(September 24, 2008 - Insidermedicine) Welcome to Insidermedicine's If I Had, where we get a chance to ask an expert what they would do if they had a medical condition.
We had a chance to speak with Dr. Carol Shields, MD, the Associate Director of the Ocular Oncology Service at Wills Eye Hospital and a Professor of Ophthalmology at Thomas Jefferson University School of Medicine.  She has authored an astonishing 700+ articles, and is widely recognized as a preeminent authority on ocular tumors.  Of interest, Dr. Shields also played basketball for the Notre Dame Fighting Irish, and was given their highest honor for excellence in academics and leadership.

What I would do if I had a mole in my eye
If I had a mole in my eye I would first want to see an ophthalmologist who could dilate my eyes, look in the back and quantify the amount, or the size of the mole in the back of my eye. Knowing that moles are fairly common, about seven percent of Caucasians have a mole, I don’t think I’d be too worried, but I would make sure that the doctor checks me at least once or twice a year. I would want a photograph at each visit. And I would want the doctor to examine the mole carefully, looking for associated features. Most ophthalmologists feel fairly comfortable making the diagnosis just based on clinical examination.

If the mole is in the front of the eye, in the iris, they might use one of our microscopes, called the slip-lamp, to look at the iris, document the size, document any seeding of the mole, and take a photograph. If the mole was in the back of the eye then they would have to put the head scope on, called the indirect ophthalmoscope. They would use a lens to focus in on the mole and make a drawing, and estimate the size. And look for the associated features of fluid or orange pigment. But it is very important that all moles be documented with photography. It is particularly important for moles in the back of the eye. Because it is difficult to see them. All of us can see a mole in the front of the eye, but moles in the back of the eye are invisible to the naked eye. A photography is necessary to document the size and location.

The ophthalmologist would likely choose to see me back in three months just to confirm this mole is not new. Some melanomas can be mistaken for moles. That’s why you want to be re-evaluated in three to six months. If it is a melanoma it will likely change in size or configuration. If it is a mole it will likely remain stable. At each visit, perhaps on a six months basis, the ophthalmologist would check the size of the mole, compare the mole with their scope, to the photographs that had been taken initially, if any differences are found they generally send the patient on to see an ocular oncologist or retina specialist.

Once we divide out the moles into suspicious and non-suspicious we generally just photograph the non-suspicious moles. Sometimes we will do an OCT, optical coherence tomography, this is a nice simple to do test where a light beam is shined into the eye and it allows us to identify the retinal features overlying a mole. The non-suspicious or chronic moles, tend to show very chronic changes in the retina. Where the outer layers of the retina get thinned. That’s good, that tells us the mole is chronic and it’s not likely to evolve into a melanoma. Whereas, the suspicious moles tend to have less chronic findings on OCT. They may have a little bit of fluid, but not the thinning of the retina. That makes them more suspicious. These tests are important because they assist in deciding whether a mole is really suspicious or not. Another test that is helpful is the ultrasound. This is the test where a probe is placed on the eye, a very comfortable test, with a little bit of jelly and it allows us to look at the internal characteristics of a mole. If a mole looks really dense on ultrasound then its likely to behave itself and remain a mole. If a mole looks really hollow, echo-lucent on ultrasound, that’s a risk for transformation into melanoma. So we don’t like to see the hollow features on an ultrasound.

There is yet another test and that’s called a Fluorescein Angiography. This is a test where we give an IV injection and we look at the blood flow to the eye. Moles that are very chronic or non-suspicious tend to produce very chronic changes in the tissues in the back of the eye, giving a mottled look at the site of the mole. Whereas, melanoma tends to produce fluid. You can see a puddle of fluid and little spots of leakage overlying the melanoma. So you can separate out the two groups based on the Fluorescein results.

I think all three tests, OCT, ultrasound, and Fluorescein Angiography, are all complementary. I should say that we don’t use all three tests on all patients. Its only in cases of the most suspicious mole that we wind up using all three tests. The average mole that you might see in your practice on a day to day basis, probably only needs a photograph. The more suspicious ones need one or all three.

So what would I do if I had a mole in my eye?
First of all I wouldn’t panic, knowing that moles are common. I would follow up with my doctor twice a year. I would understand that moles could reduce my vision and that moles carry a very small risk for evolution into melanoma. And I would make sure my doctor takes a photograph at least once a year of the mole.