Radiation Macular Edema after Ru-106 Plaque Brachytherapy for Choroidal Melanoma Resolved by an Intravitreal Dexamethasone 0.7-mg Implant

Morphological Biomarkers Related to Visual Acuity in Patients With Radiation Retinopathy Treated With Intravitreal Ranibizumab

BACKGROUND AND OBJECTIVE

Our objective was to monitor variables via spectral-domain optical coherence tomography (SD-OCT) and identify the most relevant biomarkers related to best-corrected visual acuity (BCVA) in radiation retinopathy (RR).

PATIENTS AND METHODS

A post-hoc analysis of the two-year Ranibizumab for Radiation Retinopathy (RRR) trial analyzed vision and OCT parameters including intraretinal fluid, ellipsoid zone (EZ) disruption, retinal pigment epithelium atrophy, hard exudates, retinal hemorrhage, retinal neovascularization, and subfoveal fluid. BCVA and SD-OCT parameters were evaluated by univariate analysis and a mixed-effects model.

RESULTS

Forty eyes from the RRR trial were included. Intraretinal cyst vertical size (week 24: P = 0.032; week 48: P = 0.021), neovascularization (week 48: P = 0.028; week 72: P = 0.025), and EZ disruption (week 72: P = 0.029; week 104: P = 0.019) were the clinical parameters most relevant to BCVA by univariate analysis in at least two time points. The mixed-effects model confirmed the relevance of intraretinal cyst vertical size (P = 0.001) and neovascularization (P = 0.001) but not EZ disruption (P = 0.119) over the course of the study.

CONCLUSIONS

This study characterizes the course of visual loss in RR by identifying intraretinal cyst vertical size, neovascularization, and EZ disruption as biomarkers of poor BCVA over a span of two years. Larger multicenter studies are needed to confirm these findings. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

Anterior segment complications after dexamethasone implantations:real world data

PURPOSE

We aim to contribute to the literature in terms of treatment safety with our real world data by examining the anterior segment complications and follow-up results of patients who underwent dexamethasone implants in our clinic.

METHODS

The records of patients treated with at least one intravitreal dexamethasone implant for various retinal diseases: diabetic macular edema (265 eyes), central retinal vein occlusion (45 eyes), retinal vein branch occlusion (91 eyes), postoperative cystoid macular edema (18 eyes), non-infectious uveitis (37 eyes) and other (14 eyes) between July 2013 and April 2020 were reviewed.

RESULTS

After 925 injections were applied to 470 eyes of a total of 383 patients, the eyes were controlled during a mean follow-up of 24 months. No complications were detected in 328 eyes. Intraocular pressure (IOP) above 25 mmHg was detected in 97 eyes (20.6%) that had no previous history of ocular hypertension. Of these 97 eyes, 71 (73.1%) eyes with increased IOP were treated with topical monotherapy, 26 (26.8%) eyes were treated with topical combined therapy and 1 (1.03%) patient had glaucoma surgery. Cataracts requiring surgical intervention developed in 55 (%21.73) of 253 phakic eyes. Three patients have anterior chamber dislocation of dexamethasone, 1 patient was hospitalized with sterile endophthalmitis on the 7th day after the injection, and pars plana vitrectomy was performed.

CONCLUSION

This study is the first long-term follow-up study in our country evaluating the safety of dexamethasone implant injections in various retinal diseases and presenting the first real world data. Cataract progression and increased IOP were found to be the most common side effects. We observed that the patient's diagnosis did not cause a statistically significant change in the observation of side effects. As a result of our findings, close follow-up of IOP after the injection of dexamethasone implants would be appropriate.

INTRAVITREAL FLUOCINOLONE ACETONIDE IMPLANT FOR RADIATION RETINOPATHY: Report of Preliminary Findings

PURPOSE

To assess the efficacy of a 0.18 mg intravitreal fluocinolone acetonide (FA) implant (Yutiq, EyePoint Pharmaceuticals, Watertown, MA) as a treatment option for patients with radiation retinopathy-related cystoid macular edema.

METHODS

A retrospective review of seven patients treated for uveal melanoma who developed radiation retinopathy-related cystoid macular edema. They were initially treated with intravitreal anti-vascular endothelial growth factor and/or steroid injections and then transitioned to intravitreal FA implant. Primary outcomes include best-corrected visual acuity, central subfield thickness, and number of additional injections.

RESULTS

After FA implant insertion, best-corrected visual acuity and central subfield thickness remained stable in all patients. The variance in best-corrected visual acuity decreased from 75.5 ETDRS letters (range 0-199 letters) to 29.8 (range 1.2-134) after FA implant insertion. Mean central subfield thickness was 384 µ m (range 165-641) and 354 µ m (range 282-493) before and after FA implant insertion, resulting in a 30- µ m mean reduction. The number of intravitreal injections (average 4.9, range 2-10) decreased after intravitreal FA implant insertion with only two patients requiring one additional FA implant (average 0.29, range 0-1) over a mean of 12.1 months (range 0.9-18.5) follow-up.

CONCLUSION

Intravitreal FA implant is an effective treatment for cystoid macular edema radiation retinopathy. The slow release of steroid allows for sustained control of macular edema, which correlated with stable visual acuity and decreased injection burden for patients.

Intravitreal dexamethasone: variation of surgical technique and prevention of ocular complications with ASOCT follow-up

PURPOSE

To verify the correct decision-making procedure on performing an intravitreal injection by investigating the in vivo wound morphology and evolution of 22-gauge wounds after dexamethasone oblique injection with anterior segment optical coherence tomography (OCT).

DESIGN

Prospective, observational consecutive case series.

METHODS

Subjects underwent a dexamethasone injection at University Eye Clinic of Turin. All the injections have been performed in an oblique (aka beveled or angled) fashion. Patients were divided according to the number of injections already performed with dexamethasone. Group 1 consisted of patients at the first injection, group 2 of patients at a second or more injection always in the same quadrant, and group 3 of patients at the second or more injection in a different quadrant. The incisions were imaged with the Heidelberg SPECTRALIS OCT device on postoperative days 1, 8, and 15. The main outcome measure was wound structure/characteristics (e.g., presence of gaping) as evaluated with OCT. Surgical and ocular parameters were also recorded.

RESULTS

Thirty-three consecutive patients were investigated. OCT demonstrated closed wounds in all eyes on postoperative days 1, 8, and 15. In all patients, the external (entry) side of the incision was seen as a gape; however, the rest of the wound was closed. No complications were recorded in the different patients during the follow-up. In patients of group 1, we identified the scleral pathway in 10 eyes at day 1. At 8 days in 9 of 10 eyes, the sclera had returned to its restitutio ad integrum. In patients of group 2, the scleral pathway was recognizable on the first day of control; in 7 patients, this was accompanied by the presence of intrascleral edema with peri-wound fluid. At the 8-day checkup, 3 eyes still showed signs attributable to the intrascleral pathway accompanied by peri-wound edema. In group 3, it was possible to identify the intrascleral pathway in 8 patients. There were no signs of intrascleral peri-wound edema or other anatomical changes in 9 patients as early as the first day. In the 8-day follow-up, the signs of scleral edema were absent in the single patient who presented them. At 15 days, there were no signs of scleral pathway in all eyes analyzed.

CONCLUSIONS

Speaking of intravitreal injections of slow-release dexamethasone, the technique that involves moving the conjunctiva and a beveled or angled sclerotomy after a careful choice of the injection site, paying attention to vary the quadrant involved with each puncture, reduces the number of days of closure of the sclera via and the scleral damage, thus protecting the patient from complications. For the future, it is hoped that the operating microscope and intraoperative OCT will be used on every occasion.

Radiation retinopathy intricacies and advances in management

Background: Radiation retinopathy is a chronic, progressive, vision-threatening complication from exposure to various radiation sources. While several treatment modalities are available, proper management for this disease is a continuing challenge with no consensus on the most efficacious.Objective: The aim of this article is to provide an updated review of the published literature on the course of the disease, available treatments and their efficacies, frequency of regimen, core issues in patient management, and additional newer treatment modalities, including possible prophylactic approaches.Value: We also highlighted the challenges encountered with managing chronically treated patients through an analysis of a clinical case report on a patient who was treated for several years with different modalities after a diagnosis of radiation retinopathy.

[Evaluation of the effectiveness of organ preservation treatment of choroidal melanomas by optical coherence tomography findings]

Achieving local tumor control is generally considered to be the criterion of effectiveness of organ preservation treatment. In most cases it can be assessed by ophthalmoscopy and ultrasonography. However, in presence of pigmentation areas, it can be difficult to interpret the ophthalmoscopy and ultrasonography findings. The works concerning the informativity of optical coherence tomography (OCT) after organ preservation treatment of choroidal melanomas (CM) generally cover the complications (post-radiation maculopathy, neuropathy) and the identification of vitreomacular tractions. In evaluation of local control, attention is paid to the presence of subretinal fluid and/or retinal pigment epithelium (RPE) detachment.

PURPOSE

To analyze OCT findings in terms of the condition of eye fundus tissues in various outcomes of organ preservation treatment of CM.

MATERIAL AND METHODS

The study included 20 patients (20 eyes) who underwent the following organ preservation therapy 1 to 374 months prior to enrollment: transpupillary thermotherapy (TTT) - 8 eyes, brachytherapy (BT) - 8 eyes, BT with subsequent TTT - 4 eyes. Mean age of patients at the time of therapy start was 59.25±10.86 (33-81) years. In multi-step therapy (12 eyes), the mean interval between the stages was 28.08±20.39 months. According to echobiometry findings, tumor prominence at the time of therapy start was 3.35±2.08 (1-7.37) mm. At the time of post-treatment OCT scan, there was no prominence in 5 eyes, in other eyes it was 1.26±1.24 (0.4-5.7) mm.

RESULTS

Comparison of ophthalmoscopy picture with OCT findings allowed identification of the following changes: a scar and hyperplasia of pigment epithelium in the scar, a scar with reactive pigment hyperplasia at the level of RPE and choroid, radioreaction, growth area from under and inside the scar, incomplete local control, absence of local control.

CONCLUSION

The author's own expertise in evaluating the effectiveness of local choroidal melanoma therapy suggests that optical coherence tomography should be used to monitor all patients being followed up after organ preservation treatment of choroidal melanoma: after transpupillary thermotherapy - for 3 months, after brachytherapy - during first 24 months, and in case of doubts for longer.

New Therapeutic Perspectives in the Treatment of Uveal Melanoma: A Systematic Review

Uveal melanoma (UM) is a rare disease, but the most common primary intraocular cancer, mostly localized in the choroid. Currently, the first-line treatment options for UM are radiation therapy, resection, and enucleation. However, although these treatments could potentially be curative, half of all patients will develop metastatic disease, whose prognosis is still poor. Indeed, effective therapeutic options for patients with advanced or metastatic disease are still lacking. Recently, the development of new treatment modalities with a lower incidence of adverse events, a better disease control rate, and new therapeutic approaches, have merged as new potential and promising therapeutic strategies. Additionally, several clinical trials are ongoing to find new therapeutic options, mainly for those with metastatic disease. Many interventions are still in the preliminary phases of clinical development, being investigated in phase I trial or phase I/II. The success of these trials could be crucial for changing the prognosis of patients with advanced/metastatic UM. In this systematic review, we analyzed all emerging and available literature on the new perspectives in the treatment of UM and patient outcomes; furthermore, their current limitations and more common adverse events are summarized.

Radiation Retinopathy: Detection and Management Strategies

A gradual shift in trend from primary enucleation to globe salvaging radiation therapy for the management of ocular tumors has resulted in the rise of several post-treatment ocular complications including radiation retinopathy. Radiation retinopathy is a chronic, progressive, and occlusive vasculopathy that can manifest anytime between 1 month to 15 years after starting radiation therapy. The aim of treatment in most of these cases is to prevent further vision loss. Treatment options such as laser photocoagulation, anti-vascular endothelial growth factor and intraviral steroids have been described. However, despite several advances in diagnostic and therapeutic modalities, a significant proportion of eyes with radiation retinopathy eventually go blind. This review summarises some of the clinical features, investigative modalities, and recent therapeutic strategies used in the management of radiation retinopathy.

Intravitreal aflibercept for the treatment of radiation-induced macular edema after ruthenium 106 plaque radiotherapy for choroidal melanoma

PURPOSE

To assess the efficacy of intravitreal aflibercept in patients suffering from post-radiation macular edema following plaque radiotherapy for choroidal melanoma.

METHODS

This prospective, interventional case series included patients affected by radiation maculopathy (RM) with macular edema secondary to ruthenium-106 plaque brachytherapy for choroidal melanoma. The effect of intravitreal aflibercept on best-corrected visual acuity (BCVA), central foveal thickness (CFT) detected by spectral domain optical coherence tomography (sd-OCT), and Horgan's grading scale of RM was evaluated throughout the 24-month follow-up. Intraocular pressure (IOP) and possible complications were also recorded.

RESULTS

Nine eyes of 9 patients were included. A mean of 4.4 ± 1.2 injections were given over the 24 months. At the end of follow-up, mean BCVA was significantly improved, from 0.9 ± 0.19 logMAR at baseline to 0.56 ± 0.3 logMAR (P = 0.028), and mean CFT was significantly decreased, from 546 ± 123 μm at baseline to 223 ± 34 μm (P < 0.001). Intravitreal aflibercept lowered baseline maculopathy stage as well. No significant change in IOP values and no complications, such as endophthalmitis, was recorded.

CONCLUSION

Intravitreal aflibercept is an effective treatment for patients with radiation-induced macular edema, allowing functional and anatomical improvements to be achieved with a relatively low number of injections.

Safety of 6000 intravitreal dexamethasone implants

PURPOSE

To evaluate the real-life safety profile of intravitreal dexamethasone implant injection for various retinal conditions.

METHODS

Retrospective multicenter analysis of intravitreal dexamethasone implant injections (700 µg) due to various retinal conditions including central retinal venous occlusion (1861 injections), diabetic macular oedema (3104 injections), post-surgical cystoid macular oedema (305 injections) and uveitis (381 injections). The eyes were evaluated mainly for the occurrence of adverse events such as glaucoma, cataract, retinal detachment and endophthalmitis along during the follow-up period.

RESULTS

A total of 6015 injections in 2736 eyes of 1441 patients (mean age of 65.7±12.9 years) were in total analysed over an average period of 18 months (range 6 months to 102 months). A total of 576 eyes (32.5% of the phakic eyes) developed cataract requiring surgical intervention. However, visually insignificant cataract progression was observed in another 259 phakic eyes (14.6%) which did not require surgical removal. A total of 727 eyes (26.5%) experienced an intraocular pressure (IOP) rise of >25 mm Hg, with 155 eyes (5.67%) having a prior history of glaucoma and 572 eyes (20.9%) having new onset IOP rise. Overall, more than 90% of eyes with IOP rise were managed medically, and 0.5% eyes required filtering surgery. Endophthalmitis (0.07%), retinal detachment (0.03%) and vitreous haemorrhage (0.03%) were rare. There was no significant change in visual acuity (p=0.87) and central macular thickness (p=0.12) at the last follow-up.

CONCLUSION

This is the largest real-life study assessing the safety of intravitreal dexamethasone implant injections in various retinal conditions. Cataract progression and intraocular pressure rise are the most common side effects, but are often rather easily manageable.

DEXAMETHASONE INTRAVITREAL IMPLANT VS RANIBIZUMAB IN THE TREATMENT OF MACULAR EDEMA SECONDARY TO BRACHYTHERAPY FOR CHOROIDAL MELANOMA

PURPOSE

To evaluate the efficacy of an intravitreal dexamethasone (Dex) implant 0.7 mg compared with intravitreal ranibizumab (Ra) for the treatment of radiation maculopathy with macular edema secondary to plaque brachytherapy in choroidal melanoma.

METHODS

Eight patients were treated with intravitreal Ra, and eight patients received the Dex intravitreal implant. Visual acuity and foveal thickness were evaluated using spectral domain optical coherence tomography.

RESULTS

The mean calculated irradiation to the fovea and mean times from brachytherapy to maculopathy development did not differ significantly between groups. In the Ra group, a mean 7.8 ± 3.9 injections were given and the mean follow-up was 33 ± 15 months (range, 7-52 months). In the Dex group, a mean 2.1 ± 0.8 injections were given and the mean follow-up was 22 ± 7 months (range, 11-31 months). The mean visual acuity improved significantly from the baseline to the last follow-up visit in both groups. Foveal thickness decreased significantly in both groups from 459 ± 81 μm to 243 ± 58 μm and from 437 ± 71 μm to 254 ± 44 μm from the baseline to the last follow-up visit in the Ra and Dex groups, respectively. No patients developed significant cataract or ocular hypertension in both groups.

CONCLUSION

Both Ra and Dex are effective treatments for macular edema secondary to plaque brachytherapy for uveal melanoma. Dex-treated patients required fewer injections to achieve anatomical and functional improvement.

Transient reversal of macular ischemia with intravitreal steroid implant injection in a case of radiation maculopathy

Diabetic retinopathy (DR) is a well-known risk factor in the development of radiation maculopathy (RM). Steroids have been shown to improve the vision and reduce the macular thickness in patients with RM. This observational case report highlights altered course of DR after a course of radiotherapy for orbital lymphoma, after a single dose of intravitreal dexamethasone implant showed a dramatic revascularization of the ischemic macula, with a significant reduction in the size of ischemic area. This appears to be the first case in literature corroborating the favorable effect on steroids on retinal vasculature, seen angiographically.

Intravitreal dexamethasone implant (Ozurdex®) for exudative retinal detachment after proton beam therapy for choroidal melanoma

PURPOSE

To evaluate the efficacy and safety of intravitreal 0.7-mg dexamethasone implant (DEX-I) (Ozurdex®) in the treatment of extensive exudative retinal detachment (RD) associated with uveal melanoma treated using proton beam therapy (PBT).

METHODS

Data from 10 patients with exudative RD after PBT treated with intravitreal injection of 0.7-mg DEX-I were reviewed retrospectively. The main outcome measures were resolution of exudative RD, visual acuity, and safety profile.

RESULTS

Mean age was 55.6 years (range 34-85). Mean time between PBT and DEX-I was 12.4 months (range 3-25). Mean follow-up was 9.9 months (range 4-15). Intravitreal Ozurdex® reduced exudative RD in 7 cases (70%) on average 3.1 months after injection with complete resolution of RD in 6 of these (60%). For half of the patients, their level of vision remained stable; the other half experienced a deterioration in visual acuity at the end of follow-up. No adverse effects were observed.

CONCLUSIONS

In this small case series, treatment with intravitreal DEX-I reduced exudative RD in the majority of cases and had an acceptable safety profile.

Widening use of dexamethasone implant for the treatment of macular edema

Sustained-release intravitreal 0.7 mg dexamethasone (DEX) implant is approved in Europe for the treatment of macular edema related to diabetic retinopathy, branch retinal vein occlusion, central retinal vein occlusion, and non-infectious uveitis. The implant is formulated in a biodegradable copolymer to release the active ingredient within the vitreous chamber for up to 6 months after an intravitreal injection, allowing a prolonged interval of efficacy between injections with a good safety profile. Various other ocular pathologies with inflammatory etiopathogeneses associated with macular edema have been treated by DEX implant, including neovascular age-related macular degeneration, Irvine-Gass syndrome, vasoproliferative retinal tumors, retinal telangiectasia, Coats' disease, radiation maculopathy, retinitis pigmentosa, and macular edema secondary to scleral buckling and pars plana vitrectomy. We undertook a review to provide a comprehensive collection of all of the diseases that benefit from the use of the sustained-release DEX implant, alone or in combination with concomitant therapies. A MEDLINE search revealed lack of randomized controlled trials related to these indications. Therefore we included and analyzed all available studies (retrospective and prospective, comparative and non-comparative, randomized and nonrandomized, single center and multicenter, and case report). There are reports in the literature of the use of DEX implant across a range of macular edema-related pathologies, with their clinical experience supporting the use of DEX implant on a case-by-case basis with the aim of improving patient outcomes in many macular pathologies. As many of the reported macular pathologies are difficult to treat, a new treatment option that has a beneficial influence on the clinical course of the disease may be useful in clinical practice.

Intravitreal dexamethasone implant in radiation-induced macular oedema

AIMS

To evaluate the efficacy and duration of activity of a single intravitreal dexamethasone implant in patients affected by radiation maculopathy.

METHODS

Thirteen consecutive eyes of 13 patients affected by radiation maculopathy secondary to eye irradiation for a primary uveal melanoma (Iodine-125 brachytherapy) and treated with a single intravitreal 0.7 mg dexamethasone implant were retrospectively evaluated. Each patient underwent full ophthalmological examination, including fluorescein angiography and spectral domain optical coherence tomography (SD-OCT), even in en-face modality. Follow-up was performed monthly over a 6-month period.

RESULTS

At preinjection visit, the median central subfield thickness (CST) by SD-OCT was 407 µm (IQR, 357-524 µm) and the median best-corrected visual acuity (BCVA) was 61 ETDRS score (IQR, 54-67). The median gain of ETDRS letter at 1 month was 6.5 (IQR, 4-15) (p<0.01). The median CST showed a reduction of 120 µm (IQR, 62-134) (p<0.01). Further CST reduction was reported at 2 months' follow-up, with CST stabilisation at 3 months and maintenance of BCVA. At 4, 5 and 6 months' follow-up, all patients presented progressive retinal thickening (p<0.01) and BCVA reduction (p<0.01). No side effects were documented.

CONCLUSION

Intravitreal dexamethasone implant reduces macular oedema secondary to radiation maculopathy and also improved visual acuity in a consistent proportion of patients. Signs of macular oedema recurrence may be detected at a median of 4 months after injection.

Long-term follow-up of anatomical and functional macular changes after a single intravitreal implant of dexamethasone 0.7 mg for radiation macular edema secondary to proton beam therapy for choroidal melanoma

PURPOSE

To describe the efficacy and safety of a single intravitreal implant of dexamethasone in a patient affected by radiation maculopathy due to proton beam radiotherapy for choroidal melanoma.

PATIENT AND METHODS

Retrospective data of a 46-year-old woman treated with a single intravitreal injection of dexamethasone for radiation maculopathy due to proton beam radiotherapy were collected. The main outcome measures were best-corrected visual acuity and central retinal thickness. Intraocular pressure, anterior segment evaluation with slit lamp, macular changes depicted with spectral domain optical coherence tomography, retinal perfusion studied with fundus fluorescein angiography, and grade of macular edema using the Horgan classification were also evaluated during a 16-month follow-up.

RESULTS

Macular edema occurred 25 months after radiation treatment in the left eye. The patient underwent a single intravitreal implant of dexamethasone. Preinjection visual acuity and central retinal thickness were 6/12 and 502 µm, respectively. After 8 months, visual acuity was 6/6 and remained stable until 16 months. Central retinal thickness was 269 µm at 16 months.

CONCLUSION

A single intravitreal implant of dexamethasone could effectively and stably improve visual acuity and central retinal thickness in some patients with radiation macular edema for 16 months after injection.

Antiangiogenic or Corticosteroid Treatment in Patients With Radiation Maculopathy After Proton Beam Therapy for Uveal Melanoma

PURPOSE

To reveal differences or advantages in regard to different treatment options after proton beam therapy for uveal melanoma.

DESIGN

Retrospective, comparative, interventional case series.

METHODS

All patients receiving intravitreal treatment between January 2011 and July 2014 for radiation maculopathy after proton beam therapy were included. Excluded were all patients who required re-irradiation, vitrectomies, or tumor resections; and those whose treatment was performed for potentially other reasons, such as radiation-induced optic neuropathy, or where visual outcome was influenced by tumor growth under the macula or macular ischemia. Minimum follow-up was 12 months after last injection.

RESULTS

Of 78 patients, 38 (48.7%) received bevacizumab injections, 35 (44.9%) triamcinolone acetonide injections, and 5 (6.4%) a dexamethasone implant. In the bevacizumab group visual acuity improved in 11 patients (28.9%) by 0.25 logMAR (0.1-0.4 logMAR) and remained stable in 24 patients (63.2%) 4 weeks after injection. In the triamcinolone group visual acuity showed improved outcomes in 10 patients (28.6%) by 0.25 logMAR (0.1-0.4 logMAR) and stability in function in 20 patients (57.1%). Four weeks after dexamethasone implantation visual acuity remained stable in 4 patients (80%). No differences among the groups were detected regarding functional outcome or reduction in central foveal thickness.

CONCLUSIONS

This study showed that antiangiogenic or corticosteroid intravitreal treatment led to reduced central foveal thickness and visual improvement in some patients without showing differences or advantages. Therefore a patient-specific treatment choice can be recommended.

Ranibizumab for the Prevention of Radiation Complications in Patients Treated With Proton Beam Irradiation for Choroidal Melanoma

PURPOSE

To investigate the safety and potential efficacy of ranibizumab for prevention of radiation complications in patients treated with proton irradiation for choroidal melanoma.

METHODS

Forty patients with tumors located within 2 disc diameters of the optic nerve and/or macula were enrolled in this open-label study. Participants received ranibizumab 0.5 mg or 1.0 mg at tumor localization and every 2 months thereafter for the study duration of 24 months. The incidence of adverse events, visual acuity, and other measures of ocular morbidity related to radiation complications were assessed. Historical controls with similar follow-up meeting the eligibility criteria for tumor size, location, and baseline visual acuity were assembled for comparison.

RESULTS

Fifteen patients with large tumors and 25 patients with small/medium tumors were enrolled. Thirty-two patients completed the month 24 visit. No serious ocular or systemic adverse events related to ranibizumab were observed. At 24 months, the proportion of patients with visual acuity ≥ 20/200 was 30/31 (97%) in the study group versus 92/205 (45%) in historical controls (P < .001). The proportion of patients with visual acuity ≥20/40 was 24/31 (77%) in the study group versus 46/205 (22%) in controls at 24 months (P<.001). Clinical evidence of radiation maculopathy at month 24 was seen in 8/24 (33%) patients with small/medium tumors versus 42/62 (68%) of controls (P = .004). Three patients with large tumors developed metastases.

CONCLUSIONS

In this small pilot study, prophylactic ranibizumab appears generally safe in patients treated with proton irradiation for choroidal melanoma. High rates of visual acuity retention were observed through 2 years.

INTRAVITREAL DEXAMETHASONE IMPLANT FOR RADIATION MACULOPATHY SECONDARY TO PLAQUE BRACHYTHERAPY IN CHOROIDAL MELANOMA

PURPOSE

To evaluate the efficacy of intravitreal dexamethasone implant 0.7 mg (Ozurdex) in radiation maculopathy secondary to plaque brachytherapy in choroidal melanoma.

METHODS

Twelve eyes diagnosed of radiation maculopathy secondary to plaque brachytherapy and treated with intravitreal dexamethasone implant were included. Visual acuity, foveal thickness using spectral domain optical coherence tomography, and grade of macular edema, using Horgan classification, were evaluated.

RESULTS

Mean age was 65.5 ± 28 years (range, 40-82 years). Mean follow-up was 8.2 ± 7.8 months (range, 2-28 months). Mean visual acuity before treatment was, in logarithm of the minimum angle of resolution scale, 1 ± 0.58 (range, 0.4-2) and mean final visual acuity 0.8 ± 0.58 (range, 0.2-2), showing a nonsignificant trend to improvement (P = 0.091; Wilcoxon's test). Foveal thickness before treatment was 416 ± 263 μm (range, 222-725 μm) and final foveal thickness 254 ± 170 μm (range, 145-750), showing a significant decrease (P = 0.016; Wilcoxon's test). Referring to Horgan classification, a significant reduction in grades before and after treatment was demonstrated (P = 0.007; Wilcoxon's test).

CONCLUSION

Ozurdex is a useful treatment for radiation maculopathy associated to plaque brachytherapy for uveal melanoma, with a significant decrease in foveal thickness and a significant improvement in Horgan classification. This anatomical improvement was correlated with a moderate improvement in visual acuity.

Treatment of recalcitrant radiation maculopathy using intravitreal dexamethasone (Ozurdex) implant

PURPOSE

Radiation maculopathy is the most common cause of severe vision loss after radiotherapy of uveal melanoma. To date, no effective therapy exists. The authors report a novel approach to the treatment of radiation maculopathy using dexamethasone (Ozurdex, Allergan Inc) intravitreal implant.

METHODS

This is a retrospective case series of two patients who developed radiation maculopathy after radiotherapy for uveal melanoma and was treated with Ozurdex. Clinical outcomes included visual acuity, central foveal thickness by optical coherence tomography, intraocular pressure, and cataract formation.

RESULTS

Both patients were of Caucasian descent. Patient 1 received charged-particle radiation, whereas Patient 2 received iodine-125 brachytherapy for medium-sized uveal melanoma located in the midperipheral retina. Radiation maculopathy developed 47 months and 18 months after radiation exposure in Patient 1 and 2, respectively. Both patients initially received bevacizumab monotherapy followed by alternating therapy with bevacizumab and intravitreal triamcinolone. Secondary to a limited response, the patients were treated with Ozurdex implants. One patient had visual improvement, and both patients experienced a prolonged time frame of anatomical stability. Adverse effects included a rise in the intraocular pressure, which was controlled by topical hypotensive agents and posterior subcapsular cataract formation in Patient 1.

CONCLUSION

Ozurdex intravitreal implant provides a prolonged period of anatomical stabilization in recalcitrant cases of radiation maculopathy in patients who have failed multiple intravitreal bevacizumab injections and had only a partial response to intravitreal triamcinolone. Larger prospective studies are required to determine the extent of visual benefit.

Evaluation of pain during intravitreal Ozurdex injections vs. intravitreal bevacizumab injections

PURPOSE

The purpose was to evaluate the pain associated with intravitreal Ozurdex injections, and to compare it with that associated with intravitreal bevacizumab injections.

METHODS

The study included 57 eyes of 57 patients who received an intravitreal Ozurdex injection at our institution. Pain was measured by the visual analog scale (VAS). Additional parameters recorded included age, sex, indication for the injection, number of previous Ozurdex injections in the study eye, presence of diabetes mellitus, and lens status. Data were compared with a 2 : 1 sex- and age-matched control group of 114 patients who received intravitreal bevacizumab injections.

RESULTS

Indications for injection included diabetic macular edema (40.4%) and macular edema secondary to central and branch retinal vein occlusion (28% and 31.6%, respectively). Pain scores on the VAS ranged from 0 to 90, with a mean of 20.8±20.3. There was no significant difference in pain between Ozurdex and bevacizumab injections. Pseudophakia was correlated with increased pain in Ozurdex injections.

CONCLUSIONS

This is the first series evaluating the pain associated with intravitreal Ozurdex injections. Despite a larger needle gauge and tunneled injection technique, intravitreal injection of Ozurdex is not associated with increased pain compared with bevacizumab. This finding may be a potential advantage for Ozurdex, and may serve to improve patient compliance with future long-term treatment protocols.

Rhegmatogenous Retinal Detachment with a High Risk of Proliferative Vitreoretinopathy Treated with Episcleral Surgery and an Intravitreal Dexamethasone 0.7-mg Implant

Purpose

To report a case of rhegmatogenous retinal detachment with a high risk of proliferative vitreoretinopathy (PVR) effectively treated with episcleral surgery and an intravitreal dexamethasone 0.7-mg implant.

Methods

A 35-year-old Caucasian man with a macula-off rhegmatogenous subtotal retinal detachment that had persisted for 1 month in his myopic left eye presented several risk factors that could have led to the development of PVR after retinal detachment surgery. His best corrected visual acuity was hand motion. He received an intravitreal dexamethasone 0.7-mg implant (Ozurdex^®) after episcleral surgery to prevent this complication.

Results

At least 9 months after surgery, no sign of PVR or pucker has developed in the treated eye. Visual acuity improved to 0.2, the retina was attached and no complications were observed.

Conclusion

Intravitreal dexamethasone 0.7-mg implant (Ozurdex) could be considered as off-label treatment following episcleral surgery to prevent PVR.

Effects of radiotherapy on uveal melanomas and adjacent tissues

Most uveal melanomas are treated with radiotherapy. An adequate understanding of the effects of radiation on the tumour and the healthy ocular tissues is necessary. Ionizing radiation damages cell membranes, organelles, and DNA. Irradiated cells are lysed or undergo apoptosis, necrosis, and senescence. These effects occur in tumour cells and vascular endothelial cells, resulting in tumour shrinkage, ischaemia, infarction, exudation, and fibrosis, which can cause exudative maculopathy, serous retinal detachment, rubeosis, and neovascular glaucoma (ie, 'toxic tumour syndrome'). Such abnormalities must be distinguished from collateral damage to healthy ocular tissues that receive high doses of radiation, and these include radiation-induced retinopathy, optic neuropathy, choroidopathy, cataract, and scleral necrosis. Radiation retinopathy can be treated effectively with photodynamic therapy, anti-angiogenic agents, and intravitreal steroid injections. In some patients, optic neuropathy may improve with intravitreal steroids or anti-angiogenic agents. Neovascular glaucoma resolves with intra-cameral bevacizumab. Exudative retinal detachment can regress with intra-vitreal steroid injections. Cataract is treated in the usual manner. Scleral necrosis, if severe, may require grafting, possibly using a lamellar flap from the same eye. Depending on the bulk of the residual toxic tumour, treatment can consist of intra-vitreal steroids and/or anti-angiogenic agents, transpupillary thermotherapy or photodynamic therapy to the tumour, or surgical removal of the tumour by endo- or exo-resection. Measures aimed at preventing collateral damage include eccentric placement of ruthenium plaques or iodine seeds and delivery of a notched proton beam. The decision to treat a uveal melanoma with radiotherapy requires the ability to manage iatrogenic side effects and complications.