Small Choroidal Melanoma Research Articles

Primary treatment of choroidal amelanotic melanoma with photodynamic therapy

The management of choroidal melanoma involves a delicate balance between preserving vision and preventing metastasis. Plaque brachytherapy has become standard management of most small lesions; however, this can result in radiation retinopathy and optic neuropathy. Transpupillary thermotherapy avoids these side-effects; however, it can also result in visual loss and its effectiveness is limited in amelanotic lesions. Photodynamic therapy with verteporfin has shown promise in animal studies of choroidal melanoma, and has recently been used in the management of lesions that have failed to respond to conventional therapy. The authors report a case of primary treatment of a small choroidal amelanotic melanoma with photodynamic therapy using verteporfin.

Outcomes of Iodine 125 Plaque Radiotherapy after Initial Observation of Suspected Small Choroidal Melanomas: A Pilot Study

To determine the visual and survival outcomes for patients undergoing plaque radiotherapy of suspected small choroidal melanomas after observation for growth in a pilot study.Noncomparative interventional case series.Forty-five patients with suspected small choroidal melanomas who were seen at the Bascom Palmer Eye Institute between 1974 and 2001 and had iodine 125 (I125) plaque radiotherapy between 1991 and 2002.Patients with suspected small choroidal melanomas were monitored by clinical examination, photography, and echography. When the melanoma grew or developed orange pigment, patients were treated with I125 plaque radiotherapy. Outcomes included visual acuity, ocular complications, tumor dimensions, metastasis, and death.Melanoma-specific mortality.In our pilot study, 1 patient died from metastatic melanoma. One patient developed metastatic disease and is still alive. One patient developed marginal tumor recurrence after treatment and after enucleation was performed. Globe conservation was achieved in 97.8% of patients. In patients with tumor margins >2 mm from the optic nerve, vision was preserved with less than a doubling of the visual angle (within approximately 2 Snellen lines of preoperative acuity) in 90.6% (29/32) of patients at 1 year postoperatively, 65.6% (21/32) at 2 years, and 52.2% (12/23) in the long term (4-11 years).Five-year melanoma-specific mortality after I125 plaque radiotherapy of suspected small choroidal melanomas was 3.9% (95% confidence interval, 0%-11.2%). This information can be used to counsel patients with small suspected choroidal melanomas and to compare with other treatment modalities.

Tratamiento primario del melanoma de coroides mediante termoterapia transpupilar

To determine if primary transpupillary thermotherapy can achieve local remission of choroidal melanoma. Secondary objectives were to determine safety of treatment, visual acuity and evaluate complications. The long term objective was to evaluate the impact of treatment on survival without metastatic disease. Thirty-one patients with small choroidal melanomas were treated with transpupillary thermotherapy between 1st December 1997 and 15th June 2001. These patients satisfied predetermined inclusion criteria. To perform the treatment, an infrared diode laser (810 nm) with emission adapted for use with a surgical microscope was used, applying the treatment through a Mainster contact lens. In most patients, the diameter of the irradiation beam was 2 mm, the exposure time was 1 minute and the level of energy given was between 250 and 800 mW. Of 31 patients treated, 26 patients were evaluated in this study. With a mean follow-up of 23.13 months (standard deviation (S.D.): 15 and median: 18.6 months), tumoral remission was observed in 50% of the evaluated tumors. The post-treatment visual acuity in the patients with tumoral remission was better than in patients with treatment failure (P = 0.004). Primary treatment of choroidal melanomas with transpupillary thermotherapy may be a good therapeutic option in selected cases.

Indocyanine green angiography and fluorescein angiography of malignant choroidal melanomas following proton beam irradiation

The vascularisation features of intraocular tumours may be characterised by indocyanine green angiography (ICG-A) and fluorescein angiography (FA). Proton beam irradiation is an established method of treating malignant melanoma of the choroid. The aim of this study was to describe the vascularisation features of small choroidal melanomas and to examine the influence of proton beam irradiation on these tumours. We examined 39 choroidal melanomas by ICG-A and FA from 1998 to 2001 in a prospective study. The tumours had a mean prominence of 3.65 mm (1.2-7.5 mm) and a common feature of all was their parapapillary or paramacular localisation. Angiography was always performed immediately before proton beam radiotherapy and at intervals of 3 months, half a year and 1 year thereafter. Two hundred and forty angiographies were analysed in total. Intra-tumoral vessels could be visualised in 89% of all tumours by ICG angiography but in only 33% by FA. Neither ICG-A nor FA detected changes 3 months after irradiation; however, ICG-A disclosed strong leakage from vessels in the tumour area after 6 months. These changes increased markedly after 12 months and were also visible by FA. A disadvantage of FA, however, was the faster escape of dye from the vessels, which caused rapid leakage in the tumour area and meant that details could no longer be demonstrated. ICG-A and FA detect marked vascular changes within the tumours examined.

Clinical factors in the identification of small choroidal melanoma

The detection and treatment of choroidal melanoma early in its natural course is critical to providing the patient with the best prognosis. Studies of tumour doubling time have indicated that metastasis from choroidal melanoma can occur quite early in the course of the disease, when the tumour is about 3.0 mm in basal dimension and 1.5 mm in thickness. Clinical studies have shown that, at 5 years, metastasis occurs in 16% of patients with small choroidal melanomas (less than 4 mm thick), compared with 32% of those with medium-sized (4-8 mm thick) choroidal melanomas and 53% of those with large (more than 8 mm thick) choroidal melanomas.The difficulty with early detection of choroidal melanoma relates to its clinical similarity to benign choroidal nevus. Factors that assist in differentiating small choroidal melanoma from choroidal nevus can be remembered using the mnemonic “TFSOM” (to find small ocular melanoma), where T = thickness greater than 2 mm, F = subretinal fluid, S = symptoms, 0 = orange pigment and M = margin touching optic disc. Choroidal melanocytic tumours that display none of these factors have a 3% risk of growth into melanoma at 5 years and most likely represent choroidal nevi.Tumours that display one factor have a 38% risk of growth, and those with two or more factors show growth in over 50% of cases. Most tumours with two or more risk factors probably represent small choroidal melanomas, and early treatment is generally indicated.Therefore, ophthalmologists should be aware of the clinical factors that identify small choroidal melanoma so that early treatment and better prognosis can be achieved for their patients.

Recent developments in the management of choroidal melanoma.

To describe recent advances in the management of choroidal melanoma. During the past 10 years, there has been a trend in the management of choroidal melanoma from enucleation to conservative nonenucleation treatments such as thermotherapy, plaque radiotherapy, charged-particle radiotherapy, and local resection. Recently published information regarding conservative management has revealed that plaque radiotherapy combined with thermotherapy offers 97% tumor control, similar to charged-particle radiotherapy. Additionally, patient survival after treatment of medium-size melanoma is similar when comparing plaque radiotherapy versus enucleation. Risk factors identifying small choroidal melanoma include patient symptoms, tumor thickness more than 2 mm, presence of associated subretinal fluid, presence of orange pigment on the tumor surface, and location of the tumor margin at the optic disc. These factors assist in early detection of choroidal melanoma. The management of choroidal melanoma continues to improve with earlier detection of tumors and better treatment methods. Local tumor control is excellent with radiotherapeutic methods. Future studies should investigate control of subclinical metastasis.

Kinetics of indocyanine green (ICG) and clinical use for enhancement of transpupillary thermotherapy (TTT) in hypopigmented small choroidal melanomas

To determine the efficacy of intravenous indocyanine green (ICG) as an adjuvant to TTT for hypopigmented choroidal melanomas. ICG kinetics in melanoma tissue were evaluated by taking standardized ICG angiograms in 28 eyes with small choroidal melanomas. In a prospective non-randomized analysis 12 eyes with hypopigmented choroidal melanomas (posterior to the equator with thickness </= 4.5 mm) were treated with the TTT standard protocol developed by an intravenous injection of 100 mg ICG in 10 ml aqueous solvent 2 minutes after starting TTT. These eyes were followed-up for at least 22 months (mean 29). Pharmacokinetic analyses revealed the onset of fluorescence after 42 seconds (mean) in pigmented versus 22 seconds in amelanotic tumors. Persistence of maximum fluorescence was found for 20 minutes (mean) irrespective of the grade of pigmentation. Six eyes revealed tumor regression within 2 - 4 months after one treatment session. Three eyes flattened after two sessions within 6 - 8 months. Three eyes were judged as failures (two required ruthenium-106 radiotherapy because of insufficient regression after two sessions of TTT and one eye was enucleated because of regrowth after radiotherapy and TTT). Visual acuity was unchanged or improved in 7 eyes. Ocular side effects were epiretinal gliosis (2), macular edema (1) and temporary retrobulbar pain (3). TTT with adjuvant ICG was successful in 9 out of 12 hypopigmented tumors. Further research with a larger sample of patients in a prospective and randomized analysis and longer follow-up are mandatory to determine the role of ICG in TTT.

Transpupillary thermotherapy versus plaque radiotherapy for suspected choroidal melanomas

Purpose To examine the outcomes and complications of transpupillary thermotherapy for treatment of small choroidal melanomas. Design Retrospective case-matched comparative study and retrospective observational study. Participants The case-matched study consisted of 36 patients treated with either transpupillary thermotherapy or plaque radiotherapy (18 patients per group). The observational study consisted of 21 patients treated with transpupillary thermotherapy alone (primary transpupillary thermotherapy) and 9 patients treated with transpupillary thermotherapy plus plaque radiotherapy (adjuvant transpupillary thermotherapy). Main outcome measures Visual acuity, local tumor control, and metastasis. Results The case-matched groups did not differ significantly with respect to age, gender, initial visual acuity, tumor location, or length of follow-up (mean, 33 months for transpupillary thermotherapy vs. 40 months for plaque radiotherapy). There was no significant difference in final visual acuity ( P = 0.810) or postoperative visual acuity change ( P = 0.919) between the 2 groups. In the observational study, the mean follow-up was 32 months (range, 4–58 months). Indications for primary transpupillary thermotherapy included documented growth (10 patients) and the presence of ≥3 risk factors for growth (11 patients). Retinal complications occurred in 16 patients (76%). The mean posttreatment visual acuity change was minus 2 lines (range, minus 9 to plus 7 lines). Local failure occurred in 6 patients (29%). Local failure was associated with an increased number of transpupillary thermotherapy spots per session ( P = 0.023) and decreased tumor pigmentation ( P = 0.001). Indications for adjuvant transpupillary thermotherapy included tumor radioresistance (6 patients) and the presence of risk factors for local failure (3 patients). All 9 tumors that received adjuvant transpupillary thermotherapy regressed rapidly, with no local failures. The mean postoperative visual acuity change was −1.9 lines (range, −9 to +5 lines). No patient in either study developed metastasis. Conclusions The recent interest in transpupillary thermotherapy as primary therapy for choroidal melanoma is based largely on the assumption that transpupillary thermotherapy may provide better visual outcomes than plaque radiotherapy. However, this study found no significant difference in visual outcomes between transpupillary thermotherapy and plaque radiotherapy. Further, the local failure rate with transpupillary thermotherapy was substantially higher than with plaque radiotherapy. The most promising role for transpupillary thermotherapy seems to be as an adjunct to plaque radiotherapy. The appropriate indications for transpupillary thermotherapy in the management of choroidal melanoma need to be re-evaluated.

Invasão do nervo óptico por melanoma peripapilar: relato de caso

Tumores pigmentados localizados sobre o disco óptico são raros e representam desafio diagnóstico. Paciente masculino, 60 anos, apresenta baixa da acuidade visual no olho esquerdo devido à lesão pigmentada que cobre o disco óptico. Foi indicada a enucleação com recusa pelo paciente. O quadro evoluiu com descolamento de retina. Examinado em outro serviço teve indicação de vitrectomia também recusada. Retorna aos nossos cuidados; feita a enucleação o diagnóstico anatomopatológico revelou melanoma maligno da coróide com invasão pós-laminar do nervo óptico. A importância prognóstica da invasão do nervo óptico por melanoma da coróide ainda não está totalmente esclarecida. Embora raro, tumor pigmentado cobrindo o nervo óptico pode representar melanoma maligno. O diagnóstico diferencial destes casos é geralmente difícil, porém seu reconhecimento à ultra-sonografia ocular é patente e descolamento de retina associado é sinal de atividade tumoral. Os riscos de disseminação da doença exigem atenção na suspeita diagnóstica e conduta precisa.

Clinical features of small choroidal melanoma.

The detection and treatment of choroidal melanoma early in its natural course is critical to providing the patient with the best prognosis. Patients with small choroidal melanoma (< 4 mm thickness) develop metastasis in 16% of cases at 5 years follow up, whereas those with medium choroidal melanoma (4-8 mm thickness) and large choroidal melanoma (> 8 mm thickness) develop metastasis in 32 and 53%, respectively. The difficulty with early detection of choroidal melanoma relates to its clinical similarity to benign choroidal nevus. Factors that differentiate small choroidal melanoma from choroidal nevus can be remembered using the mnemonic TFSOM, indicating To Find Small Ocular Melanoma. The letters in this mnemonic represent T (Thickness >2 mm), F (subretinal Fluid), S (Symptoms), O (Orange pigment), and M (Margin touching optic disc). Choroidal melanocytic tumors that display 0 factors have 3% chance for growth at 5 years and most likely represent choroidal nevi. Tumors that display one factor have a 38% chance for growth and those with two or more factors show growth in over 50% of cases at 5 years. Most of those tumors with two or more risk factors probably represent small choroidal melanoma and early treatment is generally indicated. Therefore, ophthalmologists should be aware of the important factors that identify small choroidal melanoma so that early treatment and better life prognosis can be achieved for their patients.

Primary transpupillary thermotherapy (TTT) for malignant choroidal melanoma.

To evaluate the efficacy of transpupillary thermotherapy (TTT) as the only method of treatment for small choroidal melanoma. In a prospective non-randomized analysis, 20 patients with primary choroidal melanoma (posterior to the equator with base < or = 2 and thickness < or = 4.5 mm) were treated with TTT as the only method of treatment (diode laser at 810 nm, beam diameter 3 mm, power setting 0.3-0.9 W, exposure time 20-37 min). During follow-up of at least 6 months, clinical aspects, ultrasonographic tumour thickness, fluorescein and indocyanine green angiographic patterns, visual acuity and ocular side-effects were recorded. In 17 eyes the tumour regressed significantly within 3 months after one treatment session (to a flat chorioretinal scar in 15 eyes). Despite a clinically flattened chorioretinal scar, fluorescein and indocyanine green angiography revealed that choriocapillary vessels in the heat-treated areas of 15 eyes remained perfused. Three amelanotic melanomas showed almost no response to TTT after repeated treatment at higher power settings. Visual acuity remained unchanged or improved in 12 eyes. Ocular side-effects included posterior synechia of the iris (1), macular oedema (2) and temporary retrobulbar pain (2). No patient showed tumour recurrence or metastases during follow-up. Preliminary results obtained by this study demonstrate good efficacy and visual outcome following TTT as the only method of treatment for small choroidal melanoma. However, indocyanine green angiographic findings suggest that tissue damage in the choroidal layer might be less effective, which perhaps may lead to a higher rate of tumour regrowth. Long-term follow-up is required to obtain data on late ocular side-effects, tumour recurrence and metastasis.

Primary transpupillary thermotherapy for small choroidal melanoma in 256 consecutive cases: outcomes and limitations

Objective The objective of this report was to evaluate ocular and systemic outcomes after primary transpupillary thermotherapy for choroidal melanoma and to identify the limitations of this treatment method. Design Noncomparative interventional case series. Participants The participants included 256 patients with newly diagnosed choroidal melanoma. Main outcome measures The outcome measures included local tumor recurrence and visual acuity. Results Before treatment, the mean tumor base was 7.1 mm, and mean tumor thickness was 2.7 mm. Overlying subretinal fluid was present in 215 cases (84%) and orange pigment on the tumor surface in 200 cases (78%). All tumors showed either photographic documentation of growth (114 cases; 45%) or substantial risk factors for growth (142 cases; 55%). After a mean of three treatment sessions, complete tumor control without recurrence was found in 232 cases (91%) and recurrence in 24 cases (9%). The mean time to recurrence was 22 months, and the mean recurrent tumor size was 3.8 mm base and 2.4 mm thick. Of the recurrent tumors, additional thermotherapy was successful in controlling 13 (5%), plaque radiotherapy in 8 (3%), and enucleation in 3 (1%). Using multivariable analysis, the risk factors for tumor recurrence included increasing number of thermotherapy sessions (reflecting less responsive tumor) ( P = 0.0001) and optic disc overhung by tumor ( P = 0.03). Kaplan Meier estimates revealed that 4% showed recurrence at 1 year, 12% at 2 years, and 22% at 3 years follow-up. When analyzing those 214 patients without multivariable risk factors for recurrence, Kaplan Meier estimates for recurrence were 2% at 1 year, 8% at 2 years, and 10% at 3 years. The visual acuity after treatment was 20/20 to 20/40 in 128 cases (50%), 20/50 to 20/100 in 47 (18%), and 20/200 or worse in 81 (32%). Using multivariable analysis, the most statistically significant factors at initial visit that were predictive of poor visual acuity (20/200 or worse) after treatment included documented tumor growth before treatment ( P = 0.0001), mushroom tumor configuration ( P = 0.002), initial symptom of blurred vision ( P = 0.008), poor initial visual acuity ( P = 0.005), superior quadrant tumor location ( P = 0.03), underlying diabetes mellitus ( P = 0.04), and optic disc overhung by tumor ( P = 0.04). Tumor-related mortality occurred in two patients (1%), one of whom showed complete tumor regression to thermotherapy and the other with diffuse choroidal melanoma and local tumor margin recurrence. Conclusions Transpupillary thermotherapy is an effective treatment for certain small choroidal melanomas. Appropriate tumor selection is critical to successful treatment. Patients with tumors abutting or overhanging the optic disc or those requiring more than three sessions for tumor control are more likely to develop ultimate tumor recurrence. Transpupillary thermotherapy can cause damaging effects to the retina, leading to visual loss shortly after treatment.

TTT as rescue treatment for choroidal melanoma not controlled with iodine-125 brachytherapy

Purpose: To describe the use of transpupillary thermotherapy in the management of two small choroidal melanomas that continued to grow following Iodine-125 brachytherapy. Methods: Case reports from a tertiary care center. Results: One small growing choroidal melanoma showed a partial response to Iodine-125 brachytherapy; four years later, it regrew to a thickness of 2.7mm. After transpupillary thermotherapy (TTT), the tumor regressed to a flat scar and has remained inactive for more than three years. A second small melanoma failed to show regression after Iodine-125 brachytherapy; it progressively grew to 3.6mm. TTT was used to treat the tumor on two successive occasions six weeks apart. The tumor regressed to a flat scar within three months and has remained inactive for 2.5 years. Conclusion: TTT may be considered as a rescue treatment for small choroidal melanomas that have failed to respond satisfactorily to brachytherapy.

The Infrared Diode Laser (810 nm) for Transpupillary Thermotherapy in Human Malignant Choroidal Melanomas

Purpose: To demonstrate efficacy of transpupillary thermotherapy (TTT) with an infrared diode laser (810 nm) as primary and non adjuvant treatment modality for choroidal melanoma.Case report and method: Performance of TTT and postoperative findings are evaluated in case of a patient, who developed a malignant choroidal melanoma in the temporal midperiphery of his better right eye. Vision of his left eye was very poor because of strabismic amblyopia. Tumor thickness was 2.3 mm. TTT was performed using a diode laser (810 nm) with a beam diameter of 2.0 mm, power setting of 0.3 watt and exposure time of 1 minute. During permanently slit lamp observation the energy level was raised stepwise until edema turned the tumor tissue grey-whitish. Follow-up examinations took place in four-week-intervals. Clinical aspect, ultrasonographic tumor thickness, fluorescein angiography, visual acuity and side effects were recorded during 21 months follow-up. During 4 months after TTT the tumor regressed completely to a flat chorioretinal scar. No tumor thickness remained ultrasonographically and no residual tumor vessels were detected by fluorescein angiography. Visual acuity was 0.5. During almost two years follow-up no ocular side effects, no tumor recurrence or metastases were observed.Discussion: Transpupillary thermotherapy is a new treatment modality for choroidal melanoma, which is generally used complementary to brachytherapy. Our case report demonstrates efficacy and safety of TTT as single and non adjuvant therapy of a small choroidal melanoma in the midperiphery of an oculus ultimus functionalis. Larger studies and longer follow-up are necessary for data regarding tumor recurrence and metastases.

Termoterapia transpupilar em melanoma maligno da coróide

Objetivo: Vários métodos vem sendo utilizados para o tratamento dos melanomas da coróide. A proposta deste trabalho preliminar é avaliar a eficácia da termoterapia transpupilar (TTT) como tratamento primário de melanomas da coróide pequenos. Métodos: Foi realizado um trabalho prospectivo e não-randomizado para avaliar os aspectos clínicos, resposta do tumor, complicações e resultados visuais de pacientes portadores de melanomas da coróide pequenos (até 4,0 mm de espessura e 12 mm de diâmetro basal) tratados por termoterapia transpupilar utilizando-se sucessivas aplicações de laser diodo contínuo de 810 nm. Resultados: Foram tratados 11 pacientes portadores de melanomas da coróide pequenos. O tumor era único e pigmentado em 100% dos casos. Crescimento documentado esteve presente em 5 pacientes (45,45%) previamente ao tratamento e fatores de risco para crescimento ou metástase estavam presentes em todos os pacientes. O tempo de seguimento destes pacientes a partir do tratamento foi em média de 5,72 meses (3 - 8 meses). Foram utilizadas 3 sessões de laser em 5 pacientes (45,45%) e 4 sessões em 6 pacientes (64,64%). As lesões apresentavam, por ocasião do diagnóstico, uma espessura média de 2,65 mm (1,85-3,86 mm), com maior diâmetro basal médio de 7,98 mm (4,2-11,33 mm). Após o tratamento, a espessura média foi de 1,83 mm (0,98-2,93 mm) e o maior diâmetro basal médio foi de 6,59 mm (3,81 mm -10,67 mm). Das lesões tratadas, 100% apresentaram diminuição da altura e do máximo diâmetro basal, tendo sido a diminuição média da espessura de 0,89 mm e do máximo diâmetro basal de 1,39 mm. A acuidade visual manteve-se inalterada em 5 casos (45,45%) e piorou após o tratamento em 6 casos (54,54%). Ocorreram complicações em 9 casos, tendo sido considerada complicação grave 1 caso de descolamento parcial da retina (9,09%); as outras complicações foram consideradas leves: pequenas hemorragias intra-retinianas em 7 pacientes (63,63%), vitreite associada a tênues membranas vítreas em 1 paciente (9,09%) e quemose associada a edema palpebral em 1 paciente (9,09%). Controle tumoral local com conservação do globo ocular foi observado durante este pequeno tempo de seguimento em 100% dos pacientes tratados. Por ocasião da "última revisão", 100% dos pacientes estavam vivos e sem doença metastática. Conclusão: Este estudo preliminar sugere que a termoterapia transpupilar apresenta-se como um método efetivo e seguro para o tratamento de selecionados melanomas pequenos da coróide. Para melhor avaliação é necessário tempo de seguimento prolongado.

Indocyanine Green (ICG) Enhanced Transpupillary Thermotherapy (TTT) for Hypopigmented Choroidal Melanoma

Objective: Transpupillary thermotherapy (TTT) using an infrared diode laser at 810 nm is a new treatment modality for small choroidal melanoma, but less effective in hypopigmented tumors. We evaluate the effectiveness of intravenous ICG as an adjuvant to increase heat uptake in the tumor tissue and it's influence on tumor regression. Methods: In a prospective nonrandomized analysis 12 eyes suffering from primary choroidal melanoma (hypopigmented and posterior to the equator with thickness ≤4.5 mm) were treated with ICG augmented TTT (diode laser at 810 nm, beam diameter 2–3 mm, power setting 0.5–1.0 Watt, exposure time 6–26 minutes). The energy of the laser beam starting with 0.3 Watt at the tumor center was increased by 50 mW-steps for one minute till development of gray edema on the tumor surface indicates completion of the treatment spot, which were delivered in overlapping confluency, including 0.5 mm of clinically normal tissue around the tumor margin. 2 minutes after start of TTT 100mg indocyanine green in 10 cc aqueous solvent were injected intravenously over 20 seconds. 8 tumors previously showed insufficient regression after TTT without dye or ruthenium-106 plaque radiotherapy. 4 amelanotic melanoma had no previous treatment. Patients were followed up for at least 9 month. Results: 6 eyes revealed tumor regression to a completely flattened scar within 2–4 month after one treatment session. 3 eyes flattened after two sessions within 6–8 month. 3 eyes were judged as failures (two required ruthenium-106 radiotherapy because of insufficient regression after two sessions TTT and one eye was enucleated because of regrowth after radiotherapy and TTT). Visual acuity was unchanged or improved in 7 eyes. Ocular side effects were epiretinal gliosis (2), macula edema (1) and temporary retrobulbar pain (3). No metastases were seen during follow-up. Conclusions: Indocyanine green is an effective dye to increase heat uptake and efficiacy of transpupillary thermotherapy for primary hypopigmented choroidal melanoma as well as residual tumor prominences with secondary loss of pigmentation after brachytherapy or TTT. Longer follow-up is necessary for data regarding ultimate local tumor control and metastatic disease.

Transpupillary thermotherapy as primary treatment for small choroidal melanomas. Trans Am Ophthalmol Soc 1999;97: 407–427.

Transpupillary thermotherapy as primary treatment for small choroidal melanomas. Trans Am Ophthalmol Soc 1999;97: 407–427.

Transpupillary thermotherapy for small choroidal melanoma

PURPOSE: To report the treatment of small choroidal melanoma with transpupillary thermotherapy.METHODS: We examined a nonrandomized and uncontrolled series of 14 eyes of 14 patients who were followed up with serial ophthalmoscopy, ultrasonography, and photography. Transpupillary thermotherapy was performed upon documented evidence of tumor growth.RESULTS: After transpupillary thermotherapy, mean follow-up ± SD was 16 ± 6.41 months (range, 7 to 28 months) with 10 eyes followed up for at least 1 year. The mean preoperative tumor height was 1.79 ± 0.59 mm (range, 0.78 to 2.60 mm). Six months after treatment, the mean height was 0.54 mm ± 0.57 mm (range, 0.00 to 1.16 mm). In 10 eyes, the treated lesion flattened entirely with a mean interval between treatment and flattening of 8.7 months (range, 3 to 21 months). Three patients required retreatment for lack of regression or recurrent growth. The average time to retreatment was 11 months (range, 5 to 15 months). No eye was retreated more than once. There were three amelanotic lesions, all treated in a single session without recurrence. Complications consisted of retinal hemorrhage, retinal vascular occlusion, retinal traction, exudative serous neurosensory detachment, vitreitis, and postoperative pain. The sole treatment failure occurred in an eye treated with a juxtapapillary tumor, with recurrence developing from a previously flattened lesion. This eye was enucleated 10 months after the single initial treatment. At the time of writing, there had been no tumor-related death.CONCLUSIONS: Transpupillary thermotherapy may represent a viable treatment alternative for both pigmented and amelanotic small choroidal melanoma. Diligent follow-up is axiomatic because retreatment may be necessary. Recurrent tumors may develop from flat lesions. Juxtapapillary tumors may be at higher risk for recurrence. Definitive statements regarding the role of transpupillary thermotherapy in the management of small choroidal melanoma await 5-year and 10-year morbidity and mortality data.

Extraocular extension of unrecognized choroidal melanoma simulating a primary optic nerve tumor: Report of two cases

BackgroundOrbital extraocular extension of choroidal melanoma is well known and is usually detected in eyes with medium and large tumors, but it is very rare with small melanomas. It is particularly unusual for choroidal melanomas of any size to invade the optic nerve or its meninges. DesignTwo case reports. ParticipantsTwo patients with small, relatively inconspicuous juxtapapillary pigmented choroidal lesions were referred with the diagnosis of primary optic nerve tumor. Both demonstrated a large nodular tumor in the meninges of the optic nerve, immediately posterior to the globe. MethodsRetrospective review of clinical records and histopathology. ResultsIn both cases, orbital magnetic resonance imaging confirmed the presence of a hyperintense enhancing nodular mass near the anterior portion of the optic nerve, prompting optic nerve biopsy in one case. Subsequent fundus examination disclosed a small juxtapapillary pigmented choroidal lesion measuring 1.0 mm or less in thickness. These observations suggested that the optic nerve tumor might be nodular extraocular extension of a small choroidal melanoma. Modified enucleation was performed in both cases, and histopathologic examination revealed a nodule of malignant melanoma within the meninges that compressed the optic nerve and extended extraocularly from a small, relatively inapparent juxtapapillary choroidal melanoma. In both cases, the extraocular component was large and symptomatic, whereas the intraocular component was inconspicuous. ConclusionsSmall juxtapapillary choroidal melanomas can exhibit prominent extension into the orbit. All patients with orbital tumors should have careful ophthalmoscopy.

Transpupillary thermotherapy for choroidal melanoma.

The management of choroidal melanomas depends on many factors, most importantly, tumor size and location. Small choroidal melanoma in the posterior fundus is amenable to treatment options such as enucleation, radiotherapy, laser photocoagulation, and transpupillary thermotherapy or a combination of these methods. Transpupillary thermotherapy is a technique of tumor heating by infrared radiation delivered through the pupil into the tumor. This method causes dramatic tumor necrosis in choroidal melanomas up to 4 mm in thickness. With properly selected small choroidal melanomas, tumor control is approximately 94%. The heat induces cellular damage at the site of treatment with few remote side effects; therefore, complications are generally limited to the site of treatment and include retinal vascular obstruction (23%), retinal traction (20%), retinal neovascularization (6%), and retinal hole with detachment (< 1%). Tumors located temporal to the foveola demonstrate a statistically higher risk for retinal traction than those located in other quadrants. Tumors near the optic disk demonstrate a higher incidence of retinal neovascularization due to heat-induced obstruction of a major retinal vascular arcade. Overall, vision preservation is satisfactory after thermotherapy for choroidal melanoma, with more than 50% of patients maintaining the same or better vision after treatment, depending primarily on tumor location. In summary, small choroidal melanomas can be controlled with transpupillary thermotherapy, especially those near the optic disk and foveola in areas that are otherwise difficult to irradiate. Longer follow-up is necessary to assess for local recurrence and the impact of treatment on life prognosis.