LAUREN DALVIN: So today we're treating a choroidal melanoma using plaque radiotherapy. The first step of our surgery is to do a conjunctival peritomy. And because the tumor is infratemporal, we're going to try to expose just our lateral and inferior rectus muscles. And I like to keep my peritomy nice and tight to the limbus. That makes for an easy closure down the road at the end of the case.

So now we're going to give ourselves some nice exposure by spreading in the quadrants between the muscles with our curved Stevens scissors. And we want to make sure we get nice and deep so that we dissect the Tenon's away from the globe. This will again give us a nice working space. And we're dissecting on both sides of both the lateral and the inferior rectus muscles.

So now we're going to be hooking each of those muscles using our Gass muscle hook. And this allows us to manipulate the eye during our surgery to get adequate exposure to see where our tumor is. We use a silk suture to imbricate each of our muscles here. And this is going to give us a nice control over the globe during our case.

So the next thing we're going to be doing is inspecting this infratemporal quadrant. We'll use our Schepens to make sure, again, that we have good exposure in this area. So as you can see, we have good visualization of the sclera in this area. And this is where our tumor should be located.

So the next step we're going to do is called transillumination. In this, we use a light pipe and shine it through the eye. And when we have a large anteriorly located pigmented tumor, we should be able to see a tumor shadow that helps us mark out the tumor borders.

OK so as you can see, we actually get a really nice tumor shadow here. So we see a dark shadow. So the white sclera allows light to shine through it. But the pigmented tumor is dark, so no light passes through. And we actually get a shadow in that area.

So we're going to dry off this area. And we're going to be marking the borders of our tumor. This tells us where to place the plaque. And generally, I mark the anterior tumor border and the lateral margins of the tumor. It's pretty hard to get to the posterior margin of the tumor, but this will be sufficient to let us know that our plaque is going to be in good position.

We're done with our transillumination step. So now we're going to be using our dummy plaques. So this is actually clear and allows us to see through the plaque. And that's going to be very useful since we've been able to mark out our tumor borders.

And you can see that we can see our marks that we made around that tumor shadow within this clear plastic dummy plaque. That lets us know that we're covering all of our margins of the tumor that we saw from our shadow. So our islets are where we actually aim to suture our plaque to the sclera, so that we hold it in place during treatment.

So I like to use three stabilization points. So we have six islets total, I'll suture to three. So we've made nice tiny marks there.

So now we'll remove our plastic dummy plaque. And we're going to be placing our sutures that will be used to hold our plaque in place.

And when I'm coming out with my needle, I'm always staying parallel to the globe. That's very important. If you sort of round up and dig the tail of your needle into the sclera, you can actually perforate the sclera that way. So I'm very cautious.

So now we have all three of our sutures in place. And we're going to take our metal dummy plaque. So our metal dummy plaque is used because this is opaque on our ultrasound. So when we do ultrasound, we'll actually be able to see our metal dummy plaque. Slide this back into that infratemporal quadrant there. And we're going to align our islets again.

We're going to touch this only with our instruments. We're not going to touch this with our hands because it's radioactive. And my assistant is going to be ready with a nice exposure for me to place this exactly in that infratemporal quadrant.

That's going to be in excellent position. We're going to take our needle driver and we're just going to put each of these sutures in place.

Here's our third and final suture. So we're going to go ahead and start tying these down nicely.

So once we've got this tied down, last needle back. And we're going to again rotate the eye infratemporally now. We're going to place some gel on the surface of the eye.

So now we're done using our muscles to manipulate the eye. We can go ahead and cut our imbrication sutures there.

So on Monday, we placed this radioactive iodine plaque infratemporally to treat a choroidal melanoma. And it's been in place with a big patch over the eye since then.

So here we are on Friday. And all we get to do today is cut this plaque off so that this gentleman is free from radioactivity. And then we're going to watch the tumor shrink down into a flat scar over the next several months.

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