A total of 102 eyes (50 right eyes and 52 left eyes) of 102 patients were evaluated. Sixty-three patients were female (63/102, 61.7%) and thirty-nine patients were male (39/102, 38.2%). The mean patient age at surgery was 67 years (range 41–102 years). Associated systemic disease comorbidities are presented in . Average follow-up after vitrectomy was 19.5 months (range 6.1–54.6), and total follow-up from plaque removal to last follow-up appointment was 57.7 months (range 12.0–219.9). Average time from plaque to PPV was 38.1 months (range 3.8–178.6). Fifty-nine patients (57.8%) had a choroidal melanoma, 37 patients (36.2%) had ciliochoroidal detachment, and six patients (5.8%) had a ciliary body tumor with posterior/anterior extension. All patients had radiation-related complications, including retinal detachment at the time of surgery in all eyes (100%), vasculopathy in 91 eyes (89.2%), optic neuropathy in 32 eyes (31.3%), and vitreous hemorrhage in eight eyes (7.8%) ().
Patient demographics and characteristics (n = 102 eyes)
Visual acuity outcomes
The mean baseline BCVA in the affected eye was 20/258. At 1-week follow-up, BCVA improved to 20/157, at 1 month to 20/101, at 3 months to 20/110, at 6 months to 20/116, and at 12 months to 20/113. Improvements in visual acuity (VA) were statistically significant from baseline to all follow-up intervals (P < 0.05) ().
Logarithm of the minimum angle of resolution (logMAR) mean visual acuity before pars plana vitrectomy (initial), at 1 week, and at 1, 3, 6, and 12 months after surgery.
At 3 months, 37.6% gained two or more lines of vision compared with baseline while 8.6% lost two or more lines (). At 6 months, 32.5% gained two or more lines of vision compared with baseline while 8.9% lost two or more lines (). At 12 months, 36.7% gained two or more lines of vision compared with baseline while 19.1% lost two or more lines ().
Scatter plot of pre- versus postoperative logarithm of the minimum angle of resoluction (logMAR) visual acuities at 3 months.
Scatter plot of pre- versus postoperative logarithm of the minimum angle of resoluction (logMAR) visual acuities at 6 months.
Scatter plot of pre- versus postoperative logarithm of the minimum angle of resoluction (logMAR) visual acuities at 12 months.
Final BCVA was better than 20/50 in 37 patients (36.2%), between 20/50 and 20/400 in 36 patients (35.2%), and between 20/400 and 5/200 in 19 patients (18.6%). Only 10 patients (9.8%) had a nonambulatory final VA (worse than 5/200) (). From the group of patients with final VA ≥ 20/50 (37/102), 37.8% (14/37) had a final BCVA of 20/25, 21.6% (8/37) of 20/40, 13.5% (5/37) of 20/20, 13.5% (5/37) of 20/30, and 13.5% (5/37) of 20/50 (). The mean BCVA prior to surgery for this group of patients was 20/73, with a statistically significant improvement after the surgical procedure (P < 0.05) ().
Final best-corrected visual acuity in patients with visual acuity ≥ 20/50 group (n = 37/102).
The current study did not find an increased incidence of complications related to the vitrectomy. There were no cases of endophthalmitis or suprachoroidal hemorrhage. Vitreous biopsy was positive in three patients. Six patients developed systemic metastasis (5.8%). Retinal toxicity from intravitreal or subconjunctival injections was not observed. Nine patients (8.8%) developed secondary neovascular glaucoma. No eyes required enucleation, but one patient died from metastatic disease (0.9%). Mean IOP did not present a statistically significant increase after the procedure (13 mmHg at baseline and 14 mmHg at the last follow-up; P > 0.05) ().
There was no intra- or extraocular tumor dissemination, and no cases of tumor recurrence. Average tumor size (length × width × height) showed a statistically significant decrease after I-125 plaque brachytherapy treatment (13.83 × 11.43 × 4.23 mm before brachytherapy versus 11.50 × 10.09 × 2.66 mm after brachytherapy), and, again, after MIVS (10.70 × 9.36 × 1.96 mm), with a P value < 0.05 (). Seven patients required surgical reintervention (6.86%), and three patients had persistence of exudative retinal detachment at the last follow-up (2.94%).
A 59 year-old male with history of posterior UM in the left eye, macula located, measuring 12 × 8.5 × 2.6 mm, was treated with I-125 brachytherapy in August 2004. He presented for follow-up appointment 88 months after treatment with a decrease in VA in the left eye. He had history of hypertension and hypercholesterolemia. On ocular examination, BCVA was 20/25 OD and 20/60 OS, IOP 12 and 14, the iris was flat, without rubeosis or mass. He presented with a 2+ nuclear cataract in the left eye. Comprehensive ophthalmoscopy showed a small nevus in the right eye with no malignant transformation or vascular activity. Evaluation of the left eye showed a small cup-to-disc ratio, good rim coloration and perfusion, increasing vascular activity with radiation retinopathy, and a dome-shaped lesion with involution to a size of 9 × 8.5 × 1 mm, with focal exudative retinal detachment just superior to macula ().
(A) Preoperative fundus photograph. (B) Three months postoperative fundus photograph.
After the risks, benefits and alternatives were discussed, informed consent was obtained and the patient underwent 23G MIVS combined with phacoemulsification, IOL implantation, membrane peeling, endolaser tumor ablation, vitreous biopsy, and intravitreal triamcinolone acetonide injection to the left eye (). At 1 month, postoperative VA improved to 20/50 with improvement, but persistence of vascular activity secondary to radiation maculopathy. IOP was 14. The tumor was stable, and the retina was attached with no proliferative vitreoretinopathy formation. Vitreous biopsy result was negative for malignancy. Bevacizumab 1.25 mg/0.05 mL was injected OS. At 3 months follow-up, BCVA improved to 20/25, IOP was 13, and the primary tumor was stable, with laser ablation and intratumoral focal hemorrhage ().
Combined microincisional vitrectomy and phacoemulsification. (A) Phacomulsification with intraocular lens implantation. (B) 23-gauge pars plana vitrectomy, and membrane peel. (C) Laser tumor ablation.