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Sonali Nagendran, Paul T Finger; Extraocular Muscle Repositioning for Ophthalmic Plaque Radiation Therapy for Choroidal Melanoma. Invest. Ophthalmol. Vis. Sci. 2014;55(13):2600.
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To evaluate extraocular muscle surgery associated with plaque brachytherapy for choroidal melanoma.
This is a single center retrospective cohort study of 331 eyes of 331 consecutive patients with clinically diagnosed choroidal melanoma who underwent palladium-103 plaque brachytherapy with or without extraocular muscle surgery. Outcome measures included type of muscle surgery required for each tumor size and location, incidence of diplopia, timing and length of diplopia and requirement for treatment.
Two-hundred fifty-six patients (n=256/331,77.3%) required muscle surgery, including 107 patients (32.3%) who required surgery to two or more muscles. Surgery commonly affected the lateral rectus (35.0%, 116 muscles) and inferior oblique (21.1%, 70 muscles), correlating with need to access the lateral posterior pole (the most common location for choroidal melanoma). Muscle surgery was uncommon in tumors anterior to the equator, occurring in 6/63 (9.5%) cases. From this information we created a nomogram to predict the type of muscle surgery required depending on tumor size and location. Forty-one patients (n=41/331,12.4%) in the cohort experienced post-operative diplopia, including 2 who did not undergo muscle surgery during plaque insertion. Diplopia occurred immediately after plaque removal in all patients. Of the 41 patients, diplopia resolved within 1 month in 18 (43.9%), between 1 and 6 months in 12 (29.2%) and over 6 months post-operatively in 5 (12.2%). The incidence of persistent diplopia in the cohort was 1.8% (6 patients), including 1 patient who had not undergone muscle surgery. One patient refused treatment, 3 (0.9%) were successfully treated with prisms and 2 (0.6%) required strabismus surgery.
Extra-ocular muscle surgery is frequently required in plaque brachytherapy but its effect is often overlooked. While persistent post-operative diplopia is rare and treatable, transient diplopia occurred in 12.4%. Therefore, patients should be made aware of this risk during the surgical consent process and monitored post-operatively for ocular motility disturbances.
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