Trabeculectomy in patients with uveal melanoma after proton beam therapy

Abstract

Trabeculectomy is an option in intractable glaucoma in patients with uveal melanoma after proton beam therapy in single cases. Secondary interventions are common. Inoculation metastases are possible. Secure local tumor control must be a prerequisite for filtrating operations.

Iris melanoma presenting as childhood glaucoma

“… 17 Successful treatment of these tumors prior to filtering surgery may reduce the likelihood of extrascleral spread and systemic metastases in the short term. 18 , 19 Though little data is available on long-term risk, present data suggests that the risk of extrascleral spread, systemic metastasis, and death does increase with time ( Table 1 ), even with treatment of the tumor. 15 , 18 In a pediatric patient with a life expectancy of several decades, the life-time risk of metastasis and premature death, even after treatment of the melanoma, must be weighed with appropriate gravity.…”

Outcomes of Glaucoma Drainage Device Surgery in Eyes with Treated Uveal Melanoma

“…However, our data support the assumption that in cases in whom the primary tumor has been definitively treated (i.e., eyes with no evidence of tumor growth at the time of GDD placement), the risk to the patient following invasive glaucoma surgery is not greater than clinical risk factors, namely tumor size and molecular prognostic profile, would suggest. Treatment of glaucoma in eyes with intraocular tumors, which is often caused by multiple mechanisms (incidence rate of 15.3% [Kim et al, manuscript under revision]) [1, 3, 28], may be challenging, and medical therapy, laser trabeculoplasty, and cyclophotocoagulation may not lead to adequate IOP control [11, 29, 30]. Cyclophotocoagulation is a treatment that may result in eventual phthisis if repeated more than once; therefore, offering cyclophotocoagulation may be minimally better than enucleation for ocular preservation [31].…”

“…The success rate in our study sample was comparable to that of the above study (80%) after 1 year. Riechardt et al [11] reported on the outcomes of trabeculectomy in 15 patients with uveal melanoma treated with proton beam radiation therapy. Two out of 15 patients were diagnosed with local treatment failure.…”

“…The success rate for IOP control, with the same criteria as ours, was 91% after 1 year. Four patients (26%) needed bleb needling and 3 patients (20%) required complete revision of trabeculectomy [11]. Overall, preliminary evidence to date suggests that glaucoma filtration surgery is an effective approach to control IOP if medical treatment is not adequate; however, local tumor control is a prerequisite for performing any type of filtering or invasive surgery in patients with uveal melanoma.…”

“…Conventional modalities to control IOP include medical treatment, trabeculectomy, or placement of a glaucoma drainage device (GDD) and ciliary body ablation [1]. Medical therapy alone is frequently inadequate for controlling IOP in eyes with treated uveal melanoma [11, 12]. In contrast to eyes with other forms of secondary glaucoma, glaucoma filtration surgery and placement of a GDD are not considered first-line approaches in eyes harboring a melanoma, despite tumor control with radiotherapy.…”