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

Hung-DA Chou; Heinrich Heimann; Bertil E Damato; Rumana N Hussain

doi:10.1016/j.ajo.2025.05.043

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

Am J Ophthalmol. 2025 May 31:277:356-364. doi: 10.1016/j.ajo.2025.05.043. Online ahead of print.

Authors

Hung-DA Chou¹, Heinrich Heimann², Bertil E Damato³, Rumana N Hussain⁴

Affiliations

¹ From the Liverpool Ocular Oncology Centre (H.-D.C., H.H., R.H.), Liverpool University Hospitals Foundation Trust, Liverpool, UK; Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Main Branch, Taoyuan, Taiwan and College of Medicine (H.-D.C.), Chang Gung University, Taoyuan, Taiwan.
² From the Liverpool Ocular Oncology Centre (H.-D.C., H.H., R.H.), Liverpool University Hospitals Foundation Trust, Liverpool, UK.
³ Ocular Oncology Service and St. Erik Ophthalmic Pathology Laboratory (B.D.), St. Erik Eye Hospital, Stockholm, Sweden; Ocular Oncology Service, Moorfields Eye Hospital (B.D.), London, UK; Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences (B.D.), University of Oxford, Oxford, UK.
⁴ From the Liverpool Ocular Oncology Centre (H.-D.C., H.H., R.H.), Liverpool University Hospitals Foundation Trust, Liverpool, UK. Electronic address: Rumana.Hussain@liverpoolft.nhs.uk.

PMID: 40456397
DOI: 10.1016/j.ajo.2025.05.043

Abstract

Objective: To determine the incidence, risk factors, management, and outcomes of inadvertent scleral perforation during primary choroidal melanoma surgeries.

Design: A retrospective interventional case series from a national ocular oncology referral center.

Subjects: 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.

Intervention: Plaque surgery (n = 697) or marker surgery (n = 684).

Main outcomes and measures: Incidence and risk factors of inadvertent intraoperative scleral perforation and the related management and clinical outcomes.

Results: 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.

Conclusions: 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.