Scottish Ocular Oncology Service

Plaque radiotherapy is a form of internal radiotherapy. A radioactive piece of metal known as a plaque is attached to the sclera (white part of the eye) next to the tumour. This is around the size of a 5 pence coin (please see picture above). This is done in the operating theatre and is left in the eye between 3 and 7 days before being removed.  Patients usually stay in ward 1C for this treatment. The tumour starts to shrink around 4-6 months after the plaque is removed.

The effects can last for several years. Although being an effective treatment, the radiation can sometimes damage other parts of the eye. This may cause cataract, retinal detachment, nerve damage, or macular oedema (swelling of the back of the eye). New blood vessels may grow after treatment; these can sometimes block the drainage angle in the eye causing glaucoma. If we are unable to control this, we may have to consider removing the eye. Although there are risks of plaque radiotherapy, this treatment can stop growth of the tumour in around 80% of cases.

This is where radiation with charged particles called protons are targeted at the tumour from outside the eye. This treatment is used if the tumour is too large or located too far back in the eye for plaque radiotherapy to work. As this treatment is highly specialised, the Douglas Cyclotron Unit, Clatterbridge, Liverpool is the only centre in the United Kingdom where the treatment is given.

Please follow the link to the patient journey through proton beam therapy.

If proton beam radiotherapy is the best option for you, we will organise transport to Clatterbridge and accommodation for you in near the Hospital (please see the team photo of the Clatterbridge team and the hospital above). This involves two separate visits to the Clatterbridge. At the first visit a treatment mask is made and fitted- this helps the team target the radiotherapy at the correct part of the eye. At the second visit, one to two weeks later, the treatment is given. You will likely travel down Sunday evening and return Friday later that week. Final measurements are made on the Monday and then the radiation is given over the remaining four days during (Tuesday to Friday).

Each treatment session takes around 20 minutes and is pain free. Before going down to Liverpool, however, we have to perform a small operation on the affected eye in Gartnavel General Hosptial, Glasgow. This is where we stitch tantalum markers (small metal discs smaller than a paper clip- please see photo above) to the sclera (white part of the eye) next to the tumour. We usually do this under General Anaesthetic. This helps the team target the radiation treatment more effectively when you go down to Clatterbridge. Proton beam radiotherapy takes a little longer to work than plaque radiotherapy.

We usually wait six months to see if the tumour starts to decrease in size.  Although effective at treating tumours, the radiation can also damage normal parts of the eye and tissues around the eye when given. This may cause loss of eyelashes, loss of pigmentation of the eyelids, and inflammation of the conjunctiva causing a watery eye. Sometimes small blood vessels can grow at the back of the eye and into the drainage angle at the front of the eye. This can cause the pressure to build up in the eye and cause glaucoma. If we are unable to control the pressure and the eye becomes very uncomfortable, unfortunately we may have to consider removing the eye.

This is where radiation from a machine is targeted at cancer cells from outside the body. We find this treatment useful in patients that have cancer else where in the body that has spread to the back of the eye. On the other hand, if there has been a large tumour inside the eye that has grown behind the eye, we may choose to use radiotherapy after removing the eye. This treatment is spit into fractions.

This means the treatment is divided into smaller doses and spread out over a few days. This gives healthy cells in the body a chance to recover between treatments. If we are using radiation to treat the eyes or lymph nodes around the head and neck, then a special mask is usually made for patients. This mask is worn during treatment and helps aim the radiation at only the cancer cells. Although this helps prevent damage to healthy cells around the tumour, treatment may still cause loss of eyelashes, loss of pigmentation of the eyelids, and inflammation of the conjunctiva causing a watery eye.

Transpupillary Thermotherapy (TTT) uses an infrared laser beam to heat the tumour up and kill the cancer cells. This technique is useful if there is uncertainty if the suspicious area is a melanoma or a naevus, or if the choroidal melanoma is small and radiotherapy is inappropriate due to poor health.

This treatment is sometimes combined with plaque radiotherapy as it reduces swelling and leakage from the blood vessels. After TTT the tumour gradually shrinks down  if successful. Repeat treatment may be required at 6 months.

Possible complications from this treatment include retinal detachment, blockage of blood vessels, growth of new blood vessels, iris burns and cataract.  Unfortunately tumour recurrence after treatment is common. This is more likely to occur if the melanoma is thick, close to the optic nerve, or non-pigmented.

A light sensitive dye is injected into the blood stream. As the dye travels through the blood vessels to the back of the eye through the blood vessels, a special light is shined into the eye. This activates the dye and causes the abnormal blood vessels to close, shrink, and stop leaking.

This is useful in patients with a naevus or melanoma that is leaking fluid and building up at the back of the eye (macular oedema). Although this is not the main treatment for choroidal melanoma, we may find it useful in some cases where radiotherapy treatment is not possible.

Enucleation is the medical term for removing the eye. This is recommended when the tumour is too large for other treatments or has started to invade behind the eye. Removing the eye along with the tumour is sometimes preferred if there is a lot of pain and discomfort in the eye. This can be due to high pressure inside the eye caused by blockage of the drainage angle by tumour or new blood vessels grown after radiotherapy.

The idea of having your eye removed is scary. With current technology, however, we can get excellent cosmetic results with uniquely designed and fitted artificial eye implants (please click below to see photos). Our artifical eye clinic is run in Gartnavel General Hospital, Glasgow. Alternatively, some patients may prefer to just wear an eye patch after the tumour is removed.

After removing the eye, although this gets rid of the tumour growing in the eye, unfortunately this does not prevent the tumour growing else where in the body later in life. The most likely place for melanoma to regrow is the liver. For this reason we may decide to organise a liver ultrasound scan every year at your local hospital to screen for cancer growth.

Artificial Eyes

After the eye is removed, a temporary cosmetic shell is fitted in the operating theatre (see first picture above). We choose a colour to match the patient’s other eye. Although not a perfect colour match, this temporary shell will remain in place until the final artificial eye is made.

Once the eye socket has healed, the temporary cosmetic shell is removed and the final artificial eye implant can be fitted. This is done in the prosthetic eye department in Gartnavel General Hospital, Glasgow. The team will take photos of your normal eye. The artificial implant is then painted in fine detail to match the photo of your healthy eye. Please see the two other photos above (note both the healthy eyes have been dilated in clinic to examine the back of the eyes so the pupil sizes do not look symmetrical).

Exenteration means removing the eye with the tumour and the soft tissue around the eye. This treatment is required if the cancer has spread behind or around the eye. Sometimes the eyelids or part of the bone around the eye have to be removed if the tumour has invaded here. If this is the case, we will likely perform the operation at the Queen Elizabeth University Hospital with the help of our Oral and Maxilofacial Surgeon colleagues.  Sometimes this treatment is combined with radiotherapy or chemotherapy. Our medical oncology team will help us choose the best treatment for you.

Excellent cosmetic results can be achieved after the tumour is removed. This involves further reconstructive surgery and being fitted with an artificial eye. Some patients, however, may prefer just to wear an eye patch or leave things as they are instead of having further surgery. After the cancer is removed we can plan treatment that suits your needs.

This can be performed under local or general anaesthetic and as a day case. After tumour removal as much normal tissue is left behind to help keep the eyelid looking as normal as possible. The tumour is sent to the pathology laboratory to confirm the type of tumour and if it has all been removed. Eyelid tumours (mainly basal cell carcinomas) may be removed by a dermatologist (skin specialist). This is where a small part of the skin is removed then inspected under a microscope straight away. If cancer cells are still visible, then more tissue is removed and inspected again. This is repeated until there are no more cancer cells seen under the microscope. This helps remove as little normal tissue as possible mean while ensuring all the cancer is removed.

After the tumour is removed the eyelid is reconstructed to get the eyelid looking and functioning as normal as possible. If the tumour removed was small then this can usually be done on the same day.  If the tumour removed was large and a lot of the eyelid had to be removed then reconstruction may be done on a different day. Skin or tissue can be taken from the other eyelid or from other parts of the body to re-form the eyelid. We commonly use the skin in front of the ear or from the inner surface of the upper arm. Sometimes we use tissue from the inner surface of the cheek- this heals very well after surgery. As there are many options, we aim to choose the best treatment option for you. 

This freezes the tumour helping destroy the cancer cells. This can be used in combination with surgical excision, or on its own if surgery is not an option. Cryotherapy can is usually done the operating theatre under local or general anaesthetic. Treatment lasts several minutes. Although helping prevent tumour growth, no samples are sent to the lab so confirmation of tumour death is not always possible. If this is the case, we will monitor you carefully in the clinic. Sometimes we have to repeat this treatment more than once. 

This treatment involves targeting the cancer with high energy radiation beams. This kills the cancer cells and stops them multiplying. This is used if surgery is not possible, for example, if the patient is too unwell or desperately does not want surgery. It may, however, be the preferred treatment of choice; for example, in lymphoma. This treatment is performed as an out-patient. This treatment is spit into fractions. This means the treatment is divided into smaller doses and spread out over a few days. This gives healthy cells in the body a chance to recover between treatments. If we are using radiation to treat the eyes or lymph nodes around the head and neck, then a special mask is usually made for patients. This mask is worn during treatment and helps aim the radiation at only the cancer cells. Although this helps prevent damage to healthy cells around the tumour, treatment may still cause loss of eyelashes, loss of pigmentation of the eyelids, and inflammation of the conjunctiva causing a watery eye.

Mitomycin C (MMC)

This is a chemotherapy drug that is applied to the surface of the tumour in theatre. MMC works by sticking the cancer cells’ DNA (the cell’s genetic code) together, stopping the tumour or cancer cells from growing.

This is applied to the surface of the cancer cells and therefore  side effects of chemotherapy such as nausea, vomiting or hair loss are not experienced.

If MMC eye drops are being used, however, this can irritate the eye. We may give lubricant or steroid drops to treat this. 

5-fluorouracil (5-FU)

This treatment, also called imiquimod, is a chemotherapy drug which is applied to the surface of skin tumours. Sometimes we use this to treat eyelid tumours. This drug causes the body’s immune system to produce a chemical called interferon. This attacks and kills cancer cells. It may irritate the skin when applied, this means the treatment is working. It is applied 3 – 5 nights a week and treatment can last up to 6 weeks.

We have bus and train links that travel to Gartnavel General Hospital daily.

Traveling by Train

Hyndland Station is the nearest train stop to Gartnavel General Hospital. We are a 5 to 10 minute walk from the Hyndland Station. Trains leave both Glasgow Queen Street Station and Glasgow Central Station every 10-15 minutes. The journey takes roughly 10 minutes to get to there. The following websites will help you plan your train journey if you are traveling from else where in Scotland:

• www.thetrainline.com
• www.scotrail.com

Traveling by Bus

Buses run frequently to from Glasgow City Centre to Great Western Road; this is a 5 minute walk to the main entrance to the hospital. Travel time may take up to 30 minutes during rush hour. The buses run every 10-15 minutes from the city centre. Please see the following links for time tables and to plan your journey:

• www.firstgroup.com/ukbus/scotland/swscot/home
• www.arrivabus.co.uk

Travel Help for Visitors

When visiting family members on the ward, people who are elderly or live with a disability may find the evening hospital visitor transport service useful:

• http://www.spt.co.uk/bus/accesstohealthcare/

Parking

Parking is extremely limited at Gartnavel General Hospital. A maximum four hour stay operates in patient and visitor car parks from 7.30am until 4.30pm Monday to Friday. If there are no spaces, the Glasgow Pond Hotel next to Gartnavel General Hospital offer parking at reasonable rates. There is a designated drop off points outside all the entrances to the hospital. Please avoid parking on disabled spaces unless you hold a valid badge, and also taking care not to park on ambulance car parks or yellow lines.

We appreciate that patients and relatives may be travelling a long distance to attend the clinic. If you choose to travel the day before, Leonardos Inn Hotel is next to Gartnavel General Hospital. Please see their website for reservation and bookings.

An Ultrasound scan is often used in pregnancy and uses sound waves to create an image of inside a part of the body. It is very safe and can look at organs in the abdomen, for example the liver, or of the eye. Either a doctor or a sonographer (health professional trained to perform ultrasound scans) will perform the scan. You may be asked to follow certain instructions before your scan- such as drinking a lot of water, fasting for a few hours etc- it is important you try and follow these instructions to get the best images possible. Cold gel is applied to the skin over the area they wish to scan.

The ultra-sound probe is gently placed on the skin and moved over the gel. If the eye is being scanned, the ultrasound probe is gently applied to the surface of the eyelid. The ultrasound images are then collected and analysed. Ultrasound scans of the body may take between 15-45minutes to perform. Ultrasound of the eye, however, is much quicker and will sometimes be performed in the eye clinic. Results of the eye USS will be given on the same day. Results of liver ultrasound scans, if carried out your local hospital, will be discussed at your next eye clinic appointment. 

This is a large camera, which creates 3D pictures of the back of the eye. After having your pupils dilated with drops, the scan takes minutes to perform. This helps us check for fluid leaking at the back of the eye from abnormal blood vessels or from a tumour. It can be repeated at each visit, and helps us pick up changes at the back of the eye.

CT scans are also known as CAT scans. They use several X-ray images to create a detailed scan of the body. When you arrive at the department you will have a short safety questionnaire to complete; due to radiation CT scans are not usually recommended in women who are pregnant. Sometimes contrast dye is injected into the vein during the scan to help get more detailed images.

The CT scanner itself is a large circular machine, which you lie flat in. You will be asked to stay still and breathe normally. The x-ray parts move inside the big circular ring creating the images. During the scan, you will be able to communicate with the radiographer in the next room through an intercom system. The scan takes around 10 to 20 minutes to do. After the scan, the images are analysed and the results will be given to you at your next clinic appointment.

Add/copy info from UmbMRI stands for magnetic resonance imaging. Instead of X-ray radiation, It uses magnets and radio waves to produce images of inside the body. It gives very fine detailed pictures of the eye, the optic nerve, and the brain. When you arrive at the department you will have a short safety questionnaire to complete; if you have any metal inside the body or are claustrophobic you may not be able to get the MRI scan. Sometimes contrast dye is injected into the vein during the scan to help get more detailed images.

The MRI scanner is a large circular tube, which you lay down flat in. The radiographer then leaves the room to operate the scanner from the next room. You will be able to communicate with them however through an intercom system. During the scan you will be asked to lie still and to breathe normally. You may hear loud tapping noises during the scan- this is normal. You will be given earplugs or headphones to wear so you can listen to music. The scan takes 30 minutes to an 1 hour to complete. After the scan, the images are analysed and the results will be given to you at your next clinic appointment.

X-rays are used to produce pictures of the heart, lungs and other parts of the body. This is quick to perform in the radiography department and is useful if we want to check for lung cancer.

This is where a yellow dye is injection into a vein in the arm, which travels through the blood vessels to the back of the eye. As the dye reaches the back of the eye, several pictures are taken with a special camera. This gives us more information about the blood supply to suspicious areas at the back of the eye.

This is similar to fluorescein angiography, except a different dye is used. This looks more closely at the choroid at the back of the eye, which is the layer deeper to the retina. It is therefore useful at detecting abnormalities in the blood vessels in the choroid.

The 24 hour Bowl-a-thon organised by one of our patients took place at the Renton Bowling club, Dunbartonshire, on the 8th/9th July 2017. This was a hugely successful event raising over £3,500 for the Scottish Ocular Oncology Service. 

On Easter Monday 2018 one of our patients Elaine and her sister, cousin, son, daughter, friend and niece walked part of the west highland way from Crainlarich to Bridge of Orkey.  

From their heroic efforts they managed to raise a fantastic £1,454 for Scottish Ocular Oncology Service. Well done!

a) What is cavernous haemangioma?

This is where abnormally dilated blood vessels behind the eye collect together and form a tumour. This is the most common benign orbital tumour in adults. It occurs more often in females and can develop anywhere in the orbit. More commonly, however, it develops beside the muscles that move the eye. Although this tumour is benign, it can grow slowly behind the eye and cause damage.

b) What are the symptoms of cavernous haemangioma?

There may be no symptoms. If the cavernous haemangioma continues to grow, however, it can cause the following:

• Proptosis (Eye sticking out)

• Double vision

• Blurring of vision

c) Will I need any tests?

We may take pictures of the eye and consider the following tests:

• CT scan

• MRI scan (picture above)

This can help us measure the size of tumour and where it is. This is useful if we are planning surgery or to check if the nerve is being squashed. Cavernous haemangioma on MRI scan.

d) What is the treatment of cavernous haemangioma?

If not causing problems we may just observe routinely in the clinic. If, however, it is growing and causing problems, surgery is the best treatment. Unfortunately bleeding, infection or damage to nerves and muscles of the eye can occur during surgery. The risk of this depends on the tumour location and size.

a) What is pleomorphic adenoma?

This is the most common benign tumour of the lacrimal gland. It is also known as benign mixed cell tumour. It is formed from the cells and ducts that produce tears in the lacrimal gland. They also commonly occur in the salivary glands. Although labelled as benign, very rarely pleomorphic adenoma can turn into malignant tumours.

b) What are the symptoms of lacrimal gland pleomorphic adenoma?

This causes a painless lump in the lacrimal gland and sometimes swelling to the top eyelid. This can slowly cause the eye to stick out (proptosis – picture above). It can also push the eye down and inwards. This may cause double vision and decreased the vision.

c) Will I need any tests?

Different types of scans can be used to help diagnose this benign tumour. It is also useful if surgery is being planned. Scans may include:

• CT scan

• MRI scan

• US scan

d) What is the treatment for lacrimal gland pleomorphic adenoma?

Removal with surgery may be required. We aim to remove the whole tumour without cutting into the tumour – this may cause it to spread and re-grow at a later stage. For this reason biopsy we do not take a biopsy before surgery.

a) What is lacrimal gland carcinoma?

This is a rare malignant tumour of the lacrimal gland. The commonest malignant lacrimal gland carcinoma is called adenoid cystic carcinoma. This tumour can grow quickly and spread to the bones and the nerves around the eye.

b) What are the symptoms of lacrimal gland carcinoma?

This tumour can grow quickly and cause swelling of the top eyelid. The eye may stick out (proptosis- picture above) or be pushed downwards and inwards. This can cause double vision and blurring. If the tumour spreads into the bone and the nerves this can cause pain or numbness over the face.

c) What are the risks of getting lacrimal gland carcinoma?

The following increase your risk of lacrimal gland carcinoma:

• Age – it is more common in your 30s.

• Previous radiation treatment to the face,

• Previous removal of a benign lacrimal gland pleomorphic adenoma.

d) Will I need any tests?

We may perform the following scans:

• CT scan

• MRI scan

• Ultrasound scan

This helps us measure the size of the tumour, position, and check if there is any spread into the bone. Biopsy of the tumour is sometimes performed to confirm the diagnosis in the laboratory.

e) How is lacrimal gland carcinoma treated?

Surgery and radiotherapy is usually required. Surgery may include removal of the tumour and tissue around the lacrimal gland. If the tumour has spread out of the lacrimal gland then exenteration may be required. Unfortunately treatment is rarely curative, however, our medical oncology team will guide us on the best treatment for you.

a) What is optic nerve glioma?

Optic nerve glioma is a slow growing tumour developing within the optic nerve. It is more common under the age of 20. Another name for this tumour is a pilocytic astrocytoma. Patients who get this tumour commonly have an under lying medical condition called neurofibromatosis type 1. This is a genetic condition that makes you more likely to grow tumours along your nerves.

b) What are the symptoms of optic nerve glioma?

Since this tumour is slow growing, it usually causes a gradual decrease in vision in the affected eye. The tumour can push the back of the eye causing the eye to stick out (proptosis- picture above). Rarely, the vision may quickly deteriorate. This may be due to bleeding into the tumour, causing it to squash the nerve or the blood vessels to the eye. Sometimes the tumour can spread backwards into the brain. If this happens then headaches (worse in the morning), nausea and vomiting may occur.

c) Will I need any tests?

If optic nerve glioma is suspected then scanning the orbit and the brain is likely to be required. This may include:

• MRI scan

• CT scan

• US scan

If neurofibromatosis is suspected then genetic testing may be performed. A full body scan may also be useful to look for other tumours else where in the body. If the diagnosis is uncertain we may decide to take biopsy.

d) What is the treatment for optic nerve glioma?

If not causing any problems then treatment may not be required. If, however, the tumour is growing and causing forward displacement of the eye or decreasing the vision, then surgery is recommended. Unfortunately, because the tumour is on the optic nerve, removing this may cause damage to the vision. Radiotherapy and chemotherapy may also be used if the cancer has spread to the brain. Our medical oncology team will guide us on the best treatment for your case.

e) How effective is the treatment?

Treatment is effective in slow growing optic nerve gliomas. These are more common in children. In adults, however, aggressive fast growing optic nerve gliomas are more common and are more likely to spread back into the brain and threaten life. These are more difficult to treat.

a) What is optic nerve sheath meningioma?

Wrapped around the optic nerve is a sheath. This is similar to the insulation layer of a wire. Along this sheath, a benign tumour called a meningioma can develop. This more commonly occurs between 30 and 60 years of life. It is 4 times more likely to occur in woman. This tumour can also develop in the protective layer of the brain and the spinal cord. Meningiomas may grow fast or slow.

b) What are the symptoms of optic nerve sheath meningioma?

The faster the tumour is growing then the quicker the symptoms will develop. This may include:

• Poor vision

• Proptosis (eye sticking out)

• Double vision .

c) Will I need any tests?

If meningioma is suspected, scanning of the orbit and the brain is usually carried out. Scans may include:

• MRI scan (picture above)

• CT scan

• US scan

Scans may be repeated at a later date to see if the meningioma is growing. If the diagnosis is uncertain we may decide to take a biopsy.

d) What is the treatment of optic nerve meningioma?

Treatment may not be required if the tumour is slow growing and not causing symptoms. This is more common in middle aged patients. In younger patients, however, the tumour is more likely to be aggressive and fast growing. If this is the case, surgery is required. Unfortunately surgery may damage the nerve and cause poor vision. Sometimes radiotherapy is given after surgery to reduce the risk of it coming back later in life. Unfortunately, radiotherapy may also damage the vision.

a) What is lymphoma?

In lymphoma, the white cells that usually fight infection are “out of control”, keep dividing, and do not die. These abnormal cells collect and grow in the lymph nodes. They can also develop elsewhere in the body, including behind the eye. There are two different types of lymphoma – hodgkins lymphoma (20% of cases) and non-hodgkins lymphoma (80% of cases). Hodgkins lymphoma is the easiest to treat, however, treatments for both types of lymphoma are very effective and can be cured in most cases.

b) What are the symptoms of orbital lymphoma?

This may cause:

• Proptosis (eye sticking out- picture above)

• Double vision

• Decreased vision

c) Will I need any tests?

A biopsy may be required to confirm the diagnosis. Scanning the eye, orbit, and rest of the body is important to make sure the lymphoma is not affecting anywhere else. This may include:

• CT scan

• MRI scan

• US scan

This helps us decide which treatment is needed.

d) What are the treatments for orbital lymphoma?

Treatments include:

• Radiotherapy

• Surgery

• Chemotherapy

Treatments vary patient to patient, however, discussion with our medical oncologist and pathologist will help us choose the best treatment for you.

a) What are orbital metastases?

Tumours starting elsewhere in the body can spread behind the eye in the orbit. This is rare, however, if a tumour is first found in the orbit then cancer elsewhere may have to be considered and looked for. Common places for cancer to grow first before spreading to the eye include the breasts, lungs, prostate, skin, bowel and kidneys.

b) What are the symptoms of orbital metastasis?

Orbital metastases may cause:

• Proptosis (eye sticking out- picture above)

• Double vision

• Decreased vision

In certain tumours, enophthalmos can occur; this is where the eye moves backwards into the orbit making the eye appear smaller. If cancer elsewhere is present then some of the following symptoms may be experienced:

• Shortness of breath

• Long standing cough

• Coughing up blood

• Breast lump

• Difficulty passing urine

• Blood in urine or stools

• Change in bowel habit

c) What tests will I get?

Scanning the eye and elsewhere in the body depending on symptoms experienced. Scans may include:

• CT scan

• MRI scan

• PET CT scan

• Chest X-ray

• Blood tests

If we are unsure of the diagnosis, an orbital biopsy may be carried out. This, however, will be discussed further in clinic.

d) What is the treatment for orbital metastasis?

Treatments may include:

• Radiotherapy

• Chemotherapy

• Surgery

The main goal is to preserve vision and keep the eye comfortable. Our medical oncologist will help us choose the best treatment for you.

a) What is basal cell carcinoma?

Basal cell carcinoma (BCC) is the commonest type of skin cancer. The number of BCCs diagnosed is increasing every year due to the hotter summers in the UK and increasing foreign travel. These can grow on the skin of your eyelid. Due to their appearance they are often called ‘rodent ulcers’. They can grow along the eyelid, and if left untreated, can spread into or behind the eye. It is very rare for BCCs to spread around the body and can be cured if removed.

b) What are the symptoms of basal cell carcinoma?

Usually they are painless. They often look like a flat red mark, or have a pearly rim surrounding a crater. Sometimes they can bleed and scab over.

c) Risk Factors Risk factors for this condition include:

• Sun damage

• Fair skin

• Previous basal cell carcinomas

• Open wounds that resist healing

• Exposure to ionising radiation

• Chronic inflammatory skin conditions

d) What tests will I need?

A biopsy may be taken from the affected area. If it is suspected that the BCC has started to spread into the eye or behind the eye, scans may have to be performed. These may include:

• CT scan

• MRI scan

• Ultrasound scan

e) How are basal cell carcinomas treated?

Treatments include:

• Surgery (surgical excision)

• Radiotherapy

• Chemotherapy cream (5 Fluorouracil)

After surgery, the eyelid is reconstructed to make the eyelid appear and function as normal as possible. This may be carried out as a separate operation.

a) What is squamous cell carcinoma?

Squamous cell carcinoma (SCC) is the second most common skin cancer behind basal cell carcinoma. This is more aggressive, however, and can spread to other parts of the body. It can be tricky to diagnose on clinical appearance alone. The number of SCCs diagnosed in the world, and in the UK, is increasing each year. They are more common in Caucasians, in the elderly and in the male population.

b) What are the risks of squamous cell carcinoma spreading around the body?

Factors that increase the risk of metastases include:

• Large SCC greater than 2cm in diameter or deeper than 4mm

• SCC after radiation treatment

• SCC recurrence after surgical resection

• Long standing ulceration from Bowen’s disease (skin condition)

• Patients with a poor immune system from certain treatments or diseases

If the cancer has started to spread swelling of the lymph nodes around your ear or under your chin may occur.

c) What are the symptoms of squamous cell carcinoma?

They often appear as a non-healing ulcer with hard raised edges. There may be redness, crusting or bleeding. They commonly occur on the lower eyelid. Decreased vision may occur if the cancer spreads behind the eye.

d) What are the risks of getting squamous cell carcinoma?

Risk factors for this condition include:

• Sun damage

• Fair skin

• Pre-malignant conditions such as Bowens disease, actinic keratosis or keratoacanthomas.

• Poor immune system (e.g. HIV)

e) What tests will I need?

A biopsy will likely be taken. If there is high suspicion of SCC, the abnormal area of skin may be completely removed in theatre. If it is suspected that the SCC has started to spread into the eye or behind the eye we may arrange the following scans:

• CT scan

• MRI scan

• Ultrasound scan

f) Management Treatments include:

• Surgery (surgical excision)

• Radiotherapy

• Chemotherapy cream (5 Fluorouracil)

After surgery, the eyelid is reconstructed to make the eyelid appear and function as normal as possible. This may be carried out as a separate operation.

a) What is sebaceous gland carcinoma?

Sebaceous gland carcinoma is a rare and aggressive type of skin cancer. They grow from sebaceous glands, which normally produce our oil for our skin. These glands are also found in the eyelids. This can be tricky to diagnose as it is often mistaken for a chalazion or blepharitis – two common benign eyelid conditions. If there is a delay in treatment then the tumour may spread to other parts of the body including the liver, lungs, brain and bones. This can occur in up to a quarter of patients.

b) What are the symptoms of sebaceous gland carcinoma?

This commonly looks like a small, red or yellow, firm lump on the eyelid. This may gradually increase in size and cause irritation to the eye.

c) What are the risks of getting sebaceous gland carcinoma?

The following increase your risk of getting sebaceous gland carcinoma:

• Getting benign adenomas (non cancerous lumps) of the skin.

• Exposure to radiation e.g. radiotherapy to the face

• Asian ethnicity Spreading to other areas of the body unfortunately occurs in around 1 out of 5 cases.

d) Will I need any tests?

After taking a picture we will likely take a biopsy of the suspicious area and send it to the laboratory for testing. If we suspect the cancer has spread behind the eye or to other parts of the body we may organise the following scans:

• Chest X-ray

• CT scan

• MRI scan

e) What is the treatment for sebaceous gland carcinoma?

Treatments include:

• Surgery (surgical excision)

• Radiotherapy

• Chemotherapy cream (5 Fluorouracil)

After surgery, the eyelid is reconstructed to make the eyelid appear and function as normal as possible. This may be carried out as a separate operation Biopsy or removal of the lymph nodes may have to be performed if we suspect is has spread from the eyelid to the lymph nodes. Unfortunately the tumour can grow back after treatment.

a) What is melanoma?

Melanoma is a serious type of skin cancer which can affect the eyelids. It grows from cells called melanocytes, which normally produce pigment in our skin, hair, and eyes. This gives them a dark and pigmented appearance Eyelid melanoma, although less common than other skin tumours, is dangerous because it can spread around the body if not treated early.

b) What are the symptoms of melanoma?

The following skin changes may be due to melanoma:

• Increased pigmentation or darkening of the skin

• A new mole

• A change in an existing mole

These are more likely to have an irregular shape, be more than one colour, and grow quickly.

c) What are the risks of getting eyelid melanoma?

The following increase your risk of getting eyelid melanoma:

• Pale skin

• Large numbers of moles or freckles

• Red or blond hair

• Blue eyes

• Poor immune system (e.g. HIV)

Melanoma can be prevented with good skin care when travelling abroad or in sunny climates. Careful monitoring of pigmented areas of skin is key to detecting skin melanoma early.

d) Will I need any tests?

We will likely take photographs to monitor changes. If the diagnosis is uncertain we may take remove all of the abnormal area and send it to the laboratory for where a diagnosis can be made . If it is suspected that the melanoma has started to spread to other parts of the body then we may organise the following scans:

• CT scan

• MRI scan

Blood tests, including liver function tests, may be carried out if spread to the liver is suspected. Liver ultrasounds carried out every year to monitor for spread at your local hospital.

e) What is the treatment for eyelid melanoma?

Treatments include:

• Surgery

• Radiotherapy

• Chemotherapy

If radiotherapy or chemotherapy is needed, our medical oncologist and pathologist will help guide our treatment.

f) What happens if the eye melanoma spreads to different parts of the body?

This can be scary and upsetting. If spread of disease has been picked up we involve other health professionals at our MDT (multidisciplinary team) meeting. Our clinical team consists of a radiologist, pathologist, and a medical oncologist. Collectively we will decide on the rights tests and treatments for you as an individual. Accepting and coming to terms with the diagnosis can be challenging. For this reason, we have specialist ophthalmic nursing staff in the clinic who are here to council and help you through this difficult time.

a) What s ocular surface squamous neoplasia?

Ocular surface squamous neoplasia is pre-cancerous or cancerous changes to the surface of the conjunctiva. Pre-cancerous changes can cause a condition called conjunctival intraepithelial neoplasia. This condition can turn into squamous cell carcinoma, which is a sinister tumour. This can spread onto the cornea causing decrease in vision. It usually affects one eye and is caused by sun damage.

b) What are the symptoms of ocular surface squamous neoplasia?

A fleshy pale lump is usually noticed on the surface of the eye next to the cornea. It may grow onto the cornea and, if large, can cause:

• Grittiness to the eye

• Watering

• Blurring of vision

Sometimes it can grow form the conjunctiva onto the eye lid.

c) What are the risks of getting ocular surface squamous neoplasia?

Risk factors for this condition include:

• Sun damage

• Fair skin

• Older age

• Conditions decreasing the immune system (e.g. HIV)

d) Will I need any tests?

In the clinic we may take pictures of the front of the eye. It is difficult to tell apart conjunctival intraepithelial neoplasia (pre-cancerous) from squamous cell carcinoma (cancerous). If the abnormal area is removed with surgery then it is sent to the laboratory to help confirm the diagnosis.

e) What is the treatment for ocular surface squamous neoplasia?

The main treatment is surgery (surgical excision). We may, however, use freezing treatment (cryotherapy) and Mitomycin C (MMC) eye drops as well. MMC can, however, irritate the eye. To treat this we may provide you with lubricant or steroid eye drops.

a) What is primary acquired melanosis?

Primary Acquired melanosis (PAM) is newly formed brown pigmentation of the conjunctiva. People with white skin are more likely to get this. It usually affects one eye only. There are two different types of PAM: ‘PAM without atypia’ and ‘PAM with atypia.’ PAM without atypia is benign with no risk of transformation into melanoma. PAM with atypia, however, can turn into melanoma. Around 3 out of 4  conjunctival melanomas come from PAM with atypia. If you have dark skin, brown pigmentation of the conjunctiva from birth is very common and usually affects both eyes. This is known as conjunctival epithelial melanosis and is not likely to progress to melanoma.

b) What are the symptoms of primary acquired melanosis?

Uneven, painless, newly formed brown pigmentation is usually noted on the white of the eye. If the pigment is growing quickly or changing colour then it is more likely to be a conjunctival melanoma.

c) Am I likely to get primary acquired melanosis?

If you are middle aged and fair-skinned you are more likely to get primary acquired melanosis.

d) Will I need any tests to exclude melanoma?

If it is felt to be PAM without atypia we may take pictures in the clinic to help us monitor change. Sometimes a biopsy of the pigmented area, however, is needed to exclude cancer. When doing so we try to remove all of the pigmented area. The following features make us more likely to biopsy:

• Larger than 5mm

• Increasing in size

• Has thickened the conjunctiva

• Has a distinct nodule arising within it (pigmented or non-pigmented raised area)

• Has feeder vessels (blood vessels running into the pigmented area)

• Involving the cornea

• Involving the conjunctiva under the eyelids

• Previous melanoma

e) Is treatment needed for primary acquired melanosis?

PAM without atypia can be monitored in the clinic. The main treatment for PAM with atypia is surgery (surgical excision) with or without freezing therapy (cryotherapy) and Mitomycin C (MMC).

a) What is conjunctival melanoma?

Melanomas are tumours which come from pigmented cells in our body. As well as growing on the skin, they can grow on the conjunctiva of the eye. Conjunctival melanoma accounts for 2% of eye cancers. It arises most commonly form primary acquired melanosis, or from a naevus (freckle) already present on the eye. Least commonly it arises on its own; this is known as primary conjunctival melanoma. This cancer can spread to other organs in the body, most commonly, the liver.

b) What does conjunctival melanoma look like?

Conjunctival melanoma looks like an uneven, raised, grey or pink lump growing on white conjunctiva or from a pigmented area on the conjunctiva. This may cause irritation and watering from the eye.

c) What are the risks of getting conjunctival melanoma?

The following increase your risk of developing conjunctival melanoma:

• Having pale skin

• Red or blond hair

• Blue eyes

• Over 50 years of age

• Large number of moles or freckles

• Poor immune system (e.g. HIV)

d) How likely is the conjunctival melanoma to spread around the body?

There are some features that increase the risk of the melanoma spreading. These include:

• Large tumours (large basal diameter, and tumour thickness of greater > 2mm)

• Nodular tumours (rounded and raised)

• Tumour involving the eyelids

• Tumour involving the corner of the eye near the nose (plica or caruncle)

If the tumour has grown on white conjunctiva instead of a pigmented conjunctiva, then the tumour may be more aggressive. Most common place is the liver. A liver ultrasound scan is arranged at your local hospital every year to exclude spread of disease.

e) Will I need any tests?

A biopsy may be required to confirm the diagnosis. If we decide to biopsy we usually remove the whole abnormal area. We may perform CT or MRI scan to make sure the melanoma has not spread to other parts of the body. If the tumour is greater than 2mm thick or growing in the corner of the eye we may need to consider doing a sentinel lymph node biopsy (SLNB). This is where a sample is taken from the glands that drain fluid away from the eye and analysed for tumour cells. These glands are found at the front of the ear and in the neck. This is the first place the tumour spreads to before metastasising around the body. This procedure is carried out in the Queen Elizabeth University Hospital in Glasgow with help from our maxilo-facial surgeon colleagues. If the SNLB detects cancer cells then the glands can be removed with surgery or treated with radiotherapy.

f) What is the treatment of conjunctival melanoma?

Surgery (surgical excision) is performed with or without:

• Cryotherapy

• Mitomycin C (MMC)

• Radiotherapy

• Chemotherapy

Sometimes the tumour is too big or has spread behind the eye. In these situations enucleation may be the best option. If there is involvement of the eyelids or of tissue behind the eye, we may have to consider exenteration. If there is spread of disease to the lymph nodes in the neck, we may have to remove these or treat with radiotherapy.

g) Can the conjunctival melanoma come back after treatment?

Unfortunately the answer to this is yes. Even if the tumour is completely removed there is always a chance of the tumour re-growing in the same place or in other parts of the body. For this reason, we monitor in the clinic after treatment.

a) What is lymphoma?

Lymphoma is a condition where the white cells that usually fight infection are “out of control”, keep dividing, and do not die. These abnormal cells can collect and grow in the lymph nodes. They can, however, grow elsewhere in the body including the conjunctiva. Conjunctival lymphomas are mostly of non-Hodgkin’s B-cell type. Follicular lymphoma is the next most common lymphoma. The lymphoma may just affect the conjunctiva or can affect other areas in the body as well.

b) What are the symptoms of conjunctival lymphoma?

Conjunctival lymphoma looks like a large “salmon pink” growth on the conjunctiva. This may cause grittiness, watering, or irritation to the eye.

c) Will I need any tests?

A biopsy is usually required to confirm the diagnosis. If we suspect the lymphoma is behind the eye or affecting else where in the body we may organise:

• Ultrasound scan

• CT scan

• MRI scan

d) What is the treatment for lymphoma?

After biopsy confirms the diagnosis of lymphoma, we may treat with:

• Radiotherapy

• Chemotherapy

Our choice of treatment is be guided by the haematologist or medical oncologist.