Post-brachytherapy tumor endoresection for treatment of toxic maculopathy in choroidal melanoma

Abstract

Purpose: Toxic tumor syndrome may occur when the irradiated choroidal melanoma releases cytokines, by exudation from irradiated ischemic tissue. We report our experience and outcomes in a series of post-brachytherapy tumor endoresection to mediate radiation complications.

Methods: Patients who underwent endoresection of a choroidal melanoma treated with iodine-125 plaque brachytherapy were evaluated. Baseline patient and tumor parameters were tabulated.

Results: Five patients underwent post-brachytherapy tumor endoresection with intraocular gas or silicone oil tamponade. Three of the five patients underwent concomitant phacoemulsification with intraocular lens placement. Initial tumor height ranged from 2.03-8.91 mm (mean 5.81 mm). Time between brachytherapy and endoresection ranged from 13-62 months (mean 26.8 months), and total follow-up time from brachytherapy ranged from 2.5-9.75 years (mean 5.2 years). Vision post-brachytherapy and pre-endoresection ranged from 20/30 to 20/400. Final visual acuity ranged from 20/70 to no light perception. One patient developed neovascular glaucoma. Radiation maculopathy increased in all patients. One patient developed metastasis at last follow-up. No patient developed exudative retinal detachment, none had local treatment failure, and none required enucleation.

Conclusion: Although tumor endoresection post-brachytherapy is a technically feasible procedure, all patients in our series experienced progressive radiation maculopathy with gradual visual decline.

Figure 1

Macular photograph and mid-phase fluorescein angiogram 15 months after iodine-125 plaque brachytherapy for a 8.91-mm choroidal melanoma located in the inferonasal equatorial fundus (tumor not shown). Angiogram reveals foveal capillary drop-out. Ocular coherence tomography reveals trace thinning of the outer plexiform layer at the fovea. Vision is 20/30 (Case 4).

Figure 2

Macular photograph of same patient demonstrating typical features of radiation maculopathy: exudates, peripapillary nerve fiber layer infarcts, retinal hemorrhages, and disk pallor 26 months (2.17 years) after tumor endoresection (41 months (3.42 years) after brachytherapy). Ocular coherence tomography reveals disorganization of photoreceptor outer segments, intraretinal fluid and exudates worse on the nasal side. Vision is counting fingers.