Roman Dunavoelgyi

Local Tumor Control, Visual Acuity, and Survival After Hypofractionated Stereotactic Photon Radiotherapy of Choroidal Melanoma in 212 Patients Treated Between 1997 and 2007

PURPOSE To evaluate long-term local tumor control, visual acuity, and survival after hypofractionated linear accelerator-based stereotactic photon radiotherapy in patients with choroidal melanoma. METHODS AND MATERIALS Between 1997 and 2007, 212 patients with choroidal melanoma unsuitable for ruthenium-106 brachytherapy or local resection were treated stereotactically at a linear accelerator with 6-MV photon beams at the Medical University of Vienna in five fractions over 7 days. Twenty-four patients received a total dose of 70 Gy (five fractions of 14 Gy), 158 a total dose of 60 Gy (five fractions of 12 Gy) and 30 patients a total dose of 50 Gy (five fractions of 10 Gy) applied on the 80% isodose. Ophthalmologic examinations were performed at baseline and every 3 months in the first 2 years, every 6 months until 5 years, and once a year thereafter until 10 years after radiotherapy. Assessment of visual acuity, routine ophthalmologic examinations, and measurement of tumor base dimension and height using standardized A-scan and B-scan echography were done at each visit. Funduscopy and fluorescein angiography were done when necessary to document tumor response. RESULTS Median tumor height and volume decreased from 4.8 mm and 270.7 mm3 at baseline to 2.6 mm and 86.6 mm3 at the last individual follow-up, respectively (p<0.001, p<0.001). Median visual acuity decreased from 0.55 at baseline to hand motion at the last individual follow-up (p<0.001). Local tumor control was 95.9% after 5 years and 92.6% after 10 years. Thirty-two patients developed metastatic disease, and 22 of these patients died during the follow-up period. CONCLUSION Hypofractionated stereotactic photon radiotherapy with 70 to 50 Gy delivered in five fractions in 7 days is sufficient to achieve excellent local tumor control in patients with malignant melanoma of the choroid. Disease outcome and vision are comparable to those achieved with proton beam radiotherapy. Decreasing the total dose below 60 Gy seems to be possible.

Randomised clinical trial of intravitreal Avastin vs photodynamic therapy and intravitreal triamcinolone: long-term results

PurposeTo compare 1-year functional and anatomic outcomes of intravitreal bevacizumab (IVB) and photodynamic therapy plus intravitreal triamcinolone (PDT+IVTA) combination in patients with neovascular age-related macular degeneration (AMD).MethodsIn this prospective, randomised, controlled clinical trial, 28 patients were included. All patients were randomised 1 : 1 to 0.04 ml/1 mg of IVB or PDT plus same day 0.1 ml/4 mg IVTA (PDT+IVTA). Follow-up examinations were performed in monthly intervals in IVB group and every 3 months in PDT+IVTA group. Main outcomes were change in mean visual acuity (VA), mean central retinal thickness (CRT) and the mean number of treatments.ResultsAt month 12, mean VA improved to a 1.5-line gain in IVB group, and lost three letters in PDT+IVTA group (P=0.02). Mean CRT was reduced from 357 μm at baseline to 244 μm at month 12 in IVB group and from 326 μm to 254 μm, respectively, in PDT+IVTA group (P=0.8). The mean number of treatments was 6.8 in the IVB group vs1.9 in the PDT+IVTA group. No significant local or systemic safety concerns were detected during follow-up time.ConclusionsPatients treated with IVB showed a significant better VA outcome compared with the PDT+IVTA group despite the fact that both modalities showed equal potency in reducing CRT during a 12-month period.

Rapid improvement of radiation‐induced neovascular glaucoma and exudative retinal detachment after a single intravitreal ranibizumab injection

Neovascular glaucoma is a serious complication arising from irradiation of uveal melanoma. Treatment options include panretinal photocoagulation, peripheral retina cryotherapy, photodynamic therapy with verteporfin, triamcinolone injections and surgical removal of the dying tumour mass. Nevertheless, enucleation of the affected eye often is inevitable. The authors describe a case report of a radiation‐induced neovascular glaucoma and exudative retinal detachment caused by malignant melanoma of the uvea that was treated with intravitreal ranibizumab.

Biocompatibility of hydrophilic acrylic, hydrophobic acrylic, and silicone intraocular lenses in eyes with uveitis having cataract surgery: Long-term follow-up.

PURPOSE: To evaluate the long‐term uveal and capsular biocompatibility of 5 intraocular lenses (IOLs) in eyes with uveitic cataract. SETTING: Department of Ophthalmology, Medical University of Vienna, Vienna, Austria. DESIGN: Comparative case series. METHODS: Patients with uveitis of various origin were consecutively recruited for cataract surgery (1998–2006) and received 1 of 3 hydrophilic acrylic IOLs (Hydroview, AcrySof MA60BM, or Injectacryl F3000), a silicone IOL (CeeOn 911), or a hydrophilic acrylic IOL with heparin surface modification (BioVue3). A 7‐year follow‐up was performed in the Hydroview, AcrySof, and CeeOn groups. Visual acuity, anterior chamber flare measurements, specular microscopy, biomicroscopy, and fundoscopy were performed postoperatively at 6 months and 1, 2, and 3 years. RESULTS: The study enrolled 136 eyes of 115 patients. There were no significant differences in anterior chamber flare results between the 5 groups. The Hydroview group had the highest grade and the CeeOn IOL and AcrySof groups had the lowest grade of posterior capsule opacification. The BioVue3 and Injectacryl IOLs had good uveal biocompatibility. Patients in all groups had better visual acuity postoperatively. CONCLUSIONS: Overall, patients with uveitis benefited from cataract surgery. The long‐term results indicate that all sharp‐edged hydrophilic and hydrophobic IOLs performed well in eyes with uveitis. Higher uveal biocompatibility was achieved with the modern hydrophilic acrylic IOLs than with the hydrophobic acrylic IOL. Modern hydrophilic acrylic IOLs seem to be a good option in these cases. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Radiogenic Side Effects After Hypofractionated Stereotactic Photon Radiotherapy of Choroidal Melanoma in 212 Patients Treated Between 1997 and 2007

PURPOSE To evaluate side effects of hypofractionated stereotactic photon radiotherapy for patients with choroidal melanoma. PATIENTS AND METHODS Two hundred and twelve patients with choroidal melanoma unsuitable for ruthenium-106 brachytherapy or local resection were treated stereotactically at the Medical University of Vienna between 1997 and 2007 with a Linac with 6-MV photon beams in five fractions with 10, 12, or 14 Gy per fraction. Examinations for radiogenic side effects were performed at baseline and every 3 months in the first 2 years, then every 6 months until 5 years and then once a year thereafter until 10 years after radiotherapy. Adverse side effects were assessed using slit-lamp examination, funduscopy, gonioscopy, tonometry, and, if necessary, fundus photography and fluorescein angiography. Evaluations of incidence of side effects are based on an actuarial analysis. RESULTS One hundred and eighty-nine (89.2%) and 168 (79.2%) of the tumors were within 3 mm of the macula and the optic disc, respectively. The five most common radiotherapy side effects were retinopathy and optic neuropathy (114 cases and 107 cases, respectively), cataract development (87 cases), neovascular glaucoma (46 cases), and corneal epithelium defects (41 cases). In total, 33.6%, 38.5%, 51.2%, 75.5%, and 77.6% of the patients were free of any radiation retinopathy, optic neuropathy, cataract, neovascular glaucoma, or corneal epithelium defects 5 years after radiotherapy, respectively. CONCLUSION In centrally located choroidal melanoma hypofractionated stereotactic photon radiotherapy shows a low to moderate rate of adverse long-term side effects comparable with those after proton beam radiotherapy. Future fractionation schemes should seek to further reduce adverse side effects rate while maintaining excellent local tumor control.

Hypofractionated stereotactic photon radiotherapy of posteriorly located choroidal melanoma with five fractions at ten Gy – Clinical results after six years of experience

PURPOSE To evaluate long-term safety and efficacy of hypofractionated stereotactic photon radiotherapy with 5 five fractions at 10 Gy each in patients with centrally located choroidal melanoma. MATERIALS AND METHODS Ninety-one patients with centrally located choroidal melanoma were treated stereotactically at a linear accelerator with 6 MV photon beams with 5 fractions at 10 Gy each. Examinations were performed at baseline and every 3 months in the first 2 years, then every 6 months until 5 years and yearly thereafter. Median follow-up was 37.8 months (IQR 19.2-49.9). They included visual acuity assessment, routine ophthalmological examinations with fundoscopy, echography for measurement of tumor dimensions, medical examinations and, if necessary, fluorescein angiography. RESULTS Initial tumor base diameters, height and volume were 11.20mm (IQR 9.10-13.70), 9.80 mm (IQR 7.80-11.70), 4.53 mm (IQR 3.33-6.43) and 253.8mm(3) (IQR 127.5-477.0). Local tumor control and eye retention rates were 97.7% and 86.4% after 5 years, respectively. Eight patients developed metastatic disease and 3 of them died due to metastatic disease during the follow-up period. Median visual acuity decreased from 0.67 initially to 0.05 at the last individual follow-up (p<0.001). The most common toxicities (any grade) were radiation retinopathy (n=39), optic neuropathy (n=32), radiogenic cataract (n=21), neovascular glaucoma (n=15) and dry eye syndrome (n=10). The 5 year probabilities to remain free of these side effects (any grade) were 26.0%, 45.4%, 55.4%, 72.6% and 80.5%, respectively. The most important prognostic factors for toxicities were the largest tumor base diameter, tumor height and tumor distance to the optic disk. CONCLUSION Hypofractionated stereotactic photon radiotherapy with a total dose of 50 Gy delivered in 5 fractions is a highly effective treatment option in patients with centrally located choroidal melanoma and has a moderate toxicity profile.

Thirty-month follow-up after intravitreal bevacizumab in progressive idiopathic macular telangiectasia type 2

AimThe aim of this study is to evaluate the long-term efficacy of intravitreal bevacizumab (IVB) for eyes with non-proliferative idiopathic macular telangiectasia type 2 (IMT2) and acute vision loss.MethodsIn this interventional case series, treatment-naive eyes of 13 consecutive patients with IMT2 were included. Eyes with a recent onset of visual loss were treated with 0.04 ml IVB (n=7). Fellow eyes and eyes of patients without disease progression served as control group (CG) (n=12). Follow-up examinations included ophthalmoscopy, best-corrected visual acuity (BCVA), optical coherence tomography, and fluorescein angiography (FA).ResultsMean follow-up time was 32±5.7 months in the treatment group (TG) (n=7) vs 29±8.8 months in the CG (n=16). Mean BCVA increased from logMAR 0.47±0.32 at baseline to logMAR 0.33±0.31 (P=0.21) at the last visit in the TG and decreased from logMAR 0.25±0.39 to logMAR 0.30±0.40 in the CG (P=0.17). All patients in the TG showed stabilisation or improvement in vision in Snellen lines in contrast to the CG (χ2-test P=0.04). Patients received on average 2.3±1.3 IVB injections. Mean central millimetre thickness in TG and CG was 260±83 and 201±32 μm at baseline vs 237±69 and 199±29 μm at the last visit, respectively (P=0.23 and 0.77). FA revealed a significant decrease of the juxtafoveal staining size at month 3 (P= 0.004) and a slight reduction at the last visit (P= 0.11) in the TG.ConclusionDespite an overall moderate effect of IVB treatment, individual patients experience a marked functional and morphological long-term benefit.

Comparison of retinal thickness values and segmentation performance of different OCT devices in acute branch retinal vein occlusion.

PurposeTo compare retinal thickness (RT) measurement and segmentation performance of time domain (TD, Stratus) and spectral domain (SD) optical coherence tomography (OCT) devices (Cirrus, Spectralis) for imaging macular oedema (ME) secondary to branch retinal vein occlusion (BRVO).MethodsIn this study, 20 eyes of 20 consecutive patients with acute BRVO were included. A total of 18 unaffected fellow eyes served as control group. RT measurement was analysed in the five inner fields of the early-treatment diabetic retinopathy grid, and proportional segmentation errors were evaluated.ResultsCentral millimetre thickness (CMT) showed a mean difference of −64, −74, and −18 μm (P<0.001) in the control group and −31 μm (P=0.107), −92 μm (P<0.001), and −105 μm (P=0.016) in the BRVO group, between Stratus and Cirrus, between Stratus and Spectralis, and between Cirrus and Spectralis, respectively. Mean RT showed the highest variability between different devices in the area most intensively affected by BRVO-related ME. In eyes with BRVO, 14.6% of Spectralis, 20% of Stratus, and 36.6% of Cirrus scans demonstrated moderate and severe segmentation errors.ConclusionRT measurement in eyes with BRVO, by TD and SD OCT, is compromised by a significant rate of segmentation errors. Deviations are most pronounced in the areas most severely affected by ME.

Evaluation of anterior-segment inflammation and retinal thickness change following cataract surgery

Purpose:  To investigate the physiological retinal response to uneventful cataract surgery using conventional time‐domain (TD‐OCT) and current spectral‐domain optical coherence tomography (SD‐OCT) in combination with an assessment of the anterior chamber inflammatory reaction by laser flare/cell meter (LCFM).

Response of retinal sensitivity to ranibizumab treatment of macular edema after acute branch retinal vein occlusion.

Purpose: To evaluate microperimetry changes in patients with acute macular edema secondary to branch retinal vein occlusion during a follow-up period of 12 months with intravitreal ranibizumab treatment (Lucentis; Novartis). Methods: Patients with macular edema secondary to branch retinal vein occlusion received an intravitreous injection of 0.5 mg of ranibizumab (0.05 mL). Best-corrected visual acuity, Spectralis OCT (Heidelberg Engineering), and color fundus photography were performed at monthly intervals over a follow-up period of 1 year. Macular function was documented by microperimetry (Nidek, MP-1) at baseline, 3, and 12 months. Results: Data of 20 patients without lack of microperimetry results were included to the statistical analyses. The size of the area of absolute scotoma was reduced from 16% at baseline to 11.7% at Month 3 and remained stable in the entire study duration (P > 0.05). Mean differential light threshold improved significantly under therapy from 9.47 dB at baseline to 12.53 dB at 12 months (P < 0.001). Best-corrected visual acuity correlated significantly with central millimeter thickness and mean retinal sensitivity at baseline and at 12-month follow-up visits. Conclusion: In addition to anatomical restoration and increased visual acuity, intravitreal ranibizumab also improved the central macular function in patients with acute macular edema after branch retinal vein occlusion.