Abstract
BackgroundOcular damage from radiation treatment is a well established phenomenon. Many factors are now known to influence the incidence of radiation retinopathy, including total dosage and daily fraction size. Patients who are diabetic, hypertensive or received previous chemotherapy are more susceptible to radiation retinopathy.Case PresentationA 55 year old male was referred from the oncology department with epiphora. His medical history included Type 2 Insulin treated Diabetes Mellitus and hypertension. One year prior to presentation he had undergone a total rhinectomy with a 4 week course of post-operative radiotherapy for an aggressive sqaumous cell carcinoma of the nose. On examination the visual acuity was noted to be 6/36 left eye and 6/9 right eye. Posterior segment examination revealed marked retinal ischaemia present in the posterior pole and macular region of both eyes. The appearance was not thought to be typical of diabetic changes, radiation retinopathy being the more likely diagnosis especially in view of his history. Over the next four months the vision in both eyes rapidly deteriorated to 3/60 left eye and 1/60 right eye. Bilateral pan retinal photocoagulation was thought to be appropriate treatment at this point.ConclusionThis case highlights the importance for ophthalmologists and oncologists to be aware of the close relationship between diabetes and radiation treatment and the profound rapid impact this combination of factors may have on visual function. Radiation is being used with increasing frequency for ocular and orbital disease, because of this more cases of radiation retinopathy may become prevalent. Factors which may potentiate radiation retinopathy should be well known including, increased radiation dosage, increased fraction size, concomitant systemic vascular disease and use of chemotherapy. Counselling should be offered in all cases at risk of visual loss. As no effective treatment currently exists to restore visual function, monitoring of visual acuity in all cases and early referral to the ophthalmologist as appropriate is warranted.
Highlights
Ocular damage from radiation treatment is a well established phenomenon
This case highlights the importance for ophthalmologists and oncologists to be aware of the close relationship between diabetes and radiation treatment and the profound rapid impact this combination of factors may have on visual function
Radiation is being used with increasing frequency for ocular and orbital disease, because of this more cases of radiation retinopathy may become prevalent
Summary
The clinical features of radiation retinopathy include microaneurysms, cotton wool spots, capillary dilation, telangectasia, and capillary closure. Our patient was initially asymptomatic and found to have cotton wool spots, retinal haemorrhages, exudates, choriodopathy and retinal ischaemia involving posterior pole and peripheral retina These findings relate to stage 2 of Finger's radiation retinopathy classification, stage 2 carries a guarded prognosis for vision having a moderate risk of visual loss. Finger et al suggest that early pan retinal photocoagulation is useful in inducing regression of radiation retinopathy and that treatment before clinically apparent radiation retinopathy is present may be more effective than treatment after its onset, especially in high risk cases. This is especially important in cases of radiation maculopathy as prevention is more likely to preserve vision than treatment after its onset. Clinical trials need to be performed to establish whether early PRP is beneficial in reducing the onset of radiation retinopathy in eyes at risk and to determine if early PRP is useful in inducing regression of established radiation retinopathy and improve visual outcomes
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