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Most eye cancers are melanomas (also known as ocular melanomas or intraocular melanomas). The main factors in deciding on treatment for eye melanoma include:

• The location and size of the tumor
• The likelihood of saving vision in the eye
• Whether the cancer has spread outside of the eye

Your treatment plan will depend on your situation, and it could be different than what's described below.

What are the most common treatments for eye melanoma?

Radiation therapy is the most common treatment for eye melanomas that haven’t spread, although surgery or laser therapy might also be options in some situations.

For more advanced eye melanomas, other treatments might be used, including immunotherapy or targeted drugs, chemotherapy, or treatments directed at the liver (if the cancer has spread there).

Be sure to talk with your doctor before treatment about the goals of your treatment and what is most important to you.

Treatment to help with symptoms

Managing symptoms of eye cancer may be called palliative care or supportive care. This is an important part of your care, regardless of which treatments you’re getting. It is often started soon after diagnosis and continued throughout treatment. Be sure to talk with your health care team about any symptoms you’re having, especially new or changing symptoms, so they can be treated.

Treating choroidal melanomas

Treating melanomas that start in the choroid depends on the size of the tumor and how well the eye is working. The smaller the tumor, the less likely surgery will be needed, unless the eye is already badly damaged or vision has been lost.

Small melanomas: There are often several options for treating small choroidal melanomas. You and your doctor should decide together which option is best for you:

• Careful observation (also known as watchful waiting). Not all of these melanomas grow quickly and need to be treated right away. And sometimes, it’s very hard for the doctor to even be sure if a spot on the choroid is truly a melanoma. If the tumor is very small, watching it closely with exams and tests (usually every few months) and treating it only if it starts to grow is often a reasonable option.
• Radiation therapy, such as brachytherapy (plaque therapy), proton beam therapy, or stereotactic radiation therapy
• Laser therapy, including transpupillary thermotherapy (TTT), most often after brachytherapy
• Surgery, which can range from removing only the tumor to enucleation (removing the entire eye). This might be needed if the eye is severely damaged by the tumor.

Medium-sized melanomas: These tumors can usually be treated by many of the same approaches used for small melanomas:

• Radiation therapy, such as brachytherapy (plaque therapy), proton beam therapy, or stereotactic radiation therapy
• Laser therapy, including transpupillary thermotherapy (TTT), typically after brachytherapy
• Surgery, which can range from removing only the tumor to enucleation (removing the entire eye). This might be needed if the eye is severely damaged by the tumor.

Once again, the choice of treatment should be made by both you and your doctor. Radiation and surgery appear to be about equally effective. Radiation offers the best chance of preserving vision in the eye, but some people who have radiation may eventually need surgery, too.

Large melanomas: The standard treatment for these cancers is usually radiation. Plaque therapy (brachytherapy) might be an option if it can cover the tumor completely. If not, proton beam therapy or stereotactic radiation therapy might be used. Further treatment with surgery or lasers may also be considered if the radiation doesn’t destroy the tumor completely.

If radiation therapy isn’t an option for some reason, removing the eye with surgery (enucleation) is usually the preferred treatment. Enucleation might also be considered for cancers that:

• Take up more than half of the eye orbit
• Cause significant pain
• Have caused loss of vision in the eye

In rare cases where the cancer has grown extensively outside of the eye, the doctor might recommend removing other structures in the eye socket, such as muscles or part of the eyelid, as well.

Treating iris melanomas

Melanomas of the iris (the colored part of the eye) are usually small, slow-growing tumors.

One option for people with a small iris melanoma is to watch it closely to see if it grows. A series of special photographs can be taken to help monitor the tumor. If it begins to grow, treatment options may include surgery or radiation therapy (in certain situations).

If surgery is recommended, the amount of eye tissue to be removed depends on the extent of the cancer. Types of surgery for early iris melanomas include:

• Iridectomy (removal of part of the iris)
• Iridotrabeculectomy (removal of part of the iris, plus a small piece of the outer part of the eyeball)
• Iridocyclectomy (removal of a portion of the iris and the ciliary body)
• Enucleation (removal of the eyeball)

Treating ciliary body melanomas

These rare cancers can be treated with either surgical removal of the tumor, if it is small enough, or radiation therapy.

For more advanced tumors or if the eye is very damaged, enucleation (removal of the eyeball) may be needed.

Treating conjunctival melanomas

Melanomas of the conjunctiva are rare, but they tend to be more aggressive than other eye melanomas. They are more likely to grow into structures around the eye and spread to distant organs like the liver and lungs, where they can become life-threatening.

Treatment is focused on removing the tumor with surgery. Other treatments, such as extreme cold (cryotherapy) or alcohol might then be applied to the area to try to destroy any cancer cells that might have been left behind.

This might be followed by adjuvant treatment with radiation, usually in the form of plaque radiation therapy (brachytherapy), to lower the risk of the cancer spreading.

Other adjuvant therapy options may include:

• Topical chemotherapy, most commonly with mitomycin C
• Interferon alfa, an immunotherapy drug applied topically or given by injection

Because these tumors are aggressive, a biopsy may be done initially to look for certain traits that can predict the likelihood the cancer will spread or come back after treatment. If the chances are high, more frequent follow-up exams after treatment may be recommended.

Treating advanced and recurrent eye melanomas

Most uveal melanomas are still only within the eye when they are first found. It’s rare for the cancer to have already spread outside of the eye. But in about half of all people the melanoma will come back at some point after treatment.

Cancer that comes back after treatment is called recurrent cancer. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the lungs or liver).

Treating melanomas that come back depends on many factors, including where the cancer recurs and what type of treatment was used initially.

Local recurrence

Treatment options for cancers that recur within the eye (intraocular recurrence) depend on where in the eye the cancer comes back, how big it is, and what treatments were used before. Treatment options might include:

• Surgery
• Radiation therapy
• Laser therapy
• Cryotherapy (using extreme cold to destroy the tumor)

Sometimes more than one type of treatment might be used, especially if the tumor extends outside of the eye.

Advanced eye melanomas or distant recurrence

When eye melanoma spreads (metastasizes) or recurs outside the eye (extraocular recurrence), it most often goes to the liver. It might also spread to other areas, like the lungs or bones. These cancers are often hard to treat.

Locoregional treatments

Locoregional treatments are focused on one part of the body.

If the cancer is only (or mainly) in the liver, different types of treatments might help keep the cancer under control or help relieve symptoms. Options might include:

• Surgery (if there is only one or a few tumors)
• Radiation therapy
• Destroying (ablating) tumors by heating or freezing them
• Injecting chemo drugs directly into the liver to try to kill the tumors
• Injecting other substances into the liver to try to cut off the blood supply to the tumors (known as embolization)

(To learn more about how some of these treatments might be used for tumors in the liver, see Ablation for Liver Cancer and Embolization Therapy for Liver Cancer.)

For cancers that have spread to other parts of the body, such as the lungs, tumor ablation, radiation, and surgery might be options.

Systemic treatments

These treatments enter the blood and reach all areas of the body.

If locoregional treatments can’t be used, or if they aren’t likely to be (or are no longer) helpful, medicines that reach all parts of the body might be options for some people.

Lab tests might be done on your blood or cancer cells to see if immunotherapy or targeted drugs might be good treatment options. These treatments might be especially helpful for people with conjunctival melanomas, whose cancer cells tend to have many of the same gene changes as melanomas of the skin. Chemotherapy might be another option for some people.

Because current treatments for advanced eye melanomas are limited, clinical trials of newer treatments might also be a good option. (See What's New in Eye Cancer Research? for some examples of newer treatments now being studied.)