Dosimetric advantages of enhanced dynamic wedge in small field irradiation for the treatment of macular degeneration

Abstract

Exudative macular degeneration is a process that affects the central retina and is the chief cause of blindness in people over 55 years old. Radiation appears to improve or stabilize visual acuity in some of these patients, although definitive clinical studies are ongoing. The delivery of radiation in patients with macular degeneration is unique and challenging because of the location of the surrounding structures, such as the lens and the opposite retina. The “standard” treatment technique has been an anterior oblique beam 20° above lateral to limit dose to these structures. In preference to the undesirable hot spot caused by this single-beam technique, we have employed a superior and inferior oblique pair utilizing the Enhanced Dynamic Wedge (EDW). Couch rotation was used to establish the desired treatment angles. The anterior half of the fields were blocked with the asymmetric jaw (AJ). Studies were performed to determine the value of these methods in reducing lens dose. Although the peripheral dose measurements at D max using a 60° metal wedge for ≥10 cm square fields were higher than for an open field or the EDW, for the small retinal fields there was no lens-dose reduction attributable to the EDW. However, the steep wedge angles achievable with the EDW were useful for optimizing the dose distribution for the most desirable field angles. As expected, the independent collimator was more effective in reducing transmitted dose to the lens than a typical Cerrobend block. Measurements required to predict dose in and out of the field are discussed along with the dosimeters employed in evaluating small fields (less than 5 cm square) with the EDW. The technical challenges of positioning, immobilization, treatment planning and treatment delivery are presented.