We read with interest the report by Modarres et al. regarding the massive recurrence of choroidal melanoma following endoresection. Readers of the aforementioned article might come to the conclusion that the case presented provides evidence that endoresection performed properly is particularly dangerous. However, the results of this case should not be used to evaluate the safety or efficacy of endoresection because parameters for appropriate patient selection, technique and post-operative surveillance (as described in the literature) were likely not adhered to.
In their article, the authors do not describe the tumor preoperatively in terms of its ultrasonographic measurements, location or extent and leave out other important clinical details such as presence of retinal detachment, tumor involvement of retina or vitreous or extraocular extension. The authors do describe a tumor width of “15 disk diameters,” which implies a dimension >20 mm. The authors do cite some of the pioneering work regarding endoresection, but they do not mention that only patients with tumors measuring 8.2 mm in width or less were included in that cohort. A more recent series on endoresection included only patients with tumors measuring 11.1 mm in width or less. Furthermore, the authors describe the tumor in their patient as presenting on “the nasal side of the fundus” –if the tumor was truly >20 mm in diameter and located nasal to the optic nerve, it should have involved the ciliary body, which is not amenable to endoresection. In summary, a choroidal melanoma such as the one described in the present article is much too large and most likely in the wrong anatomical area to be treatable successfully with endoresection.
Furthermore, the authors do not describe their procedure in sufficient detail. Most importantly there is no mention of cryotherapy of the sclerotomy ports, which is an essential part of the procedure to improve safety.
It is also noteworthy that the authors did not identify tumor recurrence in their patient until 5 years had elapsed post-operatively. This suggests a delay in the detection of the tumor recurrence, because reported recurrences of much smaller tumors treated with endoresection have been detected within the first 3 postoperative years. The great extent of the recurrence in this case provides additional evidence that the postoperative surveillance of the patient may have been inadequate. More information on the frequency and method of postoperative examinations would be useful. The authors also do not mention the more recently published favorable long-term results of properly performed endoresection for smaller melanomas.
No surgical procedure is safe unless performed properly. The case presented by Modarres et al. is an important reminder that endoresection for choroidal melanoma should not be performed when enucleation is indicated because of excessively large tumor size. In addition, endoresection is likely best performed by suitably-trained, experienced ocular oncologists who rigorously adhere to accepted selection criteria and who meticulously and skillfully provide adequate postoperative monitoring, which must be life-long.
1. Modarres M, Rezanejad A, Falavarjani KG. Recurrence and massive extraocular extension of choroidal malignant melanoma after vitrectomy and endoresection Indian J Ophthalmol. 2014;62:731–3
2. Damato B, Groenewald C, McGalliard J, Wong D. Endoresection of choroidal melanoma Br J Ophthalmol. 1998;82:213–8
3. Konstantinidis L, Groenewald C, Coupland SE, Damato B. Long-term outcome of primary endoresection of choroidal melanoma Br J Ophthalmol. 2014;98:82–5
4. García-Arumí J, Zapata MA, Balaguer O, Fonollosa A, Boixadera A, Martinez-Castillo V. Endoresection in high posterior choroidal melanomas: Long-term outcome Br J Ophthalmol. 2008;92:1040–5