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Using TikTok to Empower Patients with Dr. Zack Oakey | The Eye Believe Podcast · The Eye Believe Podcast

• 0:03
  alright you guys
• 0:04
  welcome back to the Eye Believe Podcast
• 0:06
  i'm your host Danet
• 0:06
  and today i'm joined by a new ocular oncologist in town
• 0:10
  from irvine california
• 0:11
  in orange county say hi to Dr. Oakey
• 0:15
  Zack can you just give us
• 0:16
  give us a little bit of um
• 0:18
  the background for your tiktok channel
• 0:19
  can you tell us like
• 0:20
  what that is and what kind of content you create
• 0:23
  as an ocular oncologist and why
• 0:26
  yeah i started tiktok because uh
• 0:30
  every time i'd meet someone
• 0:31
  i noticed i was like waving my hands a lot
• 0:34
  trying to describe like
• 0:35
  the eye where's the retina
• 0:38
  where's the lens and i thought well
• 0:40
  why don't why don't i actually
• 0:41
  in my exam room have a tv sitting there with like
• 0:45
  a drawing of the eye and so on
• 0:46
  and it got to the point where
• 0:47
  i had all these skills built up
• 0:49
  so i decided if someone wants to
• 0:52
  learn more about what we're talking about
• 0:54
  they can go to some channel of mine and look at it so
• 0:58
  and besides that
• 0:59
  there are a lot of people out there who
• 1:01
  they're recently diagnosed with something
• 1:04
  maybe they live in some other area of the country
• 1:06
  and they want to learn more about it
• 1:08
  i felt like that's a service to the public
• 1:10
  so in a little three minute increment
• 1:13
  i can kind of deliver a little message
• 1:15
  and i think it helps people out
• 1:18
  yeah so what are some of the like
• 1:20
  kind of things that you've highlighted
• 1:22
  maybe in the last month at the beginning of the year
• 1:25
  yeah i'm actually a retina specialist too
• 1:28
  so i probably spend frankly
• 1:29
  most of my time talking about retina problems
• 1:32
  like retinal detachments diabetic retinopathy
• 1:35
  macular degeneration
• 1:37
  i do talk about eye cancers quite a bit though
• 1:40
  so usually i describe like
• 1:43
  what an ocular melanoma looks like
• 1:45
  how do we diagnose it
• 1:47
  what are the things to look out for
• 1:50
  um symptoms people have
• 1:52
  what's an ocular oncologist
• 1:53
  most people don't even know
• 1:54
  what an ocular oncologist is
• 1:56
  in fact most people think we're optometrist
• 1:58
  we're not we're a special kind of ophthalmologist
• 2:02
  so some of my content is just merely educating people
• 2:06
  about who we are and
• 2:07
  and what we do and how we diagnose things
• 2:10
  yeah okay
• 2:11
  so why don't you just give us in your definition
• 2:13
  what is an ocular oncologist
• 2:15
  i know those of us in the ocular melanoma community
• 2:17
  most of us have either seen an ocular oncologist
• 2:21
  a retina specialist who treats
• 2:22
  or probably some combination of the two
• 2:26
  yeah ocular oncology
• 2:28
  like technically defined as
• 2:30
  someone who was trained in a specific fellowship
• 2:34
  in ophthalmology ophthalmology is a big discipline
• 2:38
  most ophthalmologists uh
• 2:40
  well they're all medical doctors
• 2:41
  every one of them
• 2:42
  they go to medical school and they do a residency
• 2:45
  kind of more known for doing like
• 2:46
  lasik and cataract surgery and stuff
• 2:49
  but ocular oncology is the specific field
• 2:52
  in which
• 2:53
  someone learns how to take care of tumors of the eye
• 2:56
  whether they're malignant or benign
• 2:58
  and there's a whole host of benign tumors
• 3:00
  we usually focus in on the malignant ones
• 3:02
  cause obviously those are life threatening
• 3:03
  but there's a whole set of vascular tumors
• 3:07
  and other kinds of neuronal tumors that happen
• 3:11
  happen in the eye
• 3:13
  so yeah someone who's an ocular oncologist
• 3:15
  technically
• 3:16
  is someone who's done a whole year or a couple years
• 3:19
  learning under someone who is also an ocular oncologist
• 3:23
  they learn how to take care of things like eye melanoma
• 3:26
  retinoblastoma
• 3:28
  lymphoma tumors on the ocular surface
• 3:31
  tumors that surround the eye
• 3:33
  in a structure we call the orbit
• 3:35
  or tumors that are deep within the eye
• 3:38
  but there there are so few of us that have done this
• 3:41
  a fellowship so
• 3:42
  there are a lot of people
• 3:43
  who take on various aspects of ocular oncology
• 3:47
  for example
• 3:47
  there are cornea specialists who will work with
• 3:50
  in the ocular surface realm
• 3:53
  they'll treat things like ocular surface
• 3:55
  squamous neoplasia or conjunctival melanoma
• 3:59
  and there are oculoplastics doctors who like
• 4:02
  might do a blepharoplasty or facelift
• 4:05
  but if an eye is full of cancer
• 4:07
  let's say
• 4:07
  then they'll help out and they'll take out the eye
• 4:10
  let's say if it's necessary
• 4:13
  or if there's a tumor in the orbit surrounding the eye
• 4:16
  then they can biopsy and so on
• 4:17
  and then there are retina specialists who might treat
• 4:20
  like lymphoma inside of the eye
• 4:22
  or do ocular melanoma
• 4:24
  and all of this is to help the public
• 4:26
  they're they're going out of their way
• 4:27
  to learn these special tools and techniques
• 4:30
  so there in other words
• 4:32
  when you use the word you're really referring to like
• 4:34
  one kind of person
• 4:36
  but there are a bunch of people who join the club
• 4:38
  shall we say
• 4:39
  and there are some pretty well known people actually
• 4:41
  who are retina specialist
• 4:43
  never did a fellowship in ocular oncology
• 4:44
  and they do a great job yeah
• 4:46
  no i think that's
• 4:47
  that's totally accurate for
• 4:49
  and at least in like
• 4:50
  my local experience i've
• 4:51
  i saw
• 4:52
  both a retina specialist who treated ocular melanoma
• 4:54
  because he was just the only one in the area
• 4:56
  who was able to do that and had the
• 4:58
  the surgical experience but then i also like
• 5:01
  was able to find an ocular like
• 5:03
  you know
• 5:03
  a trained ocular oncologist who did a fellowship
• 5:06
  i think with like
• 5:06
  Dr. Javid
• 5:07
  so who did you do your fellowship with when you like
• 5:09
  finished out your schooling
• 5:11
  i completed residency at UC Irvine
• 5:13
  here in southern california
• 5:14
  and i did my retina fellowship
• 5:16
  at the university of wisconsin
• 5:17
  i actually picked that place
• 5:19
  because i had an interest in ocular oncology
• 5:21
  at the outset
• 5:23
  and it was one of the few retina fellowships
• 5:25
  where the retina fellow
• 5:26
  and the retina faculty take care of eye tumors
• 5:29
  as well
• 5:30
  but i realized i need a little bit more training
• 5:33
  so i went to the cleveland clinic
• 5:35
  and Dr. Arun Singh was my mentor there
• 5:40
  he uh
• 5:41
  he trained me in ocular oncology
• 5:42
  and it was a great experience
• 5:44
  i love that man well
• 5:46
  and actually
• 5:46
  it was the cleveland clinic ocular oncology symposium
• 5:49
  that we met at last summer
• 5:51
  that's right when yeah
• 5:52
  um when Dr. Singh had A Cure In Sight come out
• 5:55
  as part of the like
• 5:56
  advocacy groups that were there for that symposium
• 5:58
  and that was really neat like i
• 6:00
  i mean i know we talk a lot in the community
• 6:02
  about how there's so few ocular oncology specialists
• 6:05
  but it was really neat to see so many of them
• 6:06
  all in one room
• 6:08
  kind of makes it feel like more than there are
• 6:09
  but you know
• 6:10
  obviously when they're spread around
• 6:11
  the fifty states like
• 6:12
  becomes a little more sparse
• 6:14
  it makes the meetings kind of funny
• 6:16
  'cause you you see the same people everywhere
• 6:19
  oh yeah
• 6:19
  that's true you just kind of go to a different country
• 6:22
  or different city whereas like in
• 6:24
  in retina or like
• 6:25
  regular ophthalmology it's huge
• 6:27
  you know you'll go to a conference
• 6:29
  and there are people you've never met before
• 6:31
  oh that makes sense
• 6:32
  okay so you talked a little bit before
• 6:34
  like about how you have done videos
• 6:35
  kind of just explaining how a melanoma is diagnosed
• 6:39
  why is that something that you in california are more
• 6:42
  kind of more passionate about and
• 6:44
  you know why do you think your experience in
• 6:47
  i guess really in your region like
• 6:48
  has helped you to identify those small lesions
• 6:51
  yeah so the usual
• 6:53
  like classic story of someone who has like
• 6:56
  for example choroidal melanoma in the back of the eye
• 7:00
  is that someone has like
• 7:02
  diabetes or they develop floaters
• 7:04
  and all of these things demand a dilated eye exam
• 7:08
  and so someone will dilate the eye
• 7:10
  like an optometrist or something
• 7:11
  and they'll see a brown tumor in the back of the eye
• 7:14
  and in most cases it's big enough that it's
• 7:18
  shall we say obvious
• 7:19
  it's a brown lesion a tumor
• 7:23
  it has body to it it looks really thick
• 7:25
  it's kind of dome shaped
• 7:27
  there's certain obvious features that tell us
• 7:30
  this is a melanoma but uh
• 7:33
  there are many scenarios in which the tumor is so small
• 7:36
  that it's almost impossible to decide
• 7:38
  are you a melanoma with one visit
• 7:41
  and depending on the geography
• 7:43
  there are some locations of the world
• 7:45
  where people are getting their eyes looked at
• 7:46
  all the time and i
• 7:48
  i live in such a place in orange county
• 7:51
  there are people getting pictures taken of their eyes
• 7:53
  all the time at costco
• 7:54
  target or other various private practices
• 7:59
  and so that's created a scenario for me
• 8:01
  where a patient usually comes to my clinic with a
• 8:05
  a very small spot or lesion in their eye
• 8:09
  rather than someone usually showing up with like
• 8:11
  a big tumor that's so easy and obvious to diagnose
• 8:15
  so this is something that we talk about
• 8:17
  in ocular oncology a lot
• 8:19
  how do we discriminate between a small tumor
• 8:21
  and we can't decide is it a freckle or is it a melanoma
• 8:24
  we actually have terminology for this
• 8:26
  these are called indeterminate melanocytic tumors
• 8:29
  or in the indeterminate melanocytic lesions
• 8:32
  there's a whole literature
• 8:34
  which is meant to allow people to make a diagnosis
• 8:38
  and really there's
• 8:39
  there are only two ways to go about it
• 8:41
  first one has to understand freckles
• 8:44
  there's a huge literature about freckles
• 8:47
  how big are they what size are they
• 8:49
  what do they look like why do freckles develop
• 8:51
  at what age do they develop
• 8:53
  at what age do they stop developing
• 8:55
  so people like me
• 8:57
  have to understand this literature first
• 8:59
  before going into that conversation
• 9:02
  but i think
• 9:02
  there are some pretty basic things to say about it
• 9:05
  freckles usually don't grow at all
• 9:08
  and so one way one easy way to make a diagnosis
• 9:12
  well easy for me anyway
• 9:14
  is to get photographs from the past
• 9:17
  and if you get a photograph from the past
• 9:19
  let's say a year from the visit in which i'm involved
• 9:23
  and you see the brown spot inside of the eye
• 9:25
  and it looks almost the same size
• 9:27
  or identical to the same size
• 9:29
  at the time i meet someone
• 9:30
  i think it's pretty confident
• 9:32
  you can say this is likely a
• 9:33
  a freckle or a choroidal nevus
• 9:35
  let's say
• 9:37
  on the other hand if you see a brown spot in the past
• 9:40
  and it's smaller let's say it's half the size
• 9:43
  and then i look at the
• 9:44
  the lesion inside of the eye today
• 9:46
  you can pretty well claim this is a melanoma
• 9:49
  because freckles don't grow like this
• 9:51
  there's some other clues like if
• 9:54
  if a lesion has what we call orange pigmentation
• 9:57
  if there's fluid underneath the retina
• 9:59
  if it's of a certain size
• 10:00
  at least you could suggest that this lesion
• 10:03
  has a high probability of becoming a melanoma
• 10:05
  we consider these risk features
• 10:08
  and that's one approach
• 10:09
  the other approach is to biopsy it
• 10:12
  one issue with biopsies particularly for small lesions
• 10:15
  is that the biopsy yield is pretty low
• 10:18
  and also there can be side effects
• 10:20
  from biopsying inside of the eye
• 10:21
  particularly around the retina
• 10:23
  if you biopsy within the retina
• 10:25
  then there's a higher chance
• 10:26
  that there could be bleeding in the eye
• 10:28
  and if you think about it
• 10:30
  it it could be this absurd thing
• 10:31
  like we biopsy the inside of the eye
• 10:33
  there's bleeding only to find out that it
• 10:36
  there's a freckle in the eye
• 10:38
  so really for me
• 10:39
  the most reliable way to look into this
• 10:42
  is to look at photographs from the past
• 10:44
  and if they're not available
• 10:46
  then we usually follow things carefully
• 10:48
  like for example
• 10:49
  if some of these risk features are present
• 10:51
  has orange pigmentation etcetera
• 10:54
  then i usually recommend that we follow someone
• 10:56
  really carefully
• 10:57
  let's say every three months for at least a year
• 10:59
  and there are various studies showing this
• 11:01
  like Dr. Singh for example
• 11:03
  and i
• 11:03
  we've published that once we've feel like there's a
• 11:07
  a freckle that has a high risk of becoming melanoma
• 11:10
  in almost ninety percent of cases
• 11:11
  in nine months it reveals itself
• 11:13
  it increases in size we're able to treat it
• 11:16
  and
• 11:16
  that does not confer any additional risk of mortality
• 11:19
  if we just watch for that brief period
• 11:22
  yeah just to give yourselves like
• 11:23
  that added security and i
• 11:25
  i mean i think it makes total sense
• 11:26
  if you think about the world of medicine
• 11:28
  like i think i just have
• 11:29
  kind of grown up understanding and feeling
• 11:31
  like most doctors kind of live by the rule
• 11:34
  if we want to do the least harm possible
• 11:36
  in order to treat the problem
• 11:37
  or to address whatever the problem might be
• 11:39
  so it makes sense like
• 11:40
  i mean i think that it's easy for us
• 11:43
  like as patients to just be like
• 11:45
  well i would just like a concrete answer right
• 11:47
  like i just want you to biopsy my eye
• 11:48
  but it also is important to take into account
• 11:52
  what you said like that the eye is so it's
• 11:54
  it's a very delicate little organ
• 11:56
  like if you poke holes little
• 11:57
  little tiny holes
• 11:58
  like that can cause more problems than we need
• 12:01
  especially for something that turns out to be benign
• 12:03
  right and the retina is like
• 12:05
  the most vascular organ in the body practically
• 12:07
  there are blood vessels everywhere
• 12:09
  i've seen biopsies that have led to bleeding
• 12:11
  and i you know
• 12:12
  you wonder was that even a good thing for us
• 12:14
  but um yeah
• 12:17
  so that that's
• 12:17
  that's why to me
• 12:19
  at least the way i was taught
• 12:20
  the way i tend to approach it
• 12:21
  is just watch over time see if
• 12:23
  see if it does behave like a melanoma
• 12:25
  Dr. Oakey
• 12:26
  you have like
• 12:27
  talked a little about diagnosing these small lesions
• 12:29
  and using the historical pictures like
• 12:32
  that patients have had taken
• 12:33
  which i feel like just emphasizes at A Cure In Sight
• 12:36
  like we really emphasize to patients
• 12:38
  to family and friends like
• 12:39
  when spreading awareness about ocular melanoma
• 12:41
  and proactively diagnosing
• 12:44
  like obviously
• 12:45
  the best scenarios are gonna be
• 12:46
  when we have a smallest like
• 12:48
  the smaller lesion um
• 12:49
  i think historically
• 12:50
  most of the studies that we've seen from COOG from
• 12:53
  you know independent studies between
• 12:55
  you know doctors like yourself
• 12:56
  Dr. Singh like
• 12:56
  we're seeing those smaller lesions are easier to treat
• 13:01
  and also easier to have you know
• 13:02
  like that lower mortality rate in terms of
• 13:04
  is it gonna spread later down the line
• 13:07
  yeah obviously never
• 13:08
  never a guarantee that if it's small
• 13:09
  that you'll never have to deal with cancer ever again
• 13:11
  but it's just a lot better of a chance
• 13:14
  that's kind of my understanding
• 13:15
  so you have these pictures that you
• 13:17
  wanted to share
• 13:18
  so let's just go through some of these examples
• 13:20
  and you can just walk us through like
• 13:21
  what do these small lesions look like
• 13:23
  because i feel like this could be really
• 13:24
  really helpful to somebody who maybe
• 13:26
  maybe has an indeterminate spot that they're watching
• 13:28
  i totally agree
• 13:29
  so i just wanted to show like
• 13:31
  what a like
• 13:32
  shall we say a standard
• 13:34
  pretty obvious melanoma looks like
• 13:37
  this is a this is a
• 13:38
  like a classic example
• 13:40
  this is the right eye of a
• 13:42
  of a patient and off to the left side
• 13:44
  you kind of have to everything in the eye is opposite
• 13:47
  on the right side of the screen is the lesion
• 13:49
  but it's off to the left side in their eyes
• 13:50
  what i mean
• 13:51
  there's a brown spot here
• 13:52
  it's kind of off whitish
• 13:54
  but it's largely brown there's like
• 13:56
  a little bit of fluid underneath the retina
• 13:58
  it's dome shaped it has body
• 14:01
  to us this is a pretty clear sign that there's at least
• 14:04
  a lesion of some kind of concern here
• 14:07
  and then if we do an ultrasound
• 14:09
  this is an ultrasound of that spot
• 14:11
  it looks hollow on the inside
• 14:13
  these are shall we say
• 14:15
  like if you were to
• 14:16
  if you were to describe a tumor
• 14:18
  on the inside of the eye
• 14:19
  to even an ophthalmology resident
• 14:21
  they'd say this is concerning for a melanoma
• 14:23
  and someone like me
• 14:24
  with a lot more confidence and experience in
• 14:26
  this field would say oh yeah
• 14:27
  that's a melanoma we need to treat it
• 14:30
  but then you have lesions like this one
• 14:34
  like if we look at it
• 14:36
  first of all this is someone's left eye
• 14:38
  there's a brown spot there
• 14:40
  but there are certain features about it
• 14:41
  first of all it's size
• 14:43
  you can actually use like
• 14:45
  little internal rulers to say what the size of it is
• 14:49
  from here all the way over there
• 14:52
  it may be like let's say
• 14:54
  six or seven millimeters in its largest width
• 14:57
  there's also these little orange spots
• 15:00
  within the lesion
• 15:02
  and there's also a little bit of subretinal fluid there
• 15:04
  i have a question when i'm looking at this picture
• 15:06
  like i see the circle
• 15:08
  and i see like
• 15:09
  kind of the reddish orange and the yellow all around it
• 15:11
  i can see all the veins and then in the middle
• 15:14
  i see kind of like a like
• 15:15
  what looks like a a kind of bluish gray
• 15:18
  maybe greenish mass area
• 15:20
  is that the part that you're referencing
• 15:21
  is the tumor or is it a different spot in the eye
• 15:23
  that's right
• 15:24
  that brownish spot in the middle
• 15:27
  that is the tumor that we're trying to answer
• 15:30
  like are you a
• 15:31
  are you a melanoma or are you a freckle
• 15:35
  and you can see it underneath the
• 15:37
  the blood vessels of the retina
• 15:39
  the choroid is where these things develop
• 15:41
  the choroid is a large layer of blood vessels that sits
• 15:44
  underneath the retina and within that spot
• 15:47
  you're right
• 15:48
  there's like this kind of bluishness within the middle
• 15:50
  but just above that there are these like
• 15:53
  little orangy deposits
• 15:56
  it's almost like you're digging for gold
• 15:58
  and you see the gold kind of sparkling out of the dirt
• 16:01
  they're like
• 16:01
  these little orangey spots kind of showing themselves
• 16:04
  and then on the bottom section of this
• 16:06
  of this lesion
• 16:07
  there's almost this transparent white looking thing
• 16:10
  that tells us that there's fluid underneath the retina
• 16:15
  so the question we have is
• 16:17
  are you a melanoma or are you not
• 16:19
  it's not nearly as obvious as the prior image
• 16:22
  the prior image is this big thing
• 16:23
  dome shaped it has mass to it
• 16:26
  whereas this thing is it looks pretty flat
• 16:28
  but it has certain
• 16:30
  what we would consider concerning things
• 16:32
  that's the question we diagnose it by looking at it
• 16:37
  uh comparing old photos
• 16:39
  or we could biopsy it and just a list
• 16:41
  like what are the risks
• 16:43
  features that we talk about
• 16:45
  we talked about the orange pigmentation
• 16:47
  this is one of them little subretinal fluid
• 16:49
  we found that lesions
• 16:51
  that are above ten millimeters in size
• 16:53
  tend to have a higher risk
• 16:54
  of becoming a melanoma in the future
• 16:56
  there are some publications suggesting that
• 16:59
  if it's close to the optic nerve
• 17:01
  inside of the eye that constitutes another risk feature
• 17:03
  and then it's thickness
• 17:05
  and the way to look at the thickness of any lesion
• 17:08
  inside of the eye usually is with an ultrasound
• 17:10
  so we don't have an ultrasound image here
• 17:12
  we're just going off of how it looks clinically
• 17:16
  now the interesting thing about this uh
• 17:18
  lesion is on the bottom left here
• 17:19
  if you can see it there's a date
• 17:22
  this image was taken july twenty seventh
• 17:24
  twenty twenty one
• 17:27
  and if we fast forward a year later
• 17:30
  and compare this lesion what do we see
• 17:34
  well the biggest thing we want to look for is growth
• 17:38
  because remember nevi freckles
• 17:40
  they don't grow whereas melanomas do
• 17:43
  and you could cause a lot of confusion here
• 17:46
  you could look at this thing and
• 17:47
  and make one image larger than the other and say oh
• 17:50
  it looks bigger than the other
• 17:51
  and therefore there's a melanoma present
• 17:54
  and we don't actually do that
• 17:55
  because we don't wanna be confused
• 17:56
  we wanna diagnose accurately
• 17:58
  and the way to diagnose accurately
• 18:00
  is to look at points of reference within the eye
• 18:03
  that are shared no matter which camera is used
• 18:05
  no matter what year and that is blood vessels
• 18:08
  so
• 18:08
  if you look at the blood vessels of the lesion in 2021
• 18:13
  and then you compare their location
• 18:14
  relative to the edge of the tumor
• 18:17
  in twenty twenty two
• 18:18
  you'll see that this thing hasn't changed in size
• 18:21
  in other words this is a freckle
• 18:25
  because if a melanoma would have grown over that year
• 18:29
  that goes between the photos
• 18:31
  so all i'm trying to point out
• 18:33
  here is that
• 18:33
  even though there are some features that tell us
• 18:35
  this lesion
• 18:36
  may have a high risk of becoming a melanoma
• 18:39
  it is not in fact
• 18:40
  a melanoma but i have an example in which actually
• 18:43
  a melanoma did develop
• 18:45
  yeah for this patient
• 18:46
  like you said you monitored
• 18:48
  like someone who has something that you're questioning
• 18:50
  you have you know
• 18:51
  cause to investigate further
• 18:53
  you said you would image that eye
• 18:55
  like roughly every three months
• 18:58
  yeah particularly for something like this
• 19:00
  yeah okay
• 19:01
  so then after you hit this
• 19:02
  this year mark and you had okay
• 19:04
  i've got a solid year there's no growth
• 19:06
  what happens after that point
• 19:07
  did you just send them on
• 19:08
  like do you send them on their way
• 19:09
  or is that someone who you still recommend seeing
• 19:11
  pretty regularly
• 19:12
  i would still recommend seeing this patient
• 19:14
  because there are so many risk features
• 19:16
  for it to become a melanoma
• 19:18
  we have various calculators
• 19:20
  and scientific research to reference
• 19:22
  to ask what is the probability of a lesion like this
• 19:25
  becoming a melanoma it's much higher than average
• 19:29
  uh the incidence of a
• 19:30
  of a freckle we estimate to become a melanoma
• 19:33
  is about one in eight thousand
• 19:34
  all freckles
• 19:36
  but if you look at individual freckles like this one
• 19:39
  with fluid underneath the retina
• 19:41
  orange pigmentation etcetera
• 19:43
  then we probably believe
• 19:44
  that the chance of this thing becoming a melanoma
• 19:47
  is much higher compared with like
• 19:48
  a standard joe blow average freckle
• 19:51
  so in that case i
• 19:53
  i usually say you're still in my clinic
• 19:56
  in fact depending on the circumstances
• 19:58
  i probably i might even recommend
• 20:00
  that we check it out twice a year
• 20:01
  just out of excess caution
• 20:03
  yeah for sure
• 20:05
  okay well
• 20:05
  i think that makes sense i have another example
• 20:08
  in which this whole process
• 20:10
  led to me diagnosing a melanoma
• 20:12
  i wanna show it to you
• 20:15
  so this is another patient
• 20:17
  they had known that they had a freckle in the past
• 20:20
  and they were starting to lose some vision
• 20:23
  and i got a text message from my friend
• 20:25
  she said my patient is losing vision
• 20:28
  he has a freckle in the eye
• 20:29
  can you have a look at at the
• 20:31
  the lesion in the eye and i said i'd be happy to
• 20:34
  anytime someone is losing vision
• 20:36
  that is there are symptoms from a freckle
• 20:38
  this may also be another risk feature that we consider
• 20:42
  and this was the spot in this person's eye
• 20:45
  now in order for me to diagnose a melanoma
• 20:47
  remember we have two ways we can go about it
• 20:50
  we can biopsy this or we can look at it over time
• 20:52
  and it just so happened
• 20:54
  that this person had photographs taken
• 20:56
  at an optometry practice in town
• 20:58
  and so i called them
• 20:59
  and this is the photo that they sent to me
• 21:02
  so i met the patient in twenty twenty five
• 21:04
  and they showed me a photograph from twenty nineteen
• 21:08
  so here was the lesion
• 21:09
  then if you look at just the bottom aspect of that spot
• 21:13
  already
• 21:14
  there's a little bit of orange pigmentation developing
• 21:17
  so to me at the time this would have been
• 21:20
  let's say a different kind of freckle
• 21:22
  one that we'd want to pay attention to
• 21:24
  and
• 21:24
  since it was a photograph that was about six years old
• 21:27
  now i can look at it
• 21:28
  and compare its size over the course of time
• 21:31
  and here they are
• 21:32
  so the one on the right is my patient today
• 21:36
  and the one on the left is my patient six years ago
• 21:39
  and if we just very carefully
• 21:41
  map out all of the little blood vessels
• 21:43
  and make a comparison this is what it looks like
• 21:46
  i put little white dots where the lesion used to be
• 21:49
  six years ago and if you look at the border now
• 21:53
  you can tell
• 21:53
  this thing has gotten larger over the course of time
• 21:57
  so this is this is one way to diagnose melanoma
• 22:00
  and again if we just review how it looked in the past
• 22:03
  there's spots of of orange pigmentation
• 22:05
  so this this would tell you that there's actually
• 22:07
  probably a higher than average chance of
• 22:09
  of becoming a melanoma in the future
• 22:12
  and even at the time i met the patient
• 22:13
  this is an oct scan over the lesion
• 22:17
  there's a little bit of fluid underneath the retina
• 22:19
  as well
• 22:21
  um i have another example of this
• 22:23
  this is a patient who was told that they had a freckle
• 22:26
  years ago
• 22:28
  and the patient was referred to a retina specialist
• 22:31
  and the retina specialist did the right thing
• 22:33
  they looked at it and they said
• 22:34
  this is the size let's follow it over time
• 22:36
  but then it started to develop orange pigmentation
• 22:39
  and fluid underneath the retina
• 22:41
  on the image to the left
• 22:43
  you can see that they're like little tiny deposits
• 22:46
  again i think of this like gold inside of dirt
• 22:48
  like if you're a
• 22:49
  a miner and you're looking for gold
• 22:52
  you just see these little sparkles
• 22:54
  it's the same thing with this uh
• 22:55
  color photograph you can see that these
• 22:58
  like little orangey deposits
• 23:00
  right by the center of the macula there
• 23:02
  and then if you scan over the tumor
• 23:05
  there's a little bit of fluid off to the right image
• 23:08
  of course you can make out the body of the tumor
• 23:10
  underneath the retina there
• 23:11
  but there's a little collection of fluid there
• 23:14
  and at the time i met this patient
• 23:16
  i'm going through the same mental process
• 23:18
  we were talking about which is
• 23:19
  i need to get an old photograph
• 23:22
  unfortunately
• 23:22
  the retina specialist who referred the patient
• 23:24
  he was really busy that day
• 23:26
  but my patient pulled out his cell phone
• 23:29
  and this is something that our patients can do too
• 23:31
  if if we're sitting here talking to the public
• 23:34
  one should be interested in getting these photos
• 23:36
  well this guy just had a picture from his phone
• 23:38
  and he pulled it out
• 23:40
  and here was the image four years before i met him
• 23:44
  so if you go through the same analysis
• 23:45
  you look at the edge
• 23:47
  the border of the tumor in twenty twenty one
• 23:50
  and then you compare that with twenty twenty five
• 23:52
  it's pretty obvious
• 23:54
  that this thing has increased in size
• 23:56
  and i even outlined it here
• 23:57
  like on the image of twenty twenty five
• 23:59
  you can see these little white dots
• 24:01
  where the border of the lesion used to be
• 24:03
  compared with where it
• 24:04
  where it is in twenty twenty five
• 24:06
  and this is what we do if we see a small tumor
• 24:09
  we want to know has it increased in size
• 24:11
  compatible with a melanoma
• 24:12
  well it's pretty obvious that it has
• 24:14
  and one might suspect even in 2021
• 24:17
  there's a little orange pigmentation
• 24:19
  there's a little risk feature there
• 24:20
  that this thing should be followed carefully
• 24:24
  i think it's interesting like
• 24:25
  looking at these two pictures side by side that
• 24:27
  like the first one
• 24:28
  the twenty twenty one i guess on my screen at least
• 24:31
  i don't know about you guys listening
• 24:32
  but on my screen it looks kind of more like
• 24:34
  almost greenish like yeah
• 24:36
  like
• 24:36
  the colors that i see on the screen look more green
• 24:38
  like i can see a few of those kind of like
• 24:40
  little deposits like you said
• 24:41
  like the kind of more orangey brown areas
• 24:43
  but it's not as prevalent in the color
• 24:46
  but then even like but then in twenty twenty five
• 24:48
  like honestly
• 24:48
  if you had shown me the twenty twenty five picture
• 24:50
  just alone i probably would have been like
• 24:52
  well that doesn't look like much like it
• 24:54
  it looks like all the same color like
• 24:56
  but the
• 24:57
  the shadow underneath it is definitely more distinct
• 24:59
  and the coloring seems a lot more like
• 25:02
  to the brown side as opposed to like
• 25:04
  the green side yeah
• 25:05
  this the image technology is always different
• 25:07
  this is why earlier i was saying like
• 25:10
  a lot of times a
• 25:11
  a photograph will be taken at some other clinic
• 25:14
  by a different kind of camera
• 25:16
  with different optics
• 25:18
  and therefore
• 25:18
  you have to use universal points of reference
• 25:21
  to assess
• 25:22
  whether or not the tumor has increased in size
• 25:24
  like the image that was taken off to the right in 2021
• 25:28
  that was using an optos camera
• 25:30
  which has a red green laser scanning technology
• 25:34
  whereas the one in 2025
• 25:35
  that was taken in my clinic with the same camera
• 25:38
  except it has red green and blue scanning laser
• 25:41
  so when you add a blue hue
• 25:43
  it actually makes the image look more realistic
• 25:46
  whereas if we go back to like
• 25:47
  for example this image
• 25:48
  this is a
• 25:49
  an image taken using a completely different camera
• 25:52
  this is a canon camera and it's a true flash
• 25:56
  so that's why oftentimes
• 25:58
  when we're talking about these kinds of images
• 26:01
  we have to in the mind
• 26:03
  kind of subtract away some of the distractions
• 26:06
  and some of the distractions really are the color
• 26:09
  in a way although
• 26:09
  orange pigmentation
• 26:11
  is a very prominent thing we look for
• 26:14
  but like if an
• 26:15
  if a tumor looks browner in the past
• 26:17
  and it looks brighter in the future
• 26:19
  vice versa those might be a distraction based on even
• 26:23
  not even just the camera technology
• 26:25
  like which camera was used
• 26:27
  but like if the
• 26:28
  if the patient is closer to the camera or further away
• 26:31
  then the image
• 26:32
  the light might actually reflect more from the eye
• 26:34
  and therefore it can look brighter or darker
• 26:36
  depending on what happened
• 26:38
  also people can have cataracts
• 26:40
  people can have a dry eye
• 26:42
  and that can make the image kind of fuzzy
• 26:44
  for example so
• 26:45
  the mind has to kind of
• 26:46
  get rid of some of these distractions
• 26:48
  and look at the very basic details of like
• 26:50
  what are we concerned about
• 26:51
  fluid orange pigmentation
• 26:53
  but mostly primarily the size
• 26:55
  the border of the lesion over time
• 26:58
  yeah absolutely
• 26:59
  that makes sense
• 27:00
  i love that you said that
• 27:01
  this patient
• 27:02
  was able to pull up the picture on their phone
• 27:05
  like i was someone who
• 27:06
  the very first time that my eye had a picture taken
• 27:08
  which i regret to say
• 27:09
  was the time that i basically had a retina detachment
• 27:12
  it was a retinal detachment
• 27:14
  due to the ocular tumor growing so big
• 27:16
  that was the
• 27:17
  first time i had ever seen the inside of my eye
• 27:20
  in a picture versus just a dilated eye exam report
• 27:23
  and i took a picture of that
• 27:24
  and it's crazy to like
• 27:26
  look at that picture versus the healthy eye
• 27:28
  it's like obviously something is very wrong
• 27:30
  yeah like
• 27:30
  and um
• 27:31
  but i mean just in
• 27:33
  in having those pictures to track
• 27:34
  and also just having the ability as patients to like
• 27:37
  advocate for you know
• 27:38
  within our own care and be like okay
• 27:40
  like can i take a picture of that
• 27:41
  just so that i have it that's
• 27:43
  that's such a smart thing to do
• 27:44
  like i
• 27:44
  i just think that's that's really
• 27:47
  it's gotta be helpful like just
• 27:49
  especially if you're kind of in a situation
• 27:50
  where you're really feeling like
• 27:52
  pretty reasonably certain that this is a melanoma
• 27:54
  like now you have
• 27:56
  in office confirmation
• 27:57
  that you can feel more confident in moving forward
• 28:00
  totally and i
• 28:01
  i always advocate this for my patients
• 28:03
  particularly the ones who are moving
• 28:05
  like i have some patients who
• 28:07
  for whom i don't know yet if they have a melanoma
• 28:09
  i just met them and they'll be telling me oh
• 28:12
  i'm i'm moving to florida now
• 28:15
  and i think it's my job to provide them the tools
• 28:18
  necessary for someone else to take up the baton
• 28:21
  so that there can be a future comparison
• 28:23
  in fact i'll even identify someone
• 28:25
  in the place that they're moving to
• 28:27
  and i'll say i know this person
• 28:28
  i'd like to communicate with them
• 28:31
  do i have your permission to share images
• 28:33
  and then i also provide my patient
• 28:35
  with the highest resolution image possible
• 28:38
  in fact on our
• 28:39
  on my practice website
• 28:41
  when an outside doctor wants to refer patients to us
• 28:44
  we have a protected section of the website
• 28:46
  where you can just drag in images from a computer
• 28:49
  so that you don't have to mess with faxes
• 28:51
  and all sorts of low resolution images
• 28:54
  we want the highest res possible
• 28:56
  that's super cool technologies advance so much
• 28:59
  you've given us some really good examples
• 29:00
  but if someone has one of these
• 29:02
  kind of initially indeterminate lesions
• 29:05
  it sounds like you know
• 29:06
  just in summary that the best thing for them to do
• 29:09
  is to either pull up past imaging
• 29:11
  if that's possible
• 29:13
  continue getting imaging like regularly
• 29:15
  and to just track it over time
• 29:17
  that's right and then proceed with treatment
• 29:19
  obviously if
• 29:19
  if that became something that needed to be addressed
• 29:22
  i think another important variable
• 29:24
  is the person with whom you're working
• 29:26
  the physician you really wanna find
• 29:28
  someone who has experience with this
• 29:30
  because sometimes
• 29:31
  the growth pattern is not really readily recognized
• 29:34
  with someone who might be well meaning
• 29:36
  but doesn't have a lot of experience
• 29:38
  no to like
• 29:39
  understanding what we're talking about
• 29:41
  even though
• 29:42
  a lot of things we're talking about seem pretty simple
• 29:44
  there are some complexities here
• 29:46
  so uh
• 29:47
  finding like
• 29:48
  like we were talking about
• 29:49
  like a retina specialist who is able to treat this
• 29:52
  or has a lot of confidence and experience with it
• 29:55
  or even an ocular oncologist
• 29:56
  this is where you really wanna
• 29:58
  monitor these kinds of things
• 30:00
  because the moment there is any detectable melanoma
• 30:03
  you wanna be able to treat it
• 30:04
  or at least know how to get to treatment
• 30:06
  yeah that makes sense
• 30:08
  ok so
• 30:08
  you mentioned just a couple of key things
• 30:10
  that patients could look for
• 30:11
  in a like
• 30:12
  in a new ocular oncologist
• 30:14
  what do you think makes you
• 30:15
  someone who patients should want to come to
• 30:17
  and like
• 30:18
  what do you also look for
• 30:19
  if you're referring a patient
• 30:20
  who's moving out of state
• 30:21
  like in another you know
• 30:22
  another ocular oncologist or practicing physician
• 30:25
  yeah what i'm looking for
• 30:26
  is someone's educational background
• 30:29
  like i i feel like most retina specialists
• 30:32
  for example
• 30:33
  are equipped to understand a high risk lesion
• 30:36
  versus a low risk lesion
• 30:38
  so that's what i'm realistically looking for
• 30:41
  at least in most cases there are a lot of states
• 30:43
  that don't even have an ocular oncologist
• 30:46
  and especially if i know them
• 30:47
  like i know that they're a really good person
• 30:49
  they're really thoughtful
• 30:51
  i like to be a guide for them
• 30:52
  and if you're starting off and you don't know anyone
• 30:54
  then it's good
• 30:56
  just to meet the first ophthalmologist you can find
• 30:58
  and say hey i
• 30:59
  i have this spot in my eye
• 31:01
  what do you think do you know anyone whom you trust
• 31:03
  who can have a look at this
• 31:04
  that would be one approach
• 31:06
  of course if
• 31:07
  if you live in a place
• 31:08
  where there's an ocular oncologist
• 31:09
  it's probably best just to meet them
• 31:11
  so yeah absolutely
• 31:13
  why me well
• 31:15
  you know i'm a handsome guy
• 31:17
  i think no i'm just kidding
• 31:20
  now uh
• 31:21
  i like i said
• 31:22
  i've done a fellowship in this stuff
• 31:23
  i i feel like i understand it really well
• 31:25
  um there
• 31:27
  there are other people in my territory
• 31:29
  like in los angeles there's Dr. Mccannel
• 31:31
  Dr. Berry
• 31:32
  there are various people
• 31:33
  that work with kaiser permanente
• 31:35
  like Dr. Seider these are great people
• 31:37
  and in fact a lot of times
• 31:38
  people come to my clinic and i
• 31:39
  i inform them there is a melanoma in the eye
• 31:42
  and my patients will say
• 31:43
  i'd like to have someone else weigh in
• 31:44
  and i i feel totally comfortable with that
• 31:47
  because i know that my colleagues in los angeles
• 31:49
  or even san diego they have aptitude and the training
• 31:53
  the experience that we're talking about
• 31:54
  that's necessary to make a diagnosis
• 31:57
  yeah absolutely
• 31:58
  with patients like you have been um
• 32:00
  practicing like you
• 32:01
  you have a private practice in irvine
• 32:03
  and you see patients in that
• 32:05
  you know in that local area
• 32:07
  what do you find like
• 32:08
  over the last few years and
• 32:09
  you know throughout your fellowship
• 32:10
  as you've learned from doctor singh and other doctors
• 32:12
  what do you find are the best approaches
• 32:14
  for breaking the news of an ocular melanoma diagnosis
• 32:17
  to the like as a patient
• 32:18
  i learned this really early on
• 32:20
  actually from A Cure In Sight
• 32:22
  i went to a conference first of all
• 32:25
  at the very outset
• 32:26
  i've been able to deliver some tough news
• 32:28
  just as a retina specialist
• 32:29
  like telling people you're
• 32:31
  you're going blind there's nothing we can do about it
• 32:33
  that's tough news of course
• 32:35
  but um
• 32:36
  seeing my mentors discuss this issue
• 32:39
  has been really helpful but as i was saying i
• 32:42
  i learned this really well
• 32:44
  from someone who's a member of A Cure In Sight
• 32:46
  when i was at a conference
• 32:48
  i was talking to someone who had ocular melanoma
• 32:51
  and she told me something that i don't forget
• 32:54
  which is that
• 32:54
  when her ocular oncologist told her she had melanoma
• 32:58
  she didn't hear one word he said after that
• 33:01
  and i feel like that's a pretty common experience
• 33:04
  most people don't even know
• 33:05
  that people can get eye cancer
• 33:07
  like they don't even think they will get a cancer
• 33:10
  let alone in the eye and
• 33:12
  to imagine
• 33:14
  all the implications of having a cancer in the eye
• 33:17
  it can threaten a very important sensation
• 33:20
  but also important threaten someone's life
• 33:22
  that's a lot to swallow so when i
• 33:25
  when i deliver tough news first
• 33:27
  i like to show someone
• 33:29
  on what basis am i making this statement
• 33:34
  i have the photos in front
• 33:35
  of me in all my exam rooms
• 33:37
  i have these big tvs
• 33:38
  i have the photograph from the past
• 33:41
  i have the current photograph
• 33:43
  and before that i even educate people
• 33:45
  this is what we're looking out for
• 33:46
  now let's look at the photos
• 33:47
  and we see that the lesion has increased in size
• 33:50
  and so i ask a very basic question
• 33:52
  how else do we interpret this as a melanoma
• 33:55
  and usually at that point
• 33:58
  i like to tell people
• 33:59
  we have a lot that we need to talk about
• 34:01
  but
• 34:02
  because we're really talking in some heavy subjects
• 34:04
  here i usually like to suggest
• 34:07
  let's end the visit right now
• 34:09
  obviously
• 34:10
  call me if you have any thoughts or questions
• 34:12
  between now and next visit
• 34:13
  but if you could give it like
• 34:14
  a week to let some of these ideas simmer for a minute
• 34:18
  maybe think of some questions
• 34:20
  when you're not feeling so nervous and hot
• 34:23
  you know uh
• 34:24
  i found that that's really helpful
• 34:25
  in fact i've had patients
• 34:27
  i had a i had a really smart patient
• 34:29
  working for one of these big aeronautic firms
• 34:32
  um in la county
• 34:34
  i remember this patient told me
• 34:36
  i have no questions at all
• 34:37
  i just wanna get to treatment
• 34:40
  and just being me trying to
• 34:42
  trying to be a kind understanding person
• 34:43
  i said i
• 34:44
  i completely understand that
• 34:46
  and i'm prepared to talk about
• 34:47
  whatever you'd like to talk about
• 34:48
  i take all the time we need
• 34:50
  but i in the final analysis
• 34:52
  i did recommend to him like let's
• 34:54
  can we just give it like
• 34:55
  a week or so i know you're gonna have some thoughts
• 34:57
  that you're not gonna be able to have right now
• 34:59
  and then he revisited my clinic about a week later
• 35:01
  and he said you were right
• 35:02
  i wasn't thinking clearly at all
• 35:05
  and he came back with like
• 35:06
  a whole list of things and we talked about it
• 35:08
  i think that's a good pretty universal approach
• 35:11
  i find very few exceptions to this like
• 35:13
  thing where someone comes back and they say
• 35:15
  i had no thoughts
• 35:16
  i wish we would have gotten to work when we first met
• 35:18
  you know hearing this tough news
• 35:20
  i think is is like
• 35:22
  the language we use is important
• 35:23
  of course
• 35:24
  but just giving someone a lot of breathing room
• 35:26
  because we're in a hot confined room
• 35:28
  the the exam room is like
• 35:30
  the door is closed
• 35:31
  people feel kind of confined in some situation
• 35:34
  so giving people a lot of room to kind of
• 35:36
  think things through to me
• 35:37
  is like
• 35:38
  a really important ingredient to the whole conversation
• 35:41
  yeah i think that makes a ton of sense honestly
• 35:43
  and i think you know
• 35:44
  when you get i mean
• 35:46
  just as a patient myself like
• 35:47
  when you get that diagnosis
• 35:50
  you know the feelings that come up
• 35:51
  i think there's there's the shock
• 35:53
  there's kind of the denial
• 35:55
  i think there's plenty of patients who um
• 35:57
  do what i did who like
• 35:58
  want another opinion and
• 36:00
  you know when you have that time
• 36:01
  where you can get another opinion
• 36:02
  you can you know
• 36:03
  feel out two different doctors
• 36:05
  but also like you said
• 36:06
  have that room to breathe in accepting your diagnosis
• 36:10
  even just at the very like
• 36:11
  the very surface level of just acceptance of like okay
• 36:14
  i have this now what like
• 36:16
  i think that that becomes a really
• 36:18
  like that can become a really pivotal point
• 36:20
  for patients
• 36:20
  in their ocular melanoma diagnosis journey
• 36:23
  so once they've had that you know
• 36:25
  initial you told them the diagnosis said okay
• 36:28
  we'll talk more about the plan
• 36:29
  like i need you to take a week
• 36:31
  come back let's talk a little more
• 36:32
  and we'll talk about you know
• 36:34
  what's the next plan or the next step in the plan
• 36:37
  how do you approach that next
• 36:38
  you know kind of prior treatment visits
• 36:41
  yeah the next visit is almost always like
• 36:43
  a let's get down to business visit
• 36:45
  because usually after a week or so
• 36:48
  people have kind of wrap their mind around it
• 36:51
  uh they maybe they visited A Cure In Sight
• 36:53
  i tell people all about it
• 36:55
  even facebook groups
• 36:56
  there are people on tiktok talking about their journey
• 36:58
  and a lot of people have looked into it
• 37:00
  and they realize that
• 37:01
  that this is a real thing and it's happening to them
• 37:04
  so by the time they come back to my clinic again
• 37:07
  it feels like we're just gonna get down to business
• 37:10
  like people wanna talk brass tacks pretty quickly
• 37:13
  i have a lot of patients who tell me
• 37:15
  wait a second remind me how this happened
• 37:18
  so we almost always revisit the pathophysiology
• 37:21
  like the pathway of disease progression
• 37:25
  how does someone develop a freckle
• 37:27
  what are the risk features
• 37:28
  of a freckle becoming a melanoma
• 37:30
  we almost always cover that um
• 37:33
  and that that's where we have to kind of
• 37:35
  break
• 37:35
  a little bit of the twenty first century mentality
• 37:38
  a lot of people in the twenty first century
• 37:40
  want to point their finger at something
• 37:42
  or someone or whatever
• 37:43
  and say this is what caused my melanoma
• 37:45
  it was this injury i had in high school
• 37:48
  or vietnam or whatever i hit my head
• 37:51
  and that's why i got a melanoma in the eye
• 37:52
  we have to confront that
• 37:54
  and break some intuition that we think we have
• 37:57
  but we don't really have that
• 37:58
  that almost always happens but
• 38:01
  but then the brass tacks we get the
• 38:03
  we get down to that too
• 38:05
  i feel like that's so universal for cancer in general
• 38:07
  though like even
• 38:10
  even if it's not eye melanoma
• 38:12
  like that's just everybody
• 38:13
  everybody wants that answer right
• 38:15
  you wanna know well
• 38:16
  why did this happen
• 38:17
  and i think that's one of the hardest things to accept
• 38:19
  as a cancer patient is you may never know exactly why
• 38:22
  like on a physiological level
• 38:23
  sure we can explain what changed
• 38:25
  but we can't necessarily explain why
• 38:27
  or what triggered the change
• 38:29
  and i think that can be
• 38:30
  that can be a hard pill to swallow
• 38:32
  i definitely have seen patients get hung up on that
• 38:35
  for patients who are listening
• 38:36
  who maybe are in that spot
• 38:37
  what would you say to them to kind of like
• 38:39
  help them through
• 38:40
  so that we can just move from that kind of fixation
• 38:43
  maybe to let's
• 38:44
  let's take action here yeah i
• 38:47
  i agree it can be
• 38:48
  you could describe it as a fixation for sure
• 38:50
  it's i think
• 38:51
  it's actually
• 38:52
  one of the most fundamentally important questions
• 38:54
  that we deal with and so what i try to do is
• 38:58
  is reintroduce someone to the idea
• 39:02
  that we live in nature and we are frail humans
• 39:06
  trying to understand how nature works
• 39:08
  and there are many things in nature
• 39:10
  that we don't yet understand
• 39:12
  number one
• 39:13
  and their influences that we have no control over
• 39:15
  again this is breaking the 21st century mind
• 39:18
  cause we we pull out our iphone
• 39:19
  and we think we have control over the universe
• 39:21
  but we don't
• 39:23
  so i have to introduce to people conceptually
• 39:25
  the process of developing a freckle
• 39:28
  a single pigment making cell
• 39:30
  when it replicates it can make an air in the dna
• 39:33
  the dna can mutate
• 39:35
  and with further mutations in the dna
• 39:37
  then one of these freckles might become a melanoma
• 39:39
  it's almost statistically probable
• 39:42
  that some people will develop it
• 39:45
  the 21st century mind has a hard time grasping that
• 39:48
  and of course when we talk about like
• 39:50
  what is reported in the literature
• 39:52
  it's almost absurd
• 39:53
  you look at what is associated with eye melanoma
• 39:56
  it's like
• 39:57
  fair complexion and a blue eye
• 40:01
  that describes like
• 40:02
  billions of people yeah
• 40:05
  that describes you
• 40:06
  that describes me and many other people on the earth
• 40:09
  you know yeah
• 40:10
  but it absolutely doesn't explain
• 40:12
  some of the more rare demographics of people who
• 40:14
  i think that was something that you mentioned
• 40:16
  when we talked before is that you
• 40:18
  like in irvine
• 40:18
  california
• 40:19
  you have the opportunity to see some of these
• 40:21
  more rare demographics of patients
• 40:23
  like what are just a few of the
• 40:25
  i guess the categories of like
• 40:26
  ethnicities and people that you've seen um
• 40:28
  just to kind of break that stereotype
• 40:30
  because i think that can be maybe validating for
• 40:33
  for patients who are in the less common group
• 40:36
  it definitely is a stereotype of
• 40:38
  i mean it
• 40:38
  if you look at the incidence of eye melanoma uh
• 40:41
  people with a fair complexion definitely predominate
• 40:44
  the number of people who have it
• 40:45
  but nevertheless
• 40:46
  people without a fair complexion can get it
• 40:48
  in fact today
• 40:49
  i will be doing a radioactive plaque
• 40:51
  for someone who's of japanese ancestry
• 40:54
  in irvine in orange county
• 40:56
  we have a a wide variety of ethnicities
• 41:01
  there is a large vietnamese population in one city
• 41:05
  being in southern california
• 41:06
  there are a lot of people who have immigrated
• 41:08
  from latin countries
• 41:10
  and there are people who are african american
• 41:12
  for example
• 41:13
  so yeah
• 41:14
  i definitely see a difference
• 41:17
  in the way a melanoma appears in the eye
• 41:19
  as compared with someone of a fair complexion
• 41:21
  particularly for african americans
• 41:23
  it can definitely happen it's quite rare
• 41:25
  but the tumors tend to be much darker
• 41:27
  they tend to be diagnosed late for various reasons
• 41:30
  whether they're socioeconomic reasons
• 41:32
  or the tumor wasn't recognized uh
• 41:36
  early on because it's so dark
• 41:37
  as compared with the complexion of the back of the eye
• 41:40
  so it definitely presents some challenges
• 41:43
  for sure
• 41:43
  and this is where we utilize all the tools that we have
• 41:45
  the basic tools do tumors grow over time
• 41:49
  biopsies can be helpful in fact
• 41:50
  we usually draw more from biopsy technology
• 41:53
  in certain instances
• 41:54
  yeah that's super interesting
• 41:56
  well i feel like we could talk so much more about
• 41:58
  you know obviously
• 41:59
  we could talk about the treatment process
• 42:01
  we could talk about after treatment happens
• 42:03
  but i do wanna just kind of reiterate as we close
• 42:06
  as an ocular oncologist
• 42:08
  at what point do you refer to a medical oncologist
• 42:11
  like someone who's going to track scans
• 42:13
  watch the liver
• 42:14
  at what point do you see that kind of
• 42:16
  being the most effective transition
• 42:18
  yeah in ocular oncology
• 42:20
  you'll see a wide variety of opinions on this subject
• 42:23
  the way i was trained and the way i understand
• 42:25
  the best use of medical resources and patients time
• 42:28
  is to assess the tumors
• 42:30
  that have the highest probability
• 42:31
  of developing metastasis and at that point
• 42:34
  involve a medical oncologist
• 42:36
  so this would include people with
• 42:38
  like a large uveal melanoma
• 42:40
  or someone who has high risk genetics
• 42:43
  if both are present or either are present
• 42:46
  i usually ask a medical oncologist to join the
• 42:49
  the screening team but for like
• 42:52
  let's say a small melanoma of low risk genetics
• 42:55
  um an ocular oncologist is usually well suited to
• 42:58
  to do liver metastasis surveillance
• 43:02
  we have a whole literature describing like
• 43:04
  which technology is best used
• 43:05
  like whether it's ultrasound
• 43:07
  liver mris etcetera
• 43:08
  so we draw from that literature a lot of experience
• 43:11
  but also at least in my practice
• 43:13
  and i know very few exceptions to this
• 43:15
  the highest risk lesions usually go to medical oncology
• 43:20
  and the other really important facet of that
• 43:22
  is that the ocular oncologist
• 43:24
  works closely with the medical oncologist
• 43:26
  i demand that i have everyone's cell phone
• 43:30
  i usually text people with my patient's permission
• 43:33
  this is my patient they're coming to you
• 43:36
  these are their genetics this is the tumor size
• 43:38
  i even asked my patients
• 43:39
  can i share you the images with them
• 43:41
  so that they can see
• 43:41
  what the original tumor looked like
• 43:43
  because usually
• 43:44
  medical oncologists don't look inside of the eye
• 43:46
  at all they don't even know what we're talking about
• 43:48
  by the time a patient shows up
• 43:49
  in their clinic it's just a normal looking person
• 43:51
  maybe the eyes a little red
• 43:52
  and that's it
• 43:54
  so no
• 43:55
  i think that's such an important distinction to make
• 43:57
  and
• 43:57
  that's actually something i've never even thought of
• 43:59
  in most cancers you see a medical oncologist
• 44:02
  and they are both responsible for the primary tumor
• 44:05
  and for surveillance well
• 44:07
  our primary tumor is in the eye
• 44:09
  it requires some kind of an eye specialist to treat it
• 44:12
  right
• 44:12
  and then you go to medical oncology and they're like
• 44:15
  i just feel like i can see that being a disconnect
• 44:17
  that could be it would
• 44:19
  it would be interesting i think
• 44:20
  to like see
• 44:22
  you know if you put doctor's heads together
• 44:24
  more like i know it's happening off
• 44:26
  obviously
• 44:26
  it's happening more and more in ocular melanoma
• 44:28
  because as ocular oncologists and medical oncologists
• 44:30
  you guys see the benefit of working together
• 44:32
  but i would just be really interesting to see
• 44:34
  like
• 44:35
  what we could learn from putting our heads together
• 44:37
  in that setting like
• 44:38
  from the moment of a primary
• 44:40
  like high risk tumor
• 44:42
  it'd be interesting to see what
• 44:43
  what that could lead to
• 44:44
  yeah i
• 44:44
  like i said i
• 44:45
  i demand it i'm very loud
• 44:49
  i mean i think that's
• 44:50
  that's a really good thing to have in a doctor
• 44:51
  is someone who's gonna advocate
• 44:53
  you know for you and with you
• 44:54
  you guys like
• 44:55
  if you're listening and you didn't know about Dr. Oakey
• 44:58
  please
• 44:58
  head to our physician finder on ACureInSight.org
• 45:00
  you guys can actually connect with him
• 45:02
  get in um
• 45:03
  get in to go and see him at his clinic
• 45:04
  if you're planning to move to that area
• 45:06
  because you just you know
• 45:07
  want to live close to disneyland
• 45:08
  like make sure you go and say hi to Dr. Oakey
• 45:11
  we've talked about this on a few episodes
• 45:13
  but we do have this physician finder
• 45:14
  and so if you're listening to this youtube channel
• 45:16
  this is your your first opportunity
• 45:18
  of hearing from us at A Cure In Sight
• 45:19
  please head to our website
• 45:21
  um if you can't find it
• 45:22
  you can go ahead and send us a message
• 45:24
  at a contact@ACureInSight.org
• 45:26
  and we will help like
• 45:26
  locate a physician close by
• 45:28
  but i mean that was something that
• 45:29
  that Dr. Oakey and i really wanted to highlight
• 45:31
  was that you know
• 45:32
  there are doctors
• 45:33
  there are physicians from coast to coast
• 45:35
  like
• 45:35
  there really are ocular oncologists from east to west
• 45:39
  and everywhere in between
• 45:40
  like it's just a matter of finding them and
• 45:41
  you know finding the network of people who
• 45:43
  you know
• 45:43
  they know each other and they refer to each other
• 45:46
  totally i have everyone's cell phone
• 45:49
  oh yes
• 45:49
  that's good to know good to know
• 45:50
  so now i have your cell phone
• 45:52
  so if i have somebody that i need to get a hold of
• 45:54
  i'm gonna ask you
• 45:56
  so if patients wanna connect with you on um
• 45:59
  tiktok
• 45:59
  or they wanna just follow your tiktok to learn about um
• 46:01
  what's the channel called
• 46:03
  and can we also include that in our description
• 46:05
  oh yeah
• 46:05
  of course um
• 46:07
  the one on tiktok is the name of my practice
• 46:09
  which is blue coast retina
• 46:11
  i also have uh
• 46:13
  my name on instagram Dr. Zack Oakey
• 46:16
  i have a facebook account
• 46:17
  i have a youtube channel as well uh
• 46:20
  that that goes into the handle of blue coast retina
• 46:22
  in this world you know you
• 46:23
  it's kind of hard to figure out handles and
• 46:27
  account names no i
• 46:28
  i feel like that makes sense
• 46:29
  and we'll make sure to link
• 46:30
  you know these different things as well
• 46:32
  for those of you guys listening
• 46:33
  if you wanna go and check out his practice
• 46:34
  or check out his youtube channel
• 46:36
  tiktok channel all those different ways
• 46:38
  but Dr. Oakey like
• 46:39
  thank you so much for being here
• 46:40
  and for sharing your expertise and
• 46:42
  you know making yourself known to the patient community
• 46:45
  i feel like it makes a huge difference
• 46:46
  i appreciate the privilege
• 46:49
  awesome well
• 46:49
  i just want to give a huge shout out to our sponsors
• 46:52
  we couldn't do this podcast
• 46:53
  without the help of our sponsors
• 46:55
  please use these kinds of resources if you can
• 46:57
  use them to help in explaining things right
• 47:00
  like we as patients
• 47:01
  don't have to bear the load of
• 47:02
  explaining our diagnosis
• 47:03
  explaining how our diagnosis happens
• 47:06
  um and thank you again
• 47:07
  Zack for just
• 47:08
  all of
• 47:08
  your references to what we do here at A Cure In Sight
• 47:10
  and your willingness to you know
• 47:11
  collaborate with us and to help patients find us
• 47:14
  um we really appreciate it
• 47:15
  i love it
• 47:16
  awesome well
• 47:17
  we will see you guys next time