Pars plana incisions of four patients: histopathology and electron microscopy.

The pathology of pars plana incisions of four patients is described: three with light microscopy and one with light and electron microscopy. Two eyes were removed because of choroidal melanoma, immediately and 8 days after vitrectomy and transvitreous retinal biopsy. Considerable disruption of tissues surrounding the pars plana incisions was observed. Vitreous was incarcerated in the wounds, which healed with granulation tissue. One eye was examined 4 months after vitrectomy for diabetic retinopathy and a failed pars plana filtering operation. It contained fibrovascular ingrowth from all the incisions, infiltrating the vitreous base with granulation tissue and causing vitreous haemorrhage and retinal detachment. One eye was removed 1 year after vitrectomy for anterior hyaloidal fibrovascular proliferation and early phthisis. The wound had fibrous ingrowth histologically and evidence of active fibroplasia.     

Secondary endoresection for previously treated choroidal melanomas with a non-responsive course and persistent exudative retinal detachment

AIM:To evaluate the results and complications of secondary endoresection via pars plana vitrectomy for choroidal melanoma and review the previously reported endoresection studies on the treatment of choroidal melanoma.METHODS:The medical records of 6 patients with choroidal melanoma who underwent secondary endoresection between March 2012 and March 2020 were retrospectively reviewed.The indications for secondary endoresection were progressive or recurrent tumor and severe exudative retinal detachment after previous treatment with plaque radiotherapy/Cyberknife radiosurgery/transpupillary thermotherapy(TTT).RESULTS:Before endoresection,2 eyes had Iodine-125 plaque radiotherapy and TTT,1 eye had Ruthenium-106 plaque radiotherapy and TTT,1 eye had Cyberknife radiosurgery and TTT,1 eye had Cyberknife radiosurgery,and 1 eye had TTT only.Preoperative visual acuity ranged from 20/63 to 20/1600(Snellen) and from 0.5 to 1.9(mean:1.1) on the log MAR scale.The mean tumor base diameters were 9.5×8.7 mm and the mean tumor thickness was 5.4 mm.After secondary endoresection,transient vitreous hemorrhage developed in 2(33.3%) eyes and retinal detachment in 1(16.7%) eye.Cytopathological examination revealed epithelioid cell melanoma in 4(66.7%) eyes and mixed cell melanoma in 1(16.7%).Melanoma cell type was not specified in 1(16.7%) eye.At a mean follow-up of 49.6 mo(range:16-90 mo),mean visual acuity did not improve and 1 eye was enucleated due to tumor recurrence.Final visual acuity ranged from 20/63 to 20/1600(Snellen) and from 0.5 to 1.9(mean:1.2) on the log MAR scale.Two patients with choroidal melanoma developed metastasis and eventually expired.CONCLUSION:Secondary endoresection seems to be an effective treatment option for globe salvage in choroidal melanoma not responsive to conventional treatment and displaying persistent exudative retinal detachment.There was no visual acuity increase among the treated eyes but globe salvage was possible in most cases in this study.     

Consecutive choroidal melanoma in the same eye of a patient

PURPOSE: To report the occurrence of two entirely separate choroidal melanomas in the same eye of one patient. DESIGN: Observational case report. METHODS: Retrospective case report from one clinical practice. Two choroidal melanomas were observed to develop in the same eye of one patient. RESULTS: An inferonasal choroidal melanoma was diagnosed in the left eye of a 30-year-old woman in 1990. This was successfully treated with proton beam radiotherapy. In 1996, a superotemporal choroidal tumor in the same eye was observed to grow rapidly and it was treated with a ruthenium plaque in 1996. There was a history of cutaneous malignant melanoma. CONCLUSIONS: It is extremely rare for two choroidal melanomas to develop in one eye, and there may be a genetic predisposition.     

Pars plana vitrectomy in eyes containing a treated posterior uveal melanoma

PURPOSE: To determine the safety of pars plana vitrectomy in eyes containing a treated posterior uveal melanoma. DESIGN: Interventional case series. METHODS: Retrospective case series of patients with posterior uveal melanoma who underwent pars plana vitrectomy. Complications, vitreous cytology, local tumor control, and metastasis were assessed. RESULTS: Nine patients met study criteria. Tumors were treated with (125)I plaque radiotherapy (seven patients) or transpupillary thermotherapy (two patients). Vitrectomy was performed for vitreous hemorrhage (five patients), macular pucker (two patients), macular hole (one patient), and rhegmatogenous retinal detachment (one patient). Vitrectomy was performed at a mean of 24.7 months (range, 7-47 months) after melanoma treatment. Dispersion of tumor cells at vitrectomy was not observed in any patients. Melanoma cells were detected in the vitreous aspirate in one of seven cases examined cytologically. This patient had intratumoral and vitreous hemorrhage before plaque radiotherapy, underwent combined vitrectomy/cataract extraction, and developed intraocular tumor dissemination 56 months after vitrectomy. No other patients developed intraocular tumor dissemination. At mean follow-up of 24 months (range, 3-63 months) after vitrectomy, none of the nine patients developed systemic metastasis. CONCLUSIONS: Pars plana vitrectomy rarely may lead to intraocular tumor dissemination, although the risk of this complication is probably low if the tumor has been treated and has responded to therapy before vitrectomy. Vitrectomy should be approached with caution if a vitreous hemorrhage is present, especially if the hemorrhage occurred before tumor treatment, as this may seed tumor cells into the vitreous cavity.     

Scleral Buckle-Associated Ciliochoroidal Melanoma

Purpose: To describe a case of a ciliochoroidal melanoma arising from the site of a scleral buckle. Design: Observational case report. Method: A 69-year-old female was referred for evaluation of decreased vision and occasional floaters in the left eye for two months. Eight years previously, she had undergone vitrectomy and scleral buckling for rhegmatogenous retinal detachment repair in the same eye. Clinical examination revealed an elevated, pigmented choroidal mass in the inferonasal periphery at the crest of the scleral buckle. Clinical and ultrasonographic features were consistent with ciliochoroidal melanoma. Results: The patient underwent Iodine-125 brachytherapy with plaque placement directly on the scleral buckle. Intraoperative ultrasonography confirmed accurate plaque position. Appropriate tumor response was demonstrated at serial follow up-evaluations; however, over 48 months, the patient developed gradual decline in vision secondary to radiation retinopathy. Conclusion: Choroidal melanomas may arise from the same location as a scleral buckle and local tumor control with brachytherapy can be achieved without manipulation or removal of the buckle element. However, we encourage orbital surgeons to consider the radiation attenuating effect of silicone, found in the buckle, in order to prevent undertreatment of these melanomas.     

Rhegmatogenous retinal detachment after transscleral local resection of choroidal melanoma

OBJECTIVE: To report on the incidence and outcome of rhegmatogenous retinal detachment after transscleral local resection of choroidal melanoma. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: One hundred fifty-six patients with choroidal melanoma treated by transscleral local resection between January 1993 and June 2000. INTERVENTION: Transscleral choroidectomy or cyclochoroidectomy for uveal melanoma, with ocular decompression by single-port pars plana vitrectomy and, in most patients, adjunctive ruthenium plaque radiotherapy. MAIN OUTCOME MEASURES: Incidence of rhegmatogenous retinal detachment according to predictive factors and outcomes reported in terms of anatomic success, visual acuity, and ocular conservation. RESULTS: Rhegmatogenous retinal detachment occurred in 28 (18%) eyes and was significantly more common in patients with thick tumors (Cox univariate analysis, P = 0.001) and in males (Cox univariate analysis, P = 0.013), with posterior tumor extension being of borderline significance (Cox univariate analysis, P = 0.069). Surgical treatment of the retinal detachment was performed in 25 patients; it was undertaken at our center in 22 patients and at the referring hospital in 3 patients. Anatomic success was achieved in 21 (84%) of these 25 patients, with 7 eyes retaining counting fingers vision, and 3 eyes seeing 6/60 or better. Ten eyes treated for retinal detachment were enucleated because of recurrent tumor (four eyes), retinal detachment (three eyes), wound dehiscence (one eye), phthisis (one eye), and poor visual acuity (one eye). Eleven eyes known to have a retinal tear underwent prophylactic vitreoretinal surgery at the end of the local resection, with only one (9%) of these subsequently developing retinal detachment. CONCLUSIONS: Rhegmatogenous retinal detachment after transscleral choroidectomy or cyclochoroidectomy for uveal melanoma is a serious complication requiring early vitreoretinal surgery.     

Orbital melanoma metastatic from contralateral choroid: management by complete surgical resection

We discuss a clinicopathologic correlation of orbital metastasis from a contralateral choroidal melanoma wherein the orbital tumor was removed completely by surgical resection. In October 1982, a 29-year-old woman was treated with cobalt-60 plaque radiotherapy for a choroidal melanoma in her right eye. The tumor responded well but recurred after 9 years, necessitating enucleation. In August 1999, 17 years after initial presentation, metastatic melanoma to liver, lung, and brain were found and the patient had a favorable response to chemotherapy and brain irradiation. Five months later, in November 2000, an enlarging orbital mass was documented to be compressing the left optic nerve. Complete surgical removal of the tumor was achieved by a superotemporal orbitotomy. Histopathologically, the tumor was a malignant melanoma with features similar to the choroidal tumor. The contralateral orbit can be the site of late metastasis from choroidal melanoma. In rare instances, an orbital metastasis can be completely removed surgically without subjecting the patient to orbital irradiation.     

Plaque radiotherapy for large posterior uveal melanomas (> or =8-mm thick) in 354 consecutive patients

OBJECTIVE: To assess treatment complications and tumor control after plaque radiotherapy for large posterior uveal melanomas measuring 8 mm or greater in thickness. DESIGN: Prospective noncomparative interventional case series. PARTICIPANTS: Three hundred fifty-four patients each of whom had a posterior uveal melanoma measuring 8 mm or greater in thickness treated with plaque radiotherapy. MAIN OUTCOME MEASURES: The four endpoints included (1) poor final visual acuity (20/200 or worse), (2) enucleation, (3) local tumor recurrence, and (4) metastasis. The clinical data regarding patient features, tumor features, and radiation parameters were analyzed for their impact on the four main outcomes using Cox proportional hazards regression models. RESULTS: Using Kaplan-Meier estimates, final visual acuity was poor in 57% at 5 years and 89% at 10 years follow-up. Using multivariate analysis, the most important risk factors for poor visual acuity included retinal invasion by melanoma, increasing patient age, iodine 125 (I(125)) isotope, and <2 mm distance to the optic disc. Treatment-related complications at 5 years included proliferative retinopathy (25%), maculopathy (24%), papillopathy (22%), cataract (66%), neovascular glaucoma (21%), vitreous hemorrhage (23%), and scleral necrosis (7%). Enucleation was necessary in 24% at 5 years and 34% at 10 years follow-up. Using multivariate analysis, the risk factors for enucleation included left eye, peripheral tumor margin anterior rather than posterior to the equator, increasing tumor thickness, and ruthenium 106 (Ru(106)) isotope. Using Kaplan-Meier estimates, local tumor recurrence was found in 9% at 5 years and 13% at 10 years follow-up. Using multivariate analysis, risk factors for tumor recurrence included Ru(106) radioisotope and ciliary body involvement with tumor. Tumor-related metastases were found in 30% at 5 years and 55% at 10 years follow-up. Using multivariate analysis, risk factors for metastases included inferotemporal meridian, anterior extension of the tumor to the iris root, increasing tumor base, and posterior margin < 2 mm from the optic nerve. CONCLUSIONS: Plaque radiotherapy provided tumor control at 10 years in 87% of patients with selected large posterior uveal melanomas (>8 mm thick) that otherwise would have been managed with enucleation. The large intraocular mass and associated features and radiation complications led to poor visual acuity in most patients. At 10 years follow-up, enucleation was necessary in 34% of patients, and metastasis developed in 55% of patients.     

Changing concepts in the management of choroidal melanoma

PURPOSE: To review emerging information related to changing concepts in the management of choroidal melanoma. DESIGN AND METHODS: This perspective reviews and discusses selected studies from the past two decades that have influenced management strategies for large, medium, and small-size choroidal melanomas. RESULTS: Large choroidal tumors continue to be managed primarily by enucleation. The large tumor trial of the Collaborative Ocular Melanoma Study (COMS) demonstrated neither a positive nor negative effect on 5- and 8-year mortality rates among more than 1000 patients whose eyes containing large choroidal melanomas were randomized to treatment between enucleation alone or enucleation preceded by external radiation. The medium-size tumor trial of the COMS randomized more than 1300 patients between iodine-125 brachytherapy and enucleation. Mortality rates following brachytherapy did not differ from mortality rates following enucleation for up to 12 years after treatment. Iodine-125 has become the most commonly used isotope for brachytherapy in North America. Ten-year follow-up of eyes treated with helium ion and 20 years of experience with proton beam confirm the relative safety and efficacy of these modalities for treatment of choroidal melanoma. Although there is a trend toward earlier treatment of small melanomas, controversy exists regarding the indications for treatment as well as the choice of specific therapy. Recurrences of melanoma after eye-sparing treatment appear to be associated with an increased rate of metastatic disease. Effective adjunctive therapy to prevent or treat melanoma metastasis is lacking. CONCLUSIONS: Choroidal melanoma is a lethal tumor. Although evidence suggests that patients with untreated choroidal melanomas have a poorer prognosis than patients who receive treatment, our current treatments are unable to prevent tumor-related deaths for many patients. The use of preoperative external radiation as an adjunct to enucleation for large choroidal melanomas is unsupported by data from the COMS trial. The use of radiation with either brachytherapy or charged particles for the management of medium-size choroidal melanomas is well supported on the basis of long-term follow-up studies. There is a trend toward treatment of smaller choroidal melanomas. Treatment of melanomas should be directed toward minimizing the potential for recurrences as recurrent melanomas are associated with an increased rate of metastatic disease. Gains in our ability to manage choroidal melanoma will likely be modest at best until effective systemic therapies can be identified.     

Macular Pucker in Association with RPE Adenoma: A Report of a Case and Review of the Literature

Abstract

Background: Retinal pigment epithelium (RPE) adenoma is an extremely rare tumor of the posterior segment which must be differentiated from other choroidal tumors, such as choroidal nevus or melanoma. We report the case of a patient with RPE adenoma coincident with macular pucker who underwent successful pars plana vitrectomy and membrane peeling. Patient and Methods: A 58-year-old female patient was diagnosed with RPE adenoma and epiretinal membrane and subsequently underwent pars plana vitrectomy and epiretinal membrane peeling. Results: RPE adenoma was diagnosed and, following vitrectomy with membrane peeling vision, improved to 20/20 with resolution of symptoms of distortion. Sixteen months of follow-up revealed no clinical change in the RPE adenoma and stable vision. Conclusion: The diagnosis of RPE adenoma can be made upon consideration of unique clinical characteristics of these benign tumors. RPE adenoma may be more closely associated with epiretinal membrane than previously believed, given recent advances in imaging technology. We describe our management strategy, which included observation of the adenoma and surgical removal of the epiretinal membrane.     

Two differing presentations, treatments, and outcomes of malignant choroidal melanoma.

BACKGROUND: Choroidal melanomas represent the most common primary malignancy of the eye. As primary eye care providers, optometrists must be able to identify suspicious lesions to facilitate proper referrals and timely treatment. Metastasis occurs in approximately 75% of cases. Ongoing studies such as the Collaborative Ocular Melanoma Study are bringing new information on how to best manage choroidal melanoma. Current treatments include enucleation, plaque brachytherapy, and transpupillary thermotherapy. CASE REPORT: Two patients presented to the Veterans Affairs (VA) Illiana Health Care System optometry clinic for routine visits and had malignant melanomas diagnosed. The first patient was in for a 6-month routine glaucoma follow-up, noting that the right eye seemed to be worse. The second patient was new, complaining of a painful, red eye. Both were referred to a retinal specialist and later treated by an ocular oncologist with enucleation and plaque brachytherapy, respectively. Their differing chief complaints and cases are discussed. CONCLUSION: Patients with malignant choroidal melanomas present with a wide variety of complaints, and optometrists need to be diligent in properly assessing the cause of seemingly common conditions, such as anterior uveitis, as well as performing routine dilated fundus examinations. Given the relationship between size and prognosis, early detection is important.     

Treatment options for choroidal malignant melanoma: a case report featuring transpupillary thermotherapy.

BACKGROUND: Choroidal melanoma is the most common primary ocular tumor in adults. These tumors are almost always unilateral and develop spontaneously or arise from pre-existing nevi. Historically, treatment for choroidal melanoma was enucleation. New therapies have been developed to treat choroidal melanoma and to preserve the eye. Currently, these treatment options include brachytherapy and transpupillary thermotherapy. CASE REPORT: A 51-year-old man came to the eye clinic with symptoms of mildly decreased fluctuating vision and floaters with no flashes in the temporal visual field of the right eye. Best-corrected visual acuities were 20/30 O.D. and 20/20 O.S. A small-to-medium choroidal lesion was found in the right eye. Ultrasonography and A-scan showed this lesion to be a choroidal malignant melanoma. The patient's surgical options included enucleation, brachytherapy, and transpupillary thermotherapy. The patient opted to have transpupillary thermotherapy to preserve the eye, and subsequently underwent two procedures that eventually obliterated the melanoma, resulting in best-corrected visual acuity of 20/40. CONCLUSION: Transpupillary thermotherapy is an excellent option for treatment of small-to-medium choroidal melanomas. Brachytherapy is also an option for treatment, but with increased ocular side effects and complications. Enucleation is still commonly performed on medium and/or large choroidal melanomas.     

Long-term anatomical and visual outcome of vitreous surgery for retinal detachment with choroidal coloboma

CONTEXT: Vitreous surgery has been advocated as an alternative treatment of selected retinal detachments with choroidal colobomas. AIM: To study the long term anatomical and visual outcome of choroidal coloboma with retinal detachment managed by pars plana vitrectomy with silicone oil tamponade. SETTING AND DESIGN: Retrospective study conducted in a tertiary eye care hospital. MATERIALS AND METHODS: Fourty two eyes of 40 patients with retinal detachments related to coloboma of the choroid without any peripheral breaks were analyzed. All eyes underwent pars plana vitrectomy with internal tamponade using silicone oil. Endolaser was performed along the coloboma border. Silicone oil was removed in 50% of patients. The main outcome measures were retinal reattachment and visual recovery. SPSS (Statistical Package for the Social Science), version 10.0 was used for analysis. RESULTS: The retina in all cases (100%) undergoing vitrectomy were completely reattached intra-operatively. After a mean follow-up of 14 months, 37 (88.1%) eyes had attached retina. The best corrected visual acuity was 10/200 or better in 33 (78.4%) eyes. The best corrected visual acuity improved from a preoperative median of counting fingers (range 20/40 to perception of light) to median best corrected visual acuity of 20/200 (range 20/40 to perception of light) at the end of 6 months. Of the 50% (21) cases that underwent silicone oil removal, two eyes had re-detachment of retina. CONCLUSION: Pars plana vitrectomy along with silicone oil tamponade for retinal detachment related to choroidal coloboma improves the long-term anatomical and visual outcome.     

Lensectomy-vitrectomy indications and techniques in cataract surgery

Lensectomy-vitrectomy is the removal of the crystalline lens through a transscleral retrociliary incision (usually the pars plana) under clinical conditions in which the vitreous gel has to be partially or totally removed. It was designed in the early 1970s at the onset of modern vitreous surgery. The vitreous cutter was used to remove the lens and the vitreous (lensectomy as vitrectomy). With the development of small incision cataract surgery, foldable IOL, the term lensectomy-vitrectomy also applies to separate incisions in one procedure combining lens and vitreous surgery. With this in mind, it covers several very different situations from neonatal congenital cataracts to adult or senile-associated diseases. This type of surgery is widely accepted, and the main controversy is about the consequences of neonatal surgery and the age of IOL implantation in uni- or bilateral congenital cataracts. My personal work with laser flare and cellmetry demonstrates that pars plana vitrectomy alone creates very little trauma to the blood-aqueous barrier, as can be checked by the anterior chamber level of proteins (ie, flare). The postoperative flare in pars plana vitrectomy alone is very close to the preoperative level. Therefore, the association of pars plana vitrectomy and lens surgery should not be more traumatizing to the eye than lens surgery alone. This review will first report the consequences of neonatal lensectomy-vitrectomy to the eye. Subsequent indications for surgery and implantation will be discussed as well as special indications and complications in congenital cataracts, dislocated nucleus in cataract operation, cataract and associated vitreoretinal disorders in diabetes, and giant retinal tears and removal of the lens during vitrectomy.     

脉络膜黑色素瘤眼球保留治疗结果初步观察

目的 观察保留眼球的治疗法治疗脉络膜黑色素瘤的临床效果。 方法 回顾分析44例脉络膜黑色素瘤患者44只患眼接受眼球保留治疗的临床资料，观察分析全身转移情况、眼球保留率以及视力预后。患者均为单眼发病，其中，以经瞳孔温热疗法（TTT）作为首选治疗者7只眼，占15.9%；以 106 Ru放射敷贴器近程放射治疗为首选治疗者25只眼，占56.8%；肿瘤切除联合 106 Ru放射敷贴器近程放射治疗者12只眼，占27.3%。治疗后随诊观察时间平均为13.3个月。 结果 44例患者在观察期内均未出现肿瘤全身转移。39例成功保留眼球，占88.6%。6只小肿瘤眼、14只中等大肿瘤眼和24只大肿瘤眼的眼球保留率分别为100%、92.9%和 83.3%。11只眼视力≥0.3，占28.2%；18只眼视力≥0.05~＜0.3，占46.2%；10只眼视力＜0.05，占25.6%。 结论 106 Ru放射敷贴器近程放射治疗和TTT治疗可以有效治疗中、小脉络膜黑色素瘤；部分大肿瘤选择肿瘤切除联合 106 Ru放射敷贴器近程放射治疗，其综合效果是否优于眼球摘除手术尚需进一步观察。 (中华眼底病杂志, 2006, 22: 150-153)     

Long-term surgical outcome of posterior choroidal melanoma treated by endoresection

PURPOSE: To report the visual acuity, enucleation rates, and initial mortality after transvitreal endoresection of posterior uveal melanoma. METHODS: Twenty consecutive patients with medium-sized posterior choroidal melanomas were treated. Vitrectomy was performed, followed by posterior hyaloid dissection, retinotomy, melanoma removal with a vitrectomy probe, retinal reattachment with perfluorocarbon liquid, and silicone oil or gas exchange. RESULTS: Twenty patients (13 men [65%] and 7 women [35%]) were included in the study. The mean patient age +/- SD was 47.1 +/- 16 years (range, 22-70 years). Tumor thickness and tumor diameter ranged from 5.5 mm to 11 mm and 8.0 mm to 15.7 mm, respectively. Preoperative visual acuity ranged from hand motion to 20/40, and postoperative visual acuity ranged from no light perception to 20/30. Two eyes (10%) were enucleated during tumor resection due to severe bleeding. Enucleation was performed on 3 eyes (15%) during follow-up due to tumor recurrence at the edge of surgical coloboma in 1 patient, new focus of tumor in another sector distant from surgical coloboma in 1 patient, and painful blind eye in 1 patient. Fifteen eyes (75%) were saved. One patient (5%) died of metastasis to the liver. The mean follow-up period +/- SD was 89.55 +/- 38.4 months (range, 24-132 months. CONCLUSION: These data suggest that transvitreal endoresection of posterior uveal melanoma is an acceptable management option to conserve the globe and functional vision in selected patients. Distant metastasis is an infrequent event in this modality of treatment.     

<Emphasis Type="Italic">Pseudomonas aeruginosa</Emphasis> choroidal abscess in a patient with bronchiectasis

Purpose: To report a case of Pseudomonas aeruginosa endophthalmitis with choroidal abscess formation in a patient with bronchiectasis. Methods: Case report. Results: A 75-year-old gentleman with bronchiectasis and P. aeruginosa pneumonia developed painless loss of right eye vision. The patient had previously undergone bronchoscopy to exclude pulmonary neoplasm. Slit-lamp examination revealed intense anterior chamber inflammation with hypopyon and B-scan ophthalmic ultrasound showed a choroidal mass consistent with choroidal abscess. Systemic and topical antibiotics did not prevent further progression of the infection. Patient declined pars plana vitrectomy and opted for enucleation. Polymerase-chain-reaction-based restriction fragment-length polymorphism (PCR-RFLP) of the enucleated eye confirmed P. aeruginosa to be the causative organism. Conclusion: P. aeruginosa cannot be completely eradicated by systemic antibiotics, and bronchial colonization of P. aeruginosa can remain a potential source for metastatic infection. P. aeruginosa choroidal abscess, previously reported only in patients with cystic fibrosis, can also occur in bronchiectasis. Physicians should therefore have a high index of suspicion of endogenous endophthalmitis and treat aggressively, especially in patients with subretinal invasion and abscess formation.     

Combined plaque radiotherapy and transpupillary thermotherapy in choroidal melanoma: 5 years' experience

AIM: To evaluate the results of combined plaque radiotherapy and transpupillary thermotherapy (TTT) in 50 consecutive patients 5 years after treatment. METHODS: 50 adult patients with choroidal melanoma were treated with ruthenium-106 ((106)Ru) plaque radiotherapy combined with TTT. A flat scar was the preferred end point of treatment. The mean tumour thickness was 3.9 mm (range 1.5-8.0 mm), the mean tumour diameter was 11.3 mm (range 5.8-15.0 mm). TTT was performed with an infrared diode laser at 810 nm, a beam diameter of 2-3 mm, and 1 minute exposures. Tumours >5 mm thick received an episcleral contact dose of 800 Gy (106)Ru; tumours 3 mm thick (log rank test p = 0.01). Eight melanomas were amelanotic, seven of which required multiple TTT sessions. In one patient the tumour recurred at the central margin of the treated area; this eye was enucleated. In one patient the tumour failed to regress 6 months after treatment and enucleation was performed at the patient's request. Three eyes developed severe proliferative retinopathy. Radiation maculopathy caused a loss of the best corrected visual acuity: before treatment 31 patients had a best corrected visual acuity of 20/60 or better but in only 12 patients did it remain in this range 5 years after treatment. Three patients developed distant metastasis to the liver. CONCLUSION: The 5 year results for combined plaque radiotherapy and TTT as treatment for choroidal melanoma are favourable in terms of complete tumour regression and low rate of recurrences; however, there was considerable loss of visual acuity as a result of radiation maculopathy.     

Endogenous endophthalmitis caused by Histoplasma capsulatum var. capsulatum: a case report and literature review

OBJECTIVE: We report the first case of clinically diagnosed endogenous endophthalmitis caused by Histoplasma capsulatum var. capsulatum in a patient with the acquired immune deficiency syndrome. DESIGN: Interventional case report and literature review. INTERVENTION: Pars plana vitrectomy and scleral buckling procedure in the left eye with intravenous and intravitreal amphotericin in both eyes. MAIN OUTCOME MEASURES: The clinical features, culture results, visual outcome, and complications were studied. RESULTS: This case demonstrates a bilateral endophthalmitis with severe subretinal exudation, choroidal granulomas, and intraretinal hemorrhage leading to exudative bilateral retinal detachments. Vitreous cultures grew H. capsulatum var. capsulatum. Treatment consisted of intravenous amphotericin, intravitreal amphotericin (both eyes), pars plana vitrectomy (left eye), and scleral buckling procedure (left eye) with resulting counting fingers vision (right eye) and 20/300 (left eye). Four cases of Histoplasma endophthalmitis have been reported previously, all of which had a documented history of disseminated histoplasmosis and resulted in enucleation. CONCLUSIONS: H. capsulatum should be considered a possible etiologic agent of endophthalmitis, especially in patients with a history of disseminated histoplasmosis and/or immune deficiency.