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Efficacy of Proton Therapy in Circumscribed Choroidal Hemangiomas Associated with Serous Retinal Detachment

OBJECTIVE The purpose of the study is to evaluate the efficacy and safety of proton therapy in complicated circumscribed choroidal hemangiomas. DESIGN The study design was a retrospective review. PARTICIPANTS Studied were 13 patients (13 eyes) who had circumscribed choroidal hemangioma associated with serous retinal detachment. Of these, four eyes previously underwent laser unsuccessfully. INTERVENTION Proton therapy including a total dose of 30 Cobalt-Gray-Equivalent was administered to each eye. MAIN OUTCOME MEASURES Patients were controlled for initial and final best-corrected visual acuity, slit-lamp examination, intraocular pressure, fundus examination, fluorescein angiography, and tumor thickness on B-scan ultrasonography. RESULTS The mean follow-up period was 26 months (range, 9-48 months). Retinal reattachment was obtained in all cases after a mean period of 52 days. The tumor height decreased in all cases. Visual acuity improved to two lines or more in eight eyes (62%) and reached 20/200 or more in nine eyes (69%). No radiation complication was detected during follow-up. CONCLUSIONS Proton radiation seems to be effective and safe in the management of choroidal hemangioma associated with serous retinal detachment. It may be useful when photocoagulation can not be performed.

Neuronal pathways for the propagation of herpes simplex virus type 1 from one retina to the other in a murine model.

Herpetic retinitis in humans is characterized by a high frequency of bilateral localization. In order to determine the possible mechanisms leading to bilateral retinitis, we studied the pathways by which herpes simplex virus type 1 (HSV-1) is propagated from one retina to the other after intravitreal injection in mice. HSV-1 strain SC16 (90 p.f.u.) was injected into the vitreous body of the left eye of BALB/c mice. Animals were sacrificed 1, 2, 3, 4 and 5 days post-inoculation (p.i.). Histological sections were studied by immunochemical staining. Primary retinitis in the inoculated eye (beginning 1 day p.i.) was followed by contralateral retinitis (in the uninoculated eye) starting at 3 days p.i. Infected neurons of central visual pathway nuclei (lateral geniculate nuclei, suprachiasmatic nuclei and pretectal areas) were detected at 4 days p.i. Iris and ciliary body infection was minimal early on, but became extensive thereafter and was accompanied by the infection of connected sympathetic and parasympathetic pathways. The pattern of virus propagation over time suggests that the onset of contralateral retinitis was mediated by local (non-synaptic) transfer in the optic chiasm from infected to uninfected axons of the optic nerves. Later, retinopetal transneuronal propagation of the virus from visual pathways may have contributed to increase the severity of contralateral retinitis.

Systemic adverse effects of topical ocular treatments

Some eyedrops, gels or ointments may cause adverse effects as serious as those observed with systemic therapies. Because of their relatively poor penetration into eye tissue, ophthalmic drugs usually contain high concentrations of their active ingredient. Asking patients about these drugs to prevent interactions is useful when prescribing a new systemic treatment. Conversely, it is advisable to ask about ophthalmic drugs during the etiological investigation of possible iatrogenic effects.

Intraocular inflammation after proton beam irradiation for uveal melanoma

AIM To describe the inflammatory reaction that can occur following proton beam irradiation of uveal melanomas based on a large series of patients and to try to determine the risk factors for this reaction. METHODS Data from a cohort of patients with uveal melanoma treated by proton beam irradiation between 1991 and 1994 were analysed. The presence of inflammation was recorded and evaluated. Kaplan-Meier estimates and statistical analysis of general and tumour related risk factors were performed. RESULTS 28% of patients treated during this period presented with ocular inflammation (median follow up 62 months). Risks factors were essentially tumour related and were correlated with larger lesions (height > 5 mm, diameter > 12 mm, volume > 0.4 cm3). Multivariate analysis identified initial tumour height and irradiation of a large volume of the eye as the two most important risk factors. Ocular inflammation usually consisted of mild anterior uveitis, resolving rapidly after topical steroids and cycloplegics. The incidence of inflammation after proton beam irradiation of melanomas seems higher than previously reported and is related to larger lesions. Evidence of inflammation associated with uveal melanoma has been described and seems to be associated with tumour necrosis (spontaneous or after irradiation). The appearance of transient inflammation during the follow up of these patients may be related to the release of inflammatory cytokines during tumour necrosis. CONCLUSION Inflammation following proton beam irradiation is not unusual. It is correlated with larger initial tumours and may be related to tumour necrosis.

Phacoemulsification combined with silicone oil removal through the posterior capsulorhexis tear.

Purpose To evaluate phacoemulsification combined with silicone oil removal through the posterior capsulorhexis tear. Method The records of 20 patients with cataract after silicone oil repair of retinal detachment with giant retinal tear or complicated by proliferative vitreoretinopathy were reviewed. All eyes underwent phacoemulsification, posterior capsulorhexis, aspiration of silicone oil with an irrigation–aspiration hand piece, and intraocular lens implantation into the capsular bag. Lens calculation was based on the fellow eye. The mean follow-up period after cataract surgery was 15.4 months. Results There were three recurrences of retinal detachment (15%). Transient corneal edema was noted in two eyes. Unpredictable refraction was the main problem, but the myopic refractive error was <4.5 diopters in all cases. Conclusion Cataract extraction combined with silicone oil removal is an effective technique.

Résultats du traitement du mélanome malin de l’uvée par faisceau de protons : 10 ans de recul

Introduction Nous avons etudie les resultats a long terme du traitement par faisceau de protons du melanome malin de l’uvee sur une serie de patients ayant un recul minimum de 10 ans. Patients et methodes Les patients ont ete traites par faisceau de protons entre septembre 1991 et decembre 1992. Ils ont eu un bilan initial comprenant une acuite visuelle, un fond d’œil, une echographie et une biometrie de l’œil, des photographies du fond d’œil et une angiographie ainsi qu’un bilan general comprenant une radiographie pulmonaire et une echographie hepatique. Nous avons delivre une dose de 60 Gray equivalent cobalt en 4 fractions sur 4 jours successifs au centre de protontherapie d’Orsay. Resultats Cent soixante-sept patients ont ete traites avec un recul median de 116 mois. L’âge median etait de 59 ans. Treize tumeurs etaient anterieures a l’equateur, 76 a cheval sur l’equateur et 78 en arriere de l’equateur. Un decollement de retine etait note dans 41 cas ; la papille etait envahie dans 10 cas. Le diametre tumoral median etait de 12 mm et l’epaisseur tumorale mediane de 5,8 mm. L’acuite visuelle initiale moyenne etait de 4/10 e . La survie globale a 10 ans etait de 62,9 %. 72,9 % des deces etaient en relation avec des metastases du melanome. Les facteurs influencant la survie de maniere statistiquement significative en analyse multivariee etaient un diametre tumoral superieur a 12 mm (p = 0,0004) et un âge superieur a 60 ans (p = 0,0001). Le taux de metastases a 10 ans etait de 31 %. Les metastases touchaient le foie dans 97,8 % des cas. Les facteurs de risque en analyse multivariee pour l’apparition de metastases etaient le siege anterieur de la tumeur, un volume superieur a 0,4 cm 3 et la presence d’un decollement retinien initial. Le taux d’enucleation secondaire a 10 ans de 13,2 % etait lie principalement a des complications post therapeutiques notamment le glaucome neovasculaire. Le taux de recidives locales etait de 6 %. 42,1% des patients avaient une acuite visuelle superieure a 1/10 e a 10 ans. La baisse visuelle etait liee principalement a une maculopathie ou a une papillopathie postradique. Conclusion Cette etude confirme les resultats de la litterature concernant le traitement par faisceau de protons a long terme. Cette therapeutique permet un bon controle local de la tumeur, un excellent taux de conservation oculaire et le maintien d’une acuite visuelle utile pour presque la moitie des cas.

A PRELIMINARY COMPARATIVE TREATMENT PLANNING STUDY FOR RADIOTHERAPY OF AGE-RELATED MACULOPATHY

PURPOSE We present a comparative planning of different approaches for external radiotherapy in age-related maculopathies. MATERIALS AND METHODS Calculated dose distributions and dose-volume histograms for (a) bilateral irradiation with 6 MV photons, (b) a single lateral-oblique beam using either photons, electrons or protons and (c) an anterior circular proton beam. RESULTS For lateral photon or electron beams the dose to the lens is usually lower than 10% of the dose to the macula. The entrance doses for bilateral photon beams are about 50% which increase up to 100% at the orbital bone. About 5 mm of optic nerves are irradiated at the maximal dose while the optic chiasma is spared. A single photon beam gives 50% of the dose to the fellow eye. The electron beam spares the fellow eye but gives a rather inhomogeneous dose to the target volume. For a lateral proton beam, 4 mm of optic nerve receives 90% of the dose, the skin dose is at least 70% of the dose to the macula and the lens and the fellow eye are spared. An anterior proton beam gives 90% of the dose to 1 mm of optic nerve and the 50% isodose approaches the periphery of the lens. CONCLUSION Doses to the critical structures can be dramatically diminished for all the techniques by reducing the beam size, but only if very precise set-up techniques are used. Proton beams are an attractive solution, but the impact of such a choice on the use of proton facilities and on the national health system should be carefully evaluated, as well as the risk of radio-induced secondary neoplasias.

Preliminary results with one-year minimum follow-up of the first 146 patients with a uveal melanoma treated with protons at CPO (Orsay)

Summary Proton therapy began at the ‘Centre de Protontherapie d’Orsay’ (CPO) in September 1991. Our treatment protocol and the preliminary results have been presented on the first 146 irradiated patients with one-year minimal follow-up. The subsequent developments have also been mentioned.

An unusual variant of diffuse retinoblastoma in an adult

Case reportA 19-year-old woman was referred to our institutionfor the evaluation of pearls in the anterior chamber ofher left eye in 1987. She had undergone enucleationof the right eye for a retinoblastoma at the age of 22months. Between 1982 and 1987, she was treated forposterior uveitis in the controlateral eye that failed toresolve. Slit-lamp examination of the eye disclosedsmall pearls in the anterior chamber (Figure 1).Retinoblastoma cells were found in aqueous fluidaspirated at anterior chamber paracentesis. Evalua-tion of metastatic dissemination included a chest x-ray, bone marrow aspiration, and cerebrospinal fluidexamination were all negative. The neuronal specificenolase level was markedly elevated at 1 000 units.The patient underwent a course of radiotherapy tothe left eye up to a total dose of 45 Gy. She remaineddisease free for 6 months. Multiple small retinoblas-toma nodules were then discovered throughout theinner retina and also floating around the anteriorchamber. She underwent irradiation with an iodineplaque delivering 40 Gy to the iris.A RB germline mutation was found in exon 20,681insTCTGG, with generation of stop codon,697X. No other cases had been reported in thefamily suggesting a de novo mutation. Three monthslater, the patient relapsed. She refused enucleation,therefore, chemotherapy combining vincristine andcyclophosphamide was administered but this treat-ment failed. She was then enrolled in an immu-notherapy protocol with Interleukin 2 plus interferongamma but again treatment results were negative. Atthis point, the patient refused further treatments anddid not turn up for follow-up. Three years later, shepresented with a massive exophytic intra-orbitaltumor with extra-scleral extension and homolateralpretragal lymph node metastases. A CT scan dis-closed an intra-orbital enhancing mass measuring2 2 cm with anterior, lateral and posterior spread.An extensive work-up revealed no other metastases.The patient was treated with four courses of high-dose ifosfamide (4 g/m

Choriorétinite syphilitique chez l’immunodéprimé: À propos d’un cas

Syphilitic chorioretinitis is a rare manifestation of secondary syphilis. The Authors report a case of a patient tested positive for human immune deficiency virus. A 26-Year-old man presented with a history of suddenly blurred vision in the right eye. Because of a central scotoma, visual acuity was reduced to counting fingers. Slit-lamp examination found one-plus anterior chamber cells and one-plus vitreous cells. Results of ophthalmoscopic examination showed a large yellow lesion in the macular area with a papillar edema and peripheral vasculitis. Serum and cerebrospinal fluid were positive for syphilitic serology. Visual acuity improved to 20/20 after three courses of intravenous ceftriaxone (2g/day for 15 days). The fundus lesion resolved almost completely, resulting in slight pigmentary changes in the macular area. This case report highlights the need for syphilitic serology in cases of uveitis in immunocompromised patients.