Hidden Health Dangers Uncovered by an Eye Exam

Last month, I attended a conference for physicians presented by Dr. Jesse Berry, an associate professor of ophthalmology at USC and the director of the Ocular Oncology and the Retinoblastoma Programs at Children’s Hospital in Los Angeles, who reminded us how important it is to have yearly dilated eye exams.

Below is Sam’s case, which illustrates just that.

Case study

Sam was a tall, blond, blue-eyed computer engineer. When, at the age of 66, he started having worsening blurry vision in his right eye, he made an appointment to see an ophthalmologist. The ophthalmologist recommended dilating Sam’s pupils so that the peripheral retinas could be examined. Sam couldn’t remember the last time he had his eyes dilated. It had been years.

As soon as the ophthalmologist looked in Sam’s retinas through his dilated pupils, she knew something was wrong. A large, 21-millimeter diameter (almost one-inch diameter) blackish area with uneven borders was seen at the back of Sam’s right eye.

After an urgent referral to a specialist and many types of ocular imaging, the ophthalmologist told Sam the bad news: Sam had an aggressive cancer of the eye called choroidal melanoma. Given the size of the tumor, the best treatment was to remove his right eye (a surgery called eye enucleation). Sam was devastated but went ahead with the surgery.

Unfortunately, a few months after removing Sam’s eye, the aggressive cancer spread to Sam’s liver. Sam knew the prognosis was grim, and he refused to be treated. He passed away later that year.

Could Sam’s life have been saved, and could Sam have avoided losing his eye?

Yes, Sam would probably still be alive today, and he could have avoided losing his eye if he had undergone dilated eye exams every year after age 60, as recommended by the American Academy of Ophthalmologists.

Sam’s melanoma could then have been treated by radioactive implant (plaque brachytherapy) or other forms of radiation therapy, which work best for tumors less than 20 millimeters in base and less than 12 millimeters in height.

An early diagnosis would absolutely have facilitated eye-saving therapy. Nonetheless, patients have a risk of metastasis even after successful therapy, but the risk of metastatic disease increases with tumor size as well as various molecular alterations.

Why is it important to have a dilated eye exam done by an eye specialist every year?

Because eye melanoma is a silent killer. It gives no symptoms at all until it becomes big, and then, when it is large enough to give symptoms, it may be too late to save the eye.

What percentage of all melanomas are ocular melanoma?

When people think about melanoma, they usually think about melanoma of the skin; this aggressive skin cancer often presents as a changing, often growing dark spot with irregular borders, asymmetrical shape, and different shades of black and brown colors that could be easy to spot on someone’s hands, feet, legs, arms, back, face, and even under their nails, among other places.

But what if a melanoma is in a place where it cannot easily be seen? One example of such a place is in the back of the eye. The only way to see it is with an ophthalmoscope, looking through a dilated pupil to see the back of the eye.

Dr. Berry, in her presentation, reminded us that ocular melanoma represents about 5 percent of all melanomas and that current estimates suggest there are around 2,000-3,000 new cases of ocular melanoma diagnosed each year in the U.S. The incidence rate is slightly higher in males compared to females, and the average age at diagnosis is in the early 60s. Potential risk factors include light eye color and fair skin.

What other disease can be diagnosed with dilated pupils?

Dilating the pupils allows eye doctors to better visualize the back of the eye, the optic nerve, the retina, and its blood vessels. In addition to melanomas, doctors can see early signs of cataracts, high intracranial pressure, macular degeneration, retinal detachment, glaucoma, high blood pressure, diabetes, and cancer, among other diseases. Recent studies show that an eye exam can even detect signs of Alzheimer’s.

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The ability to directly examine the blood vessels and neural tissue facilitates the detection of many systemic disorders. Because all those conditions can be completely asymptomatic, discovering them with yearly eye exams and treating them early can improve longevity and quality of life.

Summary

Because eye conditions are often asymptomatic, as a preventative measure recommended by the American Academy of Ophthalmology, make sure you get a dilated eye exam done by an eye specialist at age 40 to get a baseline evaluation and then once a year after the age of 60.

If you have diabetes, high blood pressure, macular degeneration, or any other ocular condition, you might need yearly dilated eye exams starting at age 40. The earlier the diagnosis is made, the earlier you can start treatment, which could save your life.

Remember that the back of your eye can be a window to your health.