Eye Melanoma: Types of Treatment

Approved by the Cancer.Net Editorial Board, 01/2023

ON THIS PAGE: You will learn about the different types of treatments doctors use for people with eye melanoma. Use the menu to see other pages.

This section explains the types of treatments, also known as therapies, that are the standard of care for eye melanoma. “Standard of care” means the best treatments known. When making treatment plan decisions, you are encouraged to discuss with your doctor whether clinical trials are an option. A clinical trial is a research study that tests a new approach to treatment. Doctors learn through clinical trials whether a new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Clinical trials are an option for all stages of cancer. Your doctor can help you consider all your treatment options. Learn more about clinical trials in the About Clinical Trials and Latest Research sections of this guide.

How eye melanoma is treated

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. In addition to an ophthalmologist (see Introduction), the health care team may include these individuals:

  • Radiation oncologist: A doctor who specializes in treating cancer with radiation therapy.

  • Surgical oncologist: A doctor who specializes in treating cancer with surgery.

  • Medical oncologist: A doctor who specializes in treating cancer with medication.

  • Reconstructive/plastic surgeon: A doctor who specializes in reconstructive surgery done to help repair damage caused by cancer treatment.

Cancer care teams include a variety of other health care professionals, such as physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.

Treatment options and recommendations depend on several factors, including:

  • The type and stage of eye melanoma

  • Possible side effects, including the loss of vision in the eye being treated

  • Status of vision in the unaffected eye

  • The patient’s preferences and overall health

Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. These types of talks are called “shared decision-making.” Shared decision-making is when you and your doctors work together to choose treatments that fit the goals of your care. Learn more about making treatment decisions.

The main goals for treating eye melanoma are to reduce the risk of the cancer spreading and to maintain the health and vision of the patient’s eye whenever possible.

The common types of treatments used for eye melanoma are described below. Your care plan also includes treatment for symptoms and side effects, an important part of cancer care.

Active surveillance

Active surveillance may be an option if a uveal melanoma is very small or slow growing. This approach may also be used if treating the cancer would cause more discomfort than the disease itself. For example, it may be appropriate for people without any symptoms, older people, seriously ill people, or people with a tumor in their only useful eye. Active surveillance is sometimes called “observation” or “watchful waiting.”

During active surveillance, the patient is monitored closely by the health care team. Pictures of the tumor are used to track tumor size and the rate of growth. Active treatment would begin if the tumor shows signs of becoming more aggressive or spreading. If the tumor grows larger than 10 millimeters (mm) in diameter or 2 mm to 3 mm in height (thickness), then the doctor and the patient may decide to proceed with active treatment. Talk with your doctor about how often your eye should be checked if this approach is an option.

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Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. This treatment is often recommended for small and medium uveal melanoma tumors.

When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. Most uveal melanomas in the United States are treated with brachytherapy. During a short operation, a small metal plaque is sewn on or near the tumor. The plaque delivers radiation directly into the tumor. Sometimes this is called “plaque therapy.”

Another common type of radiation treatment is called external-beam radiation therapy. This is radiation given from a machine outside the body. Traditional external-beam radiation therapy may also be used as an adjuvant therapy after surgery. Adjuvant therapy is treatment given after the main treatment. It may reduce the chance of cancer coming back by destroying any remaining cancer cells. Traditional external-beam radiation therapy may also be given as a palliative treatment (see below).

Proton beam therapy is a type of external-beam radiation therapy that uses protons rather than x-rays. At high energy, protons can destroy cancer cells. Proton beam therapy may be used to treat uveal tumors that are large or near the optic nerve. Learn more about proton therapy.

A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time. Brachytherapy often lasts for several days before the plaque is removed. External-beam radiation therapy is typically done daily over the course of several days.

Using radiation therapy to treat the tumor may result in side effects such as vision loss. It is important to talk with your ophthalmologist about what to expect after treatment. However, treatment for eye melanoma using radiation therapy is continually improving.

The extent of the side effects depends on the type and dose of radiation therapy the person receives, where the tumor is located, and the patient’s general health. For larger tumors, there is more risk for side effects or complications from radiation therapy. The side effects may not show up right away, so let your doctor know if a problem arises. Be sure to ask what problems and signs to watch out for after being treated with radiation therapy.

Common side effects include:

  • Cataracts. A cataract is when the lens of the eye becomes cloudy. People with cataracts may have cloudy or foggy vision, have trouble seeing at night, or have problems with glare from the sun or bright lights. If the cataract is causing major problems with a person’s eyesight, it may be surgically removed. A cataract can develop 2 to 5 years after initial radiation therapy.

  • Loss of eyelashes and/or a dry eye. These side effects can occur with external-beam radiation therapy and proton-beam radiation therapy.

The following side effects are less common and can cause a loss of vision:

  • Radiation retinopathy: Abnormal blood vessels develop in the retina.

  • Radiation optic neuropathy: Optic nerve damage occurs.

  • Neovascular glaucoma: New blood vessels develop and block the outflow of fluid from the eye, causing this painful condition.

  • Loss of eye: If there is significant damage to the eye from radiation therapy, the eye may need to be removed.

Learn more about the basics of radiation therapy.

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Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. This is also called surgical resection or surgical excision. An ophthalmologist typically performs eye surgery.

Surgery may be used to treat large uveal tumors or iris melanoma. During surgery, the ophthalmologist will remove part or all of the affected eye depending on the size and spread of the tumor.

Surgical options include:

  • Iridectomy: Removal of part of the iris. Very small iris melanomas may be removed with this type of surgery.

  • Iridocyclectomy: Removal of part of the iris and ciliary body. Very small iris melanomas may also be removed with this type of surgery.

  • Transscleral resection: Removal of a tumor in the choroid or ciliary body through the sclera. This surgery may be recommended for large tumors.

  • Enucleation: Removal of the eye. This surgery may be recommended for tumors that are large, cause severe pain or pressure, involve the optic nerve, or have already caused loss of vision.

  • Orbital exenteration: Removal of the eyeball as well as structures in the eye socket, such as the eyelid, muscle, nerves, and fat. This surgery may be used if a melanoma has spread from the eyeball into those structures.

Surgery is also used to place the radioactive plaque for brachytherapy (see “Radiation therapy,” above). Surgery may also be done after radiation therapy.

Potential side effects of eye surgery include a risk of infection, pain, and problems from the general anesthesia, which is the medication that blocks the awareness of pain used during surgery. In some cases, partial or total loss of vision in the eye can also occur immediately or sometime after surgery. With total removal of the eye, there is a slight risk that the tumor could come back in the orbit.

Many patients want to know immediately whether the surgery was successful. However, the success of an operation is hard to tell right away. It may take months before the doctors can determine if all of the cancer cells were removed during surgery.

Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have. Learn more about the basics of cancer surgery.

Having an eye removed

Sometimes the only choice a doctor has in treating eye melanoma is to remove the eye, called enucleation. Because of this visual loss, a person with 1 eye may have trouble with depth perception. Most people adjust to this difference.

Many people worry about what they will look like when they have an eye removed. The cosmetic surgery available today usually yields good cosmetic results. To fill the area left by the missing eye, the person is fitted for a prosthesis called an artificial eye. The artificial eye will look and behave almost the same way as a natural eye. For example, the artificial eye will move along with the person’s remaining eye, just not as much as a natural eye moves. Family members may be able to tell that the eye is not real, but it is unlikely that strangers will know.

If eye removal is required, talk with your doctor about an artificial eye as soon as possible. It may take many weeks for you to receive one. Also, ask about support services that may be available to you to help adjust physically and emotionally to the loss of an eye. Learn more about rehabilitation.

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Laser therapy

Laser therapy uses heat in the form of a laser to shrink a smaller uveal tumor. It may also be called thermotherapy or transpupillary thermotherapy (TTT). This treatment potentially has fewer side effects than surgery or radiation therapy. When side effects occur, they may include retinal bleeding, retinal detachment, and blockage of small blood vessels in the retina. Laser therapy may also be used as adjuvant therapy after brachytherapy (see above).

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Immunotherapy (updated 08/2023)

Immunotherapy uses the body's natural defenses to fight cancer by improving your immune system’s ability to attack cancer cells. In 2022, the FDA approved the immunotherapy tebentafusp-tebn for HLA-A*02:01-positive metastatic uveal melanoma or uveal melanoma that cannot be treated with surgery. It works by targeting a type of protein found in melanoma called gp100.

Different types of immunotherapy can cause different side effects. Common side effects include skin reactions, flu-like symptoms, diarrhea, and weight changes. Talk with your doctor about possible side effects for the immunotherapy recommended for you. Learn more about the basics of immunotherapy.

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Physical, emotional, and social effects of cancer

Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.

Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report that they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as surgery or radiation therapy.

Before treatment begins, talk with your doctor about the goals of each treatment in the recommended treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options. Many patients also benefit from talking with a social worker and participating in support groups. Ask your doctor about these resources, too.

During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.

Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.

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Treatment by type and stage of eye melanoma

Different treatments may be recommended for the different types of eye melanoma. The general options by type of eye melanoma are described below. For more detailed descriptions, see “How eye melanoma is treated,” above. Your doctor will work with you to develop a specific treatment plan based on your specific diagnosis and needs. In addition to standard treatments, talk with your doctor about clinical trials that are open to you, no matter the type or stage of the tumor.

Iris melanoma

Iris melanoma is not generally actively treated unless the tumor begins to grow. However, there can be exceptions. Examples of common treatment options are:

  • Active surveillance

  • Surgery (either iridectomy or iridocyclectomy)

  • Radiation therapy, including proton therapy or brachytherapy

  • Enucleation, if the tumor is too large to remove or it spreads beyond the eye

Small choroidal and ciliary body tumor

The following are some treatment options for a small choroidal or ciliary body tumor:

  • Active surveillance

  • Radiation therapy, including proton therapy or brachytherapy

  • Laser therapy

  • Surgical resection or enucleation

Active surveillance is a common treatment plan. However, patients and their doctors may choose another option depending on the location of the tumor or whether the tumor begins to grow.

Medium choroidal and ciliary body tumor

The 2 most common treatment options for medium-sized choroidal and ciliary body melanoma are radiation therapy, including proton therapy or brachytherapy, and enucleation. It is believed that there is no difference in survival rates between these 2 treatment methods for a medium-sized choroidal tumor.

Other treatment options for a medium-sized tumor may include surgery to remove the tumor or enrollment in a clinical trial (see Latest Research section).

In addition, the combination of laser therapy and radiation therapy is being used more frequently to treat this type of tumor. This is sometimes called “sandwich therapy.”

Large choroidal and ciliary body tumor

For a large tumor, radiation therapy or enucleation are the usual treatments. Results of the Collaborative Ocular Melanoma Study (COMS) revealed that patients had similar survival rates whether they received radiation therapy before enucleation or had their eye removed with no previous radiation treatment. Enrolling in a clinical trial may be another option for people with large choroidal and ciliary body tumors. Additional brachytherapy may also be an option.

Conjunctival melanoma

The most common treatment approach to conjunctival melanoma is a type of surgery called wide local excision and biopsy. During the excision, the tumor and a margin of healthy tissue around it are removed. This surgery may be followed by adjuvant therapy. Cryotherapy, which uses liquid nitrogen to freeze and kill cells, is often used.

Other adjuvant therapy options that your doctor may recommend include:

  • Topical chemotherapy (see Latest Research section), most commonly with mitomycin C

  • Interferon alfa-2b (Intron-A), an immunotherapy drug (see Latest Research section) applied topically or given by injection

  • Brachytherapy or external-beam radiation therapy

Advanced cases of conjunctival melanoma or multiple recurrences are sometimes treated with eye removal or orbital exenteration. No studies show that these treatments improve survival rates. However, they may be used as palliative therapy to reduce pain and other symptoms.

Orbital melanoma

Because orbital melanoma is so rare, treatment recommendations may vary. In general, surgery to remove the tumor is often used. Surgery is usually followed by adjuvant radiation therapy.

Extraocular extension melanoma

If an eye melanoma has spread to the outside of the eye, the optic nerve, or the eye socket, the doctor may recommend removal of the eye. Or, the doctor may perform a modified enucleation. This is the removal of the eyeball and nearby structures. In some cases, the doctor may recommend exenteration to remove the entire eye and the nearby structures. If the spread is small, some doctors will try to save the eye by removing the outer part of the tumor and treating the eye with radiation therapy.

Talk with your doctor about possible treatment options, potential side effects, and clinical trials open to you before choosing a treatment plan.

Metastatic eye melanoma

If cancer spreads to another part in the body from where it started, doctors call it metastatic cancer. For example, metastatic uveal melanoma often spreads from the eye to the liver. If you have metastatic eye melanoma, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Clinical trials might also be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.

Your treatment plan may include a combination of treatments. For eye melanoma that spreads to the liver, treatments such as surgery or radiation therapy may be recommended. Ablation, which uses heat or cold to destroy cancer cells, and drug injections may also be options. Radiation therapy, ablation, and, in some cases, systemic chemotherapy may be used to treat eye melanoma that spreads to the lungs or other parts of the body. Systemic therapy is the use of medication to destroy cancer cells.

Some patients may enroll in clinical trials that are testing other treatments, such as immunotherapy and targeted therapy, for metastatic eye melanoma. (See Latest Research.) Palliative care will also be important to help relieve symptoms and side effects.

For many people, a diagnosis of metastatic cancer is very stressful and difficult. You and your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other members of your health care team. It may also be helpful to talk with other patients, such as through a support group or other peer support program.

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Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.

A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it is important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

If the cancer returns after the original treatment, it is called recurrent cancer. Approximately 50% of uveal melanomas recur after treatment. An estimated 36% to 56% of conjunctival melanomas will also come back. A tumor may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

If a recurrence happens, a new cycle of testing will begin again to learn as much as possible about it. After this testing is done, you and your doctor will talk about the treatment options. Often the treatment plan will include the treatments described above, such as surgery or radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat recurrent eye melanoma. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

People with recurrent cancer sometimes experience emotions such as disbelief or fear. You are encouraged to talk with your health care team about these feelings and ask about support services to help you cope. Learn more about dealing with cancer recurrence.

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If treatment does not work

Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.

This diagnosis is stressful, and for some people, advanced cancer is difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.

People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

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The next section in this guide is About Clinical Trials. It offers more information about research studies that are focused on finding better ways to care for people with cancer. Use the menu to choose a different section to read in this guide.