Eye wall resection in the management of uveal neoplasms

Management of intraocular tumors, specifically uveal melanoma, is a matter of controversy. The treatment of these ocular neoplasms varies from observation to enucleation, irradiation (cobalt plaque and proton-helium particle) and eye wall resection. Over the last 18 years, we have developed two techniques for surgical resection of intraocular tumors. An encircling laser photocoagulation and limited scatter photocoagulation with laser precede both procedures. The operation is performed under hypotensive anesthesia in both techniques. The external approach is used for anteriorly located tumors (ciliary body and anterior choroidal lesions) and makes use of an eye basket to stabilize the operation area. A partial dissection of the sclera is performed, then the tumor is removed en bloc with the sclera, choroid and retina. The remaining sclera is resutured to cover the resected area. A modification of this technique is used for a limited excision of choroidal and retinal tissue for the purpose of biopsy and tissue analysis. The internal approach (developed four years ago) has been successfully used for removal of malignant and benign lesions located posterior to the equator and around the optic nerve. This technique uses vitrectomy instrumentation in addition to endolaser. Detailed surgical technique and results achieved in both procedures are described.     

Ten years experience with eye wall resection for uveal malignant melanomas

Thirty-four patients underwent eye wall resection for choroidal malignant melanoma over a period of more than ten years. Of these, 11 eyes were later enucleated for complications. Average mean follow-up has been more than 5.3 years. Postoperative visual acuity ranged from light perception to 20/30. Two patients developed liver metastasis 4 years following eye wall resection and later died. However, no local metastasis has been observed. Two patients died from unrelated causes.     

Ab interno resection of uveal melanoma

Uveal melanomas located 1 to 2 disc diameters from the disc are difficult to manage. An internal resection approach (retinochoroidectomy ab interno) for the removal of melanomas has been developed and used to remove tumors in four patients. In five additional patients this procedure was combined with external resection to remove residual suspicious tissue from the resected margins.     

Internal resection of posterior uveal melanomas

AIMS—To evaluate the safety and efficacy of internal resection in the treatment of malignant melanoma of the choroid.
METHODS—32 consecutive patients with histopathologically proved malignant choroidal melanomas were treated with internal resection. 29 of the 32 (90.6%) tumours were within 2 disc diameters of the optic nerve or fovea. The surgery was performed at two university centres by one of the authors. Follow up was between 1 and 85 months (mean 40.1 months).
RESULTS—Three patients developed distant metastases and died of malignant melanoma (metastatic and mortality rate 9.4%). In one case, distant metastases developed in association with an intraocular recurrence. There have been no other intraocular recurrences. The most common postoperative complication was vitreous haemorrhage, which occurred in 12 patients (37.5%); cataract occurred in eight eyes; and three patients developed retinal detachment postoperatively. Three of the operated eyes have been enucleated (9.4%); a total of four (12.5%) have lost light perception. 10 patients (31.2%) had visual acuities of 6/60 or better and 18 of 32 (56.3%) were between 6/120 and light perception.
CONCLUSION—These data suggest that the internal resection of posterior uveal melanomas is a reasonable globe saving management option. This treatment modality is particularly well suited to elevated tumours in close proximity to the optic nerve or fovea.

Keywords: choroidal melanoma; internal resection; malignant melanoma; posterior uveal melanoma     

Developments in the management of uveal melanoma

Uveal melanomas threaten visual loss, enucleation, and death from metastatic disease. Most patients present because of symptoms, but failures of detection and diagnosis still occur commonly. Treatments aimed at avoiding enucleation include: plaque, proton beam or stereotactic radiotherapy; trans-scleral or trans-retinal local resection; and transpupillary thermotherapy. Increasingly, different modalities are being used in combination. The ocular outcomes are related to tumour size, location, spread and cell type. Metastatic disease occurs in many patients and is related to factors such as tumour dimensions, ciliary body involvement, cell type, extravascular matrix patterns and cytogenetics. Abnormalities related to chromosomes 3, 6 and 8 are strongly related to tumour behaviour, for the first time enabling survival probability to be estimated with a high degree of reliability in an individual patient. This enables high-risk individuals to be targeted for screening while providing reassurance to those with a minimal chance of developing metastatic disease. Such targeting would allow selection of patients for adjuvant systemic therapy, should a suitable treatment become available, and would also facilitate the evaluation of such treatment by increasing the statistical power of any randomized prospective study. The high mortality in patients with monosomy 3 melanoma suggests that in these patients ocular treatment is only palliative. Cytogenetic studies suggest that some melanomas may never develop any metastatic potential and if these impressions are confirmed by further studies, then in these patients the main priority of treatment would be to conserve vision.     

Heat shock protein expression in the eye and in uveal melanoma

PURPOSE: Expression of heat shock proteins (HSPs) is of prognostic significance in several tumor types, whereas HSPs may also have clinical use as stimulators in tumor vaccination. HSP expression levels were determined in normal eyes and in uveal melanoma and tested whether HSPs expression was associated with prognostic parameters in the uveal melanoma. METHODS: Expression of HSP27, HSP70, HSP90, and glycoprotein96 (GP96) were determined on paraffin-embedded and frozen sections from seven healthy eyes, 20 primary uveal melanomas without prior treatment, and 18 uveal melanomas after prior treatment. HSP expression was determined by alkaline phosphatase-anti-alkaline phosphatase (APAAP) immunohistochemistry, using appropriate monoclonal antibodies and scored semiquantitatively. Expression of HSPs was validated on retinal tissue of a normal eye and in two uveal melanoma cell lines by Western blot analysis. RESULTS: Expression of HSPs was observed in epithelial and pigment cells of the normal eyes. In uveal melanoma, the level of expression of HSPs varied. Expression of HSP27 and GP96 was noted in more than 30 of 38 uveal melanomas (with, respectively, a mean of 66% and 53% positive cells). HSP70 and HSP90 were expressed in 6% of tumor cells. The amount of expression of any of the HSP types was not significantly associated with known prognostic factors. There was not a significant difference in expression of the HSPs between uveal melanomas with or without any type of prior treatment. CONCLUSIONS: In this study, expression of HSPs in uveal melanoma is not correlated with known histopathologic prognostic factors. The high expression of GP96 indicates that this protein is a potential vector in tumor vaccination in patients with large uveal melanomas.     

Escherichia coli endophthalmitis after trans-scleral resection of uveal melanoma

PURPOSE: To report a case of Escherichia coli endophthalmitis after trans-scleral resection of an uveal melanoma. METHODS: A large ciliary body melanoma was treated by trans-scleral resection and full-thickness sclerectomy because of epibulbar tumor extrusion, followed by adjuvant ruthenium plaque therapy. RESULTS: Two months after treatment the patient developed wound dehiscence and consecutive endophthalmitis. Cultures of the involved sclera yielded Escherichia coil. The infection resolved after systemic intravenous ciprofloxacin and ceftriaxone, with aggressive topical ciprofloxacin and tobramycin. Final visual acuity was light perception. CONCLUSIONS: We assume that the ruthenium plaque placed over the scleral patch was responsible for the delay in scleral healing, with consequent wound dehiscence and E. coli endophthalmitis.     

Current management of uveal melanoma: A review

Uveal melanoma is the most frequent primary intraocular cancer in adulthood and is mostly localised to the choroid. It can be treated using radiation therapy, laser therapy, local resection and enucleation, with the best results achieved by combining these procedures. However, up to half of patients develop metastatic disease. There are no efficacious treatment methods for patients in advanced stage or with metastasis. In recent years, several novel treatment modalities aimed at improving tumour control and reducing adverse events have emerged. This review summarises current clinical treatment methods and new therapeutic perspectives for uveal melanoma.     

Radiation pathomorphosis of malignant melanoma of the uveal tract of the human eye

The paper describes peculiarities of changes in uveal melanomas after beta application. It is shown that the degree of changes depends on the intensity of action, the cellular type of the tumor and the degree of its pigmentation. The most radiosensitive proved to be spindle cell B, mixed and epithelioid melanomas. Less radiosensitive are pigmented tumourous cells. The most intensive postradiation changes, were characterized by development of long-term existence of coagulation necrosis, growing of cellular polymorphism, hyperploidy, polynucleosis, appearance of apoptosis. The study of the reaction of monolayer culture of uveal melanomas on beta application has confirmed different radiosensitivity of melanoma cells of a different kind as well as has revealed that the growing of cellular polymorphism is a morphologic manifestation of a postradiation degeneration. The degree of postradiation changes correlated with the duration of monolayer culture of the tumor.     

Full-thickness eye wall resection of choroidal neoplasms

Sclerochorioretinal (full-thickness eye wall) resection was performed in 19 eyes with choroidal neoplasms. Thirteen of these eyes have retained useful vision, ranging from 20/25 to counting fingers. Six eyes had intraoperative and postoperative complications that have led to enucleation. During follow-up, ranging from 1 1/2 years to 6 years, none of these patients had had local or systemic metastasis. Full-thickness eye wall resection, in suitable cases, provides an alternative method of managing choroidal neoplasms.     

Full thickness eye wall resection in various species

Summary A technique for resecting a sizeable portion of the posterior segment is described. The procedure, involves stabilization of the eyeball and fixation of the operative area with a ring shaped device (eyebasket). Full-thickness (sclera, choroid, and retina) resection was performed within the ring, and the resected area was replaced with a scleral homograft. No retinal detachments occurred, and there was no inflammatory reaction to the graft. Several cases were complicated by moderate vitreous hemorrhage, but in each case, the hemorrhage was resorbed within 6–8 weeks. Prophylactic photocoagulation four weeks prior to surgery (done on 10 of the rabbits) prevented the occurrence of vitreous hemorrhage.Presented at Jules Gonin Club Meeting in Miami, Florida, October 1972.Supported in part by a grant from the National Society for the Prevention of Blindness, funds from the American Cancer Society to the University of Illinois at the Medical Center, and USPHS EY 24-14 from the National Institutes of Health.