The Scope Of Three-Dimensional Digital Visualization Systems In Vitreoretinal Surgery.

INTRODUCTION: Significant advances in three-dimensional (3D) imaging technology have allowed for the incorporation of 3D digital displays into medical and surgical devices. Despite initial adoption of the NGENUITY® 3D Visualization System in vitreoretinal surgery, there are limited publications regarding its use. The generally accepted main benefits include improved ergonomics, enhanced surgical team communication and education, reduced retinal phototoxicity, increased depth of field, and display image manipulation. Despite these potential benefits, many retina specialists have questioned its universal applicability to a wide variety of vitreoretinal surgeries. OBJECTIVE: To report on the variety of indications and surgical efficacy of the NGENUITY® 3D Visualization System in vitreoretinal surgery via a review of surgical experience at two vitreoretinal practices in both the academic and community settings. METHODS: A retrospective review was conducted of consecutive surgical cases performed on the NGENUITY® 3D Visualization System at Massachusetts Eye and Ear Infirmary and Florida Retina Institute from June 1st, 2017 to November 1st, 2018. Age, presenting diagnosis, surgical procedure, and intraoperative details were recorded. RESULTS: 272 vitreoretinal surgeries on the Alcon NGENUITY® 3D Visualization System were identified between June 1st, 2017 and November 1st, 2018 at the participating institutions. A detailed breakdown of the indications for surgery and related procedures is reported. During all 272 cases on the 3D digital system, there were no complications attributed to the visualization system. CONCLUSION: This series illustrates the diversity of vitreoretinal surgeries that can be performed on this system without compromising surgical viewing or increasing surgical complications. The Alcon NGENUITY® 3D Visualization System possesses favorable ergonomics, illumination levels, depth of field, display filters, and trainee experience.

ANALYSIS OF PARS PLANA VITRECTOMY INCISIONS USING LIVE BACTERIA.

PURPOSE: To analyze small gauge pars plana vitrectomy sclerotomies using live bacteria transformed with green fluorescent protein (GFP). METHODS: Twenty-eight human cadaver eyes were specially harvested for this study. Small gauge vitrectomy was performed on each eye and the wounds were closed with various techniques (sutured, sutureless, and cauterization). Live Staphylococcus epidermidis that has been transformed with a green fluorescent protein was applied to the overlying conjunctival surface. Analysis of all vitreous samples was analyzed with confocal laser microscopy to identify the presence of bacteria. All wounds were analyzed histopathologically. RESULTS: A high concentration of bacteria was noted in 2 of 3 eyes in the sutureless, 23-G perpendicular incision group postinoculation. There were no bacteria detected in any postvitrectomy sample that were closed with cautery or a beveled incision. No bacteria were found in postvitrectomy samples of sutureless 27-G perpendicular incisions and sutureless 27-G beveled incisions. Finally, there were no bacteria detected in both eyes with 23-G perpendicular incisions that had a partial air-fill. CONCLUSION: Live bacteria can be effectively used to analyze wound integrity. Closing sclerotomy sites with cautery proved effective in a model using fresh, human cadaver eyes. 27-G perpendicular incisions may be just as competent as 27-G beveled incisions.

Effect of aflibercept on refractory macular edema associated with central retinal vein occlusion.

OBJECTIVE: To report short-term visual and anatomic outcomes of patients who were switched to aflibercept for persistent macular edema associated with central retinal vein occlusion (CRVO). METHODS: Retrospective, consecutive, interventional case series of 17 patients with persistent macular edema secondary to CRVO (defined as intraretinal edema and either <50 µm reduction in central foveal thickness [CFT] or worsening or no improvement in visual acuity [VA] compared to baseline) despite anti-VEGF treatment who were switched to aflibercept treatment. Main outcome measures included VA, anti-VEGF treatment history, and spectral-domain optical coherence tomography evaluation of macular edema and CFT. RESULTS: The mean age was 77 years, and the mean VA at CRVO diagnosis was 20/135 with a CFT of 523.4 µm. Mean number of injections before switching to aflibercept was 12.9 (range: 3-40) and mean number of months of anti-VEGF treatment before switching to aflibercept was 18.7. Mean VA at switch to aflibercept was 20/182 (p = 0.50) with mean CFT of 547.9 µm (p = 0.66). Mean aflibercept injections were 4.0, and mean follow-up from switch to last follow-up was 5.2 months. Final mean VA was 20/115 (p = 0.017), with a CFT of 315.2 µm (p = 0.0012). Of the patients, 35.2% gained ≥3 lines. 29% of patients had complete resolution of macular edema, and the mean change in CFT was -233 µm. CONCLUSIONS: Aflibercept appears to have a beneficial effect on anatomic and VA outcomes in a subset of patients with macular edema secondary to CRVO that is refractory to treatment with bevacizumab and/or ranibizumab.

INFLUENCE OF VITREOMACULAR INTERFACE ON ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY USING TREAT AND EXTEND TREATMENT PROTOCOL FOR AGE-RELATED MACULAR DEGENERATION (VINTREX).

PURPOSE: To determine the influence of vitreomacular adhesion (VMA) on treatment outcomes in patients with neovascular age-related macular degeneration who were treated with anti-vascular endothelial growth factor agents using a treat and extend treatment regimen. METHODS: A retrospective consecutive case series of 204 eyes from 181 patients with a minimum of 1 year of follow-up at Wills Eye Hospital Retina Service. Vitreomacular interface characteristics were determined by spectral domain optical coherence tomography. One hundred and fifty-three eyes (75%) had no signs of VMA (non-VMA), and 51 (25%) had VMA. RESULTS: Baseline mean visual acuity was 20/133 with a mean central retinal thickness of 350.5 µm in the non-VMA group and was 20/145 with 371.8 µm in the VMA group. Mean visual acuity in the non-VMA group was 20/83 and 20/64 at Years 1 and 2, respectively (P < 0.01 to baseline). Mean visual acuity in the VMA group was 20/81 and 20/85 at Years 1 and 2, respectively (P < 0.01 to baseline). The central retinal thickness was 289.71 µm and 267 µm at Years 1 and 2, respectively (P < 0.01 to baseline) in the non-VMA group and was 305.3 µm and 289.24 µm (P < 0.01 to baseline) in the VMA group. The mean total number of injections at Year 1 for non-VMA was 7.4 compared with 8.4 in VMA (P = 0.001) and 5.5 versus 6.7 for the 2 groups in Year 2 (P = 0.027). The mean longest extension at Year 1 was 11.8 weeks compared with 10.1 week (P = 0.005) and for Year 2 was 14.1 weeks compared with 12 weeks (P = 0.041). CONCLUSION: The vitreomacular interface seems to have a significant influence on anti-vascular endothelial growth factor treatment intervals but not visual acuity or exudative control outcomes. Eyes with VMA on spectral domain optical coherence tomography at baseline may require more intensive treatment with decreased ability to extend treatment intervals.

Spectrum of Retinal Vascular Diseases Associated With Paracentral Acute Middle Maculopathy.

PURPOSE: To evaluate the spectrum of retinal diseases that can demonstrate paracentral acute middle maculopathy and isolated ischemia of the intermediate and deep capillary plexus. DESIGN: Retrospective, multicenter, observational case series. METHODS: This is a retrospective case series review of 9 patients (10 eyes) from 5 centers with paracentral acute middle maculopathy lesions and previously unreported retinal vascular etiologies. Case presentations and multimodal imaging, including color photographs, near-infrared reflectance, fluorescein angiography, spectral-domain optical coherence tomography (SD OCT), and orbital color Doppler imaging, are described. Baseline and follow-up findings are correlated with clinical presentation, demographics, and systemic associations. RESULTS: Five men and 4 women, aged 27-66 years, were included. Isolated band-like hyperreflective lesions in the middle retinal layers, otherwise known as paracentral acute middle maculopathy, were observed in all patients at baseline presentation. Follow-up SD OCT analysis of these paracentral acute middle maculopathy lesions demonstrated subsequent thinning of the inner nuclear layer. Novel retinal vascular associations leading to retinal vasculopathy and paracentral acute middle maculopathy include eye compression injury causing global ocular ischemia, sickle cell crisis, Purtscher's retinopathy, inflammatory occlusive retinal vasculitis, post-H1N1 vaccine, hypertensive retinopathy, migraine disorder, and post-upper respiratory infection. CONCLUSION: Paracentral acute middle maculopathy lesions may develop in a wide spectrum of retinal vascular diseases. They are best identified with SD OCT analysis and may represent ischemia of the intermediate and deep capillary plexus. These lesions typically result in permanent thinning of the inner nuclear layer and are critical to identify in order to determine the cause of unexplained vision loss.

Bilateral Straatsma syndrome with nystagmus.

PURPOSE: This case report presents a rare case of bilateral Straatsma syndrome with nystagmus and documents additional findings related to spectral domain optical coherence tomography and ocular fundus images. METHODS: Case report with fundus photography, fluorescein angiography, indocyanine green angiography, and spectral domain optical coherence tomography correlations. RESULTS: A 22-year-old man presented with extensive bilateral myelination of the retinal nerve fiber layer that encompassed both posterior poles. The patient had concomitant ocular findings of high myopia, strabismus, amblyopia, and congenital nystagmus. CONCLUSION: This case describes an unusual presentation of Straatsma syndrome and investigates the clinical features of this disease. The patient's constellation of findings is most easily explained as bilateral myelination serving as the catalyst for the associated findings of myopia and nystagmus.

Efficacy of intravitreal ocriplasmin on vitreomacular traction and full-thickness macular holes.

PURPOSE: To analyze a single center's experiences with ocriplasmin on vitreomacular traction (VMT) and the rate of VMT release, full-thickness macular hole (full-thickness MH) closure, and best-corrected visual acuity (BCVA) changes. DESIGN: Retrospective interventional case series. METHODS: Single-center study of 58 eyes of 56 patients who received intravitreal ocriplasmin for VMT with or without full-thickness MH. VMT release, full-thickness MH closure, visual acuity changes, and anatomic characteristics on spectral-domain optical coherence tomography (SD OCT) were analyzed. RESULTS: VMT resolved in 29 of 58 eyes (50%) and nonsurgical closure of full-thickness MH was achieved in 4 of 15 eyes (27%). Mean logMAR BCVA among all treated eyes improved from 0.51 (20/65) at baseline to 0.36 (20/46) at final follow-up (P = .0018) with mean follow-up of 8.7 months. When compared to eyes without VMT release, eyes with successful vitreomacular release had a better pretreatment BCVA (20/48 vs 20/89, P = .004) and final follow-up BCVA (20/31 vs 20/68, P = .0001). Improvement in BCVA was significant in eyes with VMT release (P = .0001). Transient ellipsoid zone changes were noted in 26% of treated eyes (n = 15), of which 14 had successful VMT release. Transient subfoveal fluid accumulation was noted in all these patients with vitreomacular release. Mean time to resolution of ellipsoid zone changes was within 38 days. CONCLUSION: In clinical practice, intravitreal injection of ocriplasmin achieved VMT release in approximately one half of treated eyes, with a 27% closure rate for full-thickness MH. Transient ellipsoid changes were evident in 26% of treated eyes, more common in eyes with successful VMT release.

Combination therapy with triamcinolone acetonide and bevacizumab for the treatment of severe radiation maculopathy in patients with posterior uveal melanoma.

PURPOSE: To evaluate the role of intravitreal triamcinolone acetonide in patients who developed severe, visually compromising radiation maculopathy or progressed despite anti-angiogenic treatments. METHODS: An Institutional Review Board approved, consecutive, retrospective study from 2006 to 2009 of patients who developed severe, visually compromising radiation retinopathy manifesting as macular edema secondary to iodine-125 plaque brachytherapy for posterior uveal melanoma, were treated with a combination of intravitreal bevacizumab and intravitreal triamcinolone. Patients were evaluated with spectral domain optical coherence tomography (SD-OCT) at 2-4 month intervals following plaque removal. Treatment with intravitreal bevacizumab commenced at the first signs of visually compromising macular edema diagnosed with SD-OCT. Triamcinolone acetonide was administered to patients with severe maculopathy as consolidative therapy, or for patients that were refractory to repeated bevacizumab injections with persistent or worsening cystoid macular edema and lack of improvement or progressive worsening of best corrected visual acuity (BCVA). RESULTS: Twenty-five patients were evaluated after receiving a combination of intravitreal bevacizumab and triamcinolone. Initial treatment commenced at a mean of 14.5 (range of 2-42) months after plaque brachytherapy. Patients were given a mean of two injections (range 1-6) of triamcinolone acetonide, and a mean of 8.8 bevacizumab injections (range of 1-26) with a mean follow-up of 31.2 months. Radiation maculopathy upon first detection had a mean SD-OCT grade of 3.6 (median = 4), with an associated mean entry level BCVA of 20/70. Visual acuity at time of first intravitreal triamcinolone was 20/138. At last follow-up (mean of 45.5 months after plaque brachytherapy) mean BCVA was 20/136; however, 9 of 25 (36%) patients who presented with severe radiation maculopathy demonstrated 20/50 or better vision at last follow-up. CONCLUSION: This case series suggests a beneficial role for intravitreal triamcinolone as a consolidation treatment for patients who present with severe radiation maculopathy or as an adjuvant to bevacizumab for refractory or progressive maculopathy.

Microincisional vitrectomy for retinal detachment in I-125 brachytherapy-treated patients with posterior uveal malignant melanoma.

PURPOSE: To analyze functional and anatomical outcomes following 23/25(+) gauge microincisional pars plana vitrectomy surgery (MIVS) in patients with radiation-related retinal detachment after successful 125-iodine (I-125) brachytherapy treatment for malignant uveal melanoma. PATIENTS AND METHODS: Retrospective case series of 102 consecutive eyes of 102 patients with history of uveal melanoma treated with I-125 brachytherapy that underwent MIVS at the Bascom Palmer Eye Institute. All cases were evaluated for surgical complications and local tumor control. Extended follow-up included Snellen's best-corrected visual acuity, intraocular pressure evaluation, quantitative echography, indirect ophthalmoscopy, and fundus imaging with optical coherence tomography/wide-field photography. RESULTS: All patients had radiation-related complications, including retinal detachment (102 eyes), vasculopathy (91 eyes), optic neuropathy (32 eyes), and/or vitreous hemorrhage (8 eyes). Sixty-seven patients had vitreoretinal traction. Average follow-up after MIVS was 19.5 months, and from plaque removal was 57.7 months. Interval from plaque to MIVS was 38.1 months. Initial visual acuity was 20/258, which improved to 20/101 at 1 month, 20/110 at 3 months, 20/116 at 6 months, and 20/113 at 12 months (P < 0.05). No eyes required enucleation. Melanoma-related mortality was 0.9% (1/102). There was no intra- or extraocular tumor dissemination, and no tumor recurrence. CONCLUSION: MIVS was effective in improving visual function and anatomy in patients with radiation-related retinal detachment. Tumors decreased in size and there was no evidence of recurrence or tumor dissemination. This combined procedure addresses the modifiable causes of visual loss in patients with previously treated malignant uveal melanoma and has the potential to enhance their visual function.

Intravitreal bevacizumab combined with plaque brachytherapy reduces melanoma tumor volume and enhances resolution of exudative detachment.

BACKGROUND: The purpose of this study was to evaluate intravitreal bevacizumab as an adjuvant treatment to plaque brachytherapy in the treatment of choroidal melanoma. METHODS: This was a retrospective, consecutive study of 124 patients treated from 2007 to 2009 for choroidal melanoma with plaque brachytherapy. Patients were treated with I-125 plaque brachytherapy with 2 mm margins and 85 Gy to the tumor apex. Consecutive patients were injected intravitreally with 2.5 mg/0.1 mL bevacizumab at a site away from the primary tumor and immediately following plaque removal. Choroidal melanomas were observed using indirect ophthalmoscopy, wide-angle photography, and ultrasound. The main outcome measures were tumor volume, resolution of exudative retinal detachment, and visual acuity. RESULTS: One hundred and twenty-four patients met our inclusion criteria and were included in the analysis. The mean patient age was 65.7 years, and the mean apical tumor height was 4.0 ± 2.7 mm and basal diameter was 12.7 ± 3.0 mm. Mean follow-up was 24 months. Prior to treatment, 100% of tumors had exudative retinal detachment, and pretreatment visual acuity was 20/55 (median 20/40). Tumor control was 100%, metastasis was 0% at last follow-up, and 89.8% had complete resolution of exudative retinal detachment, with a mean time to resolution of 3.36 months. At one month, 43% had complete resolution of exudative retinal detachment, which increased to 73% at 4 months. Visual acuity was 20/62 (median 20/40) at 4 months, with stabilization to 20/57 (median 20/40) at 8 months, 20/56 (median 20/30) at 12 months, and 20/68 (median 20/50) at 24 months. Tumor volume following combined therapy was shown to be reduced by 22.2% at 3 months, 28.9% at 6 months, 39.3% at 12 months, and 52.2% at 24 months (all P < 0.001). All patients tolerated the procedure well without systemic side effects. CONCLUSION: Intravitreal bevacizumab may be used as an adjuvant agent following plaque brachytherapy. Treated choroidal melanomas show reduction in tumor volume as well as resolution of exudative retinal detachments.

Models and discovery strategies for new therapies of retinoblastoma.

INTRODUCTION: Retinoblastoma is the most common primary intraocular malignancy in children. Treatment success approaches 100% at specialized centers with globe-salvaging modalities. Primary management of retinoblastoma consists of chemoreduction with local consolidation, although newer techniques include local delivery via intra-arterial chemotherapy, periocular, or intravitreal injection. Animal models have played an integral role in the understanding of retinoblastoma tumorigenesis and have contributed to the development of globe-salvaging treatments. AREAS COVERED: This review focuses on the use of models and discovery strategies on translational research in retinoblastoma. The article reviews gene expression profiling, knockout models, and transgenic animal models. In addition, the review discusses translational applications of hyperthermia, chemotherapy (systemic and local delivery), radiation therapy, and novel targets such as hypoxia, angiogenesis, cellular metabolism, and tumor suppressor functions. EXPERT OPINION: Retinoblastoma treatment success has been driven by translational research using novel animal models and discovery strategies. Future developments require further understanding of the unique genetic events that result in tumor growth and development, as well as an understanding of the complex interactions of tumor cells with the local tumor microenvironment and how this affects tumor growth, metastasis, and response to treatment.

Lasers for the treatment of intraocular tumors.

Lasers are used extensively in ophthalmology for a variety of conditions, including many choroidal and retinal tumors. With technologic advances, current therapy attempts not only to maximize survival with globe-salvaging treatment, but also to preserve vision. Each neoplasm has different indications for primary and adjuvant therapy, as well as differing laser treatment protocols. Additionally, there are numerous laser applications available for use, including laser photocoagulation, transpupillary thermotherapy (TTT), and photodynamic therapy (PDT). The current review outlines the basic principles of laser treatment for intraocular tumors, focusing on the indications, treatment protocols, efficacy, and safety, while also presenting the latest advances in intraocular tumor treatment.

Laser treatment for retinopathy of prematurity.

Retinal development involves a complex coordination of events that may be affected by premature delivery, leading to retinopathy of prematurity (ROP), a potential blinding childhood disease. The avascular retina drives further disease progression, with laser ablation reducing unfavorable anatomic outcomes as well as maintaining visual acuity. Trials have stressed the importance of early identification and treatment of threshold and high-risk prethreshold disease to improve outcomes. Retinal ablation with laser photocoagulation should involve entire treatment of avascular retina with a confluent laser spot density, avoiding skip lesions. The current review highlights the use of laser photocoagulation in the treatment of ROP.

Early SD-OCT diagnosis followed by prompt treatment of radiation maculopathy using intravitreal bevacizumab maintains functional visual acuity.

PURPOSE: To evaluate the benefits of intravitreal bevacizumab in patients with visually compromising radiation maculopathy following iodine-125 plaque brachytherapy for uveal melanoma. METHODS: In this Institutional Review Board-approved, consecutive, retrospective study from 2006-2009 of patients maintaining 20/50 or better vision following treatment for visually compromising radiation maculopathy, patients were evaluated with spectral domain optical coherence tomography at 2-4 month intervals following plaque removal. Treatment with intra-vitreal bevacizumab commenced at the first signs of radiation vasculopathy on spectral domain optical coherence tomography with associated decreased best corrected visual acuity, followed by repeat injections for recurrent or persistent vasculopathic changes. RESULTS: At 3 years following plaque brachytherapy, 81 of 159 (50.9%) patients treated for radiation maculopathy demonstrated 20/50 or better vision at median follow up of 36 months, which demonstrates significant improvement in vision as compared to the Collaborative Ocular Melanoma Study (P < 0.0001). These 81 patients were given a mean of five injections (range 1-17) over a mean of 17.6 months (range 1-54 months), starting at 15.8 months (range 3-50 months) after plaque brachytherapy. For those eyes that maintained 20/50 or better vision at the final follow-up, pretreatment mean best corrected visual acuity of 20/43 improved to 20/31. CONCLUSION: This study demonstrates that spectral domain optical coherence tomography can detect early vasculopathic changes secondary to radiation maculopathy and that prompt treatment with intravitreal bevacizumab may delay vision loss and maintain or possibly improve visual acuity in half of eyes diagnosed with radiation maculopathy. Radiation maculopathy remains a therapeutically manageable morbidity associated with radiation therapy for posterior uveal melanoma.

Ocular hypertension after intravitreal triamcinolone with vitrectomy and phacoemulsification.

OBJECTIVE: To evaluate the effect of adjunctive intravitreal triamcinolone (IVTA) on intraocular pressure (IOP) in the setting of combined vitrectomy with phacoemulsification. DESIGN: Retrospective case series. PARTICIPANTS: One hundred thirty-one consecutive eyes undergoing nonemergent vitrectomy with phacoemulsification and IVTA were reviewed and included in the analysis. All 131 eyes received 4 mg IVTA at the end of surgery. METHODS: Pre-and postoperative IOP, use of pressure-lowering medications, and rate of glaucoma surgery were analyzed. Pre-operative risk factors were analyzed. MAIN OUTCOME MEASURES: IOP, glaucoma medications, or glaucoma surgery. RESULTS: Secondary ocular hypertension (defined as IOP ≥ 25 mmHg) was found in 28 eyes (21%), the majority during postoperative day 1 only. Twelve eyes (9%) had an elevated IOP measurement noted at a visit after the first postoperative day. Five (4%) had an IOP rise of ≥10 mmHg over baseline at any time after postoperative day 1. Six (5%) required glaucoma medications. One eye required a glaucoma drainage implant for diabetic neovascular angle closure glaucoma, and one eye required enucleation for intractable neovascular glaucoma due to radiation retinopathy. Elevated postoperative IOP was statistically associated with higher baseline IOP and presence of preoperative glaucoma. CONCLUSIONS: Therapeutic intravitreal triamcinolone with combined vitrectomy and phacoemulsification causes infrequent and usually mild secondary ocular hypertension. Secondary ocular hypertension is associated with preoperative glaucoma and high IOP.

Retinoblastoma treatment: impact of the glycolytic inhibitor 2-deoxy-d-glucose on molecular genomics expression in LH(BETA)T(AG) retinal tumors.

PURPOSE: The purpose of this study was to evaluate the effect of 2-deoxy-D-glucose (2-DG) on the spatial distribution of the genetic expression of key elements involved in angiogenesis, hypoxia, cellular metabolism, and apoptosis in LH(BETA)T(AG) retinal tumors. METHODS: The right eye of each LH(BETA)T(AG) transgenic mouse (n = 24) was treated with either two or six subconjunctival injections of 2-DG (500 mg/kg) or saline control at 16 weeks of age. A gene expression array analysis was performed on five different intratumoral regions (apex, center, base, anterior-lateral, and posterior-lateral) using Affymetrix GeneChip Mouse Gene 1.0 ST arrays. To test for treatment effects of each probe within each region, a two-way analysis of variance was used. RESULTS: Significant differences between treatment groups (ie, 0, 2, and 6 injections) were found as well as differences among the five retinal tumor regions evaluated (P < 0.01). More than 100 genes were observed to be dysregulated by ≥2-fold difference in expression between the three treatment groups, and their dysregulation varied across the five regions assayed. Several genes involved in pathways important for tumor cell growth (ie, angiogenesis, hypoxia, cellular metabolism, and apoptosis) were identified. CONCLUSIONS: 2-DG was found to significantly alter the gene expression in LH(BETA)T(AG) retinal tumor cells according to their location within the tumor as well as the treatment schedule. 2-DG's effects on genetic expression found here correlate with previous reported results on varied processes involved in its in vitro and in vivo activity in inhibiting tumor cell growth.

Evaluation of the surgical learning curve for I-125 episcleral plaque placement for the treatment of posterior uveal melanoma: a two decade review.

PURPOSE: To evaluate the surgical learning curve in episceral plaque brachytherapy placement in the management of posterior uveal melanoma. METHODS: A retrospective chart review of two cohorts of 250 consecutive patients undergoing plaque placement for posterior uveal melanoma from 2002 to 2004 and from 2008 to 2009 was conducted. The plaque-tumor apposition rates verified by intraoperative echography were evaluated and correlated with surgical volume over a 19-year period. RESULTS: In an initial study of 29 consecutive patients undergoing plaque placement from January 1992 to January 1995, a suboptimal plaque placement rate of 21% (n = 29) was identified. This percentage declined to 12% (n = 100) from January 2002 to January 2004, and further declined to 4% (n = 150) from June 2008 to August 2009. The tumor-plaque apposition rates for these three groups were 79% (1992-1995), 88% (2002-2004), and 96% (2008-2009). An estimated surgical volume of 1275 cases was performed to achieve a >90% precision rate for first application of primary plaque centration. CONCLUSION: There are challenges to mastering the precise placement of radioactive plaques for posterior uveal melanoma. We have demonstrated a significant learning curve for plaque placement techniques, and have emphasized the importance of intraoperative ultrasound in the verification of plaque placement, thus allowing for intraoperative repositioning.