PREOPERATIVE DIAGNOSIS:
Choroidal melanoma versus metastatic carcinoma to choroid, right eye.
POSTOPERATIVE DIAGNOSIS:
Choroidal melanoma versus metastatic carcinoma to choroid, right eye.
PROCEDURES PERFORMED:
1. Diagnostic transscleral fine needle aspiration biopsy of choroidal tumor, right eye.
2. Implantation of iodine-125, 16 mm diameter plaque, right eye.
SURGEON: John Doe, MD
ANESTHESIA: Local/MAC.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and was positioned on the operating table. Cardiac and blood pressure monitoring devices were applied. Local anesthesia was administered in the form of a retrobulbar injection of 2% Carbocaine plain for the right eye without complications. The patient was prepped and draped in the usual fashion for a procedure of the right eye.
A lid speculum was inserted between the lids of the eye to expose the eye. A conjunctival peritomy was created with Westcott scissors, and the subconjunctival connective tissues were carefully dissected down to bare sclera in the four quadrants. Separate 4-0 black silk sutures were passed behind the insertions of the inferior, lateral, and superior rectus muscles to serve as traction sutures during the procedure. Transcorneal transillumination of the eye was then performed to cast a shadow of the choroidal tumor onto the sclera in the inferotemporal quadrant. The superior aspect of the tumor shadow extended through the insertion of the lateral rectus muscle. Consequently, the lateral rectus muscle belly was secured with a double arm, double locking 6-0 Vicryl suture and then disinserted from the sclera.
A dummy 16 mm diameter plaque was positioned on the sclera over the tumor as marked on the sclera. Four interrupted sutures of 5-0 nylon were placed as plaque fixation sutures relative to four arms of the dummy plaque. The dummy plaque was then removed. A lamellar scleral flap was raised over the center of the tumor as marked on the sclera. This flap was triangular in shape. Once the flap had been created, the fine needle aspiration biopsy was performed using 25 gauge hollow lumen straight needles and puncturing the residual sclera in the lamellar bed. Once the needle had been positioned with its tip in the substance of the tumor, aspiration was performed. The needle was withdrawn and submitted as a specimen to Cytology. Two additional needles were used to sample slightly different sites within the tumor, also via the lamellar scleral bed.
Once the biopsies had been completed, the lamellar scleral flap was closed with three interrupted sutures of 8-0 nylon. The active 16 mm diameter iodine-125 plaque was then positioned on the eye. The four plaque fixation sutures were passed through the respective holes in the arms of the plaque and tied securely. The globe was rotated back to its normal position. The lateral rectus muscle was secured to the sclera in the superotemporal quadrant. The conjunctiva was closed with interrupted sutures of 7-0 Vicryl. The traction sutures were cut and removed. Bacitracin/Polymyxin ointment was applied to the surface of the eye. The lid speculum was removed. The lids were patched with a sterile eye pad and lead shield dressing. The patient tolerated the procedure well. The patient was then transferred to the postanesthesia recovery in satisfactory condition for radiation monitoring and postoperative care.
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