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Finger PT, Stewart R, Rivard MJ, Beers RJ, Kamen J, Lama S, Chin KJ, Mohney K, Welles TS, Sauerwein WAG, Rosenzweig K. First clinical implementation of Yttrium-90 Disc Brachytherapy after FDA clearance. Brachytherapy 2023; 22:416-427. [PMID: 36948988 DOI: 10.1016/j.brachy.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/04/2023] [Accepted: 02/15/2023] [Indexed: 03/24/2023]
Abstract
PURPOSE Herein, we study if high-dose-rate (HDR) yttrium-90 (90Y) brachytherapy could be utilized by medical physicists, radiation oncologists, and ophthalmic surgeons. METHODS AND MATERIALS Yttrium-90 (90Y) beta-emitting brachytherapy sources received United States Food and Drug Administration clearance for episcleral treatment of ocular tumors and benign growths. Dose calibration traceable to the National Institute of Standards and Technology as well as treatment planning and target delineation methods were established. Single-use systems included a 90Y-disc affixed within specialized, multifunction, handheld applicator. Low-dose-rate to high-dose-rate prescription conversions and depth-dose determinations were performed. Radiation safety was evaluated based on live exposure rates during assembly and surgeries. Clinical data for radiation safety, treatment tolerability, and local control was collected. RESULTS Practice parameters for the medical physicist, radiation oncologist, and ophthalmic surgeon were defined. Device sterilizations, calibrations, assemblies, surgical methods, and disposals were reproducible and effective. Treated tumors included iris melanoma, iridociliary melanoma, choroidal melanoma, and a locally invasive squamous carcinoma. Mean calculated 90Y disc activity was 14.33 mCi (range 8.8-16.6), prescription dose 27.8 Gy (range 22-30), delivered to depth of 2.3 mm (range 1.6-2.6), at treatment durations of 420 s (7.0 min, range 219 s-773 s). Both insertion and removal were performed during one surgical session. After surgery, each disc-applicator- system was contained for decay in storage. Treatments were well-tolerated. CONCLUSIONS HDR 90Y episcleral brachytherapy devices were created, implementation methods developed, and treatments performed on 6 patients. Treatments were single-surgery, rapid, and well-tolerated with short-term follow up.
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Affiliation(s)
- Paul T Finger
- The Department of Ocular Tumor, Orbital Disease, and Ophthalmic Radiation Therapy, The New York Eye Cancer Center, New York, NY; The Departments of Ophthalmology, Radiation Oncology, and Radiation Safety, New York Eye and Ear Infirmary of Mount Sinai and Icahn School of Medicine at Mount Sinai, New York, NY; Scientific Advisory Board and Employees of Liberty Vision Corporation, Portsmouth, NH.
| | - Robert Stewart
- The Departments of Ophthalmology, Radiation Oncology, and Radiation Safety, New York Eye and Ear Infirmary of Mount Sinai and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mark J Rivard
- Scientific Advisory Board and Employees of Liberty Vision Corporation, Portsmouth, NH
| | - Raymond J Beers
- The Departments of Ophthalmology, Radiation Oncology, and Radiation Safety, New York Eye and Ear Infirmary of Mount Sinai and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jacob Kamen
- The Departments of Ophthalmology, Radiation Oncology, and Radiation Safety, New York Eye and Ear Infirmary of Mount Sinai and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shyam Lama
- The Departments of Ophthalmology, Radiation Oncology, and Radiation Safety, New York Eye and Ear Infirmary of Mount Sinai and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kimberly J Chin
- The Department of Ocular Tumor, Orbital Disease, and Ophthalmic Radiation Therapy, The New York Eye Cancer Center, New York, NY; Scientific Advisory Board and Employees of Liberty Vision Corporation, Portsmouth, NH
| | - Kyle Mohney
- Scientific Advisory Board and Employees of Liberty Vision Corporation, Portsmouth, NH
| | - Toby S Welles
- Scientific Advisory Board and Employees of Liberty Vision Corporation, Portsmouth, NH
| | | | - Kenneth Rosenzweig
- The Departments of Ophthalmology, Radiation Oncology, and Radiation Safety, New York Eye and Ear Infirmary of Mount Sinai and Icahn School of Medicine at Mount Sinai, New York, NY
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Guo J, Qiu X, Tang W, Xu G, Moyers MF, Ren W, Xing Y, Gao J, Sun J, Lu J, Kong L, Liu W. One-Year Efficacy and Safety of Proton-Beam Irradiation Combined with Intravitreal Conbercept for Refractory or Recurrent Polypoidal Choroidal Vasculopathy: A Pilot Study. Ophthalmol Ther 2021; 11:187-199. [PMID: 34773572 PMCID: PMC8770763 DOI: 10.1007/s40123-021-00409-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/01/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction To investigate the efficacy and safety of proton-beam irradiation (PBI) combined with intravitreal conbercept (IVC) injection for refractory or recurrent polypoidal choroidal vasculopathy (PCV). Methods A prospective interventional clinical trial included 12 patients with refractory PCV (defined as persistent exudation or fluid after six consecutive injections at monthly intervals and/or photodynamic therapy) or recurrent PCV (defined as new exudative signs after six monthly injections and/or photodynamic therapy) treated between January 2019 and September 2020. Every patient underwent single PBI (14 GyE) with concomitant IVC (0.5 mg) within 1 week and further doses of IVC were administered pro re nata. Results By the 12-month follow-up, the subretinal fluid was completely absorbed in 9 eyes (81.8%). The angiographic regression and closure rates of the polyps were 60% (12/20) and 90% (18/20), respectively. The mean number of IVC injections was 3.1 ± 1.37. The mean BCVA improved by 20 letters (P = 0.006). The mean central macular thickness (CMT) decreased from 476.50 ± 123.63 μm to 317.70 ± 89.34 μm (P = 0.004). The areas of branching vascular networks and polyps decreased by 37.2% and 72.3%, respectively. Radiation retinopathy was observed in five eyes, but no systemic adverse events were observed. Conclusion PBI combined with IVC appears to promote polyp regression and closure, reduce CMT, and improve BCVA, with a favorable safety profile, after 12 months. Therefore, PBI may be a useful adjuvant therapy for patients with refractory or recurrent PCV. Trial Registration Proton-Beam Irradiation Combined with Intravitreal Conbercept for Refractory or Recurrent Polypoidal Choroidal Vasculopathy: Prospective Phase II Clinical Study (ChiCTR2000038987).
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Affiliation(s)
- Jingli Guo
- Department of Ophthalmology, Eye and ENT Hospital, Fudan University, Shanghai, 200031 China
- NHC Key Laboratory of Myopia (Fudan University), Shanghai, China
- Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
| | - Xianxin Qiu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, 201321 China
| | - Wenyi Tang
- Department of Ophthalmology, Eye and ENT Hospital, Fudan University, Shanghai, 200031 China
- NHC Key Laboratory of Myopia (Fudan University), Shanghai, China
- Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
| | - Gezhi Xu
- Department of Ophthalmology, Eye and ENT Hospital, Fudan University, Shanghai, 200031 China
- NHC Key Laboratory of Myopia (Fudan University), Shanghai, China
- Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
| | - Michael. F. Moyers
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, 201321 China
| | - Wei Ren
- Department of Radiation Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Ying Xing
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, 201321 China
- Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Jin Gao
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, 201321 China
| | - Jiayao Sun
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, 201321 China
| | - Jiade Lu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, 201321 China
| | - Lin Kong
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, 201321 China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Wei Liu
- Department of Ophthalmology, Eye and ENT Hospital, Fudan University, Shanghai, 200031 China
- NHC Key Laboratory of Myopia (Fudan University), Shanghai, China
- Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China
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Yan H, Sun W, Mruthyunjaya P, Beadle B, Yu W, Kanwal B, MacDonald CA, Liu W. Dosimetry modeling of focused kV x‐ray radiotherapy for wet age‐related macular degeneration. Med Phys 2020; 47:5123-5134. [DOI: 10.1002/mp.14404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/22/2020] [Accepted: 07/07/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Huagang Yan
- School of Biomedical Engineering Capital Medical University Beijing100069 China
| | - Weiyuan Sun
- Department of Physics University at AlbanySUNY Albany NY12222 USA
| | - Prithvi Mruthyunjaya
- Department of Ophthalmology Stanford University School of Medicine Stanford CA94305 USA
| | - Beth Beadle
- Department of Radiation Oncology Stanford University School of Medicine Stanford CA94305 USA
| | - Weihong Yu
- Department of Ophthalmology Key Laboratory of Ocular Fundus Diseases Peking Union Medical College HospitalChinese Academy of Medical Sciences Beijing100730 China
| | - Bushra Kanwal
- Center for High Energy Physics University of the Punjab Lahore Pakistan
| | | | - Wu Liu
- Department of Radiation Oncology Stanford University School of Medicine Stanford CA94305 USA
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Cantley JL, Fisher DR, Lin S, Albani DM, Zorrilla A, Bolch WE. Radiation dose to non-targeted tissues of the eye during polymer-based delivery of
90
Y to ocular melanoma of the choroid. Biomed Phys Eng Express 2017. [DOI: 10.1088/2057-1976/aa73fd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Villegas VM, Aranguren LA, Kovach JL, Schwartz SG, Flynn HW. Current advances in the treatment of neovascular age-related macular degeneration. Expert Opin Drug Deliv 2016; 14:273-282. [PMID: 27434329 DOI: 10.1080/17425247.2016.1213240] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Age-related macular degeneration (AMD) is the most common cause of permanent central visual acuity loss in persons over 65 years of age in industrialized nations. Today, intravitreal vascular endothelial growth factor (VEGF) inhibitors are the mainstay of treatment worldwide. Areas covered: The following review covers the current treatments and challenges of wet AMD management. It also covers emerging therapies including radiation, latest generation anti-VEGF agents, and combination therapies. Expert opinion: Current neovascular AMD therapy is aimed at decreasing the VEGF effect at the choroidal neovascularization (CNV) complex. The most important existing challenges in the treatment of neovascular AMD are improving visual outcomes, decreasing the treatment burden, and minimizing geographic atrophy. Clinicians are using many treatment strategies to minimize intravitreal injections without sacrificing visual outcomes. Combination of anti-VEGF therapy with other previously available treatments that target a different pathophysiological mechanism may be a reasonable clinical strategy to minimize intravitreal injections. Many exciting novel drugs that target newly discovered pathways associated with CNV development and progression hold clinical promise. The results of ongoing randomized clinical trials will answer the important concerns surrounding new drugs and delivery devices: safety and visual outcomes.
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Affiliation(s)
- Victor M Villegas
- a Department of Ophthalmology, Bascom Palmer Eye Institute , University of Miami Miller School of Medicine , Miami , FL , USA
| | - Luis A Aranguren
- a Department of Ophthalmology, Bascom Palmer Eye Institute , University of Miami Miller School of Medicine , Miami , FL , USA
| | - Jaclyn L Kovach
- a Department of Ophthalmology, Bascom Palmer Eye Institute , University of Miami Miller School of Medicine , Miami , FL , USA
| | - Stephen G Schwartz
- a Department of Ophthalmology, Bascom Palmer Eye Institute , University of Miami Miller School of Medicine , Miami , FL , USA
| | - Harry W Flynn
- a Department of Ophthalmology, Bascom Palmer Eye Institute , University of Miami Miller School of Medicine , Miami , FL , USA
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Rice SR, Katz MSJ, Mehta MP. Context for Protons as Adjunctive Therapy in Neovascular Age-Related Macular Degeneration: A Review. Int J Part Ther 2016; 2:555-569. [PMID: 31772967 PMCID: PMC6871634 DOI: 10.14338/ijpt-15-00019.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 12/04/2015] [Indexed: 11/21/2022] Open
Abstract
In the last few years we have witnessed increasing availability of proton therapy in the United States and worldwide. As a result, proton therapy is considered as either a primary or adjunctive approach for numerous indications where conventional radiation therapy shows promise but is accompanied by toxicities. Age-related macular degeneration (AMD) remains the leading cause of adult blindness in industrialized nations, and third worldwide, following cataract and glaucoma. Current standard therapy is intravitreal injection of anti-vascular endothelial growth factor agents. While this treatment shows improvement and stabilization in visual acuity for 40% of patients, 60% still experience disease progression. These injections are costly, necessitate repeated office visits, and carry the risk of endophthalmitis. The pathophysiology underlying neovascular AMD (nAMD) underscores the need to simultaneously target multiple pathways to retain useful vision. Radiation can be antiangiogenic, anti-inflammatory, and antiproliferative. Early photon therapy clinical trials were heterogeneous, and a Cochrane review of data demonstrated usefulness in treatment of nAMD but recommended further studies. Advantages of proton therapy over photon therapy include the ability to deliver a focal dose to the target while minimizing dose to normal structures, which is enhanced by unique treatment planning software that uses fluorescein angiography to verify target location and allows conformation of dose to the irregular shape and thickness characteristic of choroidal neovascular membranes, the pathognomonic finding in nAMD. Preliminary data suggest a potential role for proton therapy in the treatment of nAMD. In this article we review previous treatments for AMD, including those with both photon and proton radiation, and recommend future directions for clinical investigations to evaluate the role of proton therapy as an adjunct to antiangiogenic therapy, the current standard of care in this challenging setting.
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Affiliation(s)
- Stephanie R. Rice
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | | | - Minesh P. Mehta
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
- Department of Ophthalmology, National Retina Institute, Towson, MD, USA
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Finger PT, Simhaee D, Semenova E. Regression of macular drusenoid retinal pigment epithelial detachments after plaque radiation therapy. Ophthalmic Surg Lasers Imaging Retina 2015; 46:84-6. [PMID: 25559516 DOI: 10.3928/23258160-20150101-15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Accepted: 06/10/2014] [Indexed: 11/20/2022]
Abstract
The authors describe a case in which drusenoid retinal pigment epithelial detachments (DRPEDs) melted after plaque radiation therapy for an unrelated choroidal melanoma. The patient had a history of bilateral macular DRPEDs prior to palladium-103 plaque therapy. The choroidal melanoma was located in the temporal macula. The central fovea was calculated to receive an incidental radiation dose of 34 Gy. Six months after treatment, an ipsilateral, unilateral reduction of DRPEDs was first noted by comparative fundus photography and optical coherence tomography. From his initial evaluation to his last follow-up, the patient's visual acuity slightly improved from 20/20 to 20/16.
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Chen L, Kim IK, Lane AM, Gauthier D, Munzenrider JE, Gragoudas ES, Miller JW. Proton beam irradiation for non-AMD CNV: 2-year results of a randomised clinical trial. Br J Ophthalmol 2014; 98:1212-7. [DOI: 10.1136/bjophthalmol-2013-304761] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Current treatment limitations in age-related macular degeneration and future approaches based on cell therapy and tissue engineering. J Ophthalmol 2014; 2014:510285. [PMID: 24672707 PMCID: PMC3941782 DOI: 10.1155/2014/510285] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 12/10/2013] [Indexed: 01/01/2023] Open
Abstract
Age-related macular degeneration (AMD) is the leading cause of blindness in the Western world. With an ageing population, it is anticipated that the number of AMD cases will increase dramatically, making a solution to this debilitating disease an urgent requirement for the socioeconomic future of the European Union and worldwide. The present paper reviews the limitations of the current therapies as well as the socioeconomic impact of the AMD. There is currently no cure available for AMD, and even palliative treatments are rare. Treatment options show several side effects, are of high cost, and only treat the consequence, not the cause of the pathology. For that reason, many options involving cell therapy mainly based on retinal and iris pigment epithelium cells as well as stem cells are being tested. Moreover, tissue engineering strategies to design and manufacture scaffolds to mimic Bruch's membrane are very diverse and under investigation. Both alternative therapies are aimed to prevent and/or cure AMD and are reviewed herein.
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Cantley JL, Hanlon J, Chell E, Lee C, Smith WC, Bolch WE. Influence of eye size and beam entry angle on dose to non-targeted tissues of the eye during stereotactic x-ray radiosurgery of AMD. Phys Med Biol 2013; 58:6887-96. [PMID: 24025704 PMCID: PMC3927464 DOI: 10.1088/0031-9155/58/19/6887] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Age-related macular degeneration is a leading cause of vision loss for the elderly population of industrialized nations. The IRay® Radiotherapy System, developed by Oraya® Therapeutics, Inc., is a stereotactic low-voltage irradiation system designed to treat the wet form of the disease. The IRay System uses three robotically positioned 100 kVp collimated photon beams to deliver an absorbed dose of up to 24 Gy to the macula. The present study uses the Monte Carlo radiation transport code MCNPX to assess absorbed dose to six non-targeted tissues within the eye-total lens, radiosensitive tissues of the lens, optic nerve, distal tip of the central retinal artery, non-targeted portion of the retina, and the ciliary body--all as a function of eye size and beam entry angle. The ocular axial length was ranged from 20 to 28 mm in 2 mm increments, with the polar entry angle of the delivery system varied from 18° to 34° in 2° increments. The resulting data showed insignificant variations in dose for all eye sizes. Slight variations in the dose to the optic nerve and the distal tip of the central retinal artery were noted as the polar beam angle changed. An increase in non-targeted retinal dose was noted as the entry angle increased, while the dose to the lens, sensitive volume of the lens, and ciliary body decreased as the treatment polar angle increased. Polar angles of 26° or greater resulted in no portion of the sensitive volume of the lens receiving an absorbed dose of 0.5 Gy or greater. All doses to non-targeted structures reported in this study were less than accepted thresholds for post-procedure complications.
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Affiliation(s)
- Justin L. Cantley
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL 32611 USA
| | | | - Erik Chell
- Oraya Therapeutics, Inc., Newark, CA 94560 USA
| | - Choonsik Lee
- Radiation Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, Bethesda, MD 20892 USA
| | - W. Clay Smith
- Department of Ophthalmology, University of Florida, Gainesville, FL 32610 USA
| | - Wesley E. Bolch
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL 32611 USA
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Morales-Canton V, Quiroz-Mercado H, Velez-Montoya R, Zavala-Ayala A, Moshfeghi AA, Shusterman EM, Kaiser PK, Sanislo SR, Gertner M, Moshfeghi DM. 16 and 24 Gy low-voltage X-ray irradiation with ranibizumab therapy for neovascular age-related macular degeneration: 12-month outcomes. Am J Ophthalmol 2013; 155:1000-1008.e2. [PMID: 23497847 DOI: 10.1016/j.ajo.2013.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Revised: 01/06/2013] [Accepted: 01/08/2013] [Indexed: 11/27/2022]
Abstract
PURPOSE To describe the 12-month safety and efficacy outcomes of 16 or 24 Gy radiation using low-voltage x-ray irradiation in conjunction with intravitreal ranibizumab for neovascular age-related macular degeneration (AMD). DESIGN Prospective, phase I, open-label, nonrandomized uncontrolled safety study. METHODS setting: Institutional. study population: Neovascular AMD patients. intervention: One x-ray irradiation treatment at 16 or 24 Gy was administered externally through 3 locations in the inferior pars plana. After 2 initial monthly loading doses of ranibizumab, subsequent ranibizumab was administered according to predetermined criteria. main outcome measures: Visual acuity, number of ranibizumab injections, safety and efficacy metrics at 12 months. RESULTS Forty-seven eyes of 47 patients were enrolled and completed 12 months of follow-up: 16 Gy (n = 28) and 24 Gy (n = 19). There was no evidence of radiation retinopathy, optic neuropathy, or cataract. The mean visual acuity improved in both groups: +8.4 ± 11.9 letters and +7.8 ± 12 letters for 16 and 24 Gy, respectively. In both groups, 100% of subjects lost <15 letters, with 76% and 79% gaining ≥0 letters in the 16 Gy and 24 Gy groups, respectively. Patients received a mean of 1.0 additional injection over 12 months. The mean change in optical coherence tomography central subfield thickness from baseline to month 12 was -107 and -87 μm for the 16 Gy and 24 Gy groups, respectively. CONCLUSION One treatment of 16 or 24 Gy low-voltage x-ray therapy with as-needed ranibizumab appears safe in subjects with neovascular AMD at 12 months. An overall improvement in visual acuity was observed. No radiation-related adverse effects were reported.
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Emerging Therapies for Neovascular Age-Related Macular Degeneration. Ophthalmology 2013; 120:S11-5. [DOI: 10.1016/j.ophtha.2013.01.061] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 01/08/2013] [Accepted: 01/25/2013] [Indexed: 01/18/2023] Open
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Kishan AU, Modjtahedi BS, Morse LS, Lee P. Radiation therapy for neovascular age-related macular degeneration. Int J Radiat Oncol Biol Phys 2012; 85:583-97. [PMID: 22975610 DOI: 10.1016/j.ijrobp.2012.07.2352] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 07/15/2012] [Indexed: 12/29/2022]
Abstract
In the enormity of the public health burden imposed by age-related macular degeneration (ARMD), much effort has been directed toward identifying effective and efficient treatments. Currently, anti-vascular endothelial growth factor (VEGF) injections have demonstrated considerably efficacy in treating neovascular ARMD, but patients require frequent treatment to fully benefit. Here, we review the rationale and evidence for radiation therapy of ARMD. The results of early photon external beam radiation therapy are included to provide a framework for the sequential discussion of evidence for the usage of stereotactic radiation therapy, proton therapy, and brachytherapy. The evidence suggests that these 3 modern modalities can provide a dose-dependent benefit in the treatment of ARMD. Most importantly, preliminary data suggest that all 3 can be used in conjunction with anti-VEGF therapeutics, thereby reducing the frequency of anti-VEGF injections required to maintain visual acuity.
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Three-year safety and visual acuity results of epimacular 90 strontium/90 yttrium brachytherapy with bevacizumab for the treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration. Retina 2012; 32:10-8. [PMID: 21817963 DOI: 10.1097/iae.0b013e31822528fc] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate the long-term safety and visual acuity outcomes associated with epimacular strontium 90 brachytherapy combined with intravitreal bevacizumab for the treatment of subfoveal choroidal neovascularization because of age-related macular degeneration. METHODS Thirty-four treatment-naive patients with predominantly classic, minimally classic, and occult subfoveal choroidal neovascularization lesions participated in this prospective, 2-year, nonrandomized multicenter study. Subjects from 1 center (n = 19) were reconsented and followed-up for 3 years. Each subject received a single 24-Gy beta irradiation treatment via an intraocular delivery device and 2 planned injections of bevacizumab at treatment and 1 month later. Additional bevacizumab therapy was permitted based on prespecified retreatment criteria. Adverse events were observed, and best-corrected visual acuity was measured using Early Treatment Diabetic Retinopathy Study vision charts. Subjects were evaluated every 3 months during the first year of follow-up and every 6 months during Years 2 and 3 of follow-up. RESULTS All 34 subjects were followed-up for 24 months and 19 were followed-up through 36 months. With up to 24 months of follow-up, 12 of 24 phakic patients (50%) exhibited ≥ 2 grades of progression in Lens Opacification Classification System (LOCS) II lens classification; 5 eyes underwent cataract extraction before the Month 36 visit. There was 1 case of nonproliferative retinopathy identified at 36 months of follow-up that did not have an adverse effect on visual acuity, was stable at 43 months of follow-up, and was isolated to the parafoveal region. Mean best-corrected visual acuity demonstrated an average gain of +15.0 and -4.9 letters at 12 months and 24 months, respectively; the drop in mean gain at Month 24 was largely attributable to cataract formation. At 36 months (n = 19), the mean best-corrected visual acuity was +3.9, 90% (17 of 19) of eyes had lost <15 letters from baseline, 53% (10 of 19) had gained ≥ 1 letter, and 21% (4 of 19) had gained ≥ 15 letters. Through 36 months, 11 eyes required additional bevacizumab retreatment therapy and received a mean of 3.0 injections (range, 2-7 injections). CONCLUSION Epimacular brachytherapy shows promise as a therapeutic option for subfoveal neovascular age-related macular degeneration. The procedure was safe and well tolerated, with a reasonable risk-benefit profile that warrants further study in larger subject populations. The most common adverse event was cataract progression/formation. Surgical complications are similar to those expected from standard vitrectomy trials. This novel device is currently being evaluated in two prospective, randomized, controlled trials in treatment-naive subjects (CABERNET) and in subjects already treated with anti-vascular endothelial growth factor therapy (MERLOT).
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Canton VM, Quiroz-Mercado H, Velez-Montoya R, Lopez-Miranda MJ, Moshfeghi AA, Shusterman EM, Kaiser PK, Sanislo SR, Gertner M, Moshfeghi DM. 24-Gy Low-Voltage X-Ray Irradiation With Ranibizumab Therapy for Neovascular AMD: 6-Month Safety and Functional Outcomes. Ophthalmic Surg Lasers Imaging Retina 2012; 43:20-4. [DOI: 10.3928/15428877-20111129-01] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 10/28/2011] [Indexed: 11/20/2022]
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Ten-year follow-up of eyes treated with stereotactic fractionated external beam radiation for neovascular age-related macular degeneration. Retina 2011; 31:1303-15. [PMID: 21499195 DOI: 10.1097/iae.0b013e318203ee46] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine the long-term effects of stereotactic fractionated external beam radiation on eyes treated for neovascular age-related macular degeneration. METHODS A retrospective review of all eyes treated with stereotactic fractionated external beam radiation (20-40 Gy, 2-Gy fractions) between 1997 and 2000 was performed to identify eyes with ≥ 2-year follow-up for analysis. A subset was imaged prospectively using a high-resolution Fourier-domain optical coherence tomography. RESULTS Among 94 eyes treated, 33 eyes (32 subjects) had ≥ 2-year follow-up information (mean follow-up, 6.2 years; range, 2-10 years). Final visual acuity ranged from 20/50 to no light perception. Final macular findings included central geographic atrophy (49%), disciform scar (30%), and active choroidal neovascular membrane (9%). Fourier-domain optical coherence tomography images of three eyes with geographic atrophy revealed photoreceptor layer loss within areas of geographic atrophy with intact retinal morphology in areas of radiation exposure outside geographic atrophy. Radiation retinopathy was suspected in 18% and confirmed by fluorescein angiography in 15%, ranging from mild to neovascular glaucoma/phthisis bulbi (2 eyes). Mean time from stereotactic fractionated external beam radiation to development of radiation retinopathy was 5.4 years (range, 1-10 years). CONCLUSION A moderate rate of delayed radiation retinopathy was noted in eyes with neovascular age-related macular degeneration treated with stereotactic fractionated external beam radiation. Geographic atrophy was a common finding.
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Moshfeghi AA, Canton VM, Quiroz-Mercado H, Velez-Montoya R, Lopez-Miranda MJ, Shusterman EM, Kaiser PK, Sanislo SR, Gertner M, Moshfeghi DM. 16-Gy Low-Voltage X-ray Irradiation Followed by As-Needed Ranibizumab Therapy for AMD: 6-Month Outcomes of a “Radiation-First” Strategy. Ophthalmic Surg Lasers Imaging Retina 2011; 42:460-7. [DOI: 10.3928/15428877-20110804-03] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 06/20/2011] [Indexed: 11/20/2022]
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Canton VM, Quiroz-Mercado H, Velez-Montoya R, Lopez-Miranda MJ, Moshfeghi AA, Shusterman EM, Kaiser PK, Sanislo SR, Gertner M, Moshfeghi DM. 16-Gy low-voltage x-ray irradiation with ranibizumab therapy for AMD: 6-month safety and functional outcomes. Ophthalmic Surg Lasers Imaging Retina 2011; 42:468-73. [PMID: 21830747 DOI: 10.3928/15428877-20110804-01] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Accepted: 06/24/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To describe the 6-month safety and preliminary efficacy outcomes of the use of 16-Gy radiation with intravitreal ranibizumab for patients with neovascular age-related macular degeneration (AMD). PATIENTS AND METHODS A single treatment of a non-invasive, externally delivered low-voltage 16-Gy x-ray irradiation was administered in one session through three locations in the inferior pars plana. Optical coherence tomography (OCT) and Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity (VA) examinations were performed at 1 week, 1 month, and monthly thereafter, with quarterly fluorescein angiography (FA). After the two initial ranibizumab injections, subsequent injections were administered according to the following criteria: VA decline of 10 ETDRS letters compared with baseline, increase of 100-μm central foveal thickness on OCT compared with baseline, the development of new submacular hemorrhage, and the development of a new area of classic choroidal neovascularization on FA. RESULTS Twenty-six patients completed a 6-month follow-up. There was no evidence of radiation retinopathy, optic neuropathy, or cataract. The mean baseline ETDRS score was 46.6 letters (range: 5 to 80; standard deviation [SD]: 21.5). At 6 months, the corresponding ETDRS score was 55.6 letters (range: 25 to 80; SD: 18.9) and the mean change in VA was 9.5 ETDRS letters (SD: 10.3). On responder analysis, 96% lost 15 or fewer ETDRS letters, 81% gained 0 or more ETDRS letters, and 50% gained 15 or more ETDRS letters. Patients received a total of 13 ranibizumab injections following two initial injections. At 6 months, patients received an average of 0.5 additional injections following the initial two mandated injections. CONCLUSION A single treatment of externally applied, non-invasive 16-Gy low-voltage x-ray therapy in conjunction with ranibizumab demonstrated an overall improvement of VA in patients with neovascular AMD at 6 months with no radiation-related adverse effects.
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Steinle N, Barakat M, Moshfeghi D, Kaiser PK. Radiation therapy in the treatment of exudative age-related macular degeneration. EXPERT REVIEW OF OPHTHALMOLOGY 2011. [DOI: 10.1586/eop.11.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Silva RA, Moshfeghi AA, Kaiser PK, Singh RP, Moshfeghi DM. Radiation Treatment for Age-Related Macular Degeneration. Semin Ophthalmol 2011; 26:121-30. [DOI: 10.3109/08820538.2011.554486] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Bornfeld N. Epimacular brachytherapy — old ghost or new age? Graefes Arch Clin Exp Ophthalmol 2011; 249:471-3. [DOI: 10.1007/s00417-011-1632-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 01/25/2011] [Indexed: 11/30/2022] Open
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Abstract
The reader may be eager to examine in which diseases ozonetherapy can be proficiently used and she/he will be amazed by the versatility of this complementary approach (Table 9 1). The fact that the medical applications are numerous exposes the ozonetherapist to medical derision because superficial observers or sarcastic sceptics consider ozonetherapy as the modern panacea. This seems so because ozone, like oxygen, is a molecule able to act simultaneously on several blood components with different functions but, as we shall discuss, ozonetherapy is not a panacea. The ozone messengers ROS and LOPs can act either locally or systemically in practically all cells of an organism. In contrast to the dogma that “ozone is always toxic”, three decades of clinical experience, although mostly acquired in private clinics in millions of patients, have shown that ozone can act as a disinfectant, an oxygen donor, an immunomodulator, a paradoxical inducer of antioxidant enzymes, a metabolic enhancer, an inducer of endothelial nitric oxide synthase and possibly an activator of stem cells with consequent neovascularization and tissue reconstruction.
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Affiliation(s)
- Velio Bocci
- Department of Physiology, University of Siena, via A. Moro 2, 53100 Siena, Italy
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TWELVE-MONTH SAFETY AND VISUAL ACUITY RESULTS FROM A FEASIBILITY STUDY OF INTRAOCULAR, EPIRETINAL RADIATION THERAPY FOR THE TREATMENT OF SUBFOVEAL CNV SECONDARY TO AMD. Retina 2009; 29:157-69. [DOI: 10.1097/iae.0b013e3181985915] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Thomadsen BR, Williamson JF, Rivard MJ, Meigooni AS. Anniversary Paper: Past and current issues, and trends in brachytherapy physics. Med Phys 2008; 35:4708-23. [DOI: 10.1118/1.2981826] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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Vezendi L. [Therapeutic modalities of age-related macular degeneration]. Orv Hetil 2008; 149:989-94. [PMID: 18487114 DOI: 10.1556/oh.2008.28345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Age-related macular degeneration has become a leading cause of legal blindness in the industrial countries. Some hundred thousands of people are estimated to be suffering from the disease in Hungary as well. Earlier the different forms were considered as distinct diseases. Since the whole scale and pathomechanism of age-related macular degeneration has been clarified, and at the same time the therapeutic modalities have been developed in a lot of cases, there is good chance of maintaining or even improving visual acuity. The author describes the different forms of the disease, and then writes about the treatment modalities which proved to be effective, or which have been introduced recently in detail. He emphasises the harmful role of smoking among prevention methods. Conservative treatment beside antioxidants includes the so-called metabolic therapy nowadays. Different types of laser treatment are widely used, while irradiation to a smaller extent. The role of traditional surgical intervention is also limited, but the use of anti-vascular endothelial growth factors is very promising. Costs of different methods are also referred to.
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Affiliation(s)
- László Vezendi
- Kanizsai Dorottya Kórház-Rendelôintézet, Szemészeti Osztály, Nagykanizsa.
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Saornil MA, Hincapié JS, López-Lara F, López MI, Blanco G, De Frutos JM. Episcleral brachytherapy as simultaneous treatment of choroidal melanoma and neovascular membrane. Brachytherapy 2008; 7:47-9. [DOI: 10.1016/j.brachy.2007.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2007] [Revised: 10/10/2007] [Accepted: 10/29/2007] [Indexed: 11/16/2022]
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Henderson MA, Valluri S, Lo SS, Witt TC, Worth RM, Danis RP, Timmerman RD. Gamma Knife Radiosurgery in the Treatment of Choroidal Neovascularization (Wet-Type Macular Degeneration). Stereotact Funct Neurosurg 2006; 85:11-7. [PMID: 17077651 DOI: 10.1159/000096634] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We evaluated retrospectively our institutional experience in the treatment of macular degeneration with gamma knife radiosurgery (GKR). Treatment was delivered in a single shot of 12 Gy. Seven patients were treated between March of 1999 and May of 2000. The median duration of follow-up was 2.2 years. The majority of patients maintained stable visual acuity after treatment. Our series indicates that GKR may be useful as a salvage treatment for patients who have failed or are ineligible for other treatments for their macular degeneration. Further studies are needed to better define the role of GKR in the treatment of macular degeneration.
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Affiliation(s)
- Mark A Henderson
- Department of Radiation Oncology, Indiana University Medical Center, Indianapolis, Ind., USA
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