The Ocular Tumor Tsunami

Tsunami waves don’t just suddenly appear at a coast they devastate; they are created with a ripple effect, starting with a major event, like an earthquake. We are now seeing a tsunami of ocular tumors, but our earthquake started in March 2020. When the pandemic began, the vast majority of patients stopped seeing their general ophthalmologists or other eye care professionals. The ripple effect? Fewer referrals to retina, oculoplastic, or pediatric ophthalmology specialists (the first ripple), and even fewer to ocular oncologists (the next ripple) – and this is the usual path that a patient takes to get to our practice. When this happens for an extended period, the ocular tumor cases that would normally be caught quite quickly are not addressed until they are very advanced.

Recently, we have been seeing a lot of advanced cases. Out of our usual 8–10 patients a week with uveal melanoma, an estimated 30 percent of them now have gigantic, out of control tumors. Before the pandemic, we were able to treat almost all of those patients, with perhaps one in 10 eyes being enucleated. Now, we are having to enucleate four to five eyes in a week. That is a huge increase. The same situation applies to children with retinoblastoma. Kids are coming in at a much later stage than they used to, and whereas before we’d treat them with chemotherapy, now –  with many advanced cases – it’s too risky, so we have to remove the eye.

I do think this is a temporary situation and it will get back to normal – but that makes it no more acceptable. Is there anything ophthalmologists in general, and ocular oncologists in particular, may be able to do differently in a similar situation? And what pandemic-induced solutions can ophthalmologists use day-to-day to improve patients’ outcomes? My answers are using telehealth and hybrid/satellite offices.

Telehealth has been extremely important and useful in the past year and a half. Its universally accepted use is one of the very few good things that the pandemic has given us. It is vital that general ophthalmologists or retina specialists work closely and cooperate fully with an ocular oncologist who offers telehealth solutions, and that they consider referral of patients to the next level of care if they are not comfortable dealing with an issue themselves. In my opinion, the specialist offers experienced care to a patient and a degree of relief to the referring physician. It is understood that clinicians might not know all the answers and might not have the necessary equipment to deal with every case, but they do know who can evaluated the patient with a questionable condition, and in a pandemic, this might have to be done remotely.

When a patient is referred to us by an eyecare professional, we prefer to see the patient in person and perhaps consider telehealth evaluation thereafter, if appropriate. The telehealth examination starts with the a virtual interview, where the technician takes a detailed history, a list of medications, interval changes, and then checks the vision and does a basic visual field test. All newly-taken images are uploaded to our protected system, where the specialist can review them – the images might be taken by the referring eyecare professional or at a satellite office that we staff with an ophthalmic photographer and single technician. Sometimes, the images are not of the quality that we are used to, but they are still helpful. After we have all the information collected, filed, evaluated, and described, we inform the patient of our findings and provide a printed correspondence. Monitoring visits are quite suitable to telehealth, as they can give the patient and also the referring ophthalmologist a real peace of mind – knowing that we are involved in the patient’s care and overseeing their “tumor,” even if they are unable to make it into the office.

I have seen patients from around the world – virtually, including a salmon fisher from northern Alaska, who couldn’t come to Philadelphia for an in-person visit. Our team diagnosed his condition, prescribed treatment, and he never left his hometown – and he responded well. Another example is a woman from Uruguay who had a suspicious iris nevus; we managed her care via telehealth until growth was detected and she traveled to Philadelphia for treatment. The eventual outcome was good.

When COVID-19 struck, my colleagues and I noticed that even patients from our state did not want to come into the city. Probably because the center of Philadelphia is bustling, and Wills Eye Hospital has always been busy; the waiting room of the Ocular Oncology Service is usually full of people. We decided quite early on to open satellite offices outside of downtown Philadelphia with very few staff; most offices would only have a technician and a photographer, so patients only had to interact with two or three people in the office. And a specialist would be virtually brought in to see several patients efficiently, in a short time. The patients truly appreciate this system – they not only avoid the crowds, but are also spared long commutes and downtown parking charges.

These hybrid offices were something that retina specialists, both at Wills Eye and elsewhere – like Steven Houston at the Florida Retina Institute, US – had used even before the pandemic. For ocular oncologists, this hasn’t been the case, as most of those are affiliated with universities, which may restrict the use of hybrid offices. The practice we run at Wills Eye is private, and we were able to open satellite offices at our own cost. And the cost is considerable; rent is an important consideration, which is why hybrid offices are usually relatively small spaces. You also have the initial purchase of all the equipment, and quality imaging equipment isn’t cheap. We have considered it an investment into the future, but the cost of a good fundus camera, an external camera, OCT, and ultrasound equipment quickly adds up. Then there’s the cost of a system that allows us to upload images to a server in real time, so we can see all the images at the same time they are taken. It’s not cheap but, done right, it can make a big difference.

For the past 25-30 years, I have been answering emails from doctors all over the country and overseas, sending me images and descriptions and asking my opinion on diagnosis and treatment. It was often done informally, and the system wasn’t always perfect. The pandemic pushed us all to formalize and improve this process, and a mixture of telehealth and satellite offices can now be used for patients who, for any reason, cannot come into our main office. Virtual visits are now approved by the governing bodies, and I can’t see us going back. So much care and monitoring can be done virtually, and with the right protocols, approvals, and appropriate reimbursement, it will result in huge savings of time and money, both for the clinician and the patient.

Currently, any patient who cancels a visit are offered an opportunity for telehealth or satellite/hybrid office visit, if available. All eye care providers should realize that ocular oncologists can perform effective examinations using telemedicine in its various forms – and we have taken full advantage of this silver lining of the pandemic’s dark cloud.