CURRENT MANAGEMENT OF POSTERIOR UVEAL MELANOMA

The management of malignant melanoma of the ciliary body and choroid (posterior uvea) is controversial. Authorities have disagreed about whether enucleation or conservative treatment offers the best prognosis. Although retrospective studies have suggested that the method of treatment makes no difference in the systemic prognosis, new studies in which the various therapeutic modalities are being compared are currently under way. The Collaborative Ocular Melanoma Study is attempting to address some of these issues in a randomized clinical trial. In this report, the currently available methods for managing posterior uveal melanoma are reviewed. Small asymptomatic choroidal melanomas can probably be observed periodically until evidence of growth is documented. Some small choroidal melanomas can be treated with laser photocoagulation. Alternatively, radiotherapy (either episcleral application of a radioactive plaque or charged particle irradiation) can be used. Although the two methods of radiotherapy seem equal relative to the development of systemic metastatic lesions, plaque radiotherapy is associated with fewer and less severe local complications. Selected melanomas of the ciliary body and peripheral choroid can be treated by local resection (partial lamellar sclerouvectomy). Local resection has theoretical advantages, but the surgical procedure is associated with potentially greater immediate complications. Enucleation is generally indicated for advanced melanomas that occupy most of the intraocular structures or have caused severe glaucoma. In addition, it is usually recommended for tumors that have invaded the optic nerve. The value of preenucleation radiotherapy in improving patient survival is unproved, although this technique seems reasonable in selected advanced tumors in which enucleation seems inevitable. Orbital exenteration is justified for advanced uveal melanomas with massive extraocular extension. Although chemotherapy and immunotherapy have not been shown to provide a therapeutic cure for uveal melanomas, further studies must be conducted to determine their true effectiveness.