The treatment of serous macular detachment secondary to choroidal melanomas and nevi

Laser treatment for choroidal melanoma: Current concepts

Laser treatment has offered a relatively nonsurgical alternative for eye, life, and vision-sparing treatment of malignant melanoma of the choroid. Historically, the most commonly used forms of lasers were xenon-arc, argon laser, krypton laser, and the more recent transpupillary thermotherapy (TTT) and photodynamic therapy (PDT). Melanomas selected for laser treatment tend to be smaller and visibly accessible, which means these tumors are usually located in the posterior choroid. Laser treatments have been associated with both local tumor destruction and side effects. Unlike radiation therapy, laser treatment has been commonly associated with retinal traction, hemorrhage, chorioretinal neovascularization, and extra scleral tumor extension, as well as higher rates of local treatment failure. In addition, however, laser-treatment has been successfully used to treat tumor-related retinal detachments, radiation retinopathy, and neovascular glaucoma. We review the world's experience of ophthalmic laser treatment for choroidal melanoma, offer safety and efficacy guidelines, as well as a comparison of laser treatment to radiation therapy outcomes.

Treatment response to intravitreal bevacizumab in small pigmented choroidal lesions with subretinal fluid

Background

To describe the effects of intravitreal bevacizumab injection (IVB) and/or transpupillary thermotherapy (TTT) in the treatment of small pigmented choroidal lesions with subfoveal fluid (SFF), and to investigate prognostic value of the therapeutic response in future tumor growth.

Methods

Retrospective chart review of 19 patients, who were diagnosed with choroidal neovascularization (CNV)-free small pigmented choroidal lesions and treated with IVB and/or TTT, was performed.

Results

Complete resolution of SFF was achieved in two eyes (2/14; 14.3%) after IVB, and in three eyes (3/4; 75%) after TTT. Best corrected visual acuity was improved in two eyes (2/9; 22%) after IVB, and in three eyes (3/4; 75%) after TTT. Among five patients who underwent TTT after IVB, four patients (4/5; 80%) demonstrated additional advantage. All IVBs could not reduce tumor sizes. Rather, tumor growth was detected in seven out of 14 eyes (7/14; 50%) that underwent IVB. None of the patients who underwent TTT showed tumor growth. The lack of treatment response to IVB was suggestive of malignancy, as most small pigmented lesions that had no response to IVB showed tumor growth (86%, p = 0.010).

Conclusion

IVB was not effective in reducing tumor size and subfoveal fluid in small pigmented choroidal lesions. Therapeutic response to IVB can be used as an indicator between melanoma and nevus in small pigmented choroidal lesion.

Subretinal Choroidal Neovascularization Associated with Choroidal Nevus

Purpose

Evaluation of a large series of choroidal nevi inducing the formation of a neovascular membrane in order to more clearly define the clinical presentation and to evaluate the efficacy of various treatment options.

METHOD

Retrospective study of 22 clinical cases.

Results

All nevi were situated in the posterior choroid. They had a mean diameter of 3.8 mm and a mean thickness of 1.4 mm. Neovascular membranes were classic in all cases, extrafoveal in 13 cases (59%), and subfoveal in 9 cases (41%). A serous retinal detachment was present in every case, hemorrhages were present in 13 cases (59%), and lipid deposits were present in 16 cases (73%). All extrafoveal neovascular membranes were successfully treated by thermal laser photocoagulation. Initial visual acuity was 0.1 in three cases, 0.2–0.4 in five cases, 0.5–0.8 in four cases, and 1.0 or more in two cases. Final visual acuity was 0.1 in one case, 0.2–0.4 in one case, 0.5–0.8 in four cases, and 1.0 or more in seven cases. Five subfoveal neovascular membranes were treated either by thermal laser, photodynamic therapy, or irradiation. No treatment was applied in four cases and in one of these cases, spontaneous resolution of the neovascular membrane was observed. No growth of the pigmented tumor was observed with a mean follow-up of 4.8 years.

CONCLUSIONS

Proliferation of a neovascular membrane on the surface of a pigmented choroidal tumor is a rare complication and is considered to be a relative indicator of a benign nature of the lesion. In the authors' experience, neovascular membranes are extrafoveal in more than half of cases and are accessible to laser photocoagulation. In contrast, the various modalities used to treat subfoveal neovascular membrane were ineffective and functional prognosis was unfavorable in these cases.

Leaking choroidal nevus treated with focal laser photocoagulation

PURPOSE

To present a case of leaky choroidal nevus that responded favorably to treatment with focal laser photocoagulation, shown by spectral domain optical coherence tomography, fundus autofluorescence, and fundus photography.

METHODS

Descriptive case report of a 40-year-old male patient with decreased visual acuity because of subretinal fluid associated with a choroidal nevus, which was treated with focal laser photocoagulation.

RESULTS

Treatment with focal laser photocoagulation to the surface of the choroidal nevus resulted in the resolution of subretinal fluid by 6 weeks. The therapeutic effect remained after 1 year of follow-up with continued improvement in vision and with no growth of the lesion.

CONCLUSION

Laser photocoagulation can be an effective treatment for symptomatic subretinal fluid associated with a choroidal nevus. Spectral domain optical coherence tomography, fundus autofluorescence, and fundus photography can be helpful in monitoring the treatment response.

Outcome and significance of silicone oil tamponade in patients with chronic serous retinal detachment

Purpose

To evaluate the effectiveness of silicone oil tamponade in patients with chronic serous retinal detachment (SRD) persisting for three months after the resolution of ocular inflammation.

Methods

A total of 17 eyes of 17 patients diagnosed with chronic SRD persisting for three months after the resolution of ocular inflammation and with high risk of phthisis bulbi by secondary ocular hypotony and macular detachment by subretinal fibrous membrane formation were subjected to surgical intervention. Subjects underwent silicone oil tamponade after surgical drainage of subretinal fluid. Retrospective analyses on anatomical and functional success rates were then performed.

Results

Anatomical success with retinal reattachment was observed in ten of the 17 eyes (58.82%), while functional success measured as difference in the best-corrected visual acuity before and after the surgery were logarithm of the minimum angle of resolution (logMAR) 1.95 ± 0.66 and logMAR 1.51 ± 0.66, respectively (p < 0.05).

Conclusions

This study suggests that, in patients with chronic SRD despite prolonged medical treatment and resolution of inflammation, surgical drainage of subretinal fluid with silicone oil tamponade can achieve anatomical and functional success.

VARIABLE OUTCOME OF PHOTODYNAMIC THERAPY FOR CHOROIDAL NEOVASCULARIZATION ASSOCIATED WITH CHOROIDAL NEVUS

PURPOSE

To report five cases of classic choroidal neovascularization (CNV) associated with choroidal nevus treated with photodynamic therapy (PDT) with verteporfin.

METHODS

The patients underwent an ophthalmologic evaluation, including fluorescein angiography and indocyanine green angiography. Clinical and angiographic data were retrospectively analyzed to evaluate visual acuity outcomes and both clinical evolution and angiographic evolution.

RESULTS

Two patients presented with subfoveal CNV, and three had juxtafoveal CNV. The mean follow-up was 25.8 months. Visual outcomes were extremely variable. Indeed, best-corrected visual acuity decreased in three eyes, stabilized in one case, and improved in the other case. The number of PDT sessions necessary to obtain CNV stabilization with cessation of fluorescein leakage varied from one to six.

CONCLUSION

Bearing in mind that both the natural history and the post-PDT outcome may be extremely variable, further studies are needed to assess the real benefit of PDT for classic CNV secondary to choroidal nevus.

Presumed small choroidal melanomas with serous macular detachments with and without surface laser photocoagulation treatment

We reviewed the records of 22 patients (22 eyes) who had presumed small choroidal melanomas associated with a serous macular detachment. In 13 eyes, the tumor surface was treated with laser photocoagulation to reattach the retina and improve vision. After photocoagulation, the retina reattached in 11 eyes (85%), and the visual acuity improved in eight eyes (62%), returning to 20/25 or better in six eyes (46%). Twelve of the tumors (92%) that received surface photocoagulation grew after treatment. Seven of these tumors (54%) developed a collar-button configuration and showed evidence of basal expansion. Of the nine tumors that did not receive surface photocoagulation, seven (78%) eventually grew, but none developed a collar-button configuration. Surface photocoagulation applied to a growing melanoma appears to increase the likelihood of tumor extension through Bruch's membrane in a collar-button configuration. The impact of such growth on tumor metastasis is unknown.