When the COVID-19 pandemic began in March 2020, Carol Shields, M.D., director of the Ocular Oncology Service at Wills Eye Hospital in Philadelphia, saw a dramatic drop in the number of patients in her office. Even fewer patients came in June.

Then in October, patients began pouring in with advanced eye cancers. She also saw an alarming rise in patients that required enucleation — surgical removal of the eye. This procedure is done when there is no other way to control the cancer within the eye.

“This trend started because patients began skipping their ophthalmology exams when the pandemic started,” Dr. Shields said. “Unfortunately, that meant a lot of eye disease was missed.”

COVID delayed detection of eye cancers

A patient usually ends up in an ocular oncology office after seeing an ophthalmologist and then a retinal specialist who thinks they may have an eye tumor. “During the pandemic, some eye cancers that normally would be caught early weren’t found until they were quite advanced,” Dr. Shields said.

Eye cancers are fairly rare. The American Cancer Society’s estimates that in 2021, there will be 3,320 new eye cancers — mainly ocular melanomas.

Dr. Shields’ office usually sees eight to 10 new patients with melanoma each week. Before the pandemic, the average thickness of a melanoma was 5 millimeters.

But, she says, “In 2020, we started seeing bigger tumors. The average thickness was almost 9 millimeters in June 2020. Then we had a second peak in October, with a lot of large tumors. Some were up to 18 millimeters.”

Eye removals more common during COVID

Pre-pandemic, about 94% of Wills Eye Hospital patients with melanoma were treated with a type of radiation therapy called plaque radiotherapy. The others were treated with enucleation.

“We were able to save the eye in most cases,” Dr. Shields said. In 2020, the rate was similar.

But by early 2021, only 88% of her patients were eligible for plaque radiotherapy. Eye removal rates rose to 12% — nearly double pre-pandemic levels.

“We were seeing more tumors that were too big to treat with plaque radiotherapy,” she said. “We usually have one or two enucleations per week. But earlier this year, we had several weeks with four or five enucleations.”

Dr. Shields also saw more young children with advanced cases of an eye tumor called retinoblastoma. “If it’s caught early, we can treat retinoblastoma with chemotherapy. But with many advanced cases, we have to remove the eye,” she said.

Signs of eye cancer: When to see a doctor

The symptoms of eye cancer are vague and painless, Dr. Shields said. The main symptoms include blurred vision, flashing lights or a visual field defect, meaning you can’t see out of one part of the eye.

“Don’t wait until you have eye pain,” she said. “If you have one of these three symptoms, see your eye doctor.”

Everyone over age 40 should get an annual exam with an eye dilation. The dilation gives the doctor a better view of the back of the eye, where a tumor might be. “Do it even if you feel perfect,” she said.

Children with retinoblastoma may have a drifting eye or a white pupil. “Many times parents assume the drifting eye just needs to be treated with glasses. If you notice your child’s eye drifts, ask the doctor to dilate the eye to make sure there’s no tumor in the back of the eye,” she said.

Improved access to care could prevent eye removals

The best way to avoid another wave of advanced eye cancers is to make it easier for patients to access care, Dr. Shields says. She believes telehealth can be an important part of improving eye care.

At the start of the pandemic, the Oncology Service at Wills Eye Hospital opened up three satellite offices. Each had a technician and a photographer.

“I was able to see the photographs of patients’ eyes over FaceTime. I could tell if the patient had a benign or malignant eye tumor and I could judge if it required treatment,” she said. “Patients love only having to interact with two people in the office. They can avoid crowds and long commutes.”

Because rules about telehealth were eased during the pandemic, her office can now treat patients in certain other states remotely. “With telehealth and satellite offices, more patients can receive care,” she said. “It’s the silver lining of the pandemic’s dark cloud.”