Short- and long-term outcome following thoracoamniotic shunting for fetal hydrothorax.

OBJECTIVES: To assess short- and long-term outcome in a cohort of fetuses diagnosed with hydrothorax (FHT) which underwent thoracoamniotic shunting in utero, and to examine the antenatal predictors of survival and of survival with normal neurodevelopmental outcome. METHODS: This was a retrospective analysis of 132 fetuses that underwent thoracoamniotic shunting at our center between 1991 and 2014. Data were extracted from hospital obstetric and relevant neonatal intensive care and neonatal developmental follow-up databases. Outcomes included survival to discharge and survival with normal neurodevelopmental outcome beyond 18 months. Information on malformations, syndromes and genetic abnormalities were obtained from antenatal, postnatal and pediatric hospital records or by parent report. We compared pregnancy characteristics among those who survived vs non-survivors and among those with normal neurodevelopmental outcome vs those who were abnormal or died. We explored whether there was a trend in survival over the study period. RESULTS: The mean gestational age at diagnosis of FHT was 25.6 weeks. The fetus was hydropic at diagnosis in 61% of cases, 69% had bilateral effusions and 55% had bilateral shunts inserted. Other diagnoses were present in 24% of cases, two-thirds of which were discovered only postnatally. There were 16 intrauterine and 30 neonatal deaths, with a 65% survival rate overall. The mean gestational age at delivery of liveborns was 35.4 (range, 26.9-41.6) weeks, and 88/116 (76%) were preterm (< 37 weeks). Of 87 liveborn at the treatment center, 75% experienced some respiratory and/or cardiovascular morbidity after birth, many with a lengthy hospital stay (mean, 36 (range, 1-249) days). Overall, 84% of survivors were developmentally normal beyond 18 months and outcomes were better when pleural effusions were isolated, 92% of these cases being neurodevelopmentally normal. There was no trend in survival or neurodevelopmental outcome over time. Despite the presence of FHT and neonatal respiratory issues, most (89%) of the 55 survivors with relevant follow-up had no long-term pulmonary complications. Gestational age at delivery was the only factor independently predictive of both survival and survival with normal neurodevelopmental outcome. CONCLUSIONS: FHT is associated with other pathologies in a quarter of cases and carries a significant risk of prematurity, mortality and neonatal morbidity. The outcome is good in survivors but is best in isolated cases. Predictors of outcome at diagnosis are poor. Future improvement in diagnostics at time of identification of FHT may help to identify those that would benefit most from thoracoamniotic shunting. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

[Social awareness campaign for a ban on consumer fireworks: 10 tips; doctor on the barricade]. / Maatschappelijke actie voor een verbod op consumentenvuurwerk: 10 tips.

- Describe the problem, and show why a social awareness campaign is needed- Know what you are talking about, and explain the medical jargon in plain language- Collect data and facts- Create support among colleagues- Get the media involved- Get support from the community- Create a coalition of supporters via a website- You will discover who the opposition is when you are on the barricade- Offer a safe and healthy alternative - Draw up a long-term roadmap, and persevere.

[Learning to see things from a different perspective: interns and residents collaborate with artists to become better doctors]. / Anders leren kijken en de ander leren zien.

In 2016 and 2017, we started an innovative learning track in the Radboudumc that combines arts and medical education, and appraised the learning processes involved. The voluntary track was followed by 32 and 30 participants respectively, mostly interns and a few residents. The initiative built upon the ideas of several American educational developments which incorporated museum visits. We extended the format by having participants join artists in their studios, to allow students to have an immersive experience of a different discipline, rather than only observing its end products. The track did not have specific learning objectives. However, participants were encouraged to set personal goals and to reflect on what they learned in terms of observation skills, creative thinking, personalized health care, and frame reflection. Here we report the rationale of the track, and illustrate preliminary conclusions with participants' quotes.

Twin-twin transfusion syndrome: a frequently missed diagnosis with important consequences.

OBJECTIVE: To evaluate the incidence and consequences of 'misdiagnosed' cases of twin-twin transfusion syndrome (TTTS). METHODS: Chorionicity and referral diagnoses were reviewed in pregnant women with monochorionic twin pregnancies complicated by TTTS treated with fetoscopic laser ablation. 'Misdiagnosed' cases, defined as failure to correctly identify chorionicity and/or to diagnose TTTS prior to referral, were compared with cases in whom chorionicity and TTTS were diagnosed correctly. TTTS stage, gestational age at referral, overall survival, fetal and perinatal mortality, gestational age at delivery, operating time and maternal complications were compared. RESULTS: Failure to identify monochorionicity and/or TTTS was observed in 33% (107/323) of referrals to our center. Compared with cases in whom chorionicity and TTTS were correctly diagnosed, misdiagnosed patients were referred at a more advanced stage of disease (Stage IV TTTS: 16.8% vs 7.9%, P = 0.014) and later in pregnancy (gestational age at laser: 20.9 weeks vs 20.1 weeks, P = 0.018). They also delivered more prematurely (30.3 weeks' gestation vs 31.5 weeks' gestation, P = 0.04) and fetal and neonatal mortality were higher (neonatal death within 7 days: 19.6% vs 6.0%, P < 0.001). When the diagnosis was incorrect, major maternal complications and intensive care unit admissions were increased. CONCLUSIONS: Poor recognition of chorionicity in the first trimester of pregnancy might lead to inadequate ultrasound follow up (failure to assess every 2 weeks) and patient education. Early accurate recognition of both chorionicity and TTTS, with timely referral to a fetal therapy center, are key to ensuring optimal maternal and fetal outcomes.

Unfractionated heparin for second trimester placental insufficiency: a pilot randomized trial.

OBJECTIVE: To conduct a pilot randomized controlled trial of unfractionated heparin (UFH) in women considered at high risk of placental insufficiency in the second trimester. METHODS: Women with either false-positive first trimester (pregnancy-associated placental protein-A [PAPP-A] < 0.35 MoM) or second trimester (alpha-fetoprotein [AFP] > 2.0 MoM, inhibin > 3.0 MoM, human chorionic gonadotropin > 4.0 MoM) serum screening tests or medical/obstetric risk factors were screened for placental insufficiency by sonographic evaluation of the placenta and uterine artery Doppler between 18 and 22 weeks. Thrombophilia screen-negative women with two or three abnormal test categories were randomized by 23+6 weeks to self-administration of subcutaneous unfractionated heparin (UFH) 7500 IU twice daily until birth or 34 weeks, or to standard care. Maternal anxiety and other maternal-infant outcomes were determined. RESULTS: Thirty-two out of 41 eligible women consented, with 16 women randomized to UFH and 16 to standard care. There was no statistically significant difference identified between the two treatment groups (standard care vs. UFH) for the following: maternal anxiety score (mean [standard deviation]), 14.2 [± 1.6] vs. 14.0 [± 1.8]; birth weight (median [range]), 1795 [470-3295]g vs. 1860 [730-3050]g; perinatal death, 3 vs. 0; severe preeclampsia, 2 vs. 6; placental weight < 10th percentile, 7 vs. 4; or placental infarction, 4 vs. 3. CONCLUSION: Our study design identified women at high risk of adverse maternal-infant outcomes attributable to placental insufficiency. Women with evidence of placental insufficiency were willing to undergo randomization and self-administration of UFH without increased maternal anxiety.

Congenital megalourethra: prenatal diagnosis and postnatal/autopsy findings in 10 cases.

OBJECTIVE: Congenital megalourethra is a rare urogenital malformation characterized by dilation and elongation of the penile urethra associated with absence or hypoplasia of the corpora spongiosa and cavernosa. Postnatal complications include voiding and erectile dysfunction as well as renal insufficiency and pulmonary hypoplasia. To date, only a few prenatally diagnosed cases have been reported. We report on 10 cases diagnosed prenatally and their postnatal/autopsy findings. METHODS: The study involved retrospective chart review of all cases diagnosed antenatally in three tertiary care centers over 5 years. Antenatal ultrasound images and medical records from obstetrics, genetics, urology and nephrology were reviewed. RESULTS: Ten fetuses with megalourethra were identified at a median gestational age of 19 (range, 13-24) weeks and all were confirmed postnatally or at autopsy. Three pregnancies were terminated and seven continued. All cases presented with a distended bladder and megalourethra and all cases had normal karyotype. Of seven liveborn babies, one died neonatally of pulmonary hypoplasia. All six infants alive at the time of writing had a dysfunctional urethra and three suffered from impaired or end-stage renal disease. Associated anomalies were found in half of the cases. CONCLUSION: Congenital megalourethra is caused by abnormal development or hypoplasia of the penile erectile tissue, secondary to distal urethral obstruction. When the amniotic fluid volume is normal, survival is possible. However, all liveborn infants have voiding and renal dysfunction and sexual dysfunction is expected. Megalourethra should be considered in all male fetuses presenting prenatally with megacystis and detailed fetal ultrasonography should look for an elongated and/or distended phallic structure as well as any associated anomalies.

Incorporation of femur length leads to underestimation of fetal weight in asymmetric preterm growth restriction.

OBJECTIVE: To review the performance of a variety of biometry formulae for estimated fetal weight (EFW) in the management of severely growth restricted fetuses with abnormal umbilical artery Doppler at a single perinatal institution. METHODS: Forty-three pregnancies were retrospectively reviewed. Inclusion criteria were: chromosomally/ structurally normal fetus; complete ultrasound biometry at < or = 7 days from delivery; EFW < 10(th) centile; absent/reversed end-diastolic flow in the umbilical arteries; and delivery at < 32 + 6 weeks. EFW accuracy and precision were compared among nine formulae utilizing combinations of head circumference (HC), biparietal diameter (BPD), abdominal circumference (AC) and femur length (FL) measurements. RESULTS: Twenty-six (60.5%) fetuses showed asymmetric growth (HC/AC ratio > 95(th) centile). Analysis of the systematic and random errors associated with each formula showed that the birth weight of asymmetrically-grown fetuses was most closely approximated by the Hadlock equation that utilized BPD and AC measurements only. The birth weight of symmetrically-grown fetuses was most closely approximated by EFW derived from Hadlock equations that utilized > or = three biometry measurements, including FL. Incorporation of FL into Hadlock formulae led to significant underestimation of birth weight in the fetuses with asymmetric growth (mean percentage error +/- SD: EFW(FL-AC), -13.3 +/- 9.8%; EFW(BPD-FL-AC), -10.8 +/- 9.8%; EFW(HC-FL-AC), -11.8 +/- 9.3%; EFW(BPD-HC-FL-AC), -11.7 +/- 9.5%; P < 0.001). The same equations were accurate in fetuses with symmetric growth (EFW(FL-AC), 3.1 +/- 10.0%; EFW(BPD-FL-AC), 1.0 +/- 8.9%; EFW(HC-FL-AC), 0.3 +/- 8.7%; EFW(BPD-HC-FL-AC), 0.4 +/- 15.5%). Use of the best performing equation (Hadlock 3), which does not include FL, to estimate weight in asymmetrically-grown fetuses over 28 weeks' gestation, would have reduced the proportion of those with an underestimation of fetal weight of > 100 g from nine (50.0%) to three (16.7%). CONCLUSIONS: Biometry methods that exclude FL should be considered in asymmetric intrauterine growth restriction associated with abnormal umbilical artery Doppler waveforms.

[Elderly people with visual impairment in The Netherlands]. / Visuele beperkingen bij ouderen in Nederland--risicogroepen en mogelijkheden tot interventie.

AIM: To estimate the number of elderly people with visual impairment in The Netherlands, now and in the future. Possibilities for intervention are discussed. METHODS AND MATERIALS: Estimates are based on a recent report on behalf of Foundation InZicht, ZonMw, in which prevalence data from population-based studies on blindness and low vision and its causes in The Netherlands, western Europe, The United States and Australia are related to the latest demographic data for The Netherlands. RESULTS: Of the 16.4 million Dutch in 2008 2.4 million (14.7%) are 65 years of age and older. Of this last group 155,000 persons are living in nursing homes or residential homes, the others are living in their own homes. In 2008 an estimated 77,000 persons are blind and 234,000 have low vision. Of them 79% is 65 years of age or older. Of the older people in care institutions 20% is blind (32,000) and 22% has low vision (34,000). In 62% of them the visual impairment is treatable or could have been prevented ('avoidable'). Of the older people living independently 1.2% is blind (27,000) and 6.8% has low vision (154,000). In 57% of them the affliction is avoidable. CONCLUSION: In 2008 247,000 elderly suffer from a visual impairment that could have been treated or prevented in 143,000 (58%) of them. Screening and treatment of elderly in care institutions seems indicated, as is health education to and goal-oriented screening of elderly who live independently.

S-100B protein and melanoma inhibitory activity protein in uveal melanoma screening. A comparison with liver function tests.

AIM: Our purpose was to determine whether S-100B or melanoma inhibitory activity (MIA) concentrations in the serum of patients with large uveal melanomas were better markers for the presentation of metastases than liver function tests. We also investigated whether increased marker levels were related to known clinical and histopathological prognostic parameters. METHODS: Total S-100B (A1B + BB) and MIA concentrations were measured in the sera from 104 patients with uveal melanoma prior to enucleation and in the sera from 50 healthy controls. Concentrations were also determined in the sera from 30 patients with known uveal melanoma metastases. Liaison Sangtec 100, an automated immunoluminometric assay measuring the total S-100B, and Roche MIA ELISA were used to quantify these proteins in serum. Results were compared with liver function tests [alkaline phosphatase, lactate dehydrogenase (LD), aspartate aminotransferase, alanine aminotransferase and gamma-glutamyl transpeptidase]. RESULTS: The mean S-100B and MIA concentrations were significantly higher in patients with metastases compared to melanoma patients without metastases. At the time of enucleation, S-100B and MIA were not prognostic for metastases in uveal melanoma, but S-100B and LD were the best tests to predict the occurrence of metastatic disease during the follow-up period. CONCLUSIONS: In our study, the S-100B and MIA serum concentrations were not correlated with any tested established prognostic parameter. S-100B and LD showed better performance in identifying melanoma metastases than gamma-glutamyl transpeptidase and MIA. A prospective follow-up study is needed to evaluate S-100B and MIA in identifying early micrometastasis in uveal melanoma.

Single spot PDT in patients with circumscribed choroidal haemangioma and near normal visual acuity.

BACKGROUND: In circumscribed choroidal hemangiomas (CCH) a long observation period and decreased visual acuity before treatment are risk factors for poor visual outcome. Therefore, we studied the use of limited, single spot photodynamic therapy (PDT) with Visudyne for the timely treatment of CCH. METHODS: Six consecutive patients with CCH, and metamorphopsia but (near) normal visual acuity were treated with PDT, using a single spot covering only the most prominent part of the tumour, and a radiance exposure of 50 J/cm(2). Start of treatment was 6 min following a 1-min infusion with Visudyne (6 mg/m(2) BSA), using a diode laser (692 nm). RESULTS: In all patients, the metamorphopsia disappeared, the OCT images returned to a normal foveal contour, and visual acuity remained 20/20 or improved to 20/20. In five patients, the tumour became ultrasonographically undetectable; in three after one PDT session, in one patient after two and in another patient after three PDT sessions. The last patient had a residual tumour height of 1.2 mm, but no metamorphopsia, a normal foveal contour on OCT, and fluorescein angiography showed no residual leakage. CONCLUSION: The present series demonstrates that single spot PDT might be an effective treatment for CCH with a visual acuity > or =20/30, without serious side-effects during a follow-up of at least 18 months.

Normal HLA class I, II, and MICA gene distribution in uveal melanoma.

PURPOSE: The molecules of the HLA class I and II molecules as well as the MHC class I chain-related gene A (MICA), a polymorphic and stress-induced cell surface molecule, are involved in T-cell and natural killer-cell (NK-cell) mediated immune responses. In this study we looked for any genetic susceptibility contributed by HLA class I, class II, or MICA genes with regard to the development of uveal melanoma. METHODS: Between 1998 and 2001, 159 uveal melanoma patients were typed for HLA class I and II, and 168 uveal melanoma patients were evaluated for MICA by microsatellite typing. The HLA antigen and MICA allele frequencies were compared with control groups of, respectively, 2,440 and 247 healthy Dutch individuals. RESULTS: HLA class I, HLA class II, and MICA gene frequencies in uveal melanoma patients and healthy Dutch controls showed no significant deviations after correction for the number of comparisons. CONCLUSIONS: We conclude that there is no genetic susceptibility or increased risk attributed to any HLA class I, class II, and MICA polymorphism with regard to the development of uveal melanoma.

Prevention of blindness in leprosy and the role of the Vision 2020 Programme.

Leprosy control programmes are highly successful. As a result, leprosy control will be more and more integrated into the general health services. The existing vertical, specialized control programmes will be dismantled. Eye complications in leprosy have decreased. This is a result of earlier diagnosis and highly effective multidrug treatment (MDT) of leprosy, combined with timely treatment of secondary nerve damage by steroids. Most ocular morbidity is now found among elderly and disabled leprosy patients who were diagnosed before effective MDT treatment became available. Many of these patients live in leprosy settlements. Age-related cataract has become the leading cause of blindness in leprosy. The second cause of blindness is corneal opacification, mainly as a result of neglected exposure keratitis and corneal anaesthesia. The miotic pupils in late multibacillary leprosy, in combination with small central lens opacities, may also lead to blindness. The Vision 2020 Initiative prioritises cataract surgery. Leprosy patients should be actively included. Disabled leprosy patients can also benefit from screening programmes for refractive errors and the provision of spectacles and low vision aids. Determining the most feasible surgical methods for lagophthalmos surgery remains a challenge. For all health and eye care staff, training in leprosy and its eye complications is needed, as well as a change in attitude towards leprosy patients. Staff must be prepared to welcome them in the general health services.

Paraneoplastic vitelliform retinopathy associated with cutaneous or uveal melanoma and metastases.

PURPOSE: To report unusual vitelliform fundus findings in three cases of paraneoplastic retinopathy associated with metastasised cutaneous or uveal melanoma and in one case, a unique immunoreactivity response. PATIENTS AND METHODS: Observational case series. The histories of three patients with MAR-like paraneoplastic retinopathy were reviewed. Electroretinography, Goldmann perimetry, fluorescein angiography, and in one case optical coherence tomography, immunohistochemistry and Western blotting were performed. RESULTS: All patients revealed similar paraneoplastic vitelliform retinal abnormalities. Symptoms in two cases differed from the classical MAR syndrome. In one case, western blotting and immunohistochemistry demonstrated antibodies against 120-kDa, a soluble photoreceptor protein. No immunoreactivity to retinal bipolar cells was detected. CONCLUSION: The clinical, electrophysiological, and immunological findings in our patients suggest a melanoma associated paraneoplastic origin, like in MAR syndrome. However contrary to MAR syndrome, this paraneoplastic vitelliform retinopathy exhibits a peculiar fundus picture, consisting of serous macular detachment and nummular vitelliform lesions in the posterior pole. This could be an unusual presentation of MAR or a separate paraneoplastic entity.

[Avoidable visual impairment in The Netherlands: the project "Vision 2020 Netherlands" of the World Health Organization]. / Vermijdbare slechtziendheid in Nederland: het project 'Vision 2020 Netherlands' van de Wereldgezondheidsorganisatie.

In the year 2004 there were an estimated 220,000-320,000 people in The Netherlands with visual impairment. In 150,000-220,000 (70%) of them the visual impairment is either curable or could have been prevented. Those most at risk are people with intellectual disabilities, elderly people in care institutions, elderly people in general and diabetics. 'Vision 2020 Netherlands', an initiative of the World Health Organization, was launched to eliminate avoidable visual impairment in the Netherlands by the year 2020 by means of awareness campaigns, implementation of screening programmes and by expanding eye care capacity through efficient cooperation between the professional groups involved in eye care.

Screening for uveal melanoma metastasis. Literature review.

Local tumour control in uveal melanoma has improved in the last decades. However, 5-year mortality due to metastases from large uveal melanomas remains high. Recently both isolated liver perfusion therapy and chemotherapy have reached encouraging results in improving metastasis survival. As such screening at an early stage, especially for liver metastases, becomes imperative.

Combined plaque radiotherapy and transpupillary thermotherapy in choroidal melanoma: 5 years' experience.

AIM: To evaluate the results of combined plaque radiotherapy and transpupillary thermotherapy (TTT) in 50 consecutive patients 5 years after treatment. METHODS: 50 adult patients with choroidal melanoma were treated with ruthenium-106 ((106)Ru) plaque radiotherapy combined with TTT. A flat scar was the preferred end point of treatment. The mean tumour thickness was 3.9 mm (range 1.5-8.0 mm), the mean tumour diameter was 11.3 mm (range 5.8-15.0 mm). TTT was performed with an infrared diode laser at 810 nm, a beam diameter of 2-3 mm, and 1 minute exposures. Tumours >5 mm thick received an episcleral contact dose of 800 Gy (106)Ru; tumours 3 mm thick (log rank test p = 0.01). Eight melanomas were amelanotic, seven of which required multiple TTT sessions. In one patient the tumour recurred at the central margin of the treated area; this eye was enucleated. In one patient the tumour failed to regress 6 months after treatment and enucleation was performed at the patient's request. Three eyes developed severe proliferative retinopathy. Radiation maculopathy caused a loss of the best corrected visual acuity: before treatment 31 patients had a best corrected visual acuity of 20/60 or better but in only 12 patients did it remain in this range 5 years after treatment. Three patients developed distant metastasis to the liver. CONCLUSION: The 5 year results for combined plaque radiotherapy and TTT as treatment for choroidal melanoma are favourable in terms of complete tumour regression and low rate of recurrences; however, there was considerable loss of visual acuity as a result of radiation maculopathy.

Longstanding symptomatic choroidal hemangioma managed with limited PDT as initial or salvage therapy.

PURPOSE: To describe the use of limited, low-irradiance, single-spot photodynamic therapy (PDT) with verteporfin for the treatment of symptomatic choroidal hemangiomas. METHODS: Thirteen consecutive patients with a circumscribed choroidal hemangioma were treated with limited PDT 6 min following a 1-min infusion with verteporfin (6 mg/m(2) body surface area), using a diode laser (692 nm) and a single spot large enough to cover only the most prominent part of the tumor. Exposure time was 166 s in the first three patients and 83 s in the last ten patients, resulting in a radiance exposure of respectively 100 and 50 J/cm(2). RESULTS: In all 11 not previously conventionally treated patients, visual acuity improved following PDT treatment. The two remaining patients with prior radiation treatment both reported widening of the visual field and sharper vision, but did not show an increase in ETDRS vision. In all but four patients the tumor became ultrasonographically undetectable by the first follow-up visit at 6 weeks, with only a slight irregularity at the level of the previous tumor remaining. In four patients the residual tumor was still detectable, and they received a second treatment, following which the tumor flattened completely. In all patients the retinal detachment disappeared. CONCLUSION: The present series demonstrates that even limited, low-irradiance, single-spot photodynamic therapy with verteporfin is an effective first-line treatment for choroidal hemangiomas.

Short communication: Effects of subacute ruminal acidosis on free-choice intake of sodium bicarbonate in lactating dairy cows.

The effect of inducing subacute ruminal acidosis (SARA) on the free-choice intake of sodium bicarbonate (SB) was investigated in four midlactation Holstein cows in a switchover experiment with four 1-wk periods. The SARA was induced by replacing 25% of the ad libitum intake of total mixed ration (TMR) with pellets containing 50% ground wheat and 50% ground barley and restricting access to TMR from 0700 to 1700 h. Control consisted of feeding TMR ad libitum. Powdered SB was provided for ad libitum consumption. Rumen pH was measured continuously using indwelling pH probes. Induction of SARA reduced (P < 0.05) the average daily rumen pH from 6.08 to 5.87, increased (P < 0.05) the average duration of rumen pH below 6 from 547 min x d(-1) to 916 min x d(-1), and increased (P < 0.05) the average duration of rumen pH below 5.6 from 132 min x d(-1) to 397 min x d(-1) (P < 0.05) but did not significantly affect SB intake. Average intake of SB was 26.8 g x d(-1) during SARA and 34.5 g x d(-1) during control. These low SB intakes must not have substantially affected rumen pH. Sodium bicarbonate intake differed significantly (P < 0.05) between cows. These data indicate that cows did not select SB in order to attenuate SARA.

Thermotherapy in the management of choroidal melanoma.

During the past 20 years of enucleation, which was the standard treatment for choroidal melanoma over more than a century, has largely been replaced by eye salvaging therapies such as radiotherapy or local resection. In 1995 transpupillary thermotherapy (TTT) using an infrared diode laser was introduced as a new conservative therapy for patients with choroidal melanoma. TTT can be defined as a heat treatment modality, which is delivered through a dilated pupil to the tumour surface. The technique uses a wide diode laser beam diameter with a low irradiance and a long exposure time. TTT induces tumour necrosis at sub-photocoagulation levels by a direct cell destructive effect with only a few ocular complications. TTT can be performed as sole therapy or combined with plaque radiotherapy, thus permitting a lower radiation dose. For amelanotic tumours dye-enhanced TTT with indocyanine green can be used. In this paper we review the role of sole or combined TTT, related to the current other treatment modalities for choroidal melanoma.