Microincisional vitrectomy for retinal detachment in I-125 brachytherapy-treated patients with posterior uveal malignant melanoma

Abstract

PurposeTo analyze functional and anatomical outcomes following 23/25+ gauge microincisional pars plana vitrectomy surgery (MIVS) in patients with radiation-related retinal detachment after successful 125-iodine (I-125) brachytherapy treatment for malignant uveal melanoma.Patients and methodsRetrospective case series of 102 consecutive eyes of 102 patients with history of uveal melanoma treated with I-125 brachytherapy that underwent MIVS at the Bascom Palmer Eye Institute. All cases were evaluated for surgical complications and local tumor control. Extended follow-up included Snellen’s best-corrected visual acuity, intraocular pressure evaluation, quantitative echography, indirect ophthalmoscopy, and fundus imaging with optical coherence tomography/wide-field photography.ResultsAll patients had radiation-related complications, including retinal detachment (102 eyes), vasculopathy (91 eyes), optic neuropathy (32 eyes), and/or vitreous hemorrhage (8 eyes). Sixty-seven patients had vitreoretinal traction. Average follow-up after MIVS was 19.5 months, and from plaque removal was 57.7 months. Interval from plaque to MIVS was 38.1 months. Initial visual acuity was 20/258, which improved to 20/101 at 1 month, 20/110 at 3 months, 20/116 at 6 months, and 20/113 at 12 months (P < 0.05). No eyes required enucleation. Melanoma-related mortality was 0.9% (1/102). There was no intra- or extraocular tumor dissemination, and no tumor recurrence.ConclusionMIVS was effective in improving visual function and anatomy in patients with radiation-related retinal detachment. Tumors decreased in size and there was no evidence of recurrence or tumor dissemination. This combined procedure addresses the modifiable causes of visual loss in patients with previously treated malignant uveal melanoma and has the potential to enhance their visual function.

Operative Complications of Posterior Uveal Melanoma Surgery

“…The use of transillumination, ultrasonography, and/or direct visualization with indirect ophthalmoscopy is important and may lead to adjustment of trocar placement. While extraocular extension following vitrectomy in patients with irradiated tumors appears to be rare, 66,67 there are reports of tumor development at sclerostomy sites in patients with unrecognized anterior melanoma. 68 To reduce the risk of extraocular extension, some authors recommend localized peritomies in the areas of trocar placement, cryotherapy at the sclerotomy site at the time of trocar removal, and suturing of the sclerotomies at the conclusion of the case.…”

“…A multitude of factors contributing to the high rate of recurrent RRD have been suggested and include baseline inflammation created by the uveal melanoma, ischemic and inflammatory factors following radiotherapy, increased potential for proliferative vitreoretinopathy due to the liberation of melanoma cells, and vitreoretinal interface alterations resulting from tumor size reduction after radiotherapy. 10,67 Given the complexity of repair of these retinal detachments, long-term tamponade should be considered to reduce retinal detachment recurrence. However, given the need to monitor tumor thickness to assess for local recurrence, the benefits of silicone oil tamponade should be weighed against the limits of tumor evaluation by ultrasonography.…”

“…In a series of patients by Grixti et al,21 3 of 5 patients undergoing primary PPV for RRD following choroidal tumor biopsy had a recurrent retinal detachment. A multitude of factors contributing to the high rate of recurrent RRD have been suggested and include baseline inflammation created by the uveal melanoma, ischemic and inflammatory factors following radiotherapy, increased potential for proliferative vitreoretinopathy due to the liberation of melanoma cells, and vitreoretinal interface alterations resulting from tumor size reduction after radiotherapy 10,67. Given the complexity of repair of these retinal detachments, long-term tamponade should be considered to reduce retinal detachment recurrence.…”

Complications and adverse events of plaque brachytherapy for ocular melanoma

“…For smaller exudative retinal detachments, intraoperative triamcinolone acetonide induces regression in 69% of cases, but it is associated with a side effect of steroid-induced cataract in 12% of cases [45]. Vitreous hemorrhage directly caused by the tumor itself can be treated with pars plana vitrectomy without an increased risk of intraocular, local, orbital, or systemic dissemination of the tumor [46,47]. Although with prompt surgical management, many patients can achieve improved visual outcomes, non-operative management is also possible [48].…”