Small ICG-001 posterior and amelanotic tumors can also be a challenge to mark. Here, two techniques are helpful including: posterior point source illumination (e.g., fiber optic or HeNe light sources or scleral depression combined with indirect ophthalmoscopy) and/or intraoperative ophthalmic ultrasound verification [93] and [94]. When this is not possible (e.g., iris and iridociliary melanoma), high-frequency ultrasound imaging and direct transcorneal visualization play a more important role during intraoperative tumor localization (28). In all cases, the plaque is sutured as to cover the scleral-marked target volume. Then, the extraocular muscles and conjunctiva are reattached as not to disturb brachytherapy.

When using plaque with low-energy seeds, the eye is typically covered with a lead patch shield. Typically, after 5–7 days, the patient is returned to the operating room, where the plaque is removed under regional or general anesthesia. The ABS-OOTF agreed (Level 2 Consensus) that displaced muscles should be reattached into their insertions after plaque Autophagy inhibitor removal. However, one ABS-OOTF center did not find it necessary to reattach the inferior oblique muscle. If an amniotic membrane is used to buffer the cornea during brachytherapy, it should be removed before conjunctival closure [95] and [96]. After brachytherapy,

patients are followed for local control, complications, and systemic disease. Most ABS-OOTF centers examine treated eyes every 3–6 months. This time interval can be modulated based on the likelihood FER of secondary complications. For example, intervals are shorter for patients with posteriorly located

tumors at higher risk of radiation maculopathy and radiation optic neuropathy. These complications typically occur within the first 3 years of follow-up (see radiation complications in the following sections) [8], [51], [60], [61] and [62]. Similarly, most local tumor recurrence occurs during the first 5 years. Therefore, larger and juxtapapillary tumors (at higher risk for regrowth) may require closer follow-up. In addition, patients should be periodically reexamined for evidence of metastatic disease and second nonocular primary cancers [74], [75], [97] and [98]. The ABS-OOTF agrees (Level 1 Consensus) that periodic radiographic abdominal imaging of the liver can be used to detect hepatic melanoma metastasis. We also concur that early detection yields patients with smaller tumor burdens who would more likely benefit from systemic treatment and clinical trials. Uveal melanomas are alternatively be treated by enucleation or exenteration. The former is used when the tumor is confined to the eye and the latter considered in the presence of gross orbital tumor extension. Photon-based EBRT is rarely used prior to enucleation because the COMS large tumor trial found no statistically significant survival advantage [75] and [99].