Surgery for retinoblastoma

Surgery is a medical procedure to examine, remove or repair tissue. Surgery, as a treatment for cancer, means removing the tumour or cancerous tissue from the body. This usually means cutting into the body, but surgery to remove cancer can also be done in different ways, such as by using extreme cold (cryosurgery) or heat (lasers or thermotherapy).

Surgery is usually used to treat retinoblastoma. The type of surgery used depends mainly on the size of the tumour and stage of the cancer. When planning surgery, the healthcare team will also consider other factors, such as whether the cancer is in both eyes and whether vision can be saved.

Surgery may be the only treatment or it may be used along with other cancer treatments. Surgery may be used to:

• completely remove the tumour
• reduce pain or ease symptoms (called palliative surgery)

The following types of surgery are commonly used to treat retinoblastoma.

Cryosurgery, or cryotherapy, destroys cancer cells by freezing them. Doctors apply an extremely cold liquid or gas to the eye through a metal tube called a cryoprobe. The area is allowed to thaw and then is frozen again. The freeze-thaw cycle is repeated 3 times during the same appointment.

Your child will be given a general anesthetic before cryosurgery. This means they will be asleep. Cryosurgery may be given 2 or 3 times (or sometimes more), with a month between treatments.

Cryosurgery may be used along with chemotherapy to treat small tumours in the eye.

Find out more about cryosurgery.

Laser surgery, or laser therapy, uses a powerful, narrow beam of light (called a laser beam) to deliver heat to destroy cancer cells. The laser may also be directed to the blood vessels that supply the cancer to stop the blood flow. This process is called laser photocoagulation.

Your child will be given a general anesthetic (this means they will be asleep) and drops to enlarge (dilate) the pupil before having laser surgery. The laser is aimed through the pupil to target the cancer or the tumourʼs blood vessels. Laser surgery is usually given 3 or more times, with about 1 month between treatments.

Laser surgery may be used to treat:

• small tumours in the back half of the eye
• larger tumours, following chemotherapy or radiation therapy
• cancer that has come back or was not completely destroyed by chemotherapy or radiation therapy

Find out more about laser surgery.

Thermotherapy is a type of laser surgery. It uses a powerful, narrow beam of light (called an infared laser) to deliver heat to destroy cancer cells. High temperatures can kill cancer cells by damaging proteins and structures within the cells, usually with little harm to normal cells and tissues. Heat also damages tumour blood vessels so that less blood flows to the tumour. Thermotherapy is also called transpupillary thermal therapy (TTT).

Before starting thermotherapy, the doctor uses eye drops to make the pupils larger (dilate the pupils). This allows the beam of light from the laser to pass through the pupil into the eye. Your child will also be given a general anesthetic. This means they will be asleep. The treatment is usually given 2 or 3 times, with about 1 month between treatments. Each treatment lasts about 10 minutes.

Thermotherapy may be used on its own to treat small tumours. It may also be combined with chemotherapy (called chemothermotherapy or thermochemotherapy) to treat larger tumours in the eye.

Enucleation removes the eyeball and part of the optic nerve. The eyelids, muscles, nerves, fat and bone of the eye socket (orbit) are left in place.

Enucleation surgery is done under a general anesthetic. This means your child will be asleep. The doctor will talk to you about how to prepare and what the recovery process is like. The surgery takes about 2 to 3 hours, but your child may need to stay in the hospital for 1 or 2 nights afterwards. The eye will be covered with a bandage for 2 days after the procedure to protect the area and reduce swelling.

Enucleation is not used to treat retinoblastoma as often as it was in the past. Itʼs now used only if other treatments can’t be done to treat the cancer and save vision. Enucleation may be used to:

• treat a large or advanced retinoblastoma that may have spread throughout the eye or into the optic nerve
• treat smaller retinoblastomas if other types of treatment would destroy vision or if there isn’t any useful vision in the eye

An ocular prosthesis (sometimes called an artificial or “glass” eye) is placed behind the eyelids in front of the orbital implant. It’s similar to a large contact lens, but made of plastic or glass and painted to look like a real eyeball.

The orbital implant helps hold the ocular prosthesis in place. It moves in a similar way to the remaining eye, but not quite as much.

After an enucleation, your child will need to heal before they can be fitted for an ocular prosthesis. About 6 weeks after surgery, your child will see a healthcare professional (called an ocularist) who specializes in making ocular prostheses. They will make the prosthesis to fit your childʼs eye socket and orbital implant, and paint it to match the other eye as closely as possible. (While this customized prosthesis is being made, your child will be given a temporary prosthesis.) The ocularist will teach you how to put in, remove and take care of the prosthesis.

The orbital implant and ocular prosthesis will be adjusted about every 6 months as the child grows. Both the implant and prosthesis are usually replaced every 2 years in childhood and every 5 years in adulthood.

Children who have an orbital implant and ocular prosthesis are usually advised to wear glasses with shatterproof lenses to protect the remaining working eye, especially when they play sports. Children who wouldn’t normally wear glasses can wear ones with non-prescription lenses.

Find out more about caring for an ocular prosthesis.

Side effects of surgery will depend mainly on the type of surgery and your child’s overall health. Tell the healthcare team if your child has side effects that you think are from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help your child deal with them.

Cryosurgery, laser surgery or thermotherapy may cause these side effects:

• scarring of the eye
• damage to the retina, including retinal detachment
• swelling of the eye and eyelid
• bleeding or a blood clot
• damage to the iris
• clouding of the lens of the eye (called a cataract)
• vision problems or mild vision loss

Surgery to remove the eye, or enucleation, may cause these side effects:

• permanent vision loss
• pain
• bleeding or a blood clot
• infection
• shifting of the orbital implant – this can be repaired with surgery to put the implant back in place
• slowed growth of the bone around the eye – this can give the eye a sunken appearance

Other side effects can develop months or years after treatment for retinoblastoma (called late effects). Find out more about late effects of treatments for retinoblastoma.

Find out more about surgery and side effects of surgery. To make the decisions that are right for your child, ask the healthcare team questions about surgery.