A 44-year-old man was referred to our hospital for ciliary body tumor management. A uveal melanoma in the left eye without systemic metastasis was our impression after a series of examinations. We treated this patient with eyewall resection under local anesthesia. Eyewall resection was previously regarded as a complicated procedure that should be performed under general anesthesia. Our surgery was successful, and there were no complications related to the local anesthesia. We followed up this patient for 3 years, and no recurrence was found.
Eyewall resection is a good alternative to enucleation for treating a ciliary body melanoma. Under a premise of survival, eyewall resection can maintain part of the visual function and cosmetics. General anesthesia is not indispensable when a patient's health does not allow its use.
(Chang Gung Med J 2002;25:850-3)
Keywords：
eyewall resection, ciliary body melanoma, local anesthesia.

The traditional surgical management of ciliary body melanoma consisted of enucleation. This procedure is devastating to the function and cosmesis of the eye. Eyewall resection is an ideal alternative to treat a patient with a ciliary body melanoma without metastasis. Eyewall resection surgery was previously regarded as a procedure that had to be performed under general anesthesia to prevent intraoperative complications such as expulsive vitreous hemorrhage. We report on a case of ciliary body melanoma after eyewall resection surgery, which was performed under local anesthesia with a successful result. No intraoperative or postoperative complications were found. No tumor recurrence was noted after 3 years of follow up.

CASE REPORT

A 44-year-old man was referred to our hospital with the complaint of a ciliary body tumor in the left eye, which was found incidentally during cataract surgery. His corrected visual acuity was 20/200. After the pupil had been fully dilated, we found a whitish ciliary body tumor mass in the nasal upper quadrant. The ultrasound examination revealed that this tumor exhibited low reflectivity and equal spike heights but displayed some irregularity in its internal structure (Fig. 1). The MRI showed that this tumor had high intensity on T1- (Fig. 2), low intensity on T2-, and a bright signal on T1-weighted images with contrast medium (Fig. 3). No tumor metastasis was noted after a systemic survey. Radiotherapy was not recommended by the radio-oncologist because of possible complications of the radiation.
For treatment of this tumor, we initially performed panretinal photocoagulation 3 times. Six weeks later, we performed an eyewall resection combined with endolaser photocoagulation, vitrectomy, gas-fluid exchange, and long-acting gas (C3F8) tamponade. This surgery was performed under local anesthesia because the patient's heart disease rendered him unable to withstand long-term general anesthesia. The tumor specimen was sized about 6×5×4 mm, and the pathology report indicated that it was a malignant melanoma. We followed up this case for 3 years. Neither local or systemic recurrence nor metastasis had occurred to the last follow-up date. The final visual acuity was 20/300.

DISCUSSION

Eyewall resection of a ciliary body tumor has been proven to be a good method to remove the tumor and preserve the visual function and cosmesis[ok?].(1,2) The modern eyewall resection technique was modified by Peyman in 1973.(3) It was reported that after a 10-year follow-up, patients with malignant melanoma after eyewall resection received a prognosis that was no worse than that for enucleation in regard to life expectancy.(1) It was suspected that tumor manipulation during eyewall resection increased the incidence of metastasis.(4) However, data in some reports did not support the conclusion that surgical manipulation accelerated the rate of metastasis.(1,5) The criteria for selecting tumors for possible eyewall resection include the following: (1) the base diameter of the mass does not exceed 16 mm; (2) an exudative detachment of the retina covers no more than 1/3 of the fundus; (3) the tumor is at least 3 mm from the optic disc margin; (4) the media are clear; (5) there is no evidence of metastatic disease after complete workup; and (6) the patient's general health should permit administration of general anesthesia for at least 3 to 4 hours.(1) In the present case, eyewall resection was performed uneventfully under local anesthesia. The recommendation for general anesthesia was based on complete pain relief and better control of the surgical process. Use of the hypotensive anesthesia technique might decrease the incidence of intraoperative hemorrhage and provide a better surgical field.(6) In this case, under local anesthesia, the surgery was uneventful without complicating hemorrhage. This might have been due to the preoperative photocoagulation, which effectively diminished the choroidal and retinal vascular bed, thereby minimizing the chance of hemorrhage.(3) This is the first reported case of eyewall resection under local anesthesia. This means that if general anesthesia is not suitable for a patient, a good prognosis can be maintained without compromising ocular function.
Eyewall resection is not without its drawbacks. Local resection of a posterior uveal tumor does have several potentially serious problems. The most common problem during the operation and the early postoperative period is vitreous hemorrhage. In addition, complications such as intraretinal or subretinal hemorrhage, retinal detachment, cataracts, and eventual enucleation due to a residual or recurrent tumor have frequently been reported.(5)
Eyewall resection is a safe and effective alternative to enucleation for treating a ciliary body melanoma. With eyewall resection, total blindness as a result of diagnostic tool limitations is avoidable. Surgical resection of a uveal melanoma under local anesthesia is feasible without significantly increasing operative or postoperative complications, especially for those patients who are not fit for general anesthesia after a thorough preanesthetic evaluation.

REFERENCES

1. Peyman GA, Juarez CP, Diamond JG, Raichand M. Ten years experience with eyewall resection for uveal malignant melanomas. Ophthalmology 1984;91:1720-5.
2. Peyman GA, Raichand M, Schulman J. Diagnosis and therapeutic surgery of the uvea--Part I: Surgical technique. Ophthalmic Surg 1986;17:822-9.
3. Peyman GA, Raichand M. Full-thickness eyewall resection of choroidal neoplasms. Ophthalmology 1979;86: 1024-36.
4. Robertson DM, Campbell RJ, Weaver DT. Residual intrascleral and intraretinal melanoma: a concern with lamellar sclerouvectomy for uveal melanoma. [see comments]. Am J Ophthalmol 1991;112:590-3.
5. Shields JA, Shields CL, Shah P, Sivalingam V. Partial lamellar sclerouvectomy for ciliary body and choroidal tumors. Ophthalmology 1991;98:971-83.
6. Robinson R, White M, McCann P, Magner J, Eustace P. Effect of anaesthesia on intraocular blood flow. Br J Ophthalmol 1991;75:92-3.

From the Department of Ophthalmology, Chang Gung Memorial Hospital, Taipei.
Received: Feb. 6, 2002; Accepted: Apr. 15, 2002
Address for reprints: Dr. San-Ni Chen, Department of Ophthalmology, Chang Gung Memorial Hospital, No. 5, Fu-Shin Street, Kweishan, Taoyuan 333, Taiwan, R.O.C. Tel.: 886-3-3281200 ext. 8666; Fax: 886-3-3287798; E-mail: ejubibi@cgmh.org.tw