highlighting the blood vessels in your retina and providing information about the characteristics of the tumor. A camera with special filters takes flash pictures every few seconds for several minutes, providing your doctor with useful images. Another procedure called indocyanine green angiography involves injecting a green dye. Again, using special filters, your doctor can obtain useful images that may help define the characteristics of a tumor.

Determining further spread of the cancer
Your doctor may also recommend additional diagnostic procedures to determine whether the cancer has spread (metastasized) to other parts of your body. Eye melanoma can spread through your bloodstream. The liver and lungs are the organs most often affected. Tests may include:

• Blood tests. Blood tests to measure the function of your liver are common at the time an eye melanoma is first discovered, as well as during follow-up visits. Abnormalities may indicate whether the melanoma has spread to your liver.
• Chest X-ray. Your doctor may use this procedure to determine whether your eye cancer has spread to your lungs. This is unlikely unless the cancer is in advanced stages.
• Computerized tomography (CT). Computerized tomography is an X-ray technique that produces images of your internal organs that are more detailed than are those produced by conventional X-ray exams. Conventional X-ray exams use a stationary X-ray machine to focus beams of radiation on a particular area of your body to produce two-dimensional images. CT scans use an X-ray-generating device that rotates around your body and a powerful computer to create cross-sectional images, like slices, of the inside of your body.Often, after the first set of X-rays is taken, a contrast dye is injected intravenously and a second set of pictures is taken. The dye helps better outline structures in your body.

  If you have an eye melanoma, the CT scan will concentrate on your liver and lungs because they are the most common locations to which an eye melanoma is likely to spread.

• Ultrasonography. Your doctor may have you undergo ultrasonography to generate images of your liver and help determine whether the cancer has spread to your liver.
• Magnetic resonance imaging. Magnetic resonance imaging (MRI) is a technique that uses a magnetic field and radio waves to create cross-sectional images of your head and body. Your doctor uses these detailed, clear images to identify and diagnose a wide range of conditions. MRI is a noninvasive way for your doctor to examine your body. The exam is painless and lasts between 30 and 90 minutes. In some cases, contrast agents are injected into your veins to enhance the appearance of certain tissues or blood vessels in the images. Doctors don’t routinely use MRI to assess eye melanomas because they can obtain the information they need by other, less expensive, methods above.

Tissue sample
If your doctor isn’t sure whether a tumor is a melanoma, he or she may obtain a tissue sample (biopsy). This is usually done by placing a small needle into your eye and removing a sample of tumor cells. These cells are then evaluated in the laboratory. However, doctors usually can make a confident diagnosis of eye melanoma using methods other than biopsy.

Treatment

After eye melanoma is diagnosed, you and your doctor will review your treatment options. Factors to be considered are the location and size of the melanoma, as well as your overall physical health.

Melanomas of the eye are rare, so it’s a good idea to find a doctor with experience in treating these cancers. In addition, a second opinion can provide more information and help you feel more confident about your treatment plan.

Sometimes, doctors suggest observing a small lesion rather than treating it right away. But your doctor will generally recommend treatment for a medium-sized or large-sized melanoma.

Treatment designed to destroy a melanoma often will cause some loss of vision, even though every effort is made to preserve vision. But because cancers of the eye can be fatal, in some cases you’ll need treatment even if it means loss of vision or loss of your eye.

Surgery is the foundation for most cancer treatments. If an eye melanoma is of a certain size and in a favorable location, treatment can sometimes be accomplished with surgery alone. Treatment for other eye melanomas may be done with radiation alone, or radiation combined with a therapy such as infrared laser.

Surgery
Depending on the characteristics of the tumor, your doctor may choose from a variety of surgical procedures to remove the melanoma:

• Iridectomy. This procedure removes only a part of the iris. It’s used for small iris melanomas that have not invaded other structures of your eye.
• Iridotrabeculectomy. This procedure removes parts of the iris and the supporting tissues around the cornea at the base of the iris for small iris melanomas that have invaded those tissues.
• Iridocyclectomy. This is another treatment for small melanomas of the iris and ciliary body. It involves removing part of the iris and the ciliary body.
• Choroidectomy. Part of the choroid is removed during this surgery, with or without removing part of the wall of the eye (sclerouvectomy). This complicated procedure may be followed by supplementary radiation.
• Enucleation. This surgery removes the entire eye. This procedure is used for large eye tumors when alternative treatments would destroy most of the eye anyway. It’s also commonly used if the eye has developed pain because of the tumor. An implant is inserted into the position where the eye was previously located, and the muscles are attached to it to provide normal movement for an artificial eye (prosthesis). The prosthesis is inserted later, between the lids, after the tissues have healed. Movement of the implant transmits motion to the artificial eye.

Radiation therapy
Carefully targeted and regulated doses of high-energy radiation — radiation therapy — can destroy ocular melanoma and be lifesaving.

Radiation therapy damages cells by destroying the genetic material that controls how cells grow and divide. And although both healthy and cancerous cells are damaged by radiation, the goal of treatment is to hurt as few normal, healthy cells as possible.

Doctors generally reserve radiation treatment for eye melanomas to medium-sized and large-sized melanomas. The radiation dose can be delivered with charged particles such as proton beams, which are generated from outside of your body and directed into your eye ( teletherapy ). Or, the radiation can come from small radioactive seeds that are temporarily anchored to your eye ( brachytherapy ).

In brachytherapy, a small implant (plaque) similar to a bottle cap and containing several radioactive seeds (usually iodine-125 seeds) is sutured to the wall of your eye at a site overlying the tumor. The plaque remains in place for several days until it has delivered an optimal amount of radiation for the characteristics of your tumor. The device is then removed, and your doctor will monitor the tumor at regular intervals to watch for tumor shrinkage.

Small eye melanomas
There has been a recent trend toward treating small eye melanomas with either radiation therapy or transpupillary thermotherapy (TTT) — a type of infrared laser therapy — or both. Destroying the cancerous tissue by freezing it (cryotherapy) also has been used for some small eye melanomas.

Prevention

A clear association between sunlight and melanomas of the skin has been established. This same association has not been established for melanomas of the eye.

Coping skills

Eye melanoma may result in partial or complete loss of vision and, in some cases, removal of the eye (enucleation). Although these outcomes are traumatic, you can overcome them with the support of friends and family, adequate time to heal and adjust, and modern technology.

If your cancer treatment leaves you with vision in only one eye (monocular vision), it’s still possible to do practically everything you were able to do with two working eyes. But you’ll need to make adjustments, primarily regarding your ability to judge distance, and it may be more difficult to be aware of things around you, especially things occurring on the side without vision.

If your eye must be removed, it will be replaced by a round implant and then covered by your own tissue. Your eye muscles will be attached to the implant so that the implant will move.

After several weeks, an artificial eye (prosthesis) is made. The front surface of your new eye will be custom-painted to match your existing eye, and the back surface will be custom-molded so it fits comfortably. Motion from the implant is transferred through the healed tissue to the prosthetic eye, in most cases providing a satisfactory cosmetic appearance.

You’ll be able to sleep with this new eye, but you’ll have to remove it occasionally for cleaning. In most cases, these artificial eyes last for decades.