Craig G. Wells

The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma: IV. Local treatment failure and enucleation in the first 5 years after brachytherapy. COMS report no. 19.

OBJECTIVEnTo describe the frequency and predictors of local treatment failure and enucleation after iodine 125 (I(125)) brachytherapy in patients with choroidal melanoma treated and followed up in a large randomized clinical trial.nnnDESIGNnProspective, noncomparative, interventional case series within a randomized, multicenter clinical trial.nnnPARTICIPANTSnPatients enrolled in the Collaborative Ocular Melanoma Study (COMS) trial of enucleation versus brachytherapy between February 1987 and July 1998; tumors measured 2.5 to 10.0 mm in apical height and no more than 16.0 mm in longest basal dimension.nnnMETHODSnI(125) brachytherapy was administered via episcleral plaque according to a standard protocol. Follow-up ophthalmic evaluations, including ophthalmic ultrasound and fundus photography, were performed according to a standard protocol at baseline, every 6 months thereafter for 5 years, and subsequently at annual intervals. Survival analysis methods were used to estimate the cumulative risk of postirradiation treatment failure and enucleation. Factors associated with treatment failure and enucleation of plaqued eyes were evaluated using Cox proportional hazards analysis.nnnMAIN OUTCOME MEASURESnReports of enucleation and of local treatment failure, defined as tumor growth, recurrence, or extrascleral extension, derived from clinical reports based on echographic and photographic documentation.nnnRESULTSnAs of September 30, 2000, 638 of the 650 patients randomized to brachytherapy and so treated had been followed up for 1 year or longer, and 411 had been followed up for at least 5 years. Sixty-nine eyes were enucleated during the first 5 years after brachytherapy, and treatment failure was reported for 57 eyes. The Kaplan-Meier estimate of proportion of patients undergoing enucleation by 5 years was 12.5% (95% confidence interval [CI], 10.0%-15.6%); the risk of treatment failure was 10.3% (95% CI, 8.0%-13.2%). Treatment failure was the most common reason for enucleation within 3 years of treatment; beyond 3 years, ocular pain was most common. Risk factors for enucleation were greater tumor thickness, closer proximity of the posterior tumor border to the foveal avascular zone, and poorer baseline visual acuity in the affected eye. Risk factors for treatment failure were older age, greater tumor thickness, and proximity of the tumor to the foveal avascular zone. Local treatment failure was associated weakly with reduced survival after controlling for baseline tumor and personal characteristics (adjusted risk ratio, 1.5; P = 0.08).nnnCONCLUSIONSnLocal treatment failure and enucleation were relatively infrequent events after I(125) brachytherapy within the COMS. Treatment failure typically occurred early and was associated weakly with poorer survival. The COMS randomized trial documented the absence of a clinically or statistically significant difference in survival for patients randomly assigned to enucleation versus brachytherapy. This analysis documents the efficacy of brachytherapy to achieve sustained local tumor control and to conserve the globe.

Photocoagulation treatment of radiation retinopathy

We studied the visual and anatomic effects of focal photocoagulation for clinically significant radiation macular edema in five eyes of four patients and panretinal photocoagulation for proliferative radiation retinopathy in six eyes of three patients. Focal and limited scatter photocoagulation was successful in preventing further vision loss in all five eyes treated for macular edema. Three eyes treated with panretinal photocoagulation had regression of neovascularization. The other three eyes treated for proliferative retinopathy subsequently had dense vitreous hemorrhages that required vitrectomy for restoration of useful vision.

The coms randomized trial of iodine 125 brachytherapy for choroidal melanoma

arms, 5- and 10-year all-cause mortality rates were 19% and 35%, respectively; by 12 years, cumulative all-cause mortality was 43% among patients in the 125 I brachytherapyarmand41%amongthoseintheenucleationarm. Five-, 10-, and 12-year rates of death with histopathologicallyconfirmedmelanomametastasiswere10%,18%, and 21%, respectively, in the 125 I brachytherapy arm and 11%,17%,and17%,respectively,intheenucleationarm. Olderageandlargermaximumbasaltumordiameterwere the primary predictors of time to death from all causes and death with melanoma metastasis. Conclusion:Longer follow-up of patients confirmed the earlier report of no survival differences between patients whose tumors were treated with 125 I brachytherapy and those treated with enucleation.

Degenerative Retinoschisis with Giant Outer Layer Breaks and Retinal Detachment

Five unusual cases of retinal detachment were caused by giant (more than 90 degrees) posterior breaks in the outer layer of degenerative retinoschisis. All retinas were successfully reattached by a variety of surgical techniques. The two cases managed with scleral buckling required subsequent buckle removal because of macular distortion. Treatment with cryotherapy or laser, together with intraocular air and postoperative positioning, gave better anatomic results.

Progressive Inherited Retinal Arteriolar Tortuosity with Spontaneous Retinal Hemorrhages

Tortuosity of the retinal arterioles complicated by spontaneous retinal hemorrhages is inherited as an autosomal dominant trait. Even when hemorrhages involve the fovea, spontaneous clearing with recovery of normal vision is the rule. We have studied members of three families in which arteriolar tortuosity increases with age. Tortuosity increases most dramatically during adolescence and affects small arterioles in the macular area. Retinal hemorrhages in children from two pedigrees led to extensive laboratory investigation because arteriolar tortuosity, later unmistakeable, was not recognized initially. Inherited retinal arteriolar tortuosity may be overlooked easily, particularly in children. Patients with spontaneous retinal hemorrhages and their relatives should be examined for retinal arteriolar tortuosity before being subjected to cardiovascular or hematologic studies.

Bilateral vasoproliferative retinal tumors in a patient with autosomal dominant aniridia.

PURPOSEnTo document retinal vasoproliferative tumors in a patient with aniridia.nnnMETHODSnA 32-year-old woman with known autosomal dominant aniridia and lifelong visual acuity of approximately 20/80 noted further visual acuity loss.nnnRESULTSnExamination revealed horizontal nystagmus and visual acuity of 20/100 in both eyes. Both eyes displayed a narrow rim of rudimentary iris with visualization of the entire lens and zonule. The cornea was clear and minimal posterior subcapsular cataract was noted. Both eyes showed diffuse retinal pigment epithelial alterations. The fovea was flat and without depression on optical coherence tomography. Inferiorly in both eyes was exudative retinal detachment from ill-defined vascular retinal tumors of approximately 15 mm diameter and 3.5 mm thickness. Both eyes were treated with plaque radiotherapy.nnnCONCLUSIONSnAlthough aniridia typically affects the anterior segment of the eye, vision-threatening retinal detachment from vasoproliferative tumor can occur.