Moles of this type were first brought to public attention by John le Carré, the British spy novelist in his classic tome, Tinker, Tailor, Soldier, Spy, although Francis Bacon coined the word in 1626 in a history of King Henry VII. Aldrich Ames is the infamous CIA operative who was incarcerated in a small cell in Terre Haute, Indiana, in 1994 for espionage on behalf of the Soviet Union. The 1998 movie A Traitor Within tells the story of this mole very well, in my opinion. So that just leaves mushrooms—the third type of clandestine mole.
Most people have pigmented spots on their bodies; when flat, we call them “freckles,” and when raised, they are known as moles, or naevi in medical-speak. Babies are rarely born with such lesions, but if they do enter the world’s stage with a mole, they tend to be larger than those acquired during life. Moles come in a range of shapes, sizes, and colors, but all result from pigment-producing cells growing in clumps. There are many different types of moles, including blue naevi, halo moles, lentigo (“age” or “liver” spots), dermal, dysplastic (or “Clark” moles), Spitz, Reed, and many others. But the key issue is, are they benign or malignant? In other words, is this a cute, cuddly mammal or a spy that is going to potentially incarcerate you in a small box in the ground?
Today, I want to consider one specific mole location, in the back of your eye under your retina. At medical school, we were taught to “beware the man with a glass eye and a large liver,” which referred to a patient who had lost an eye to malignant melanoma, a mole-like lesion, and subsequently developed secondary liver tumors. The lesson here is that melanoma is a nasty disease that ideally you want to avoid by choosing your genes (!) and mitigating sun damage with high SPF lotion, clothing, and hats. Although sunglasses are a good idea for other reasons, eye melanoma is not thought to be related to UV light, unlike skin melanoma. But if you cannot avoid it, at least catch it early. While skin surveillance is regularly promoted by this author among others, checking your eye for melanoma is not sufficiently communicated to my mind. As the inside of the eye is not readily visible to us, we need help. Enter the optometrist or expert eye doctor, an ophthalmologist.
While a standard aviation medical includes a sight test with charts, there is so much more a detailed eye exam can uncover. For instance, one should have tonometry, a test to measure pressure inside the eye, which can indicate the presence of glaucoma, a condition that erodes sight (The Silent Thief, April 2023 https://pilot-protection-services.aopa.org/news/0001/january/01/the-silent-thief).
After dilating the pupil with drops, a skilled practitioner can perform a careful and detailed examination of the back of the eye including the retina, the light-detecting membrane at the back of the eye, at which time images can be taken. Abnormalities in this area might indicate issues with high blood pressure, diabetes, and other conditions. However, the focus today is on pigmented lesions, which can include:
Choroidal Nevus: This very common mole is found inside the blood vessel layer deep into the retina. The vast majority are benign, meriting occasional monitoring.
Congenital Hypertrophy of the Retinal Pigment Epithelium (CH-RPE): Effectively harmless birthmarks, often a solo, dark flat spot near the periphery and it remains unchanged throughout life.
Congenital Grouped Pigmentation: This is where there are groups of small, flat, dark lesions in one area of the retina, may be larger toward the periphery and don’t affect eyesight.
Familial Adenomatous Polyposis: This is a condition I saw in my area of surgery where colon cancer is a consequence. In the eye, one sees larger, dark spots with comma-shaped tails, often on both sides.
RPE Hyperplasia: Trauma or inflammatory conditions can lead to these thickened and pigmented lesions.
RPE Hamartoma: A rare condition where a benign tumor arises and can present as a pigmented lesion.
RPE Adenoma/Adenocarcinoma: Thankfully very rare, this potentially malignant tumor originates from the RPE and is a dark, raised mole.
So, there are a range of reasons a doctor may see a pigmented lesion, which could be nothing sinister—or might be a malignant melanoma. Truth is, all together pigmented spots are common, but are mostly symptom and consequence free, so without a regular and detailed eye check-up, how would one know there is a problem?
Assuming a pigmented lesion is seen, your doctor might perform:
Optical coherence tomography (OCT): This is a way to build a very high-quality set of cross-sectional images that will allow the doctor to determine the size, depth, and thickness of a small mole and diagnose other lesions
Fluorescein angiography (FA): One might have an intravenous injection of dye, and its course through the retinal blood vessels can be mapped, uncovering abnormal patterns that some moles produce.
Ultrasound (B-scan): A probe is placed over the closed eyelid or on the eye itself to evaluate further characteristics of the lesion’s size. Having experienced both, I vote for the former!
So how do all these data points allow an ophthalmologist to determine whether a mole is harmless or merits intervention? I talked to Professor Mandeep Sagoo, an internationally acclaimed eye surgeon who specializes in the treatment of retinal disorders and eye tumors (https://drsagoo.com/), and he told me that “larger spots, irregular borders, variable coloration, and other features matter.” That is where moles come in, specifically MOLES! This is a grading system that will allow your doctor to chart and discuss a sensible course of action:
M: Mushroom shape
O: Orange pigment
L: Large size
E: Enlarging over time
S: Subretinal fluid—one might see this on the OCT or ultrasound scans
Each of these criteria are scored 0 for absent, 1 for subtle or uncertain, and 2 for present. The score is added, and if:
0: This is a common naevus with a minimal risk of turning malignant. A monitoring protocol will be suggested depending on other factors like age.
1: This score means one subtle feature is present and although malignancy is unlikely, follow-up should be a little more frequent.
2: The suspicion of malignancy is higher and therefore monitoring should be more frequent and might include repeated OCT and ultrasound tests.
3 and higher: Malignant melanoma, a tumor that can spread elsewhere and kill, is sadly more likely and requires review by an ophthalmologist skilled in the management of this condition (an ocular oncologist). A score of 3 or above warrants prompt referral to a specialist for further evaluation and potential treatment options like laser therapy, radiation therapy, or even surgical removal.
I always think aviation analogies work well; we monitor tire and turbo inlet pressures to prevent blowouts, clean our windshields to preclude perpetual IMC, and avoid dark spots on weather radar to avoid flying into storms. Regular and detailed eye exams prevent the ocular equivalents and will ensure you see well into your future. And if an abnormality is found, consult an expert like the good Professor Sagoo!
As ever, if there is any issue compromising health, safe-ground until resolved and report abnormal findings to your AME.
Fly Well!
I am excited to announce a podcast I am doing with my old medical school colleague and dear friend, Dr. Nigel Guest.
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