Ophthalmic Plaque Radiotherapy Research Articles

Extraocular Muscle Repositioning and Diplopia: Associated with Ophthalmic Plaque Radiation Therapy for Choroidal Melanoma

To evaluate extraocular muscle surgery associated with plaque brachytherapy for choroidal melanoma. Single-center retrospective cohort study. Three hundred twenty-nine eyes of 329 consecutive patients with clinically diagnosed choroidal melanoma. Palladium 103 plaque brachytherapy with or without extraocular muscle surgery. Type of muscle surgery required for each tumor location, timing, incidence, and duration of diplopia, as well as treatment. Two hundred fifty-four patients (n = 254/329; 77.2%) required muscle surgery. One hundred seven patients (n = 107/329; 32.5%) required surgery on 2 or more muscles. Of 373 muscles repositioned, the lateral rectus muscle (n = 115/373; 30.8%) and inferior oblique muscle (n = 70/373; 18.7%) were the most common, correlating to intraocular tumor location (P<0.001). Only 6 tumors (n = 6/61; 9.5%) originating from the iris and ciliary body required muscle surgery for plaque placement. Of the 312 patients with a preoperative visual acuity better than 20/400, diplopia was reported at the first postoperative visit by 41 patients (n = 41/312; 13.1%), 2 of whom had not undergone muscle surgery. Diplopia resolved spontaneously within 1 month in 18 patients (n = 18/41; 43.9%), between 1 and 6 months in 12 patients (n = 12/41; 29.3%), and at more than 6 months in 5 patients (n = 5/41; 12.2%). Among the 312 patients, persistent diplopia occurred in 6 patients (1.9%), including 1 who had not undergone muscle surgery. Treatment was declined in 1 patient, 3 patients (n = 3/41; 7.3%) were treated with prisms, and 2 patients (n = 2/41; 4.9%) required surgery. Extraocular muscle surgery frequently is required for plaque brachytherapy. Although transient diplopia occurred in 11.2% of patients, persistent diplopia occurred in only 1.9% of patients and was treatable.

103Pd versus 125I ophthalmic plaque brachytherapy: preoperative comparative radiation dosimetry for 319 uveal melanomas.

ObjectiveThis study was conducted to compare the relative, clinical intraocular dose distribution for palladium-103 (103Pd) versus iodine-125 (125I) ophthalmic plaque radiation therapy.MethodsPreoperative comparative radiation dosimetry was performed to evaluate 319 consecutive uveal melanomas treated between 2006 and 2012.ResultsThere were 68 (21.3 %) anterior (iris and/or ciliary body) and 251 (78.7 %) choroidal melanomas examined in this study. According to AJCC staging, 7th edition, 146 (45.8 %) were T1, 126 (39.5 %) T2, 40 (12.5 %) T3, and 7 (2.2 %) T4. All were prescribed an equivalent tumor-apex dose. When compared to 125I, 103Pd was associated with a mean 41.9 % lower radiation dose to the opposite eye wall (p < 0.001), 12.7 % to the lens center (p < 0.001), 7.5 % to the optic disc (p = 0.008), and a 3.8 % decrease to the fovea (p = 0.034). However, subgroup analysis of smaller (T1-staged) tumors showed greater dose reductions to normal ocular structures compared to larger (T4-staged) tumors. Tumor and therefore plaque location also affected intraocular dose distribution. For example, palladium-103-related dose reductions to the fovea, optic nerve, and opposite eye wall were significantly greater for iris and ciliary body tumors compared to posterior choroidal melanomas (p < 0.001). After comparative dosimetry, 98.7 % (n = 315/319) were treated with 103Pd.ConclusionPreoperative comparative radiation dosimetry was performed for a large cohort of patients with uveal melanoma. It influenced radionuclide selection, offered an opportunity for radiation sparing of critical vision-related intraocular structures, and typically increased radiation within the tumors.

The American Brachytherapy Society (ABS) Consensus Guidelines for Plaque Brachytherapy of Uveal Melanoma and Retinoblastoma

To present the updated American Brachytherapy Society (ABS) guidelines for plaque brachytherapy of choroidal melanoma and retinoblastoma. An international, multicenter Ophthalmic Oncology Task Force (OOTF) was assembled to include 47 radiation oncologists, medical physicists and ophthalmic oncologists from 10 countries. Thus the ABS-OOTF produced universally acceptable collaborative guidelines, based on their eye cancer specific clinical experience and knowledge of the literature. The resultant guidelines were staged by levels of consensus. Once completed, this work was reviewed and approved by the ABS Board of Directors. 1)The ABS-OOTF reached consensus that ophthalmic plaque radiation therapy is best performed in subspecialty brachytherapy centers, experienced with plaque therapy.2)Quality assurance, methods of plaque construction/dosimetry should be consistent with the 2012 joint guidelines of the American Association of Physicists in Medicine and ABS.3)Though there exist select restrictions related to tumor-size, location and vision status; the ABS-OOTF agreed that most uveal melanomas (iris, ciliary body and choroid) could be treated with plaque brachytherapy. Specifically, the ABS-OOTF reached consensus that tumors with gross orbital extension, blind painful eyes and those with no light perception vision are unsuitable for brachytherapy.4)Only select retinoblastomas were considered eligible for plaque brachytherapy.5)Additional subjects addressed include prescription doses, dose rates, treatment durations and clinical methods. Plaque brachytherapy is an effective, eye and vision-sparing method to treat patients with intraocular tumors. Eye cancer specialists (radiation oncologists, medical physicists and ophthalmic oncologists) are encouraged to use ABS-OOTF guidelines to enhance their practice.

Palladium-103 Plaque Radiation Therapy for American Joint Committee on Cancer T3- and T4-Staged Choroidal Melanomas

Patients with larger choroidal melanomas are being treated with plaque radiation therapy. To report the methods and results of palladium-103 brachytherapy for American Joint Committee on Cancer, 7th edition, T3- and T4-sized choroidal melanomas. A retrospective analysis of the results of a clinical case series over a 10-year period of 47 consecutive patients with uveal melanoma. The patients were treated at The New York Eye Cancer Center, Beth Israel Comprehensive Cancer Center, or The New York Eye and Ear Infirmary between 2002 and 2012 and had a minimum follow-up of 6 months. Tumors had a mean preoperative apical tumor height of 8.6 mm and a mean largest basal diameter of 15.8 mm. We analyzed, but were not limited to, data on the methods of radiation therapy, local tumor control, adverse effects, vision retention, and metastatic rate. All patients completed therapy and received the prescribed tumor apex dose. At a median of 47 months (range, 6-125 months), the rate of local control was 91% and the rate of eye retention was 89%. The most common long-term brachytherapy-related complication was radiation maculopathy (66% of patients), followed by radiation optic neuropathy (51% of patients). One or both of these complications were diagnosed at a mean time of 16 months (range, 2-36 months) after brachytherapy. Secondary cataract developed in 36% of patients. Glaucoma developed in 17% of patients and resulted in enucleation in 4% of patients. The mean pretreatment visual acuity was 20/50 (range, 20/12.5 to hand motions), which evolved to a mean visual acuity of 20/100 (range, 20/20 to no light perception). Overall, 25 of 47 patients (53%) maintained 20/200 or better vision. Metastatic melanoma developed in 32% of patients. Palladium-103 ophthalmic plaque radiation therapy can be used as an eye- and vision-preserving treatment for relatively large American Joint Committee on Cancer T3- or T4-sized choroidal melanomas.

The American Brachytherapy Society consensus guidelines for plaque brachytherapy of uveal melanoma and retinoblastoma

To present the American Brachytherapy Society (ABS) guidelines for plaque brachytherapy of choroidal melanoma and retinoblastoma. An international multicenter Ophthalmic Oncology Task Force (OOTF) was assembled to include 47 radiation oncologists, medical physicists, and ophthalmic oncologists from 10 countries. The ABS-OOTF produced collaborative guidelines, based on their eye cancer-specific clinical experience and knowledge of the literature. This work was reviewed and approved by the ABS Board of Directors as well as within the journal's peer-reivew process. The ABS-OOTF reached consensus that ophthalmic plaque radiation therapy is best performed in subspecialty brachytherapy centers. Quality assurance, methods of plaque construction, and dosimetry should be consistent with the 2012 joint guidelines of the American Association of Physicists in Medicine and ABS. Implantation of plaque sources should be performed by subspecialty-trained surgeons. Although there exist select restrictions related to tumor size and location, the ABS-OOTF agreed that most melanomas of the iris, ciliary body, and choroid could be treated with plaque brachytherapy. The ABS-OOTF reached consensus that tumors with gross orbital extension and blind painful eyes and those with no light perception vision are unsuitable for brachytherapy. In contrast, only select retinoblastomas are eligible for plaque brachytherapy. Prescription doses, dose rates, treatment durations, and clinical methods are described. Plaque brachytherapy is an effective eye and vision-sparing method to treat patients with intraocular tumors. Practitioners are encouraged to use ABS-OOTF guidelines to enhance their practice.

Palladium-103 Radiation Therapy for Small Choroidal Melanoma

To evaluate outcomes after ophthalmic plaque radiation therapy for small choroidal melanomas. Retrospective study, case series. Seventy-two patients with choroidal melanomas ≥1.5 and ≤2.4 mm apical height and ≤10 mm width treated between 2002 and 2012, with a minimum follow-up of 8 months. All patients were treated with palladium-103 plaque brachytherapy. Mean radiation dose to the tumor apex was 82.4 Gy (range, 70.0-102 Gy). Local control, radiation complications, visual acuity, and metastatic rate. Plaque radiotherapy provided 100% local tumor control and eye retention at a mean 54 months of observation (95% confidence interval, 46-63 months). The most common long-term brachytherapy-related complications were radiation maculopathy (43.1%) and radiation optic neuropathy (20.8%) developing at a mean of 27 months (range, 9-72 months) after irradiation. In this series, 94.4% of patients maintained 20/200 or better vision. There has been no small choroidal melanoma-related metastasis. Palladium-103 plaque radiation therapy offered excellent local control and visual acuity outcomes for patients with small choroidal melanoma.

Ruthenium plaque radiation therapy for iris and iridociliary melanomas

To determine the long-term effects of ruthenium-106 plaque radiation therapy for iris and iridociliary melanomas in terms of tumour regression and complications. Between 1 November 1997 and 31 December 2007, 36 patients with an iris or iridociliary melanoma were treated with Ruthenium-106 (Ru-106) ophthalmic plaque radiation therapy. The median follow-up was 6.5 years with a range of 2-11 years. The mean tumour apex dose was 151.5 Gy. Main outcome measures were local tumour control and radiation-related ocular complications. The mean age of the patients at the time of treatment was 54 years (range 14-82). The tumours had a median largest basal dimension of 4.8 mm (range 3-11) and a prominence of 2.3 mm (range 0.8-5), with a median involvement of three clock hours (range 1-6). The tumours were confined to the iris in 14 patients (39%), extended into the anterior ciliary body in 12 (33%), while the anterior ciliary body tumour extended into the iris in ten patients (28%). Tumours regressed in all patients (100%) with a mean regression of 80% of the original tumour size at 7 years of follow-up. Radiation-related complications included corneal erosions on the first postoperative day in nine patients (25%), cataract in four of 11 patients free of cataract before treatment (36%) and postradiation glaucoma in one patient (3%). Visual acuity of 20/200 or worse was present in one of 20 patients (5%) at 6 years of follow-up. Local recurrences occurred in two patients (5%), 2 and 5 years after the radiation therapy respectively, and both underwent enucleation. Distant metastases occurred in one of these enucleated patients (3%) 2 years after treatment. Ru-106 plaque radiation therapy for iris and iridociliary melanoma resulted in good local tumour control and preservation of visual acuity with few and treatable side-effects.

Current Methods for the Diagnosis and Treatment of Choroidal Melanoma

Choroidal melanoma is the most common primary intraocular malignancy. Diagnosis is performed by clinical evaluation: eye cancer specialists currently use multiple diagnostic techniques, including ophthalmoscopy, fundus autofluorescence imaging (FAF), fluorescein angiography (FA), and indocyanine green angiography (ICG), as well as optical coherence tomography (OCT). Tumor biopsy has recently become popular due to the availability of diagnostic cytogenetic features, touted as biomarkers for metastasis. Standard treatments include observation (select small melanomas and indeterminate tumors), radiation therapy (plaque, proton beam), eye wall resection, and removal of the eye. Of these, ophthalmic plaque radiation therapy has become the most common and widely available conservative treatment. Successful initial treatment offers the best chance to prevent subsequent metastasis. Metastatic choroidal melanoma is typically diagnosed by combinations of physical examination, hematologic surveys, abdominal radiographic imaging (ultrasound, magnetic resonance imaging, computed tomography), and positron emission tomography–computed tomography (PET/CT). Most often initially found in the liver, metastatic choroidal melanoma carries an unfavorable prognosis for life. Herein, we report on currently available methods of diagnosis and treatment for choroidal melanoma.

Systemic Bevacizumab (Avastin) for Exudative Retinal Detachment Secondary to Choroidal Melanoma

To evaluate the safety and effect of systemic anti-vascular endothelial growth factor bevacizumab (Avastin) in treatment of exudative retinal detachment secondary to choroidal melanoma. Two patients were definitively treated with ophthalmic plaque radiation therapy and subsequently given 10 mg/kg intravenous bevacizumab every 2 weeks for 3 or 4 cycles. Complete resolution of the exudative retinal detachments occurred 1.2 months and 6.5 months after completion of systemic bevacizumab and 4.7 and 10 months after plaque therapy. The first patient's visual acuity improved from counting fingers at 1 foot to 20/80 (at 40 months), while his tumor regressed from 9.2 to 3.7 mm in apical height. The second patient's initial acuity was 20/20 and final acuity was 20/80 (at 35 months), while her tumor height regressed from 12.2 to 6.3 mm. No exudative retinal detachment, intraocular or systemic tumor recurrence was noted up to 40 and 35 months, respectively. Acute side effects of intravenous bevacizumab therapy included hypertension, headaches, and amenorrhea, which shortly resolved after completion of therapy. This pilot study suggests that systemic bevacizumab was associated with transient systemic effects as well as resolution of choroidal melanoma-related exudative retinal detachment.

MONTE CARLO SIMULATION FOR TREATMENT PLANNING OPTIMIZATION OF THE COMS AND USC EYE PLAQUES USING THE MCNP4C CODE

Introduction: Ophthalmic plaque radiotherapy using I-125 radioactive seeds in removable episcleral plaques is often used in management of ophthalmic tumors. Radioactive seeds are fixed in a gold bowl-shaped plaque and the plaque is sutured to the scleral surface corresponding to the base of the intraocular tumor. This treatment allows for a localized radiation dose delivery to the tumor with a minimum target dose of 85 Gy. The goal of this study was to develop a Monte Carlo simulation method for treatment planning optimization of the COMS and USC eye plaques. Material and Methods: The MCNP4C code was used to simulate three plaques: COMS-12mm, COMS-20mm, and USC #9 with I-125 seeds. Calculation of dose was performed in a spherical water phantom (radius 12 mm) using a 3D matrix with a size of 12 voxels in each dimension. Each voxel contained a sphere of radius 1 mm. Results: Dose profiles were calculated for each plaque. Isodose lines were created in 2 planes normal to the axes of the plaque, at the base of the tumor and at the level of the 85 Gy isodose in a 7 day treatment. Discussion and Conclusion: This study shows that it is necessary to consider the following tumor properties in design or selection of an eye plaque: the diameter of tumor base, its thickness and geometric shape, and the tumor location with respect to normal critical structures. The plaque diameter is selected by considering the tumor diameter. Tumor thickness is considered when selecting the seed parameters such as their number, activity and distribution. Finally, tumor shape and its location control the design of following parameters: the shape and material of the plaque and the need for collimation.

Risk Factors for Cataract After Palladium-103 Ophthalmic Plaque Radiation Therapy

To examine how tumor characteristics and dose affect cataract development after plaque radiation therapy. Three hundred and eighty-four patients were diagnosed with uveal melanoma and treated with palladium-103 ((103)Pd) plaque radiation therapy. Of these, 282 (74%) inclusion met exclusion criteria for follow-up time, tumor location, and phakic status. Then patient-, ophthalmic-, and radiation-specific factors (patient age, diabetes, hypertension, tumor location, tumor dimensions, and lens dose) were examined (by a Cox proportional regression model) as predictors for the development of radiation-related cataract. Radiation cataract developed in 76 (24%) of patients at a mean follow-up of 39.8 months (range, 1-192). Patients with anteriorly located tumors were noted to have a higher incidence of cataract at 43.0% (43 of 100 patients) vs. 18.1% (33 cataracts per 182 patients) for posteriorly located tumors (p <0.0001). However, multivariate Cox proportional modeling showed that increasing patient age at time of treatment (p for trend = 0.0003) and higher lens dose (p for trend = 0.001) were the best predictors (biomarkers) for radiation cataract. Although anterior tumor location, greater tumor height, and increased patient age (at treatment) were associated with significantly greater risk for radiation cataract, dose to lens was the most significant factor.

SU‐GG‐T‐378: A Monte Carlo Simulation Method for Treatment Planning Optimization of Eye Plaques Using MCNP4C Code

Purpose: Ophthalmic plaque radiotherapy using I‐125 radioactive seeds in removable episcleral plaques is often used in management of ophthalmic tumors. The goal of this study was to develop a Monte Carlo simulation method for treatment planning optimization of eye plaques. Method and Materials: MCNP4C Monte Carlo Code was used to calculate the percent depth dose curves, dose profiles and isodose curves created by three different plaques. The plaques used were Collaborative Ocular Melanoma Study‐12mm (C0MS‐12mm) with eight model 6702 seeds, COMS‐20mm with three model 6711 seeds, and University of Southern California (USC) #9 with nine model 6711 seeds. Dosimetric characteristics of I‐125 model 6702 and 671 seeds, were calculated according to recommendations of AAPM Task Group 43 protocol. Then, the geometry of each plaque was simulated and dose calculations were performed using F6 tally card in a 12mm radius spherical water phantom. Results: The comparison of calculated central axis depth doses to reported measured values, showed the deviation up to %10 for C0MS‐12mm, %3 for COMS‐20mm and %1 for USC#9. For off‐axis dose profiles the deviation was up to %9 for C0MS‐12mm, at 7mm depth, %6 for COMS‐20mm at 10mm depth and %1 for USC#9 at 17 mm depth. The results of this study show that C0MS‐12mm and COMS‐20mm plaques are suitable for treatment of symmetrical tumors with thickness‐diameter (base) of 8mm‐14mm and 4mm‐12mm, respectively. However, a USC#9 plaque is suitable for treatment of non‐symmetrical tumors with 8mm thickness and 16mm base diameter. Conclusion: The user code developed in this study can be used as an optimization tool within a few millimeters of the plaque surface. It can also be used to design custom made plaques for treatment of ocular tumors with various sizes, shapes and locations.

18F]Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (PET/CT) Physiologic Imaging of Choroidal Melanoma: Before and After Ophthalmic Plaque Radiation Therapy

To evaluate changes in [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) standardized uptake values (SUV) in uveal melanoma before and after plaque brachytherapy. A cohort of 217 patients diagnosed with uveal melanoma and eligible for ophthalmic plaque brachytherapy underwent preoperative PET/CT to evaluate their intraocular tumor and screen for metastasis. Subsequent to undergoing plaque brachytherapy, patients' PET/CT SUV were periodically reevaluated over 42 months. In this series, 37 (17%) choroidal melanoma patients were found to have an SUV of >2.0. Of these, 18 patients were able to undergo interval follow-up PET/CT scanning. There were 3 patients with T2, 11 patients with T3, and 4 patients with T4 melanomas according to 7th edition AJCC-UICC criteria. Mean apical thickness was 8.8 mm (range, 3-12.3 mm), and the largest mean tumor diameter was 15.1 mm (range, 12-19.9 mm). The mean initial SUV was 3.7 (range, 2.1-7.3). Patients were followed for a median 16 months (range, 6-42 months). The median time to a tumor SUV of 0 was 8.0 months (range, 6-18 months). There was one case of one interval increase in SUV that diminished after circumferential laser treatment. Intraocular PET/CT imaging provides a physiological assessment of tumor metabolism that can be used to evaluate changes after treatment. In this study, ophthalmic plaque radiation therapy was associated with extinguished tumor PET/CT SUV over time. PET/CT imaging can be used to assess choroidal melanomas for their response to treatment.

Risk Factors for Radiation Maculopathy after Ophthalmic Plaque Radiation for Choroidal Melanoma

To determine how tumor characteristics and radiation dose affect the incidence of radiation maculopathy (RM). Retrospective, consecutive case series. A consecutive case series of 384 uveal melanomas irradiated (mean apical dose, 71.2 Gy) were followed up for a mean 47.2 months. Tumor locations included: 122 (32%) centered anterior to the equator, 27 (7%) equatorial, and 235 (61%) posterior. Tumor sizes were American Joint Committee on Cancer class T1 (n = 180), T2 (n = 150), T3 (n = 47), and T4 (n = 7). RM occurred in 8 (7%) eyes with anterior uveal melanomas. In contrast, it was found in 82 (41%) eyes with posterior tumors. Multivariate analysis revealed the risk related to posterior location was greater compared with anterior location with a hazard ratio of 6.66 (95% confidence interval [CI], 4.94 to 22.50; P = .0001). Tumor height (> 6.0 mm) also demonstrated a high risk for RM (hazard ratio, 4.5; 95% CI, 2.68 to 10.17; P = .0001). A significant dose-response relationship was found between dose to fovea and RM (P = .0005, for trend). As compared with a dose of < 35 Gy, the risk of RM was 1.74 (95% CI, 0.98 to 3.1) for doses from 35 to 70 Gy, and the risk of RM was 2.43 (95% CI, 1.48 to 4.0) for doses of 70 Gy or more. Of interest, those anterior melanomas with RM had a mean apical height of 9.4 mm, as compared with a mean height of 3.3 mm for anterior tumors not associated with RM. Visual acuity was preserved if the fovea dose was less than 35 Gy. This study suggests that tumor location, tumor thickness, and radiation dose to the fovea are risk factors for the development of RM.

Palladium-103 Ophthalmic Plaque Radiation Therapy for Choroidal Melanoma: 400 Treated Patients

To describe 18 years of experience with palladium-103 ((103)Pd) ophthalmic plaque brachytherapy. Retrospective case series. From 1990 to 2007, 400 patients were diagnosed with uveal melanoma, found negative for metastatic disease, and treated. Episcleral (103)Pd radiation was delivered to a mean apical radiation dose of 73.3 Gy over 5 to 7 continuous days. Palladium-103 ophthalmic plaque brachytherapy. Patients were evaluated for local tumor control, visual acuity, radiation damage (retinopathy, optic neuropathy, cataract), and metastatic disease. A total of 272 tumors (68%) were located at or posterior to the equator. There were 186 (46.5%) T1 tumors, 156 (39%) T2 tumors, 50 (12.5%) T3 tumors, and 8 (2%) T4 tumors. Patients were followed for a maximum of 205 months (mean, 51.1 months). Fourteen patients required secondary enucleation (5 for tumor growth and 9 for glaucoma pain control). The local control rate was 96.7%. Life table analysis of patients with 20/200 or better before treatment (n = 357) suggests that 79% and 69% are expected to retain that acuity for 5 and 10 years, respectively. Life table analysis demonstrates a probability that 92.7% and 86.6% of patients will be free of metastatic disease at 5 and 10 years, respectively. In a nonrandomized phase I clinical evaluation, (103)Pd ophthalmic plaque radiotherapy was used to treat 400 patients with uveal melanoma. In this series, results after (103)Pd ophthalmic plaque radiotherapy were superior to those reported for alternative forms of radiation.

Finger's Amniotic Membrane Buffer Technique

To use amniotic membranes as a buffer between the cornea and radioactive eye plaques. Six melanomas were treated with ophthalmic plaque radiation therapy. Plaque-tumor localization required that a portion of the gold plaque touch the cornea during treatment. To enhance patient comfort and protect the cornea, an (0.1-mm-thick) amniotic membrane was interposed between the metal plaque edge and the cornea. Minimal ocular discomfort was noted during plaque radiation therapy. On a scale of 1 (none) to 10 (severe), all 6 patients reported pain levels of 1. As a tissue equivalent and because the mean thickness was only 0.1 mm, amniotic membranes had no significant effect on radiation dose calculations. No adverse effects, infections, or abrasions were noted. The amniotic membrane buffer technique improves patient comfort and protects the cornea during ophthalmic plaque radiation therapy.

Palladium 103 (103Pd) Plaque Radiation Therapy for CircumscribedChoroidal Hemangioma With Retinal Detachment

To describe clinical experience with palladium 103 ((103)Pd) ophthalmic plaque radiotherapy for choroidal hemangioma. One course of (103)Pd ophthalmic plaque radiotherapy was used in each of 5 patients with circumscribed choroidal hemangioma who had progressive loss of vision due to subretinal exudation. A mean apex dose of 2900 cGy (2900 rad) was delivered. Functional tests of outcome included best-corrected visual acuity. Anatomic results included changes in tumor height and subretinal fluid documented by ophthalmoscopy, fluorescein angiography, and ultrasonography. All patients had complete resolution of subretinal fluid with reattachment of the retina. All tumors decreased in height (mean, 50%) after treatment. Three patients (60%) demonstrated improvement in visual acuity at the last follow-up, and in 1 patient vision remained stable with resolution of metamorphopsia. Twenty-four months after treatment, 1 patient whose visual acuity had recovered from 20/160 to 20/32 had a loss of vision to 20/160 because of radiation maculopathy. For all patients, a mean visual acuity improvement of 2 lines was documented (95% confidence interval, 0.23-0.88). Mean follow-up was 18.6 months (range, 6-29 months). A single (103)Pd plaque radiation treatment was effective in decreasing tumor height, eliminating subretinal fluid, and improving visual acuity in patients with symptomatic circumscribed choroidal hemangiomas.

Radiation-blocking glasses allow vision during ophthalmic plaque radiation therapy

PurposeTo evaluate the use of leaded safety glasses to block radiation and allow for vision during ophthalmic plaque radiation therapy. DesignInterventional case series. MethodsEight patients were treated with palladium 103 ophthalmic plaque radiotherapy and measured for emitted radiation while wearing leaded glasses or a lead patch. Radiation emission was measured at 1 m so as to compare the glasses' ability to block radiation in vivo. ResultsIn two patients the tumor was in the patients' only seeing eye, and the leaded radiation safety glasses allowed them to function (feed themselves and walk to the bathroom unassisted). In two additional patients, the glasses allowed binocularity and were preferred over the patch. Measurements revealed that both the lead patch and leaded radiation safety glasses reduced exposure to levels acceptable for discharge to home in New York City. ConclusionsLeaded radiation safety glasses improved patients' quality of life without sacrificing radiation safety.

Plaque radiation therapy for malignant melanoma of the iris and ciliary body

PURPOSE: To report on plaque radiation therapy for malignant melanomas involving the iris and ciliary body. METHODS: Twenty-two eyes (22 patients) with anterior uveal melanomas were treated with 103Pd ophthalmic plaque radiation therapy. Transillumination and ultrasonography were used to evaluate ciliary body involvement and posterior iris extension. Plaques were placed onto the cornea to treat the anterior tumor margins. The targeted-zone included the tumor and a 2 to 3 mm tumor-free margin. After plaque removal, patients were examined at 1 day, 7 days, 4 weeks, and then every 3 to 6 months thereafter. Systemic evaluations for possible metastatic disease were performed every 6 months. RESULTS: After plaque radiation therapy, the melanomas decreased in thickness (mean 47%) in all 22 eyes, and no secondary enucleation was performed. One patient died of metastatic melanoma 5 years after radiation therapy. Despite anterior plaque placement that covered portions of the cornea, no epiphora, eyelash loss, or visually significant corneal opacities were noted. Whereas 15 of 21 phakic eyes (71%) developed secondary cataract, no eyes developed ischemic or neovascular radiation maculopathy. Four eyes were noted to have glaucoma before treatment, and two developed it after irradiation. Twenty of 22 eyes (91%) were within 2 lines of their pretreatment visual acuity. After radiation, the mean ± SD follow-up was 56 ± 34.4 months (range, 9 to 117 months). CONCLUSIONS: Plaque radiotherapy of melanomas involving the iris and ciliary body resulted in excellent local control with preservation of vision. Although there was high incidence of secondary cataracts, 103Pd plaque radiation therapy resulted in no visually significant corneal opacity or radiation retinopathy.

Discussion by Paul T. Finger, MD,1,2 Andrzej Szechter, PhD,2 Anthony M. Berson, MD1,2

Ophthalmic plaque radiation therapy continues to offer patients an eye- and vision-sparing alternative to enucleation. Pioneers of this technique first used high-energy plaques that incorporated cobalt 60 (60Co).1 Since that time ruthenium 106 (106Ru) largely replaced Co60 in Europe, as did low-energy iodine 125 (125I) in North America.1–5 Plaque radiotherapy with these new radionuclides (isotopes) delivers less unwanted radiation to the patient, the surgeon, and health care personnel.