Trends in the management of intraocular tumors over 40 years

Dear Friends, Forty years is a long time. Approximately, 40 years ago, Paul McCartney announced the dissolution of the Beatles, Pele retired from soccer, and President Nixon resigned amid the Watergate scandal. So much has happened worldwide since these events. In the ophthalmology world, 40 years ago, cataract spectacles were routinely prescribed for visual rehabilitation, but more and more patients benefited from intraocular implantation of a fairly new device, the intraocular lens. Laser treatment for diabetic retinopathy was considered, but not yet rationalized. Some patients were entered into the original Diabetic Retinopathy Study in the early 1970s. Otherwise, diabetic patients were destined to blindness. Forty years ago, we were establishing our practice in ocular oncology. Ocular tumors were dismissed as rare, often requiring the enucleation. There was little clinical interest in intraocular tumors. The subspecialty of ocular oncology did not exist. Globe-saving methods for intraocular tumors using plaque radiotherapy were a developing technique for melanoma and external beam radiotherapy for some cases of retinoblastoma. At that time, diagnostic challenges were steep, especially in the clinical recognition of various intraocular tumors as many clinicians were not familiar with wide-angle viewing with the indirect ophthalmoscope and fundus photography was in its infancy. Fluorescein angiography and ocular ultrasonography were thoughts in the process of development. Now let's morph and “dissolve into” today's world. Ocular oncology has emerged as a vitally important subspecialty, bursting with innovative treatments and remarkable success. More than saving vision, we have achieved ultimate goals of saving life and the eye. Organized local and national societies for ocular oncology educate physicians and patients, including the International Society of Ocular Oncology for global communication. Daily electronic communication and online publication allow rapid spread of information to remote regions of the world, at a button's click. The playing field for ocular cancer worldwide is slowly equalizing. In this special issue of the Indian Journal of Ophthalmology, authors from India and beyond publish their observations, achievements, and failures in ocular oncology. Regarding retinoblastoma, new methods of intravenous, intra-arterial, and even intravitreal chemotherapy have led to high rates of the globe salvage with patient safety and preservation of visual acuity. Remarkably, some children are cured with 1 or 2 doses of single-agent chemotherapy delivered into the ophthalmic artery. Vitreous retinoblastoma seeds, a previously-doomed finding, are now reversed with chemotherapy lavage of the vitreous cavity. Impressive. Regarding uveal metastasis, the introduction of fine needle aspiration biopsy, directly into the tumor, has allowed rapid and precise analysis of tumor for origin and cell type, leading to earlier detection of the primary cancer site. Treatment of metastasis with standard radiotherapy or plaque radiotherapy as well as photodynamic therapy or intravitreal injections has led to minimally-invasive tumor control, often with the return of visual acuity. Regarding uveal melanoma, tumor size and genomic status allow a better estimation of ultimate metastatic risk. A thin needle is slipped into the tumor to aspirate only 10 or 20 cells for DNA or RNA analysis, leading to a genetic profile of the tumor, predicting risk for metastasis or lack thereof. Furthermore, uveal melanomas can now be detected at an incredibly small size, under 2 millimeters in thickness, using optical coherence tomography (OCT) as well as documented risk factors. Melanomas that previously disguised as an innocent nevus can be unmasked by autofluorescence for early detection. And the nonmalignant choroidal hemangioma and retinal hemangioblastoma with their hidden threat for vision loss can be more clearly identified on indocyanine green or fluorescein angiography and OCT, with eradication using with photodynamic therapy, photocoagulation, or localized radiotherapy. Looking back, we are proud of the enormous advancement in the field of ocular oncology over the past 4 decades and most exceptionally in the past 5 years. A baby that would have otherwise been left without an eye in the 1970s, will now likely have the globe retained and with navigational vision or reading visual potential. The father that might have lost his eye to a large melanoma in the past will now likely have detection of the tumor at a 2.0 mm stage for early treatment and favorable prognosis. This progress has endured excitement and disappointment, competition and worry, darkness and sunshine. Through carefully designed protocols, diligent patient monitoring, tediously calculation of outcomes, and contemplation of results, we have succeeded. Like John Lennon of the Beatles sang, “It's been a hard day's night” but the effort is certainly worthwhile, to make our patients “feel alright”.