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You¡¯ve put on your UPF-rated clothing, applied your sunscreen and positioned your beach umbrella carefully. But are you also wearing sunglasses to protect your skin and eyes from the sun¡¯s harmful?UV rays, which can cause both skin cancer and eye cancer?

These wardrobe staples aren¡¯t just for keeping a low profile or making a fashion statement. UV-rated sunglasses can also provide critical daily protection for your eyes and the sensitive skin around them.?

So, what should you look for when shopping for sunglasses? How do you know if they offer enough UV protection? And, are some lens colors better ¡ª or more protective ¡ª than others?

We went to dermatologist , director of MD Anderson¡¯s Dermatology and Mohs Center.?She answered these and six more questions about sunglasses and eye protection.

Do all sunglasses protect your eyes from ultraviolet (UV) rays?

No. Some are just colored plastic. Look for a sticker or tag that says UV400 or UV 95-100%. This is the highest level of ultraviolet protection currently offered in sunglasses.

Are sunglasses without UV protection harmful?

Yes. Sunglasses without UV protection allow harmful UV rays to reach the skin of the eye, the front of the eye and deep inside the back of the eye.

Furthermore, because sunglasses artificially darken the environment and allow your pupils to dilate, even more harmful UV rays can reach the back of the eye than they normally would if you were not wearing sunglasses.

That's why it¡¯s so important to look for UV protection in sunglasses, especially when other features are being emphasized, such as polarized sports models that decrease eye strain.

Does ¡®polarized¡¯ mean the same thing as ¡®UV protection?¡¯

No. Polarized lenses only reduce glare, or the brightness of reflected sunlight. That¡¯s why if you look down into a river or lake with polarized glasses on, you can often see what¡¯s going on beneath the surface. UV protection is entirely different.

Are designer sunglasses any better than the cheap ones at the drugstore?

No, not from a protection standpoint. Designer sunglasses may be a lot cuter and trendier, but you don¡¯t have to buy expensive sunglasses to get good UV protection. Just look for the sticker that says UV400 or UV 95-100%.

Are certain colors of sunglasses considered better than others?

Yes. Yellow-colored lenses don¡¯t offer as much protection as grey or brown-tinted lenses do.?

Do transitional lenses offer UV protection, too?

Lenses that automatically darken when exposed to bright light and become clear under darker conditions may offer UV protection, but not always. So, talk to your retailer to confirm the details about your specific lenses.

Do I need a wraparound style of sunglasses for maximum protection?

No. Many different styles of glasses offer good UV protection. You don¡¯t necessarily need a wraparound style.

That being said, there¡¯s no such thing as eyelid sunscreen. So, you should not be applying sunscreen to your eyelids or anywhere else inside the bony orbit, or eye-socket area. That¡¯s why we rely on sunglasses and hats to shield our eyes. You don¡¯t want to introduce any irritants there.

Which eye and eyelid cancers are associated with UV exposure?

Basal cell carcinomas are the most common type of cancer caused by UV exposure. One study out of Australia estimated that about 90% of malignant tumors on the eyelid were basal cell carcinomas.?You can also get melanoma on your eyelid.

But eyelid cancers are very different from those that develop in the eyeball itself. Ocular melanomas ¡ª or those associated with the eye socket ¡ª can be further subdivided into four different categories: uveal, conjunctival, eyelid and orbital. Eyelid melanomas have been associated with UV exposure, but there is limited data associating other forms of ocular melanoma with UV light.

How else can UV exposure negatively affect your eyes?

Cataracts

About 20% of cataracts are thought to be caused by UV exposure. Cataracts can get worse over time and diminish your vision, so they often have to be removed surgically.

Pterygium

Pronounced ¡°tur-RIDGE-ee-yum,¡± this is when a section of the epithelial ¡ª or top ¡ª layer of your eyeball gets thick, yellow and overgrown. It¡¯s completely unrelated to jaundice, which is a temporary discoloration of the eyeball caused by digestive problems. Pterygium may also obscure your vision and can be treated with surgery or steroidal eyedrops. It¡¯s sometimes called ¡°surfer¡¯s eye.¡±

Photokeratitis

This is when the eyeball itself gets ¡°sunburned.¡± It¡¯s a very painful condition and needs professional evaluation. But it usually resolves on its own within a few days, using some combination of pain relievers, antibiotics, lubricants and ointments. It shouldn¡¯t affect your vision immediately, but it may cause problems later on, such as corneal degeneration.

The most important thing to remember is that none of these conditions occur right away. All of them happen very gradually, over time. But you can prevent or delay them by wearing UV-rated sunglasses and keeping your eyes lubricated.

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An eye freckle is a dark-colored spot on the eye. Doctors may also call it a nevus or mole. Nevi refers to more than one freckle.

Eye freckles may appear in the front or the back of the eye. Most are benign and will never turn into cancer. But sometimes an eye nevus can turn into uveal melanoma, which makes up about 5% of all melanoma cases.

Here, I¡¯ll share more about eye freckles, including the different types and how we treat those that become cancerous.

Eye freckles are common

Eye freckles are pretty common. Anybody can have them, but they usually occur in people with lighter skin. About 1 in 8 white people have a nevus in the eye.

Eye freckles form from melanocytes, cells that produce the color in our skin and eyes. When a bunch of these cells group together, it can form an eye nevus.

There are different types of eye freckles

You can develop an eye freckle anywhere on the pigmented part of your eye.

Iris freckle

An iris freckle develops on the front of the eye in the iris. It is typically benign and does not turn into cancer.

Choroidal nevus

A choroidal nevus is located in the back of the eye. These nevi are usually benign. But a small number of them can turn into melanoma.??

Why we look for changes in eye freckles

An ophthalmologist may monitor your eye freckles to see if they get bigger, thicker or change color. This might mean that the freckle has become cancerous.

Taking images of any eye freckles during regular eye exams can help doctors keep track of any changes.

At MD Anderson, we may use any of the following to monitor eye freckles or detect melanoma in the eye:

Slit lamp exam

During this exam, we use a device that has a microscope and bright light to examine your eye. We can also measure any nevi with the slit lamp.

Gonioscopy

We use a slit lamp and a special lens to check the eye¡¯s drainage system.

Ultrasound biomicroscopy

This ultrasound provides detailed images of the front segment of the eye.

Ocular coherence tomography

This is an imaging test that uses light waves to take cross-sectional pictures of your retina. We can then view all the layers of your retina. ?

Biopsy

If we suspect an eye nevus may be cancerous, we will order a biopsy. During a fine-needle biopsy, we stick a small needle in the eye and retrieve tissue cells. Or we may do an excisional biopsy where we surgically remove the area of the nevus. A pathologist will examine the sample to see if it¡¯s cancer. ?

It¡¯s important for your doctor to monitor eye freckles for any changes. This way, if the eye freckle becomes cancerous, they can catch it and treat it right away. ?

How to treat eye freckles that become cancerous

Most eye freckles will not turn into cancer. So, we don¡¯t treat those; we just monitor them.

When a nevus does turn cancerous, we¡¯ll typically treat it with surgery or high-dose radiation therapy.

Genetic mutations cause some uveal melanoma cases

We don¡¯t know exactly what causes some nevi to turn into cancer.

Mutations in the GNAQ and GNA11 genes are often associated with the transformation of benign nevi to cancer.

Some cancerous choroidal lesions are linked to a secondary mutation in the BAP1 gene. This can be passed down to other family members. We may refer you for genetic counseling if you have a BAP1 mutation and have been diagnosed with other types of cancer.

See a doctor about any vision changes

See a doctor if you have an eye freckle and start to notice any of the following changes to your vision:

• Blurred vision
• Flickering lights
• Distorted lines

These are clues that the nevus might have transformed to cancer. The biggest misconception people have about eye cancer is that it is always painful. Early cancer of the eye may not cause pain. That¡¯s why it¡¯s important to get checked out if you have any changes to your vision.

Remember, most eye freckles are benign

Eye freckles are similar to moles on the skin. They won¡¯t ever go away. They probably won¡¯t ever turn into cancer. But you should stay on top of any changes you see.

We always want to treat a cancerous lesion when it¡¯s small. If we can treat any concerning areas early, there¡¯s a better chance we can restore your vision. So, see your doctor if there's a change in the size or appearance of an eye freckle, or if you develop new symptoms.

, is an ocular oncologist and chief of Ophthalmology at MD Anderson.

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Retinoblastoma is a cancer that forms in the retina, a layer of tissue in the eye that¡¯s sensitive to light. It¡¯s a rare eye cancer, but it¡¯s the most common cancer that starts in the eye in children. It¡¯s typically diagnosed in children under age 2.

We spoke with ophthalmologist and retinoblastoma specialist , to learn more about retinoblastoma, including symptoms, how it¡¯s diagnosed and how it¡¯s treated.

What causes retinoblastoma?

Each retina cell normally has two retinoblastoma genes, called RB1 genes, involved in cell division. If a cell loses both copies of the RB1 gene, you can develop retinoblastoma.

About 40% of cases are germline. This means either a child inherits this gene mutation from one of their parents, or a child develops a new gene mutation spontaneously. In these cases, retinoblastoma can be passed down to the next generation. In most germline cases, children have retinoblastoma in both eyes. This is called bilateral retinoblastoma.

About 60% of cases are caused by a sporadic gene mutation. In these cases, retinoblastoma is not inherited and cannot be passed down to the next generation. This will almost always be unilateral retinoblastoma, affecting only one eye.

Is genetic testing recommended for retinoblastoma?

Yes, it¡¯s our standard to refer patients with retinoblastoma and, at times, their family members, for genetic counseling and genetic testing.

When you have a potential genetic disorder, you¡¯re really referring a family. Families need genetic counseling, especially young parents who have a child with retinoblastoma. They often want to know what the odds are that their other children or potential children will develop retinoblastoma. It could be less than 1% in some cases and as high as 45% in other cases. So, whenever you have a genetic disorder that makes you more likely to have cancer, it¡¯s vital to see a geneticist who provides both genetic testing and genetic counseling.

What are the symptoms of retinoblastoma?

The most common symptom of retinoblastoma in the United States is a white reflex in the eye, known as leukocoria. If a photo is taken with the flash on, it will look like a white spot in the center of the pupil. This is an abnormal reflection of light from the retina.

Other symptoms that could indicate retinoblastoma are strabismus (crossed eyes) or a lazy eye.

Several conditions can cause these symptoms in the eye, many of which are not cancer. But they could negatively affect a child¡¯s sight, so it¡¯s important to have your child evaluated by an ophthalmologist, a medical doctor trained in eye surgery, as soon as possible if you notice these symptoms.

How is retinoblastoma diagnosed?

The early signs of retinoblastoma, such as a white reflex in the eye, are usually found when a child visits a pediatrician. If the assessment is concerning, they will refer the child to an ophthalmologist or an ocular oncologist for a diagnostic eye exam, which may include:

• Dilated eye exam: The child will be placed under anesthesia and their pupils will be dilated so the doctor can examine all parts of the eye.
• Ultrasound: The doctor looks for signs of calcium inside the eye, which is often associated with retinoblastoma.
• Fluorescein angiogram: The doctor dilates the child¡¯s eyes and then injects a colored dye into a vein in the arm. Once the dye reaches the blood vessels in the eye, the doctor uses a special camera to examine the retina.
• MRI: The doctor scans the brain and eye socket.

A biopsy is not used to diagnose retinoblastoma because it can potentially harm the eye, and removing tissue from the tumor can cause the cancer cells to spread.

¡°After the exams and testing are done, the cancer specialist will determine whether it¡¯s retinoblastoma,¡± says Gombos, stressing the importance of seeing someone with extensive experience diagnosing eye cancers.

How is retinoblastoma treated?

Treatment for retinoblastoma depends on several factors, including how advanced the tumor is.

¡°Our treatment approach to retinoblastoma is: first, save the child¡¯s life; second, save the child¡¯s eye; and third, save the child¡¯s sight,¡± says Gombos.

Chemotherapy kills cancer cells, and it can be delivered in different ways to treat retinoblastoma. One way is intra-arterially, in which chemo is delivered through a catheter inserted into a blood vessel in the groin. It then travels to the blood vessels that feed the eye, delivering the chemo directly into the eye. Intravenous means the chemo is injected into a blood vessel and pumped throughout the body. Chemo can also be injected directly into the eye with a needle while a patient is under anesthesia. This method is called intravitreal.

¡°We use these techniques to salvage the eye and often the sight,¡± says Gombos. ¡°But if the cancer is not responding, the disease progresses or if there¡¯s concern of the tumor growing near the optic nerve, we may surgically remove the eye. We don¡¯t want to risk it spreading elsewhere.¡±

If the tumor in the eye is advanced, then there is a potential risk of the tumor spreading. If that¡¯s the case, sometimes we will remove the eye at the beginning and avoid chemotherapy altogether. If the eye is so advanced that the vision will likely not be salvaged, this is often the best option. ??

¡°We always discuss the risks and benefits with every type of treatment with the family,¡± says Gombos. ¡°We factor in everything and determine what¡¯s in the best interest of the child.¡±

Can you recover from retinoblastoma?

Retinoblastoma is a highly curative disease when caught early. That¡¯s why it¡¯s important to get treatment at a specialized cancer center with specialists who treat this type of cancer.?

What research is being done to advance retinoblastoma treatment?

MD Anderson has contributed to several retinoblastoma clinical trials. A new clinical trial is exploring whether intravenous chemotherapy combined with intravitreal chemotherapy will improve the success rates of salvaging the eyes during retinoblastoma treatment.

Experts are also looking at using a liquid biopsy to diagnose retinoblastoma. While this test has been successful in detecting blood cancers and, more recently, solid tumors, experts are trying to figure out if this would apply to eye cancers.

¡°We¡¯re researching to see if tapping into the aqueous, which is the fluid in the front of the eye, will be helpful in assessing cancer,¡± says Gombos.

Gombos began researching retinoblastoma during medical school 30 years ago, and he sees a lot of promise in the treatment advances.

¡°Retinoblastoma is a disease with a lot of hope,¡± he says. ¡°When I see these advances, I continue to see opportunities for better treatments across the globe.¡±

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Watery eyes, also known by the medical term epiphora, occur when excessive tears drain from the eyes.

This may seem common, but can watery eyes ever indicate a serious medical condition like cancer? And when should you see a doctor? We spoke with ophthalmologists , and , for answers to these questions and more.

How do our tears drain normally?

Tears are produced by the lacrimal glands in the eye socket.

¡°In the inner corner of the eye are two small openings called puncta, and they are connected to a smaller tube called a lacrimal duct,¡± explains Al-Zubidi. ¡°The lacrimal duct drains into a small sac called the nasal lacrimal sac, which then goes through the nasal lacrimal duct, a drain into the nose.¡±

This is the natural way tears drain: through the nose, not down the face.

¡°Your eyes are watering either because the structure that makes the tears is overproducing or the drainage system is underperforming,¡± says Gombos.

What causes watery eyes?

Common causes for watery eyes can include:

• allergies
• infection, like conjunctivitis (pink eye)
• inflammation
• dry eyes
• eye strain
• trauma, such as a bone injury near the eye

Are watery eyes a symptom of cancer?

Watery eyes can be a sign of cancer, says Gombos. ¡°Cancer can involve the system producing tears, but more commonly the cancer involves the drainage system, so the tears don¡¯t drain properly,¡± he adds.

However, watery eyes alone don¡¯t correspond directly to a particular type of cancer, and the presence of watery eyes doesn¡¯t predict the severity or stage of cancer, say both Al-Zubidi and Gombos.

Primary tumors can occur in the lacrimal system or in structures around the eye, such as the nasal cavity and sinuses, eyelid or skin. These tumors can be benign or malignant. Anything obstructing these systems can cause watery eyes.

Watery eyes could be a symptom of the following cancers:

• lymphoma
• squamous cell carcinoma
• basal cell carcinoma
• adenoid cystic carcinoma

¡°Though it¡¯s not common, breast cancer can spread to the eyes and the glands around the eyes as well,¡± says Gombos.

When should you see a doctor for watery eyes?

There can be many different causes of watery eyes, most of which will not be cancer.

¡°With cancer, typically there will be another symptom associated with watery eyes,¡± says Al-Zubidi. ¡°These could be a change in vision, pain, a mass or lesion, redness or double vision.¡±

You should see an ophthalmologist if your symptoms:

• are unilateral, or on one side of your face,
• increase in severity over the course of a few days or
• do not improve within three to four weeks.

How does an ophthalmologist reach a diagnosis?

¡°You¡¯ll undergo a full ophthalmology exam in the clinic, which includes a physical examination of the eye and an ocular motility test,¡± says Al-Zubidi. ¡°Then, you¡¯ll have an MRI, which allows us to see the brain and eye socket, because some tumors have very specific radiographic findings on an MRI or CT scan. This also helps show the extent of any tumors.¡±

If the doctor finds any tumors, sometimes they¡¯ll order a biopsy, so the pathologist can examine the cell tissue of the mass and determine if it¡¯s cancerous or not. You may also have a full body screening to ensure no cancer has spread to other parts of your body. This includes a PET scan and CT scan of the head, chest, abdomen and pelvis.

¡°Not every patient will need a biopsy,¡± says Al-Zubidi, ¡°but if cancer is suspected, we always do a biopsy to confirm.¡±

Oculoplastic surgeons are ophthalmologists who specialize in plastic and reconstructive surgery of the eye and facial structures around the eye. If you are diagnosed with cancer in one of these areas at MD Anderson, an oculoplastic surgeon may be part of your care team.?

Are there other ways watery eyes can be related to cancer?

Chemotherapy may cause watery eyes in some patients with cancer. The chemotherapy drugs paclitaxel and docetaxel can cause nasal lacrimal duct obstruction, say Al-Zubidi and Gombos. In recent years, the dosing for docetaxel has been altered to reduce this side effect.

¡°Radiation in the head and neck area can also be a cause of watery eyes,¡± says Gombos. ¡°So, in addressing watery eyes, we first need to determine if the patient has a history of cancer, and we need to know the treatment used to manage the cancer.¡±

For established patients who have already had some form of therapy ¨C typically chemotherapy and/or radiation ¨C more often than not, watery eyes are a side effect from that. These side effects can appear weeks, months or even years after therapy.

Can watery eyes be treated?

The cause of watery eyes determines the treatment.

¡°If it¡¯s cancer, we either surgically remove it or treat it with chemotherapy, targeted therapy or radiation therapy,¡± says Gombos. ¡°Sometimes after treating the cancer, with radiation or docetaxel, for example, there will be a secondary impact. This can involve not enough tears, which we supplement with lubrication. Or it can be inadequate drainage, in which case we would create a conduit for the tears to go. We basically create a hole from the eye to the nose, so the tears can drain properly.¡±

It¡¯s important to see a doctor if your watery eyes persist.

¡°Don¡¯t ignore it and think, ¡®I just have to live with it,¡¯¡± says Gombos. ¡°There are many noncancerous issues related to watery eyes, so it¡¯s best to determine the cause and get relief as soon as possible.¡±

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