While episcleral plaque brachytherapy provides excellent control for small- to intermediate-size choroidal melanomas, radiation-related complications have historically been high. Here, we examine the effect of modern ultrasound-guided conformal plaque brachytherapy on ophthalmologic outcomes in patients with choroidal melanoma. We retrospectively reviewed the plans and clinical charts of patients consecutively treated with I-125 episcleral plaque brachytherapy at our institution between 2017 and 2019. Ophthalmologic and dosimetric data from patients with at least 6 months of clinical follow-up were recorded and analyzed using standard statistical methods. Plaques were placed under ultrasound-guidance and the activity of I-125 sources modulated to obtain conformal plans. 90 patients were included in the analysis. All had eye physics (EP) plaque plans that conferred 100% PTV coverage by the prescription isodose line of 85Gy, which was referentially set at approximately 5mm from the inner sclera. The vast majority of patients had COMS medium lesions (90%) and 1/3 of tumors were located in the macula or near the optic disc. Visual decline was observed in 58% of patients and radiation retinopathy in 18% of cases. Changes in visual acuity were not associated with doses to individual optic structures (disc, fovea, lens) or size and location of tumor targets (p>0.05). Plans with higher Dmax (p = 0.04) and higher V85 (p = 0.01) correlated with decremental visual acuity. Patients who developed radiation retinopathy tended to have higher optic disc doses (p = 0.05). Intensity modulated plaque brachytherapy was not associated with improved visual outcomes (p = 0.6) despite predicting for more conformal plans (p = 0.03). Complication rates and visual decline remain a challenge even with image-guidance and use of conformal brachytherapy techniques. Future studies are needed to reduce dose-dependent toxicities while maintaining acceptable tumor control.