Inadvertent Scleral Perforation During Choroidal Melanoma Surgeries: Incidence, Risk Factors, Management, and Outcomes

• Published in: American journal of ophthalmology Vol. 277; pp. 356 - 364
• Main Authors: CHOU, HUNG-DA, HEIMANN, HEINRICH, DAMATO, BERTIL E., HUSSAIN, RUMANA N.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.09.2025
• Subjects: Adult; Aged; Aged, 80 and over; Brachytherapy - adverse effects; Choroid Neoplasms - surgery; Eye Injuries, Penetrating - epidemiology; Eye Injuries, Penetrating - etiology; Eye Injuries, Penetrating - therapy; Female; Humans; Incidence; Intraoperative Complications - epidemiology; Male; Melanoma - diagnosis; Melanoma - surgery; Middle Aged; Retrospective Studies; Risk Factors; Sclera - injuries; Scleral Buckling; Visual Acuity; LOOC
• ISSN: 0002-9394; 1879-1891
• DOI: 10.1016/j.ajo.2025.05.043

•Consecutive 696 plaque and 684 marker surgeries for choroidal melanoma.•Perforation risk was 6/697 (0.86%) in plaque and 1/684 (0.15%) in marker surgeries.•All 7 perforations occurred in the equatorial region, and 5 eyes had thin sclera.•Common to have a second tear during plaque removal; one needs to be cautious.•With immediate intervention, which included buckling, the prognosis was favorable. To determine the incidence, risk factors, management, and outcomes of inadvertent scleral perforation during primary choroidal melanoma surgeries. A retrospective interventional case series from a national ocular oncology referral center. One thousand and eighty-one consecutive patients with choroidal melanoma who underwent primary ruthenium plaque or tantalum fiducial marker implantation surgery between January 2011 and December 2023 were reviewed from a clinical registry. Plaque surgery (n = 697) or marker surgery (n = 684). Incidence and risk factors of inadvertent intraoperative scleral perforation and the related management and clinical outcomes. The incidence of scleral perforation was 6/697 (0.86%) for plaque and 1/684 (0.15%) for fiducial marker surgeries. Five of the 7 eyes with perforation had myopia or thin sclera. All perforations occurred between 16.3-17.6 mm from the fovea, corresponding to the equatorial region. Immediate management included cryotherapy (7/7 eyes), wound suturing (2/7 eyes), and intravitreal gas (2/7 eyes). During plaque removal surgery, the original scleral wound was torn open in 2/7 eyes, and scleral buckling was undertaken for the presence of perforation-associated subretinal fluid in 4/7 eyes. After a mean follow-up of 38 months (range, 9-87 months), no retinal detachment was noted, and the visual acuity remained unchanged in 5/7 eyes. All the tumors regressed, and there were no signs of seeding. The incidence of inadvertent scleral perforation during plaque and fiducial marker implantation was low, and with immediate intervention, the prognosis was favorable. Myopic eyes, eyes with thin sclera, and suturing in the equatorial zone might be the risk factors. During plaque removal, we recommend combined scleral buckling to address perforation-related subretinal fluid and emphasize avoiding traction on the sclera to prevent a second tear. Further prospective studies are needed to understand this complication more comprehensively.