Plaque Radiotherapy For Choroidal Melanoma Research Articles

Central subfield thickness predicts visual acuity outcomes in plaque-irradiated eyes with choroidal melanoma.

To determine the association between pre-operative central subfield thickness (CST) and post-radiotherapy visual acuity (VA), cystoid macular edema (CME), and intravitreal anti-vascular endothelial growth factor (VEGF) requirement. Single-center retrospective study. Patients with plaque-irradiated extramacular choroidal melanoma treated between 11/11/2011 and 4/30/2021. Pre-operative CST difference between the affected and unaffected eye was used. Kaplan-Meier analysis and hazard ratios were calculated. Of 85 patients, pre-operative CST was greater in the melanoma-affected eye (vs. fellow eye) by mean of 20.4 μm (median 14.0, range - 60.0-182.0). Greater CST at presentation (vs. fellow eye) was associated with larger tumor diameter (p = 0.02), greater tumor thickness (p < 0.001), and more frequent tumor-related Bruch's membrane rupture (p = 0.006). On univariate analysis of outcome data, greater CST at presentation (vs. fellow eye) was associated with higher 5-year risk (1.09 [1.02-1.17], p = 0.02) of VA 20/200 or worse and increased (1.10 [1.01-1.20], p = 0.03) likelihood for anti-VEGF injections after plaque irradiation. There was no significant association with CME. The association between CST and VA outcome remained significant on multivariate analysis accounting for impact of tumor thickness and radiation dose to optic disc, while tumor distance to fovea was the only significant factor on multivariate analysis for anti-VEGF injections. Greater CST at presentation (vs. fellow eye) was associated with worse VA outcome following plaque radiotherapy for choroidal melanoma. Large-sized tumors may contribute to a higher intraocular VEGF burden, potentially leading to greater preoperative CST, which correlates with poor VA outcome post-plaque radiotherapy.

Anterior Segment OCT of Scleral Necrosis after Plaque Radiotherapy for Choroidal Melanoma

Anterior Segment OCT of Scleral Necrosis after Plaque Radiotherapy for Choroidal Melanoma

Wide-Field (15 × 9 mm) Swept-Source Optical Coherence Tomography Angiography Following Plaque Radiotherapy of Choroidal Melanoma: An Analysis of 105 eyes.

The aim of this study was to evaluate retinal microvascular abnormalities following plaque radiotherapy of choroidal melanoma (CM) using wide-field swept-source optical coherence tomography angiography (OCTA). Single-centre retrospective review. Retrospective case series of 105 CM patients treated with I-125 plaque radiotherapy and imaged with wide-field (15 × 9 mm) SS-OCTA from March 2018 to August 2018 at the Ocular Oncology Service, Wills Eye Hospital (Philadelphia, PA). At mean follow-up of 49 months (range 4-297) after plaque radiotherapy, there were 52 eyes (50%) with clinically evident radiation retinopathy (CERR) and 53 eyes (50%) without CERR. Comparison (CERR vs controls) revealed foveal avascular zone enlargement (1.7 vs 0.23 mm, P = 0.03) and reduction of capillary vascular density (CVD) in the superficial and deep plexus in the total wide-field (43% vs 47%, P < 0.001, and 46% vs 48%, P = 0.001, respectively), peripapillary region (66% vs 77%, P < 0.001, and 66% vs 72%, P = 0.001, respectively), and papillomacular bundle (60% vs 68%, P < 0.001, and 61% vs 64%, P = 0.03, respectively). Comparison (no CERR vs controls) revealed nonsignificant foveal avascular zone enlargement (1.20 vs 0.23 mm, P = 0.16) and reduction of CVD in the superficial plexus (46% vs 47%, P = 0.008), and not the deep plexus (48% vs 48%, P = 0.42) of the total wide-field. Comparison of irradiated eyes (CERR vs no CERR) showed reduction of CVD in the superficial and deep plexus of the total wide-field (43% vs 46%, P < 0.006, and 46% vs 48% P < 0.02, respectively), peripapillary region (66% vs 74%, P < 0.001, and 66% vs 72% P < 0.01, respectively), and superficial plexus in the papillomacular bundle (60% vs 65%, P = 0.03). Following plaque radiotherapy for choroidal melanoma, wide-field swept-source optical coherence tomography angiography demonstrates retinal microvascular abnormalities in the CVD in eyes with and without CERR. These findings are important in early detection and monitoring of radiation retinopathy.

CLINICAL FEATURES, IMAGING, AND NATURAL HISTORY OF MYELINATED RETINAL NERVE FIBER LAYER.

To evaluate the natural history of myelinated retinal nerve fiber layer (MRNFL) through clinical features and enhanced depth imaging optical coherence tomography. This is a retrospective, noncomparative, case series of patients who underwent thorough clinical examination to document associated ocular and systemic features. Enhanced depth imaging optical coherence tomography was performed when MRNFL was located posteriorly and accessible to imaging. Seventy-two eyes of 62 patients had a total of 86 MRNFL lesions. Enhanced depth imaging optical coherence tomography (n = 42 eyes) showed that all lesions originated in the nerve fiber layer with preservation of the vascular structures. Mean thickness by enhanced depth imaging optical coherence tomography was 255 μm (median, 182 μm; range, 61-717 μm). Natural history was obtainable in 58 lesions with a mean follow-up duration of 57 months (median, 37 months; range, 2-253 months) with no significant change overall in largest basal diameter (2.5 vs. 2.5 mm; P = 0.361) or thickness (255 vs. 240 μm; P = 0.053). However, evidence of lesion change included growth in base only (≥0.5 mm) (3 of 58; 5%), growth in base (≥0.5 mm) and thickness (≥50 μm) (3 of 58; 5%), and reduction in base (≥0.5 mm) after plaque radiotherapy for choroidal melanoma (3 of 58; 5%). In general, MRNFL is a rare, benign retinal finding with a potential for growth in 10% of cases. This supports previous histopathological reports that MRNFL represents accumulation of both myelin and oligodendrocytes and could be an oligodendrocytic choristoma.

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

To assess the efficacy of intravitreal aflibercept in patients suffering from post-radiation macular edema following plaque radiotherapy for choroidal melanoma. 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. Nine eyes of 9 patients were included. A mean of 4.4 ± 1.2 injections were given over the 24months. 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 ± 123μm at baseline to 223 ± 34μm (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. 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.

Evaluation of Vascular Changes with Optical Coherence Tomography Angiography after Plaque Radiotherapy of Choroidal Melanoma

Aim: The purpose of this paper was to evaluate whether optical coherence tomography angiography (OCT-A) can be used to quantify the vascular changes in radiation maculopathy, and changes in the tumor vasculature in eyes treated with plaque radiotherapy for choroidal melanoma. Methods: In this prospective study, we evaluated 39 Caucasian patients with choroidal melanoma (39 eyes) treated with ruthenium-106 plaque radiotherapy. The patients underwent complete ophthalmic examination, bulbar echography, and OCT-A before and 1 year after treatment. Results: At baseline, the mean best-corrected visual acuity (BCVA) in the affected eyes was 0.35 ± 0.40 logMAR, and the mean tumor thickness was 2.68 ± 0.25 mm at A-scan echography. After treatment, the mean BCVA increased to 0.41 logMAR, the mean tumor thickness decreased to 1.66 ± 0.23 mm, and the tumor basal diameter was significantly reduced (U = 108, p = 0.001). Moreover, the capillary vessel density was significantly lower in all Early Treatment of Diabetic Retinopathy Study sectors, and both the vessel and flow areas were significantly reduced (p = 0.030 and p = 0.001, respectively). Conclusions: OCT-A is a noninvasive, reliable method with which to quantify the vessel changes in radiation maculopathy and, given the association between vascularization and malignancy, this procedure may be an aid in treatment decision-making and in monitoring the efficacy of treatment.

Intravitreal triamcinolone acetate for radiation maculopathy recalcitrant to high-dose intravitreal bevacizumab

Background/aimsTo evaluate the effect of adjuvant intravitreal triamcinolone acetonide (ITA) for radiation maculopathy (RM) recalcitrant to high-dose bevacizumab in patients with choroidal melanoma after plaque radiotherapy.MethodsEight eyes of eight patients...

Safety of Pars Plana Vitrectomy in Eyes With Plaque-Irradiated Posterior Uveal Melanoma

To determine the long-term safety of pars plana vitrectomy (PPV) in eyes with plaque-irradiated posterior uveal melanoma. In this retrospective case series, patients with plaque-irradiated posterior uveal melanoma subsequently underwent PPV for vitreous hemorrhage. The main outcome measures are the rates of intraocular melanoma dissemination, extrascleral extension of melanoma, local melanoma recurrence, and systemic melanoma metastasis after PPV. Forty-seven eyes of 47 patients underwent PPV for vitreous hemorrhage after iodine 125-labeled plaque radiotherapy for choroidal melanoma. The mean interval between the onset of vitreous hemorrhage and PPV was 13 (median, 10; range, 0-52) months. The mean time from PPV to last follow-up was 5 (range, 0.5-16) years. There were no cases of intraocular melanoma dissemination or extrascleral extension of melanoma. One patient (2%) developed local choroidal melanoma recurrence (2 years after PPV and 5 years after initial plaque radiotherapy) and was successfully managed with transpupillary thermotherapy. Systemic melanoma metastasis occurred in 4 patients (9%) during a mean interval of 5 years after plaque radiotherapy. During follow-up, 43 patients (91%) were alive without systemic metastasis and 4 patients (9%) were alive with metastasis. Management of vitreous hemorrhage by PPV in eyes with previously irradiated uveal melanoma appears to be safe and without increased risk for intraocular, local, orbital, or systemic dissemination of the tumor.

Vitreous hemorrhage as the initial manifestation of idiopathic thrombocytopenic purpura.

To report vitreous hemorrhage as the initial manifestation in idiopathic thrombocytopenic purpura, an uncommon presentation. Case report. A 69-year-old white woman presented with diffuse vitreous hemorrhage as the initial manifestation of idiopathic thrombocytopenic purpura, 12 years after plaque radiotherapy for choroidal melanoma. Unexplained and recurrent vitreous hemorrhage should be evaluated for idiopathic thrombocytopenic purpura.

Antivascular Endothelial Growth Factor Bevacizumab for Radiation Optic Neuropathy: Secondary to Plaque Radiotherapy

To evaluate the intravitreal antivascular endothelial growth factor, bevacizumab, for treatment of radiation optic neuropathy (RON). A prospective interventional clinical case series was performed of 14 patients with RON related to plaque radiotherapy for choroidal melanoma. The RON was characterized by optic disc edema, hemorrhages, microangiopathy, and neovascularization. The entry criteria included a subjective or objective loss of vision, coupled with findings of RON. The study subjects received a minimum of two initial injections of intravitreal bevacizumab (1.25 mg in 0.05 mL) every 6-8 weeks. The primary objectives included safety and tolerability. The secondary objectives included the efficacy as measured using the Early Treatment Diabetic Retinopathy Study chart for visual acuity, fundus photography, angiography, and optical coherence tomography/scanning laser ophthalmoscopy. Reductions in optic disc hemorrhage and edema were noted in all patients. The visual acuity was stable or improved in 9 (64%) of the 14 patients. Of the 5 patients who had lost vision, 2 had relatively large posterior tumors, 1 had had the vision decrease because of intraocular hemorrhage, and 1 had developed optic atrophy. The fifth patient who lost vision was noncompliant. No treatment-related ocular or systemic side effects were observed. Intravitreal antivascular endothelial growth factor bevacizumab was tolerated and generally associated with improved vision, reduced papillary hemorrhage, and resolution of optic disc edema. Persistent optic disc neovascularization and fluorescein angiographic leakage were invariably noted. The results of the present study support additional evaluation of antivascular endothelial growth factor medications as treatment of RON.

Tumor-related Lipid Exudation after Plaque Radiotherapy of Choroidal Melanoma: The Role of Bruch's Membrane Rupture

To identify the risk factors predictive of development of tumor-related lipid exudation (TRLE) after plaque radiotherapy of posterior uveal melanoma. Case-control study. Cases included 294 patients with posterior uveal melanoma who had developed TRLE after plaque radiotherapy. Controls included 294 patients with posterior uveal melanoma who had not developed TRLE after plaque radiotherapy. Controls were matched with cases for age, gender, and initial tumor thickness. Data were extracted from medical charts containing demographic, clinical, and treatment information. Detailed fundus drawings and color fundus photographs were reviewed for each patient. Tumor and ocular features of eyes with posterior uveal melanoma treated with plaque radiotherapy. Multivariate analysis identified Bruch's membrane rupture (P<0.001), serous retinal detachment (RD) before radiation (P< or =0.019), closer proximity to the optic disc and foveola (P = 0.004 and 0.013, respectively), greater tumor base (P = 0.035), failure to receive transpupillary thermotherapy (TTT) after radiation (P<0.001), and initial increase of serous RD after radiation (P<0.001) as significant risk factors predictive of development of TRLE after plaque radiotherapy of posterior uveal melanoma. Radiation dose at the tumor base correlated with maximum extent of TRLE (P = 0.003). The mean interval between plaque radiotherapy and onset of TRLE was 14 months (median, 11 months; range, 2-97 months), with 88% of cases developing TRLE within 2 years of radiation. The interval between the onset of TRLE and the first evidence of its regression was a mean of 33 months (median, 38 months; range, 2-194 months). Our study identified Bruch's membrane rupture as an important factor predisposing to development of TRLE after plaque radiotherapy of posterior uveal melanoma. Other predictive factors included serous RD before radiation, large tumor basal diameter, posterior tumor location, lack of adjunctive TTT, and early increase of serous RD after plaque radiotherapy.

An audit of eccentrically‐positioned ruthenium plaque radiotherapy of choroidal melanoma in Liverpool

Abstract Purpose Brachytherapy is usually administered with the plaque overlapping the entire tumour margin by at least 1‐2mm. With posterior tumours, our practice is to position the plaque with its posterior edge aligned with the posterior tumour margin. We audited ocular outcomes after eccentrically‐placed ruthenium plaque radiotherapy of choroidal melanoma. Methods Patients were included if receiving primary ruthenium brachytherapy for choroidal melanoma during the three years up to the 31st July 2007. A perforated template was used to facilitate plaque positioning. For posterior tumors, the template was positioned so that trans‐illumination produced a glow at the posterior tumour margin (‘sunset sign’). Minimum doses of 300‐350 Gy and 80‐90 Gy were prescribed to the sclera and apex, respectively. Results The cohort comprised 162 patients (93 female and 69 male). The time to the last known visual acuity had a median of 23 months. The initial visual acuity was 20/40 or better in 94.6%, 20/60 to 20/200 in 13.0% and worse than 20/200 in 1.9% of patients. The tumours had a mean basal diameter of 11.7mm. Ten tumours exceeded 5.4 mm in height. Tumour extension to within 5mm of optic disc, fovea or both occurred in 18 (11.1%), 28 (17.3%) and 27 (16.7%) cases respectively. Risk factors for visual loss were proximity to optic disc or fovea, initial visual acuity worse than 20/40 and tumour height exceeding 5.4 mm. In 66 patients with none of these risk factors, 92% retained 20/40 or better and 5 had vision of 20/60 – 20/200. In 72 with one risk factor, 74.3% retained 20/16 – 20/40 and 95.7% had vision of 20/200 or better. In 12 patients with 2 risk factors, these percentages were 25.0% and 91.7%. Only 3 patients had 3 risk factors and one retained vision of 20/200 or better. Tumours distanced &lt; 5 mm to fovea were divided in 3 groups, and visual acuity analysed. Three patients had local tumour recurrence and were treated respectively by proton beam radiotherapy, plaque radiotherapy and enucleation (the only eye lost in this series). Conclusion Eccentric plaque radiotherapy of choroidal melanoma achieves good rates of local tumour control, ocular retention and preservation of vision.

Plaque Radiotherapy for Juxtapapillary Choroidal Melanoma Overhanging the Optic Disc in 141 Consecutive Patients

To evaluate tumor control with plaque radiotherapy for juxtapapillary choroidal melanoma that overhangs the optic disc. Retrospective medical record review of 141 consecutive patients with data on complications of treatment, final visual acuity, visual loss, enucleation, tumor recurrence, metastasis, and death. The median patient age was 61 years. Presenting symptoms included reduced visual acuity in 72 eyes (51%), photopsia in 14 (10%), and visual field defect in 18 (13%); 35 patients (25%) were asymptomatic. The median tumor basal diameter was 11 mm and the median thickness was 5.2 mm. The tumor overhung 50% or less of the disc in 88 eyes (62%) and more than 50% of the disc in 53 eyes (38%). In 19 cases (13%), the tumor overhung the entire disc. All patients were treated with plaque radiotherapy, using a notched design in 126 eyes (89%) and a round design in 14 eyes (10%), with iodine 125 in 132 eyes (94%) and cobalt 60 in 9 eyes (6%). The median radiation dose to the tumor apex was 8500 cGy. Adjuvant transpupillary thermotherapy was used in 54 eyes (39%). During a mean follow-up of 56 months, complications included nonproliferative retinopathy in 61 eyes (51%), proliferative retinopathy in 26 (22%), maculopathy in 44 (37%), papillopathy in 57 (48%), neovascular glaucoma in 23 (19%), and vitreous hemorrhage in 48 (40%). A final visual acuity of 20/200 or worse was measured in 72 eyes (77%), and visual loss of more than 5 Snellen lines occurred in 59 eyes (63%). Enucleation was necessary in 27 eyes (23%). Tumor recurrence was found in 12 eyes (10%). Metastasis developed in 15 patients (13%) and death in 4 cases (3%). Using plaque radiotherapy for choroidal melanoma overhanging the optic disc, local tumor control was achieved in 90% of cases. Tumor and radiation effects led to poor visual acuity in 77% of eyes. The metastatic rate was 13% and the mortality rate was 3%.

Surgical treatment of severe choroidal detachment after brachytherapy for choroidal melanoma

Abstract Purpose Choroidal detachment is a rare but potentially serious complication of plaque radiotherapy of choroidal melanoma. We present a patient who was successfully treated by trans‐scleral drainage over the pars plana using an unconventional technique. Methods A 69‐year‐old man was referred to our service for an infero‐nasal, collar‐stud melanoma in the left eye. On ultrasonography, the tumour measured 14.1 x 11 mm, with a thickness of 5.8 mm. The patient was treated with a 20 mm ruthenium plaque. Two weeks after the plaque removal, the patient was referred back to our service with a painful eye and ocular hypotension. Ophthalmoscopy showed severe choroidal detachments. The patient was managed expectantly, but the pain became uncontrollable. The supra‐choroidal fluid was drained through a circumferential deep scleral incision over the pars plana and under a lamellar scleral flap hinged posteriorly. A high intraocular pressure was maintained with infusion, using a 6 mm cannula placed in an area between the choroidal detachments. The patient was on warfarin and this was not discontinued before the surgery. Results Postoperatively, the eye was comfortable, the intraocular pressure returned to normal and the choroidal detachments did not recur. Conclusion Our technique has several advantages over previously described methods. First, it avoids the risk of retinal tear, because of the pars plana location of the incision. Second, the scleral flap facilitates wound closure, also avoiding the risk of retinal prolapse. Third, it does not require the warfarin therapy to be stopped. We propose this technique as a relatively safe and effective treatment for severe, painful and persistent choroidal detachment after plaque radiotherapy of choroidal melanoma.

Plaque Radiotherapy for Choroidal Melanoma Encircling the Optic Disc (Circumpapillary Choroidal Melanoma)

To report results of plaque radiotherapy for choroidal melanoma that completely encircles the optic disc (circumpapillary melanoma). Retrospective medical record review over a 31-year period of 37 consecutive patients. The main outcome measures were treatment complications, long-term visual acuity, enucleation, tumor recurrence, metastasis, and death. The median patient age at treatment was 69 years (range, 20-86 years). The presenting complaint was visual loss in 19 eyes (51%), photopsia in 5 (14%), and visual field loss in 3 (8%). All tumors touched and encircled the optic disc for 360 degrees . The quadrantic location of the main tumor epicenter was superior in 8 eyes (22%), nasal in 10 (27%), inferior in 9 (24%), and temporal in 10 (27%). The median tumor basal diameter was 11 mm (range, 4.8-20 mm) and median tumor thickness was 3.6 mm (range, 1.8-14.8 mm). The optic disc was obscured to some extent by overhanging tumor in 19 cases (52%). The most commonly used isotope for plaque radiotherapy was iodine 125 (n = 34 cases; 92%), and a notched plaque design was used in 34 cases (92%). Planned adjunctive treatment included transpupillary thermotherapy in 17 cases (49%) and argon laser photocoagulation in 6 of 35 cases (17%) with follow-up. Of the 28 eyes with more than 5 months' follow-up (mean, 52 months; median, 46 months; range, 5-234 months), treatment complications included nonproliferative and proliferative retinopathy in 11 (39%) and 7 eyes (25%); maculopathy in 7 (25%); papillopathy in 9 eyes (32%); neovascular glaucoma in 5 (18%); and vitreous hemorrhage in 13 (46%). Pars plana vitrectomy was required in only 2 of 13 eyes (15%) with persistent vitreous hemorrhage. Long-term visual acuity of 20/200 or worse was observed in 13 eyes (62%), and 12 eyes (57%) lost more than 5 Snellen visual acuity lines, excluding 7 cases (25%) in which enucleation was necessary. Recurrence was noted in 4 cases (14%), of which 3 were treated with enucleation and 1 with transpupillary thermotherapy. Systemic metastasis occurred in 1 patient (4%) and there were no melanoma-specific deaths during the study period. Custom-designed plaque radiotherapy is a potential treatment for selected patients with circumpapillary choroidal melanoma. We found satisfactory local tumor control, and globe retention was achieved in 75% of eyes with more than 5 months' follow-up.

INTRAVITREAL BEVACIZUMAB TREATMENT FOR RADIATION MACULAR EDEMA AFTER PLAQUE RADIOTHERAPY FOR CHOROIDAL MELANOMA

To evaluate the effect of intravitreal bevacizumab treatment on patients with macular edema (ME) due to radiation retinopathy after plaque radiotherapy for choroidal melanoma. In this retrospective case series, 10 consecutive patients with ME due to radiation retinopathy after plaque radiotherapy for choroidal melanoma were treated with a single intravitreal injection of bevacizumab. Postinjection best-corrected visual acuity (BCVA) and mean foveal thickness measured by ocular coherence tomography were the primary outcome measures. The mean BCVA at the time of the diagnosis of choroidal melanoma was 20/25 (range, 20/20 to 20/40). The mean radiation dose to the foveola was 4,323 cGy (range, 1,908-7,975 cGy). Radiation ME developed at a mean of 26 months (range, 17-44 months) after plaque radiotherapy. Choroidal melanoma regressed in all patients, and there were no neovascular sequelae. At the time of radiation ME diagnosis, the mean BCVA was 20/100 (range, 20/40 to 20/200). After bevacizumab injection, the mean BCVA was 20/86 at 6 weeks and 20/95 at 4 months. Mean foveal thickness measured by ocular coherence tomography was 482 microm before injection, 284 microm 6 weeks after injection, and 449 mum 4 months after injection. Intravitreal bevacizumab injection decreases mean foveal thickness while only modestly improving BCVA on a short-term basis in patients with radiation-induced ME.

Fluorescent In Situ Hybridization for Monosomy 3 via 30-Gauge Fine-Needle Aspiration Biopsy of Choroidal Melanoma In Vivo

To report the feasibility of intraoperative transscleral fine-needle aspiration biopsy at plaque surgery to obtain cells for monosomy 3 analysis in patients with choroidal melanoma. Consecutive interventional case series. Eighteen patients (18 eyes) with choroidal melanoma who had fine-needle aspiration biopsy performed with a 30-gauge needle at time of iodine 125 plaque placement. Cytology and cytogenetic analysis for monosomy 3 were obtained from biopsy specimens. Cytology, cytogenetic analysis for monosomy 3, and complications and feasibility of transscleral fine-needle aspiration biopsy of choroidal melanoma in vivo. Fine-needle aspiration biopsy was diagnostic of choroidal melanoma in 14 of 18 cases and resulted in viable cell cultures for fluorescent in situ hybridization (FISH) analysis in 9 cases. Fluorescent in situ hybridization for monosomy 3 was positive in 4 of the 9 cases. One patient had a mild vitreous hemorrhage. Tumors between 2 and 3 mm in height and those that yielded cells that did not attach in culture were most likely to have insufficient growth for FISH analysis. Transscleral fine-needle aspiration biopsy and FISH for monosomy 3 may provide important prognostic information on patients who undergo plaque radiotherapy for choroidal melanoma.

INTRAVITREAL TRIAMCINOLONE ACETONIDE FOR ACUTE RADIATION PAPILLOPATHY

To evaluate intravitreal triamcinolone acetonide for patients with visually symptomatic acute radiation-induced papillopathy. In a prospective, nonrandomized, single-center case series, intravitreal triamcinolone acetonide (4 mg/0.1 mL) was injected through the pars plana using sterile technique in 9 patients with radiation papillopathy after plaque radiotherapy for choroidal melanoma. Status of radiation papillopathy and final visual acuity were the main outcome measures. At the time of diagnosis of the choroidal melanoma, visual acuity was 20/20 to 20/40 (n = 6), 20/60 (n = 2), and 20/100 (n = 1). The mean radiation dose to the optic disk was 6,175 cGy (median, 5,994 cGy; range, 3,571-12,760 cGy). Radiation papillopathy developed a mean of 18 months (median, 17 months; range, 6-33 months) after plaque radiotherapy. In all cases, the choroidal melanoma was regressed, and there was no retinal detachment or neovascularization of the retina, optic disk, or iris. Concomitant radiation maculopathy was found in 8 eyes manifesting as macular edema (n = 8), intraretinal dot hemorrhages (n = 6), intraretinal exudation (n = 6), or nerve fiber layer infarction (n = 3). The radiation papillopathy findings included optic disk hyperemia (n = 9), edema (n = 9), and circumpapillary hemorrhage (n = 8). At the time of diagnosis of radiation papillopathy, visual acuity was 20/70 (n = 1), 20/100 (n = 4), 20/200 (n = 1), and counting fingers (n = 3). At 1 week after injection of triamcinolone acetonide, visual acuity improvement was found in seven patients, and resolution of optic disk hyperemia and edema was noted for four and three patients, respectively. At a mean follow-up of 11 months (median, 9 months; range, 6-19 months), visual acuity was stable or improved in 7 patients, and resolution of optic disk hyperemia and edema was found in all 9 patients. The mean time to improvement in visual acuity by > or =2 lines was 3 weeks (median, 1 week; range, 1-12 weeks). The mean time to complete resolution of radiation papillopathy was 4 months. The two patients with worse final visual acuity also had macular hole and central retinal vein obstruction. The only complication of this therapy was possibly related cataract in three patients. During short-term follow-up, acute radiation-induced papillopathy appears to respond rapidly to intravitreal triamcinolone acetonide injection with resolution of optic disk hyperemia and edema and modest return of visual acuity. The long-term effects remain unknown.

INTRAVITREAL TRIAMCINOLONE ACETONIDE FOR RADIATION MACULOPATHY AFTER PLAQUE RADIOTHERAPY FOR CHOROIDAL MELANOMA

To evaluate the effect of intravitreal triamcinolone acetonide on patients with visually symptomatic radiation-induced maculopathy after plaque radiotherapy for choroidal melanoma. In this prospective, nonrandomized, single-center case series of 31 patients with visually symptomatic radiation-induced maculopathy after plaque radiotherapy for choroidal melanoma at the Ocular Oncology Service at Wills Eye Hospital of Thomas Jefferson University, triamcinolone acetonide (4 mg/1 mL) was injected through the pars plana into the vitreous cavity using sterile technique. Status of radiation maculopathy and final visual acuity were the main outcome measures. At the time of diagnosis of choroidal melanoma, visual acuity was 20/20 to 20/50 in 90% (n = 28), 20/60 to 20/200 in 10% (n = 3), and 20/400 or worse in none of the patients. The mean radiation dose to the foveola was 5,122 cGy (median, 3,280 cGy; range, 1,000-16,100 cGy). Radiation maculopathy developed at a mean of 22 months (median, 16 months; range, 6-96 months) after plaque radiotherapy. In all cases, the choroidal melanoma was regressed, and there was no retinal detachment or neovascularization of the retina, optic disk, or iris. At the time of diagnosis of radiation maculopathy, visual acuity was 20/20 to 20/50 in 19% (6/31), 20/60 to 20/200 in 58% (18/31), and 20/400 or worse in 23% (7/31) of patients. After intravitreal injection of triamcinolone acetonide, visual acuity was stable or improved in 91% (20/22) of patients by 1 month and 45% (14/31) by 6 months. Mean foveal thickness by optical coherence tomography was 417 microm at injection and 207 microm at 1 month and 292 microm at 6 months after injection. Intravitreal triamcinolone acetonide can stabilize or improve visual acuity in some patients with radiation-induced maculopathy, but its effect might not be lasting.

Enucleation versus preservation of blind eyes following plaque radiotherapy for choroidal melanoma

Background: Currently available information about patients with posterior uveal melanoma treated by plaque radiotherapy is insufficient to determine what to do about eyes that become blind as a consequence of the tumour and its treatment. Should they be enucleated, or is ocular preservation just as good in terms of survival?Methods: We performed a retrospective survival analysis of secondary enucleation versus ocular preservation in patients with a posterior uveal melanoma treated by plaque radiotherapy whose irradiated eye became completely blind following that treatment. Of the 79 patients who fulfilled defined inclusion criteria, 25 underwent secondary enucleation of the blind eye, and 54 retained their irradiated blind eye.Results: Most of the baseline demographic and tumour-related variables evaluated were similarly distributed between the subgroups. The 5-year, I 0-year and 15-year all-cause death rates in the secondary enucleation subgroup were 24.7%,51.5% and 52.0% respectively, and those in the ocular preservation subgroup were 7.4%,32.9% and 48. I % respectively. In spite of the apparent slight difference between the curves, the difference was not statistically significant (p = 0.41, Mantel-Haenszel test).Interpretation: Although a retrospective study of this type has several limitations, our results suggest that secondary enucleation is not likely to substantially improve survival of patients whose irradiated eye becomes totally blind following plaque radiotherapy for choroidal or ciliochoroidal melanoma.