Kenneth R. Diddie

The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma: IV. Local treatment failure and enucleation in the first 5 years after brachytherapy. COMS report no. 19.

OBJECTIVE To describe the frequency and predictors of local treatment failure and enucleation after iodine 125 (I(125)) brachytherapy in patients with choroidal melanoma treated and followed up in a large randomized clinical trial. DESIGN Prospective, noncomparative, interventional case series within a randomized, multicenter clinical trial. PARTICIPANTS Patients enrolled in the Collaborative Ocular Melanoma Study (COMS) trial of enucleation versus brachytherapy between February 1987 and July 1998; tumors measured 2.5 to 10.0 mm in apical height and no more than 16.0 mm in longest basal dimension. METHODS I(125) brachytherapy was administered via episcleral plaque according to a standard protocol. Follow-up ophthalmic evaluations, including ophthalmic ultrasound and fundus photography, were performed according to a standard protocol at baseline, every 6 months thereafter for 5 years, and subsequently at annual intervals. Survival analysis methods were used to estimate the cumulative risk of postirradiation treatment failure and enucleation. Factors associated with treatment failure and enucleation of plaqued eyes were evaluated using Cox proportional hazards analysis. MAIN OUTCOME MEASURES Reports of enucleation and of local treatment failure, defined as tumor growth, recurrence, or extrascleral extension, derived from clinical reports based on echographic and photographic documentation. RESULTS As of September 30, 2000, 638 of the 650 patients randomized to brachytherapy and so treated had been followed up for 1 year or longer, and 411 had been followed up for at least 5 years. Sixty-nine eyes were enucleated during the first 5 years after brachytherapy, and treatment failure was reported for 57 eyes. The Kaplan-Meier estimate of proportion of patients undergoing enucleation by 5 years was 12.5% (95% confidence interval [CI], 10.0%-15.6%); the risk of treatment failure was 10.3% (95% CI, 8.0%-13.2%). Treatment failure was the most common reason for enucleation within 3 years of treatment; beyond 3 years, ocular pain was most common. Risk factors for enucleation were greater tumor thickness, closer proximity of the posterior tumor border to the foveal avascular zone, and poorer baseline visual acuity in the affected eye. Risk factors for treatment failure were older age, greater tumor thickness, and proximity of the tumor to the foveal avascular zone. Local treatment failure was associated weakly with reduced survival after controlling for baseline tumor and personal characteristics (adjusted risk ratio, 1.5; P = 0.08). CONCLUSIONS Local treatment failure and enucleation were relatively infrequent events after I(125) brachytherapy within the COMS. Treatment failure typically occurred early and was associated weakly with poorer survival. The COMS randomized trial documented the absence of a clinically or statistically significant difference in survival for patients randomly assigned to enucleation versus brachytherapy. This analysis documents the efficacy of brachytherapy to achieve sustained local tumor control and to conserve the globe.

A Comparison of Different Cellular Inoculain an Experimental Model of Massive Periretinal Proliferation

We modified a preexisting experimental model of massive periretinal proliferation by injecting cells of differing origins into the rabbit vitreous cavity. These cells included autologous and homologous fibroblasts, homologous chondrocytes, homologous retinal pigment epithelial cells, heterologous bovine endothelial cells, and heterologous murine embryonal cells. All cell injections caused vitreous and retinal membrane formation that resulted in a process similar to massive periretinal proliferation. Clinically the character of the membranes formed and the time course in the development of traction retinal detachments was similar for all the different cell types. The initial cell dosage injected was the critical factor in determining the severity of the traction retinal detachments leading to massive periretinal proliferation.

The coms randomized trial of iodine 125 brachytherapy for choroidal melanoma

arms, 5- and 10-year all-cause mortality rates were 19% and 35%, respectively; by 12 years, cumulative all-cause mortality was 43% among patients in the 125 I brachytherapyarmand41%amongthoseintheenucleationarm. Five-, 10-, and 12-year rates of death with histopathologicallyconfirmedmelanomametastasiswere10%,18%, and 21%, respectively, in the 125 I brachytherapy arm and 11%,17%,and17%,respectively,intheenucleationarm. Olderageandlargermaximumbasaltumordiameterwere the primary predictors of time to death from all causes and death with melanoma metastasis. Conclusion:Longer follow-up of patients confirmed the earlier report of no survival differences between patients whose tumors were treated with 125 I brachytherapy and those treated with enucleation.

Lensectomy-vitrectomy in chronic uveitis.

Cataract extraction in patients with chronic uveitis may be hazardous. Recent studies have indicated an improvement in prognosis using lensectomy-vitrectomy techniques in selected cases of uveitic cataracts. The results of lensectomy-vitrectomy in 12 cases of uveitic cataract are reported. All patients had improvement in vision. No significant “flare-up” of the underlying uveitis was found and no patients deteriorated. The importance of extensive preoperative evaluation is emphasized. The major cause of decreased acuity after operation was persistent cystoid macular edema, a complication of chronic inflammation.

Primary Transpupillary Thermotherapy for Small Choroidal Melanomas

Aims: To determine visual and anatomic outcomes following transpupillary thermotherapy (TTT) as a primary treatment for small choroidal malignant melanomas. Methods: 20 patients with small choroidal melanomas who underwent primary TTT at our institution were retrospectively reviewed. Patients with choroidal melanomas posterior to the equator with a basal diameter less than 12 mm and thickness less than 3.5 mm were included if the lesion had documented growth or clinical risk factors for growth. Results: Thirteen women and seven men (mean age: 65 years, range: 41–85 years) underwent TTT. The mean preoperative tumour thickness was 1.81 mm (range: 0.78–3.40 mm). The mean follow-up time after TTT was 44.6 months (range: 11–108 months, median: 47.5 months). After a mean of 2.15 primary TTT sessions (range: 1–4), tumour regression without recurrence was attained in 11 (55%) of 20 cases. Five of the nine remaining tumours with recurrence were successfully treated with additional TTT. One patient declined further TTT and underwent enucleation. Three other tumours had recurrence after repeat TTT. The mean time to recurrence after initial TTT was 20.8 months (range: 8–37 months). The mean time to recurrence after repeat TTT was 35 months (range: 5–69 months). There was no tumour-related metastasis or death. Conclusions: Tumours treated with TTT have significant recurrence rates. Although tumour control may ultimately be achieved with TTT, close monitoring of these tumours is necessary, since repeat TTT or alternative therapies may be required.

Intraocular Gas Injection in the Pseudophakic Patient

Two patients underwent vitrectomy with the use of intraocular gas. In one patient the cornea decompensated because of lens-cornea contact and in the second patient a surgical technique devised to protect the cornea from lens contact was used successfully. The technique consisted of injecting a smaller gas bubble into the anterior chamber before the instillation of the posterior chamber gas.

Results of Anterior Segment Surgery with Vitrectomy Instruments

We used closed-eye endosurgery to treat 58 patients with anterior segment problems. These included nonsenile cataract, residual lens material, pupillary membranes, vitreocorneal touch, aphakic pupillary block glaucoma, intraocular lens complications, epithelial ingrowth, and total hyphema. Thirty-five eyes showed an increase in visual acuity of more than two Snellen lines, 13 eyes demonstrated no change, and ten eyes lost more than two lines. Complications included endophthalmitis, retinal detachment, retinal tears, increased intraocular pressure, postoperative hemorrhage, and bullous keratopathy.

Pars plana vitrectomy infusion line in retinal detachment surgery.

We used new applications for a pars plana infusion cannula in three patients with retinal and choroidal detachments. Because the cannula maintained intraocular volume and form, it was helpful in treatment bullous retinal detachment and choroidal detachment.

Further Comments on Intravitreal Sulfur Hexafluoride

Machemer and Aaberg1 discussed the problem of the rapid transfer of nitrous oxide into intravitreal sulfur hexafluoride several years ago in their text on vitrectomy. Ophthalmologists must ask the anesthesiologist to discontinue nitrous oxide anesthesia and to substitute another gas before the instillation of sulfur hexafluoride gas into the eye.