New Frontiers in Uveal Melanoma

Dr. Tara McCannel is the Director of the Ocular Oncology Center at the Stein Eye Institute at UCLA. She is a vitreoretinal surgeon who treats all retinal disease and brings vitreoretinal surgical techniques to ocular oncology to focus on the best possible vision outcomes in uveal melanoma patients. She is passionate about patient education and creates resources to help patients understand ocular melanoma, including a published patient handbook, YouTube channel, and support groups.

(*uveal melanoma = ocular melanoma = choroidal melanoma)

Choroidal Melanoma Treatment Discussion

While ocular melanoma carries serious implications including potential reduction in sight and the risk of developing metastasis, the negative messaging often given to patients stems from ophthalmology training's emphasis on not missing cancer diagnoses, as it is considered the only potentially fatal diagnosis in the field. Dr. McCannel’s treatment plan for ocular melanoma may include plaque brachytherapy, vitrectomy, and silicone oil shielding which has been shown to improve vision compared to straight plaque brachytherapy alone.

Uveal Melanoma Treatment Options

All cases of uveal melanoma are treatable, with radiation being the most effective method, typically delivered through brachytherapy plaques with over 95% success rate. Enucleation (eye removal) is rare and typically only considered when tumors exceed 20mm in greatest basal diameter or when vision is already poor. Individualized treatment plans are very important and Dr. McCannel advises all patients who may receive an ocular melanoma diagnosis to research treatment centers carefully and obtain second opinions as results can vary significantly between facilities.

Melanoma Treatment Options Discussion

For a patient diagnosed with a large ocular melanoma, enucleation is not always necessary.  In fact, many eyes can be saved through alternative treatments. Radiation therapy, including brachytherapy plaque, can effectively treat tumors involving the optic nerve and retinal detachment can improve after tumor treatment. Retinal detachment can also be treated with vitreoretinal surgery. Three effective ways to save vision are: treat small uveal melanoma early, use vitreoretinal surgical techniques to prevent radiation side-effects, and actively treat ocular diseases and conditions that occur more commonly than eye cancer.

Ocular Oncology Treatment Techniques

It is important to understand the subspecialty training of your ocular oncologist. Additional subspecialty training beyond ophthalmology residency is called “fellowship”. Did he or she complete general ophthalmology training? An oculoplastic (that is, eye-lids and eye-socket) fellowship? Or a surgical retina fellowship? The additional expertise of the ocular oncologist will determine what treatments he or she will be capable of performing. The only subspecialist who can address both tumors and vision-related problems such as repairing retinal detachments and treating vitreous hemorrhages is the ocular oncologist who is trained in vitreoretinal surgery. Surprisingly, few ocular oncologists have been trained in surgical retina and are not able to operate on the inside of the eye, at the back where the melanoma is located.

Brachytherapy-Silicone Oil Treatment Research – Since 2010

Dr. McCannel developed a technique at UCLA where 1000 centistokes silicone oil is placed inside the eye to replace the vitreous and used for radiation shielding during iodine-125 brachytherapy (Oliver SC et al, Arch Ophthalmol, 2010). This was later improved by switching to palladium-103 due to its better attenuation properties (Yang YM et al, Med Phys, 2019). Once the radiation is delivered, the potential damage to healthy ocular tissues is not usually reversible with treatments.

Dr. McCannel and colleagues also reported a potential survival benefit when silicone oil was used with brachytherapy in a small cohort of patients with ocular melanoma (Rivas A et al, Cancers (Basel), 2025). These subjects were discovered to have lower rates of metastasis and death at 5 years. Her results are being further investigated with a larger dataset. Using silicone oil requires specialized vitreoretinal surgical training and is currently being adopted by some centers and taught to our local ocular oncologists who are also vitreoretinal surgeons.

Ocular Comorbidities in Uveal Melanoma

The three most common ocular comorbidities that can impact vision in patients with uveal melanoma are cataracts, glaucoma, and exudative age-related macular degeneration. It is recommended to treat symptomatic cataracts promptly and find experienced surgeons for cataract and glaucoma procedures in affected eyes. Glaucoma surgery, including tube shunt procedures, is effective for safely controlling eye pressure in melanoma patients, contrary to past fears of performing glaucoma surgery on eyes with tumors (Fatehi N et al, Ocul Oncol Pathol, 2019).

Uveal Melanoma Metastasis Risk Factors

Uveal melanoma metastasis (that is, spread of the cancer outside of the eye) occurs in about half of all patients but is difficult to predict timing. The main risk factors are tumor size and molecular profile. Larger tumors and high-risk markers like monosomy 3 and Class 2 increase metastasis risk. Systemic surveillance is recommended every six months with MRI and CT scans. While biopsy results provide important biological information, patients must focus on controllable factors like physical and mental health, seeking multiple expert opinions, and maintaining strong social connections.

Ocular Melanoma Treatment Evolution

The landscape of treatments for uveal melanoma metastasis has significantly changed. The introduction of new therapies such as tebentafusp-kimtrak, an FDA-approved immunotherapy, and HepzatoKit, an FDA-approved liver-directed treatment have drastically changed our treatment horizon. These treatments, along with other immunotherapies and liver-directed approaches like selective internal radiation therapy (Y-90), have improved patient outcomes and quality of life, contradicting the previously pessimistic outlook on metastatic uveal melanoma. We highly recommend involving skilled interventional radiologists and oncologists in treatment plans so that patients may enjoy a high quality-of-life and new hope for their diagnosis.