To determine visual and anatomic outcomes following transpupillary thermotherapy (TTT) as a primary treatment for small choroidal malignant melanomas.20 patients with small choroidal melanomas who underwent primary TTT at our institution were retrospectively reviewed. Patients with choroidal melanomas posterior to the equator with a basal diameter less than 12 mm and thickness less than 3.5 mm were included if the lesion had documented growth or clinical risk factors for growth.Thirteen women and seven men (mean age: 65 years, range: 41-85 years) underwent TTT. The mean preoperative tumour thickness was 1.81 mm (range: 0.78-3.40 mm). The mean follow-up time after TTT was 44.6 months (range: 11-108 months, median: 47.5 months). After a mean of 2.15 primary TTT sessions (range: 1-4), tumour regression without recurrence was attained in 11 (55%) of 20 cases. Five of the nine remaining tumours with recurrence were successfully treated with additional TTT. One patient declined further TTT and underwent enucleation. Three other tumours had recurrence after repeat TTT. The mean time to recurrence after initial TTT was 20.8 months (range: 8-37 months). The mean time to recurrence after repeat TTT was 35 months (range: 5-69 months). There was no tumour-related metastasis or death.Tumours treated with TTT have significant recurrence rates. Although tumour control may ultimately be achieved with TTT, close monitoring of these tumours is necessary, since repeat TTT or alternative therapies may be required.