Alberta Cancer Foundation

Clearly Now

If he hadn’t become a medical researcher and eye surgeon, Dr. Ezekiel Weis says he would have been a professional mountain-climbing guide, shepherding less experienced climbers through dangerous, difficult climbs and making sure they lived to tell the tale. But for Carol Balcerzak, cancer patient, he did just that, metaphorically anyway.

Eyes Front: Ezekiel Weis took an opthamology elective on a whim. The first eye surgery he saw had him hooked.
Photo by Aaron Pedersen

Before the distortions and arcs of light across her vision, before the ocular angiograms and blood work and ultrasounds and anxiety, before Ezekiel Weis sutured a radioactive gold disc to the back of her eyeball, Balcerzak had 20/20 eyesight. Clear as crystal. There was a time, long past, she used to wear glasses, but laser eye surgery fixed that.

To look at Balcerzak today, you wouldn’t know that she doesn’t still enjoy perfect vision – not in one eye, anyway. The young mother of two appears totally healthy, with none of the stereotypical appearance associated with cancer treatment. Her lustrous hazel eyes move and look like a perfectly normal set of peepers.

But Balcerzak developed intraocular melanoma in her right eye in March 2011, and can only see peripherally out of that eye as a result. A treatment new to Alberta, brought to the Cross Cancer Institute by Weis and a large team of ophthalmologists, medical physicists, nurses and others, let Balcerzak keep her eye – and her life. Ocular brachytherapy debuted in the Canadian Prairies late last year, thanks in part to funding from the Alberta Cancer Foundation. Now it will help around 30 to 35 Canadians a year.

The idea of handling other people’s eyeballs for a living might strike some as grotesque, but Weis, who grew up in Calgary, says determination, training and experience trump squeamishness. “Once you sit in the driver’s seat, you have a job to do,” he says. “That takes over most of your emotions.” In the fifth year of his residency at the Royal Alexandra Hospital, he repaired the eye of an Edmonton man suffering from a machete wound. Weis recalls it as a moment of memorable triumph.

Ocular melanoma, by far the most common type of cancer found in the eye, has a survival rate of about 50 per cent. That might seem strangely low. The cancer’s deadly character stems from its access to the bloodstream. Many cancers move through the body via the lymphatic system but, since that network doesn’t extend inside the eye, ocular melanoma travels through the bloodstream, which does reach the eye. For yet-unknown reasons, it often metastasizes in the liver, at which point mortality is all but certain.

For much of the 20th century, modern medicine’s technique for preventing this was as primitive as it was effective: removal of the eye, called enucleation. While the idea might seem crude in the age of modern technology, enucleation produced the best survival rate for ocular melanoma. Plus, artificial eyes can provide a surprisingly good facsimile for the empty socket post-surgery.

And then in the 1990s, medical research revealed the power of ocular brachytherapy.

Radiation kills tumours, but it also destroys other tissue. The problem of applying its power precisely to a malignant tumour and not to adjacent healthy cells prevented conventional beam-radiation therapy from replacing enucleation as the dominant treatment for ocular melanoma. But enucleation means the total removal of the eyeball, which most people feel a figurative and literal attachment to.

The ideal solution is the precise application of radiation to tumours and not to surrounding tissue, and this is what ocular brachytherapy allows. Radiation hits the tumour and almost nothing else. Plus, 60 per cent of patients retain some kind of vision in the treated eye. Because it’s super-precise radiation and not chemotherapy, patients don’t even lose eyelashes from the treatment, never mind whole heads of hair.

The therapy achieves this by placing the source of radiation on the eyeball itself. Medical physicists prepare radioactive “seeds” of iodine, covered in plastic and silicon and embedded in a gold disc. A surgeon hand-sutures the disc onto the white of the patient’s eye at the precise location where the radiation will damage the tumour. The optic nerve has between five and eight millimetres of slack in it, which allows the eye to be rotated for this suturing. Fine control limits radiation damage to the healthy parts of the eye, and the dense gold prevents it from leaking into the delicate and squishy circuitry of the brain. The procedure requires a second surgery to remove the disc after around a week.

For Balcerzak, that might have meant another expensive and difficult trip to Toronto. She was willing to head east for the surgery, of course – an eyeball is worth more than a few plane tickets. But that didn’t make it easy. She had to take time off work, as did her boyfriend, Ryan Peterson. These things run into money. Their two young children, Jacob and Jade, stayed with their grandparents.

Fortunately for Balcerzak, at the time of her trip Weis and a large team of medical staff in the province, including Dr. John McWhae, another ocular oncologist trained in brachytherapy and working in Calgary, were reaching the closing phases of setting up an ocular brachytherapy program at the Cross Cancer Institute. (Other key members include medical physicist Dr. Matthew Larocque and radiation oncologist Dr. Kurian Joseph.) Weis, who went to medical school in Calgary and trained in Vancouver, Ottawa, Amsterdam and Philadelphia, wanted to establish a brachytherapy program in Alberta right after he finished school and came to work in Edmonton. The recent recession was rolling up its sleeves and getting down to business, so funding took a hit and the program’s start up was delayed.

This was a letdown for Weis, who decided to become an ocular surgeon while in medical school. He initially took an elective in ophthalmology on a lark, but on the first day of the class he met a man who urgently needed eye surgery. After Weis witnessed his instructor, Dr. Tom Chang, perform the delicate surgery and saw what improved vision meant for the patient, he decided to become an eye surgeon.

Photos by Aaron Pedersen

Enter the Alberta Cancer Foundation. It supplied finances to set up the program and operate it for one year, letting the team get the program off the ground. Now, the Cross Cancer Institute will provide ocular brachytherapy for western Canadians who need it, around 30 to 35 patients a year. That number will maintain the surgical team’s expertise through practice, meaning ocular brachytherapy programs won’t spring up elsewhere in the prairies.

The benefits of the location are more significant than you might think. In addition to multiple surgeries, ocular brachytherapy requires an unusual number of post-surgery checkups. Patients see their oncologist roughly every three months for the first two years after surgery, and less frequently beyond that. The procedure’s availability in Alberta means, for Balcerzak, the difference between a three-hour drive and a quarterly cross-country plane flight.

Balcerzak had actually booked the procedure in Toronto, but was able to cancel her appointment while en route to Edmonton for an appointment with Weis. He performed the first of Balcerzak’s two surgeries on Halloween of 2011. Balcerzak was able to recuperate at home instead of a hospital bed as a result, and she had the disc removed after eight days. She was surprised at how little post-surgery pain she felt and at how unobtrusive the disc seemed in her eye.

Balcerzak appreciated Weis’s demeanour and decisiveness when describing the status of her eye disease and treatment options for it. He displayed a confidence and air of knowledge that she found very reassuring.

“He’s amazing,” she says. “He’s knowledgeable, he’s caring. He just knocked all the fear out of me. I was a mess up until we met him. And then after it was like, ‘OK, it’s not going to be that bad. It’s going to be a small blip in my life.’”

Weis says it has more to do with the combination of a surgeon’s natural disposition and the world-class training he received. “I’ve had amazing teachers along the way, and from the way they interact with patients and seeing the comfort they can give patients with their bedside manner – I learned a lot from that,” he says. “You come out of there realizing that you really have a lot to offer your patients.”

Balcerzak cherishes her health and vision – her left eye remains perfect. She still enjoys playing ping-pong with Jacob and Jade, though the surgery interfered with her depth perception, giving her kids a small competitive advantage. She also likes colouring with them, where her experience with ocular brachytherapy helped her move towards an innovative and daring approach to art.

“I’m really good at art.” she says. “But I can’t colour inside the lines anymore.”

An Eye for the Operatic

Ezekiel Weis, on top of hands steady enough to sew gold discs onto eyeballs, has a host of other interests including:

  • Twenty years of mountain-climbing experience, including recent summits of Mt. Athabasca, Mt. Andromeda and Mt. Temple in the Canadian Rockies
  • Season tickets to the Edmonton Opera and a fondness for attending the opera’s preview brunches at the Westin Hotel
  • An inordinate fondness for sushi, along with the food of Vietnam and Italy
  • Fluency in Hebrew and growing familiarity with French
  • Participation in the famed Eye Care team in the Alberta Cancer Foundation Ride to Conquer Cancer
  • A child on the way with his wife Chantal, who is due in May. They met when Ezekiel was doing a fellowship in Ottawa
Make 2X the impact