The optimal approach to the primary treatment of uveal melanoma: a narrative review.

Background: Uveal melanoma is the most common primary intraocular malignancy in adults. Current management emphasises local tumour control and globe preservation, while survival remains largely determined by metastatic disease. Several eye-preserving radiotherapy modalities have replaced enucleation in many cases. This narrative review summarises indications, outcomes, and toxicity profiles of definitive local treatment strategies for primary uveal melanoma. Materials and methods: A nonsystematic literature review was conducted in accordance with SANRA guidelines. Publications from 2015-2025 were identified via PubMed using keywords related to uveal melanoma and radiotherapy. Landmark data from the COMS and recommendations from the National Comprehensive Cancer Network (NCCN) were included to provide clinical context. Studies addressing primary tumour management were eligible, while those focusing exclusively on metastatic disease were excluded. Results: Five-year local control rates exceed 90% across modalities for tumours of comparable size. Plaque brachytherapy remains the most widely used technique, offering survival outcomes equivalent to enucleation, with isotope selection varying by region. fSRT provides excellent local control for posterior or large tumours unsuitable for plaque placement, particularly with hypofractionated regimens such as 50 Gy in 5 fractions. PBT offers highly conformal dose distribution and is advantageous for large or posterior tumours, although access is limited. Despite improved local control, metastatic outcomes remain poor; ongoing trials of adjuvant tebentafusp may influence future systemic strategies. Conclusions: Treatment should be individualised within a multidisciplinary setting. Brachytherapy remains the standard for small and medium tumours, while fSRT and PBT are effective alternatives when plaque therapy is not feasible.