Eye-opening new ways to treat ocular cancer

Cara Mathis knows how to take bad news in stride. It’s why she was a good sport and perched a parrot on her shoulder during a recent cancer treatment that required her to wear an eye patch.

Her 11^th grade American literature students thought it was a blast. Mathis, 37, laughs. “If you have to go through this, you might as well laugh about it. That’s all you can do.”

The Greenville school teacher had breast cancer about six years ago. She hit the five-year mark and thought she was in the clear. Then, last fall she began to have pain in her ribs. Her parents, both alumni of MUSC, wanted her to get it checked out just to be safe. While waiting for an MRI to be done, she started seeing lights in her eyes as if headlights were going by.

Her mother, a nurse, insisted she get an appointment that day. Mathis had a detached retina, and for a reason she never suspected. An ultrasound and other testing revealed her cancer had spread not only to her ribs and lungs, but also to her eye. That’s when she found out that Storm Eye Institute at MUSC Health had an ocular oncologist on staff.

“That was just about the craziest specialty ever. I can’t imagine how much time he had to spend in school learning about cancer and the eye. I didn’t even realize you can have cancer in the eye.”

After consulting with her oncologist Frank Brescia at Hollings Cancer Center at the Medical University of South Carolina, Mathis decided treating her eye took precedent since it affected her vision. She met with ophthalmologist George Magrath, who recently returned to MUSC for just this reason – to be able to treat complicated cancers involving the eye without patients having to go out of state.

Magrath, an MUSC College of Medicine graduate, remembers a case involving a patient who lost her sight because she was uncomfortable going out of state for treatment. It’s one reason he sought specialized training at the Wills Eye Hospital in Philadelphia for the treatment of tumors and cancers in and around the eyes of children and adults, and then came back to MUSC. 

Mathis, for one, is glad he did.

When she consulted with him, what he suggested sounded like something out of science fiction. The good news is that Mathis wouldn’t have to wait for her chemotherapy therapy, that was to start Dec. 12, to be able treat her eye.

Magrath says that option would have meant her vision probably would not have come back because the tumor causes a retinal detachment that can lead to a degeneration of the retina. Instead, Magrath and radiation oncologist Samuel Lewis Cooper decided the best treatment would be to sew a radioactive disc on the right part of her eye directly over the tumor. Cooper and his team, lead by radiation physicist Michael Ashenafi, did a CT scan and took Magrath’s drawings from his exam to create a 3-D reconstruction of her eye and the tumor. Then, they custom made a radioactive plaque, a gold circle with tiny radioactive pellets glued in a configuration to best target the tumor.

“The goal is to provide enough radiation to kill the tumor and not too much where you kill the eye and destroy vision.”

Mathis had to wear a lead patch over her eye during treatment. “I didn’t even think about the fact that I would be radioactive,” she says. “It was kind of a lonely weekend because no one wanted to come into the room because I was radioactive.”

The fake parrot her sister bought her was a hit with family and friends, she says. Mathis says it was worth the masquerade to get her vision back. It had become very blurry and driving at night was scary. “Being an English teacher, my whole job is reading.”

Mathis, whose vision has returned, says she’s thankful. “It was so much better. It was like night-and-day better. I don’t know how I’m going to be able to live through all of this, but I want to be able to see things. I can’t not be able to see because it’s important.” 

Only the fourth patient to have this procedure at MUSC Health, Mathis says she knew she was in good hands. “It was amazing. They saved my vision. They are ridiculously smart, and they work super well together and communicate about their patients. Dr. Magrath called every day to check on me. They are just super doctors. I couldn’t ask for better.”

Mathis has to return periodically for injections since she’s still at risk of losing vision from the radiation. Magrath says doctors can manage that with different medicines and laser procedures. “We really have a pretty sophisticated algorithm for her for the next couple years to make sure we preserve as much vision as possible. It’s a complex disease to treat.”

Envisioning future treatments

The challenge is part of the appeal for Magrath. He wants more treatment options to be available in ocular oncology. Another area of specialty for him is treating melanoma using the radioactive disk therapy that Mathis had. One patient who already has benefited: retired firefighter James Campell. 

“He was exactly the situation I came back to treat. He was referred in, had a melanoma in the eye, and he was the first patient so at the time I told him, ‘You know we haven’t done this yet, so you can go to Philadelphia or Duke to get it done,’” says Magrath. 

“And he said, ‘I can’t travel there, so you guys take care of me.’ So we did, and he’s had a great response, a great outcome so far.” 

The therapy works in 98 percent of cases and helps preserve the eye and some vision. The alternative treatment required the removal of the eye, since nearly half of patients develop metastatic cancer of the liver or lungs, often a fatal diagnosis. This is a much better option.

Another promising area of treatment is the use of intra-arterial chemotherapy for infants who have retinoblastoma, the most common type of eye cancer in children. This type of therapy delivers the drugs directly to the tumor. It can occur in both eyes, potentially causing bilateral vision loss, and it’s fatal if not treated.

“Now that we have chemotherapy we can give directly to the eye, it’s really a game changer because when these children get recurrence, we have a really powerful option for them here now which is not available many other places in the Southeast.”

Before doctors were been able to save the eye in 44 percent of these advanced cases, but with intra-arterial chemotherapy, the rate is 91 percent. The procedure requires feeding a catheter through the groin and up through the carotid artery to reach the eyes in these infants. It’s a challenging procedure because the infants are so small. Magrath knows he has a trump card in his deck, though, in the form of interventional radiologist Imran Chaudry.

“If we didn’t have people here like Imran Chaudry, it wouldn’t be possible,” he says. “In 10 minutes he can do it, it’s no big deal for him. He’s just that good, so we’re really have a lot of talent at MUSC Health between him and Lewis Cooper, who’s incredibly smart.”

It’s why this specialized care needs to be done with special coordination of an interprofessional team and another reason he came back to MUSC. “The team of physicians, residents, and staff at Storm Eye right now is amazing.  We work together as a team and the patients really benefit from everyone’s hard work.” He also was drawn to research opportunities of an academic medical center. Magrath says it’s a promising time in ocular oncology from new stem cell therapies to the use of viral vectors and lasers that will kill melanoma tumor cells instead of having to use radiation.

“We’re staying on top of which ones are in clinical trial and the results. As they look promising, we’re ready to jump in and offer them to our patients.” 

Magrath says he was drawn to ophthalmology because, literally, it’s a very visual field. “You can look inside the eye, and you can see what’s going on in there. You can see the diabetic eye disease, you can see the cataracts, you can see the molecular degeneration, you can see the cancers, and you can see them on a very high resolution level. So there’s a lot of precision work, where you can really see the result.”

At the end of the day, that is what keeps him inspired. He has three goals in working with patients. First it’s to save their life, then it’s to save the natural eye, and the third is to preserve as much vision as possible.

“Every patient is a battle, and you’re fighting as hard as you can for them and you’re really trying everything possible to get the best outcome in these horrible situations. Even if what they have is rare, they want to have good options. Not many people are doing ocular oncology, so it’s gratifying to give these patients a chance to preserve their life and hopefully, sight.”