Intraocular Paraganglioma

An intraocular paraganglioma is a very rare tumor that starts inside the eye. It grows from a type of nerve cell called a chromaffin cell, which normally helps the body control stress hormones. When these cells grow out of control, they form a mass that can look like other eye tumors, such as ocular melanoma. Only four cases of intraocular paraganglioma have been described in medical papers, making this one of the rarest eye tumors ever reported PubMed.

Intraocular paraganglioma is an exceedingly rare neuroendocrine tumor arising from paraganglionic (chromaffin) cells located within the eye or orbit. These tumors are related to pheochromocytomas and paragangliomas found elsewhere in the body but occur intraocularly or intra-orbitally. Patients may present with painless vision loss, proptosis (bulging eye), or an intraocular mass discovered on routine examination. Histologically, they consist of nests (“zellballen”) of chief cells supported by sustentacular cells, and they stain positively for neuroendocrine markers such as chromogranin and synaptophysin. Diagnosis relies on imaging—ultrasound, MRI, and contrast-enhanced CT—to define the lesion, and on biopsy for definitive histopathology EyeWiki.

Paragangliomas and pheochromocytomas together are often called PPGLs. Pheochromocytomas grow in the adrenal gland above the kidney, while paragangliomas grow in nerve cell clusters outside the adrenal gland. Paragangliomas are itself quite uncommon, occurring in about 0.4 to 9.5 people per million each year EyeWikiWikipedia. When one appears inside the eye, it most often shows up in either the iris (the colored part) or the choroid (the layer behind the retina).

Types of Intraocular Paraganglioma

Although still very rare, intraocular paragangliomas have been reported in a few distinct locations within the eye:

1. Iris paraganglioma: This type starts in the colored ring around the pupil. It was first described in 1994, when doctors removed an iris mass and found cells that matched paraganglioma on lab tests PubMed.

2. Choroidal paraganglioma: This type grows in the pigmented layer behind the retina. In reported cases, these masses often mimic non-pigmented choroidal melanomas, making them hard to recognize without a biopsy EyeWikiPubMed.

3. Ciliary body paraganglioma (the muscle layer that helps the eye focus): Though not yet reported in the literature, it is theoretically possible since the ciliary body contains nerve cells related to the iris and choroid.

Each type can behave differently. Iris tumors may cause visible lumps or color changes, while choroidal tumors may lead to vision loss or retinal detachment.

Causes

Most intraocular paragangliomas arise without a clear trigger. However, factors that raise the risk of developing any paraganglioma include genetic changes and familial syndromes. Below are 20 known causes or risk factors for paragangliomas in general, which also apply to the very rare intraocular form:

1. Sporadic mutations in chromaffin cells, where no family history is present WikipediaMayo Clinic.

2. SDHB gene mutations (succinate dehydrogenase complex subunit B) leading to cell overgrowth Wikipedia.

3. SDHC gene mutations (succinate dehydrogenase complex subunit C) altering cell energy cycles Wikipedia.

4. SDHD gene mutations (succinate dehydrogenase complex subunit D) linked to head and neck paragangliomas Wikipedia.

5. SDHA gene mutations (succinate dehydrogenase complex subunit A) rare but implicated in hereditary cases Wikipedia.

6. SDHAF2 gene mutations (SDH complex assembly factor 2) causing familial tumors Wikipedia.

7. TMEM127 gene mutations (transmembrane protein 127) affecting cell growth signals Wikipedia.

8. MAX gene mutations (MYC associated factor X) that regulate cell death and division Wikipedia.

9. SLC25A11 gene mutations altering mitochondrial transport, linked to metastasis Wikipedia.

10. VHL gene mutations (Von Hippel-Lindau syndrome), which also cause other tumors Wikipedia.

11. NF1 gene mutations (Neurofibromatosis type 1) associated with multiple nerve cell tumors Wikipedia.

12. RET proto-oncogene mutations (MEN 2A and 2B) leading to multiple endocrine tumors Wikipedia.

13. Multiple endocrine neoplasia type 2A (MEN 2A) syndrome with thyroid and parathyroid tumors Mayo Clinic.

14. Multiple endocrine neoplasia type 2B (MEN 2B) with mucosal neuromas and paragangliomas Mayo Clinic.

15. Von Hippel-Lindau disease causing blood vessel tumors and paragangliomas Mayo Clinic.

16. Neurofibromatosis 1 (NF1), where skin and nerve tumors co-exist with paragangliomas Mayo Clinic.

17. Carney-Stratakis dyad, featuring gastrointestinal stromal tumors and paragangliomas Mayo Clinic.

18. Family history of paraganglioma, indicating inherited risk Mayo Clinic.

19. Alterations in hypoxia-inducible factors, such as EPAS1 mutations in Pacak–Zhuang syndrome Wikipedia.

20. Unknown environmental triggers (studies are ongoing), though no clear external cause has been proven to date Mayo Clinic.

Symptoms

Intraocular paragangliomas can cause both local eye symptoms and systemic signs from hormone release. Below are 15 symptoms you may notice:

1. Blurred vision when light doesn’t focus correctly on the retina EyeWiki.

2. Progressive vision loss, ranging from mild dimming to complete blindness in one eye EyeWiki.

3. Eye pain, caused by tumor pressure or inflammation EyeWiki.

4. Redness of the eye when blood vessels become more visible EyeWiki.

5. Floaters (tiny spots drifting in your field of vision) from debris in the eye EyeWiki.

6. Photophobia (sensitivity to light), due to iris involvement EyeWiki.

7. Watery eyes, as the tear system reacts to irritation EyeWiki.

8. Pulsatile tinnitus (hearing your heartbeat in your ear) from nearby blood vessel pulsation Mayo Clinic.

9. Headache, especially near the affected eye EyeWiki.

10. High blood pressure, from excess catecholamine release Mayo Clinic.

11. Palpitations (fast or irregular heartbeat) when stress hormones flood the bloodstream Mayo Clinic.

12. Sweating and diaphoresis, especially during episodes of hormone surge Mayo Clinic.

13. Anxiety or panic attacks, caused by hormone swings Mayo Clinic.

14. Unexplained shakiness in the hands or arms Mayo Clinic.

15. Often no symptoms until the tumor grows large or hormones rise EyeWiki.

Diagnostic Tests

Physical Exam

1. Visual acuity test examines how clearly each eye sees by reading letters on a chart.

2. Pupillary light reflex checks how the pupils respond to light, revealing nerve involvement.

3. Intraocular pressure measurement (tonometry) tests for pressure buildup that may accompany tumors.

4. Slit-lamp examination uses a microscope and bright light to inspect the front and back of the eye.

5. Fundoscopic (ophthalmoscopic) exam looks at the retina and choroid for abnormal masses or detachments EyeWiki.

Manual Tests

6. Amsler grid test involves looking at a grid of lines to detect scotomas (blind spots) caused by retinal distortion.

7. Color vision testing (Ishihara plates) identifies color-perception changes from retinal involvement.

8. Visual field confrontation assesses side-vision losses by comparing what you see to the examiner’s view.

Laboratory and Pathological Tests

9. Plasma free metanephrines measure stress-hormone breakdown products in a blood sample, often high in paraganglioma Mayo Clinic.

10. 24-hour urinary metanephrines collect urine over one day to detect excess catecholamine metabolites Mayo Clinic.

11. Serum chromogranin A level, a marker for neuroendocrine tumors, may be elevated.

12. Histopathology and immunohistochemistry of biopsy tissue reveal the classic “zellballen” cell pattern and stain positive for chromogranin and synaptophysin EyeWiki.

Electrodiagnostic Tests

13. Electroretinography (ERG) records electrical responses of retinal cells to light flashes, detecting dysfunction.

14. Visual evoked potentials (VEP) measure brain signals triggered by visual stimuli to check optic nerve pathways.

15. Electrooculography (EOG) tracks eye-movement electrical changes to assess retinal pigment layer health.

Imaging Tests

16. B-scan ultrasound uses sound waves to image the inside of the eye and detect masses or retinal detachment EyeWiki.

17. Optical coherence tomography (OCT) provides a cross-sectional view of the retina and underlying layers for tumor mapping.

18. Magnetic resonance imaging (MRI) of the orbit gives detailed soft-tissue contrast to locate intraocular and extraocular spread.

19. Computed tomography (CT) of the eye and brain can show calcifications, bone involvement, and mass borders.

20. 68Ga-DOTATATE PET/CT highlights neuroendocrine tumors anywhere in the body, useful if other paraganglioma sites are suspected Wikipedia.

Non-Pharmacological Treatments

Below are non-drug therapies used—often extrapolated from management of other ocular tumors—focused on local tumor control, vision preservation, or symptom relief. Each paragraph explains the therapy, its purpose, and underlying mechanism in simple terms.

1. Plaque Brachytherapy
   A small radioactive plaque (commonly Iodine-125 or Ruthenium-106) is sewn onto the sclera next to the tumor. Its purpose is to deliver a high dose of radiation directly to the tumor, with minimal exposure to surrounding healthy tissues. The seeds emit ionizing radiation that causes DNA breaks in tumor cells, leading to cell death Memorial Sloan Kettering Cancer CenterPMC.

2. External Beam Radiotherapy (EBRT)
   EBRT uses external high-energy X-rays directed at the tumor from multiple angles. It shrinks the tumor and relieves pressure symptoms. The ionizing radiation damages the tumor’s DNA, preventing cells from dividing and causing them to die EyeWikiSpringerOpen.

3. Proton Beam Therapy
   This modality employs charged proton particles that deposit most of their energy at a precise depth (“Bragg peak”), sparing overlying structures like the lens and optic nerve. It’s used for larger or irregularly located tumors to maximize tumor kill while protecting vision. Protons induce DNA strand breaks, leading to apoptosis (programmed cell death) SpringerOpen.

4. Stereotactic Radiosurgery (Gamma Knife)
   Many narrow beams of gamma radiation converge on the tumor in a single session. Its purpose is to ablate small lesions non-invasively. The focused beams induce double-strand DNA breaks, triggering tumor cell death with submillimeter precision EyeWikiSpringerOpen.

5. CyberKnife® Radiosurgery
   A robotic, image-guided system delivers multiple high-dose radiation beams from varying angles. It treats tumors not amenable to plaque placement or standard radiosurgery. The mechanism mirrors stereotactic approaches: targeted radiation causes irreparable DNA damage in tumor cells UT Southwestern Medical Center.

6. Transpupillary Thermotherapy (TTT)
   Infrared laser light is focused through the pupil onto the tumor, heating it to around 45–60 °C. The heat denatures tumor proteins, disrupts microcirculation, and kills cells. It’s used for small, flat tumors or as an adjunct after radiation to reduce residual disease PubMedMichigan Medicine.

7. Laser Photocoagulation
   Visible (green or diode) lasers are applied to the lesion to coagulate its blood vessels, causing ischemia and shrinkage. The absorbed light energy converts to heat, inducing coagulative necrosis. It’s most suited for very superficial lesions or feeder vessels in the orbit Cancer.org.

8. Photodynamic Therapy (PDT)
   A photosensitizing drug (e.g., verteporfin) is given intravenously and accumulates in tumor cells. A specific wavelength of light is then shone onto the lesion, activating the drug to produce reactive oxygen species that destroy tumor cells and their vessels. This approach offers selective cytotoxicity with minimal collateral damage UT Southwestern Medical Center.

9. Cryotherapy
   A probe cooled by liquid nitrogen or argon gas freezes the tumor tissue, forming ice crystals that rupture cell membranes and occlude blood vessels. Repeated freeze-thaw cycles cause cell death and necrosis. It’s used for accessible orbital lesions or to manage small, external tumors PMCSpecialty Vision.

10. High-Intensity Focused Ultrasound (HIFU)
    Ultrasound waves converge on the tumor, raising its temperature and causing coagulative necrosis. The acoustic energy also induces mechanical disruption of cell membranes. HIFU is non-invasive and can reach deep lesions without incisions PMCCleveland Clinic.

11. Irreversible Electroporation (IRE)
    Short, high-voltage electrical pulses create permanent nanopores in tumor cell membranes, leading to loss of homeostasis and apoptosis. The extracellular matrix remains intact, preserving nearby critical structures. IRE is emerging for tumors adjacent to optic nerves or vessels PMCWikipedia.

12. Radiofrequency Ablation (RFA)
    A needle electrode is inserted into the tumor, delivering alternating current that generates frictional heat, destroying cells by coagulative necrosis. It’s image-guided and can treat tumors up to 3 cm in size in the orbit Mayo ClinicAnnals of Palliative Medicine.

13. Microwave Ablation
    Microwaves emitted from a percutaneous antenna cause rapid oscillation of water molecules in tumor cells, producing heat and cell death. It achieves larger ablation zones faster than RFA, suitable for bulky orbital tumors PMCWikipedia.

14. Hyperthermia Therapy
    Regional or whole-body heating to 40–43 °C sensitizes tumor cells to radiation and chemotherapy. Heat disrupts proteins and cell membranes, and induces immune responses. It’s used alongside radiotherapy to enhance tumor kill Wikipedia.

15. Cryoimmunotherapy
    Combines cryoablation with immunomodulation. Freezing releases tumor antigens in situ, stimulating dendritic cells and T-cell responses. This can induce systemic anti-tumor immunity beyond the local lesion Wikipedia.

16. Sonodynamic Therapy
    A sonosensitizer drug (e.g., hematoporphyrin) accumulates in tumor cells. Ultrasound activation generates reactive oxygen species, causing cell death. It offers deep penetration and selective cytotoxicity Wikipedia.

17. Proton Microparticle Therapy
    Uses microbeams of protons to create highly localized DNA damage tracks. It’s experimental but may allow ultra-precise ablation of small, invasive tumors near critical structures SpringerOpen.

18. Electrochemotherapy (ECT)
    Short electric pulses enhance tumor cell uptake of chemotherapeutic drugs like bleomycin, increasing their efficacy without raising systemic doses. ECT combines physical and chemical modalities for focal control PMC.

19. Targeted Thermal Laser Therapy
    Nd:YAG or excimer lasers tuned to specific tumor chromophores produce localized heating. The goal is to coagulate tumor tissue while sparing retina and optic nerve Cancer.org.

20. Vision Rehabilitation Therapy
    After tumor control, structured low-vision rehabilitation—including visual aids, orientation training, and occupational therapy—enhances patients’ functional vision and quality of life. While not tumor-directed, it’s a crucial non-drug intervention for long-term well-being.

Drug Treatments

Below are key medications used when systemic therapy is indicated (especially for metastatic or unresectable disease):

1. Cyclophosphamide (Alkylating agent)

   • Dosage: 750 mg/m² IV every 21 days (part of CVD regimen).

   • Time: Cycles repeated until disease progression.

   • Purpose: Tumor cytotoxicity.

   • Mechanism: Cross-links DNA to prevent replication.

   • Side Effects: Myelosuppression, hemorrhagic cystitis, nausea. PMC

2. Vincristine (Vinca alkaloid)

   • Dosage: 1.4 mg/m² IV on Day 1 of CVD.

   • Purpose: Disrupts mitosis in dividing tumor cells.

   • Mechanism: Inhibits microtubule formation.

   • Side Effects: Peripheral neuropathy, constipation. PMC

3. Dacarbazine (Alkylating agent)

   • Dosage: 600 mg/m² IV on Day 1 of CVD.

   • Purpose: Induces DNA methylation damage.

   • Mechanism: Alkylates guanine residues.

   • Side Effects: Nausea, myelosuppression. PMC

4. Temozolomide (Oral alkylator)

   • Dosage: 150–200 mg/m²/day for 5 days in 28-day cycle.

   • Purpose: Alternative to CVD in some protocols.

   • Mechanism: DNA methylation causing apoptosis.

   • Side Effects: Fatigue, headache, thrombocytopenia.

5. High-Specific-Activity ^131I-MIBG

   • Dosage: 200 mCi IV (adjusted by whole-body scan uptake).

   • Purpose: Targets norepinephrine transporter–expressing tumors.

   • Mechanism: Radioactive uptake leads to local radiation damage.

   • Side Effects: Myelosuppression, nausea. PMC

6. Sunitinib (Tyrosine kinase inhibitor)

   • Dosage: 37.5 mg orally daily.

   • Purpose: Anti-angiogenic in metastatic disease.

   • Mechanism: Inhibits VEGFR and PDGFR pathways.

   • Side Effects: Hypertension, hand-foot syndrome. Frontiers

7. Everolimus (mTOR inhibitor)

   • Dosage: 10 mg orally daily.

   • Purpose: Inhibits tumor cell growth.

   • Mechanism: Blocks mTOR pathway, halting proliferation.

   • Side Effects: Stomatitis, hyperglycemia.

8. Lenvatinib (Multi-kinase inhibitor)

   • Dosage: 24 mg orally daily.

   • Purpose: Anti-angiogenic in unresectable cases.

   • Mechanism: Inhibits VEGFR, FGFR.

   • Side Effects: Hypertension, proteinuria.

9. Belzutifan (HIF-2α inhibitor)

   • Dosage: 120 mg orally daily.

   • Purpose: Treats advanced PPGL with EPAS1 mutations.

   • Mechanism: Blocks hypoxia pathway, reducing tumor growth.

   • Side Effects: Anemia, fatigue. Wikipedia

10. Pembrolizumab (Anti–PD-1 antibody)

    • Dosage: 200 mg IV every 3 weeks.

    • Purpose: Immunotherapy for progressive metastatic disease.

    • Mechanism: Blocks PD-1 checkpoint, enhancing T-cell attack.

    • Side Effects: Fatigue, pruritus, diarrhea. PubMed

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Dietary Molecular & Herbal Supplements

These supplements are proposed to support general health and may have antioxidant or anti-inflammatory effects; clinical evidence in paraganglioma is limited.

1. Curcumin (500 mg × 3 daily): Anti-inflammatory via NF-κB inhibition.

2. EGCG (Green Tea Extract) (300 mg daily): Antioxidant, induces tumor cell apoptosis.

3. Resveratrol (200 mg daily): Activates SIRT1, modulates cell cycle.

4. Quercetin (500 mg × 2 daily): Inhibits tyrosine kinases, antioxidant.

5. Vitamin C (1 g daily): Scavenges free radicals, supports collagen.

6. Vitamin D (2,000 IU daily): Immunomodulatory, may suppress tumor growth.

7. Vitamin E (400 IU daily): Lipid-soluble antioxidant protecting membranes.

8. Selenium (200 µg daily): Cofactor for glutathione peroxidase, antioxidant.

9. Omega-3 Fatty Acids (1 g EPA/DHA daily): Anti-inflammatory mediator production.

10. Coenzyme Q10 (100 mg × 2 daily): Mitochondrial electron transport, antioxidant.

11. Melatonin (3 mg nightly): Regulates circadian rhythm, pro-apoptotic in tumor cells.

12. Silymarin (Milk Thistle) (140 mg × 3 daily): Hepatoprotective flavonoid.

13. Ginkgo biloba (120 mg × 2 daily): Improves microcirculation, antioxidant.

14. Ashwagandha (500 mg × 2 daily): Adaptogen, may modulate stress response.

15. Ginger Extract (250 mg × 3 daily): Anti-nausea and anti-inflammatory.

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Immuno/Regenerative & Stem-Cell-Related Agents

1. Pembrolizumab (Anti-PD-1 monoclonal antibody) – see above PubMed.

2. Nivolumab (Anti-PD-1) 240 mg IV every 2 weeks – similar checkpoint blockade.

3. Ipilimumab (Anti-CTLA-4) 3 mg/kg IV every 3 weeks for 4 doses – enhances T-cell priming.

4. High-specific-activity ^131I-MIBG – see above PMC.

5. CAR T-cell therapy (investigational) – T cells engineered to target tumor antigens.

6. Belzutifan – see above Wikipedia.

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Surgeries

1. Enucleation: Removal of the entire globe for large or unresponsive tumors to prevent spread Wikipedia.

2. Evisceration: Removal of intraocular contents, leaving scleral shell to reduce pain in a blind, painful eye Wikipedia.

3. Partial Lamellar Sclerouvectomy: Microsurgical excision of tumor‐involved uveal tissue to preserve vision Wikipedia.

4. Transretinal Endoresection: Removes subretinal tumor via vitrectomy; used for certain choroidal lesions Wikipedia.

5. Vitrectomy: Addresses associated retinal detachment or hemorrhage to maintain ocular integrity EyeWiki.

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 Prevention Strategies

1. Genetic Counseling & Testing: For patients with family history of PPGL syndromes EyeWiki.

2. Regular Eye Exams: Early detection via dilated fundus evaluation Mayo Clinic.

3. Blood Pressure Control: Lowers risk of hormone‐secreting tumor complications.

4. UV Protection: Sunglasses and hats to reduce ocular UV exposure (analogy from melanoma prevention) Wikipedia.

5. Healthy Weight & Exercise: Reduces chronic inflammation and cancer risk Cancer.org.

6. Balanced Diet: Emphasize fruits, vegetables, whole grains; limit processed foods Cancer.org.

7. Avoid Tobacco & Excess Alcohol: Minimizes overall cancer risk Cancer.org.

8. Stress Management: Psychological resilience may support immune surveillance.

9. Occupational Safety: Limit radiation or toxic exposures near the head.

10. Prompt Evaluation of Eye Symptoms: Any new floaters, flashes, or vision changes warrant urgent review Mayo Clinic.

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When to See a Doctor

Seek specialist evaluation if you experience:

• Blurred or distorted vision

• New floaters or flashes

• A visible dark spot or mass in the eye

• Sudden eye pain or redness

• Uncontrolled hypertension or palpitations with eye symptoms Mayo Clinic.

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Dietary “Do’s and Don’ts”

Do eat:

• Colorful fruits & vegetables (≥ 5 servings/day) Cancer.org

• Whole grains (at least half your grain intake) Cancer.org

• Legumes and nuts for protein & fiber Cancer.org

• Fatty fish (omega-3 source)

Avoid:

• Processed meats (bacon, sausage) and red meats Cancer.org

• Sugary drinks and refined carbohydrates Cancer.org

• Excessive alcohol (no more than 1 drink/day for women; 2 for men) Cancer.org

• Trans fats and highly processed foods

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Frequently Asked Questions

1. What causes intraocular paraganglioma?
   Genetic mutations (e.g., SDH, VHL, RET) or sporadic changes cause chromaffin cells to proliferate abnormally EyeWiki.

2. How rare is this tumor?
   Only 4 cases in the literature; PPGLs overall occur in 0.4–9.5 per million people/year PubMedEyeWiki.

3. What symptoms should raise concern?
   Blurred vision, floaters, a visible mass, retinal detachment, or catecholamine excess (hypertension, palpitations) Mayo Clinic.

4. How is it diagnosed?
   Fundoscopy, ultrasound/MRI, and biopsy with chromogranin/synaptophysin staining confirm diagnosis EyeWiki.

5. Is it cancerous?
   Paragangliomas can be benign or malignant; malignancy is defined by metastasis rather than histology EyeWiki.

6. What are the main treatments?
   Plaque brachytherapy, proton beam, surgical resection, systemic therapies (CVD chemo, immunotherapy) WikipediaPubMed.

7. Can vision be saved?
   Globe-sparing treatments (plaque, proton) aim to preserve vision in small to medium tumors; larger lesions often require enucleation Wikipedia.

8. What is the prognosis?
   Data are limited; small, localized tumors treated early have better outcomes. Metastatic cases have 5-year survival rates similar to other PPGLs (30–60%) PMC.

9. Is genetic testing recommended?
   Yes, for all PPGLs to identify familial syndromes and guide screening EyeWiki.

10. Can it recur?
    Yes—monitor with regular eye exams and systemic imaging every 6–12 months.

11. Are there clinical trials?
    Immunotherapy trials (e.g., pembrolizumab) and targeted agents (sunitinib, belzutifan) are ongoing ClinicalTrials.gov.

12. How often should I have follow-up?
    Typically every 3–6 months with imaging and eye exams for the first 2 years, then annually EyeWiki.

13. What specialists are involved?
    Ophthalmic oncologist, medical oncologist, radiation oncologist, geneticist, and low-vision therapist.

14. Can lifestyle changes help?
    A healthy diet, regular exercise, and stress management support overall well-being and may aid recovery Cancer.org.

15. Where can I learn more?
    Consult patient resources from the American Cancer Society, National Eye Institute, and Rare Tumor Foundations.

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Last Updated: August 07, 2025.

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