Should patients be routinely examined for potential ocular malignancy, and if so, how often?

Issue: July 10, 2010

Practice good exam habits

John A. Hovanesian

With respect to detecting ocular tumors, it is not so much a matter of not examining often enough; it is a matter of not examining well enough.

As physicians, we develop habits in the way we examine patients, and the habits we form determine how well we are going to pick up unexpected findings that are maybe unrelated to a patient’s presenting complaint in the office. Over our careers, over time, we tend not to become more thorough — we tend to be become less thorough in our exam. Yet, we have to maintain the same level of vigilance in our 20th year of practice as we had when we first graduated from residency when we do an exam, to look at every part of the eye individually, or we are going to miss important findings. It is most often that we do not look at things or look past things that are right there.

Perhaps the most common reason that surface tumors, for example, are missed is that the exam does not include a thorough look at the conjunctiva. A commonly overlooked part of the exam is to have a patient look way up while inverting the lower lid and look way down while inverting the upper lid up, giving us a full view as far into the conjunctival fornix as possible. It is in these locations that tumors such as lymphomas will occasionally hide, and yet early detection of these tumors can be life-saving. It is in these locations that we will also find other tumors or depositions of the conjunctiva that are important.

It actually takes very little time to meaningfully screen the ocular mucosa. Likewise, a dilated exam and a good look at the fundus to screen for tumors that hide in the retina and choroid are fairly commonplace.

John A. Hovanesian, MD, FACS, is an OSN Cornea/External Disease Board Member.

No real value in wide-scale screening

Tara A. McCannel

Systemic cancers — breast cancer, colon cancer — are much more common than choroidal melanoma, and early intervention with screening has been shown to improve patient mortality. Choroidal melanomas are the most prevalent primary ocular cancers, but they are extremely rare, with about four to six cases per million per year diagnosed, and we do not have good data that early vs. later intervention improves mortality. Embarking on a screening endeavor or recommending guidelines to do routine screening on everybody for this extremely rare cancer in which early intervention has not been shown to help is controversial, especially in our environment of limited health care resources.

A patient who has not been seen in a year and is undergoing an ocular examination must have a dilated fundus examination, as should a patient with new ocular symptoms. Any patient who has metastatic cancer of a different origin and develops new ocular symptoms must be examined. However, having metastatic tumors go to the eye from other cancers is relatively uncommon, and we do not have evidence that doing ophthalmic screening is helpful. Known metastatic disease with ocular involvement is typically considered end-stage, however, we have local treatments that frequently do help their vision.

In the future, genetic and molecular testing may change this. In a study we reported last year (J Genet Counsel. 2009;18:265-274), we found that 97% of patients with choroidal melanoma wanted prognostic testing even though the results would not alter medical management. I think that indicates that information is important to patients, even if it is only useful for making plans and knowing what to expect. But as development of genetic and molecular testing continues, and as we move into the era of designer drugs, I am optimistic that we will discover targeted treatments and accurately identify who will benefit from them not just in ocular melanoma, but in other types of cancer as well.

Tara A. McCannel, MD, PhD, is the director of the Ophthalmic Oncology Center at Jules Stein Eye Institute, University of California, Los Angeles.