Care for a Frightening Diagnosis

When you think of your typical eye surgery patient, chances are you’re not imagining someone like Jacob Sanok.

At six-foot-five and 225 pounds, he’s a big guy who is a fingerprint identification technician at Wake County’s City/County Bureau of Investigation and drives a Harley-Davidson to relax. But in a kind of emphatic pronouncement of the fact that diseases don’t play favorites, Sanok has been battling ocular cancer.

Sanok, 54, knew something was wrong with his vision last September when he noticed a peculiar opaqueness -- a shadow in the peripheral vision of his left eye. After seeing his local ophthalmologist, he was seen by a local retina specialist who discovered that Sanok had an extensive retinal detachment associated with an abnormal mass or lesion in the back of the eye. The concern was that this mass was possibly cancerous, so he was referred to Prithvi Mruthyunjaya, MD, assistant professor of ophthalmology and Duke Eye Center ocular oncologist, who has been making a name for himself using the latest medical advances to fight ocular cancer.

After extensive testing, including a high resolution ocular ultrasound and other imaging tests, the diagnosis was clear: Sanok had primary ocular melanoma -- a very large one too -- threateningly close to the optic nerve.

Pursuing a Menacing Disease

Born in India, Mruthyunjaya grew up in upstate New York where several of his role models and mentors happened to be ophthalmologists. His interest in the field sparked, and he came to Duke 10 years ago as a resident. From the first day of his residency, he was attracted to the challenge of diagnosing and treating retinal diseases and was fascinated by the retina’s connection to overall systemic health.

While serving as chief resident, Mruthyunjaya was accepted for a retina fellowship, which gave him the opportunity to bring ocular oncology formally to Duke. His wife was already working as a medical oncologist at Duke, so he was familiar with the challenges presented by oncology and intrigued by the possibility of working with other physicians from the Duke Cancer Institute.

Mruthyunjaya then completed a second fellowship, this one in ocular oncology at London’s Moorfi elds Eye Hospital.

With no walkathon or ribbon associated with it, ocular cancer is not well known -- and indeed, it’s quite rare. Though most ocular cancers can be controlled, in some cases its impact can be serious, especially in the setting of metastasis (spreading of the ocular tumor outside of the eye to other organs). Such metastases have a variable occurrence depending on the type of cancer and its particular clinical features.

Duke sees a fair number of cases because it serves as a regional referral center with technological capabilities that many other hospitals lack, such as advanced high resolution ultrasound and imaging technologies capable of revealing detailed characteristics of even the smallest ocular tumors.

The most common type of tumor that Mruthyunjaya treats is primary ocular melanoma, which first occurs in the eye itself. He frequently manages the treatment of cancer metastases from other parts of the body, such as lung or breast cancer.

There are no known risk factors for these ocular melanomas. Often patients will have symptoms that mimic those of retinal detachment, such as flashing lights or floating objects in their field of vision. But many patients experience no symptoms -- it’s usually a sharp-eyed ophthalmologist who detects unusual lesions in the eye.

With Duke’s technological capabilities, Mruthyunjaya offers a unique approach to the diagnosis and treatment of eye tumors, applying a variety of imaging methods and treatments typically used for other retinal diseases. For diagnosis, in addition to the latest generation high-resolution ultrasounds, he often relies on fl uorescein or indocyanine green (ICG) angiography, a process in which dye is tracked as it passes through the retinal and deeper choroid blood vessels at the back of the eye. Optical coherence tomography (OCT), a technology analogous to ultrasounds, has proven to be useful in better predicting which lesions may be likely to develop into more aggressive tumors.

When these diagnostic modalities prove insuffi cient, Mruthyunjaya is aggressive in using the latest instrumentation to biopsy lesions that are indeterminate in the clinic.

“We make a diagnosis accurately and promptly rather than observing such lesions to see if they change,” he says.

Fighting Ocular Cancer

Mruthyunjaya says that when patients are told they may have an ocular melanoma, they’re often shocked.

“They’re floored and flabbergasted by the concept of it,” he says. “Especially when we hear the term ‘melanoma,’ we think of a funny spot on the skin. Our job is to educate patients so the reality of what’s going on starts to make sense. We try to support them from the beginning, providing emotional and psychological support. I work closely with Renee Halberg, MSW, our Eye Center social worker, who has invaluable experience working with cancer patients.”

Mruthyunjaya is guided by four main principles when making decisions about treatment. The fi rst priority is to eradicate the tumor. Second, he works to keep it from spreading. Third, if possible, he tries to save the eyeball itself. Finally, he works to preserve as much vision as he can.

“Our priority is to make the patient cancer-free,” he says. “But sometimes the eye and vision are sacrificed for the sake of eradicating the tumor.”

Treatments vary depending on the location and size of the tumor, whether it has spread outside the eye, and the patient’s overall health status and wishes. Using surgical techniques like enucleation (removal of the eye), iridocyclectomy (removal of the iris and ciliary body beyond it), and plaque brachytherapy (in which a radioactive disk is sutured to the eye for five days to kill the cancer cells), the tumor can often be removed or otherwise eradicated. In other cases, chemotherapy is applied topically, injected, or radiation therapy is used systemically.

Duke emphasizes coordinating care with a team of doctors. With eye tumors’ high metastasis rate, this approach becomes especially critical.

“We take the systemic health of our patients very seriously,” Mruthyunjaya says. “I coordinate closely with their primary doctor and local oncologist to ensure that the rest of their body is not affected by the ocular tumor and to make sure they get routine monitoring.”

Mruthyunjaya finds the integrative approach highly rewarding: primary care physicians, oncologists, radiation oncologists, and other medical professionals all coming together for the sake of the patient.

“It’s an incredible testament to the collaborative, integrative medicine that we try to practice here at Duke,” he says. “In our corner of the oncology world, we’re making strides to make that an everyday reality.”

A “Lucky” Guy

Count Sanok among the people who can appreciate Duke’s approach to patient care. Due to the size of his melanoma and its precarious position close to the optic nerve, Mruthyunjaya and Sanok decided that removing the eye would be a better option than plaque therapy, leaving the least chance that the tumor would return.

Mruthyunjaya removed the eye and replaced it with an orbital implant. Six weeks later Sanok received a prosthesis painted to resemble his remaining eye. Looking at Sanok’s hazel-green eyes, observers are hard-pressed to tell which is the prosthetic. He has healed with excellent retention of muscle function, so the prosthesis moves naturally.

Disease-free since the surgery, Sanok counts his blessings. “I’m a meat-and-potatoes type of person,” he says. “You look at your options, you choose your option, and you stick with it. I might be losing my one eye, but I’m gaining because there’s very little chance of the cancer coming back.”

Losing an eye has scarcely changed his lifestyle. He still cruises his Harley-Davidson Road King Classic and rode it on the annual Rolling Thunder trip over Memorial Day weekend to the Vietnam Veterans Memorial in Washington, DC.

“There’s only two things I cannot do legally: I can’t fly a commercial airplane, and I can’t operate as a neurosurgeon,” he says, laughing. “I consider myself very, very lucky. It could have been much worse. I had to lose one eye. To me, it was a very good trade-off. I had my moments of fear, of disillusionment and anger and such. But I said, ‘That’s it. You’ve had your five minutes to dwell on it.’”

Says Mruthyunjaya, “Cancer is difficult for anybody in any part of the body. In my ocular oncology clinic, we try to put the disease into context and help patients feel empowered in their treatment decisions. We meet head-on the issues patients and other ophthalmologists are not typically used to dealing with regarding eye disease -- because there is so much more riding on these decisions than just vision.”