Proton radiation therapy for medium and large choroidal melanoma: preservation of the eye and its functionality.

PURPOSE: Evaluation of efficacy and safety of proton radiation therapy (PRT) for medium- and large-size choroidal melanoma with focus on preservation of the eye and its function. METHODS: Retrospective review of 78 patients with 60 medium and 18 large-size choroidal melanomas at a median follow-up of 34 months. RESULTS: The 5-year data for local control, metastases-free survival, and disease-specific survival were estimated to be 90.5 +/- 3.7%, 76.2 +/- 6.7%, and 75.6 +/- 7.6%, respectively. Eye preservation was achieved in 75.3% of patients, with useful (better than 20/200) visual acuity (VA) in 49.1% of surviving patients. Both local failure and complications led to enucleation. Prognosticators were tumor close to the optic disc (p = 0.003), large tumors involving the ciliary body (p = 0.041), and local failure (p < 0.001). Prognostic factors for VA following PRT were initial VA (p = 0.001), doses to optic disc (p = 0.001) and fovea (p = 0.022) higher than 35 CGE (Cobalt Gray equivalent), tumor close to the optic disc (p = 0.034), and retinal detachment (p < 0.001). Tumor basis diameter was significantly related to metastases free survival (p = 0.02), overall survival (p = 0.033), and disease specific survival (p = 0.017), but did not impair local tumor control, rate of enucleation, and VA. CONCLUSION: The present data suggest that PRT is an effective and safe treatment for medium and large size choroidal melanoma. PRT can preserve the eye and its function in a reasonable percentage of patients. Further evaluation in controlled clinical trials comparing PRT to plaque radiotherapy and enucleation is required.

Proton beam irradiation of subfoveal choroidal neovascularisation in age-related macular degeneration.

PURPOSE: To assess the safety and potential toxicity of proton beam radiation in the treatment of subfoveal choroidal neovascular membrane (CNVM) due to age-related manner degeneration (ARMD) in a prospective, non-randomised study. METHODS: Forty-eight eyes of 46 consecutive patients with subfoveal CNVM due to ARMD, not amenable to laser photocoagulation, were treated prospectively with a single proton beam exposure. Two dose regimens were evaluated: 8 CGE (Cobalt Gray Equivalent) and 14 CGE. Patients were followed for an average of 22.1 months after proton beam treatment. RESULTS: At the 12 month follow-up, 44% of eyes in the 8 CGE group and 75% of the eyes in the 14 CGE group had stabilized or improved visual acuity. Complex size in the 8 CGE group as measured on standard fluorescein angiography (FA), decreased or had no change initially but showed less effect over time, while the eyes treated with 14 CGE maintained decreased leakage over the follow-up period of 12 months. However, 11 eyes in the 14 CGE group experienced radiation retinopathy, with the onset between 3 and 30 months. Seven of these 11 eyes have demonstrated some visual loss but only 1 eye developed severe visual loss at 15 months after proton treatment. CONCLUSIONS: To date, 14 CGE has suggested a favourable influence on visual function and growth inhibition of CNVM. Proton beam irradiation appears to inhibit CNVM growth. The 14 CGE dose regimen appears to have a longer effect of CNVM growth than does 8 CGE, with overall stabilisation of visual function and growth inhibition. Radiation retinopathy has developed over time, but severe visual loss has been limited. On the basis of the incidence of radiation retinopathy, adjustments in the total radiation dosage and/or fractionation of the dosage should be considered.

Phase I/II study of proton beam irradiation for the treatment of subfoveal choroidal neovascularization in age-related macular degeneration: treatment techniques and preliminary results.

PURPOSE: Age-related macular degeneration is the prevalent etiology of subfoveal choroidal neovascularization (CNV). The only effective treatment is laser photocoagulation, which is associated with decreased visual acuity following treatment in most patients. This study assessed both the response of subfoveal CNV to proton beam irradiation and treatment-related morbidity. We evaluated preliminary results in patients treated with an initial dose of 8 Cobalt Gray Equivalents (CGE) using a relative biological effectiveness (RBE) of 1.1. METHODS AND MATERIALS: Twenty-one patients with subfoveal CNV received proton irradiation to the central macula with a single fraction of 8 CGE; 19 were eligible for evaluation. Treatment-related morbidity was based on Radiation Therapy Oncology Group (RTOG) criteria; response was evaluated by Macular Photocoagulation Study (MPS) guidelines. Fluorescein angiography was performed; visual acuity, contrast sensitivity, and reading speed were measured at study entry and at 3-month intervals after treatment. Follow-up ranged from 6 to 15 months. RESULTS: No measurable treatment-related morbidity was seen during or after treatment. Of 19 patients evaluated at 6 months, fluorescein angiography demonstrated treatment response in 10 (53%); 14 (74%) patients had improved or stable visual acuity. With a mean follow-up of 11.6 months, 11 (58%) patients have demonstrated improved or stable visual acuity. CONCLUSION: A macular dose of 8 CGE yielded no measurable treatment morbidity in patients studied. Fluorescein angiography demonstrated that regressed or stabilized lesions were associated with improved visual acuity as compared with MPS results. In the next phase, a dose of 14 CGE in a single fraction will be used to further define the optimal dose fractionation schedule.

Pigmented tumor and acute visual loss.

A 22-year-old man presents with a history of blurring of vision in his right eye. Ophthalmologic examination reveals a pigmented mass obscuring his optic disc. Two weeks later the patient experienced the apoplectic onset of visual loss to light perception. Discussions center around the presumed diagnosis of melanocytoma of the optic nerve.

Interphotoreceptor retinoid-binding protein levels in subretinal fluid from rhegmatogenous retinal detachment and retinopathy of prematurity.

Interphotoreceptor retinoid-binding protein (IRBP) has been detected qualitatively in subretinal fluid associated with rhegmatogenous retinal detachments. We have used a quantitative enzyme-linked immunosorbent assay to determine the IRBP concentrations in 24 fluid specimens collected at retinal reattachment surgery from 22 patients, and from 17 patients who underwent surgery for retinopathy of prematurity with traction detachment. We observed a wide range of concentrations (1 to 176 micrograms of IRBP per milligram of protein). Higher concentrations were found only in fluid from the more recent rhegmatogenous detachments. The lowest concentrations were detected among fluids drained from under rhegmatogenous detachments ranging from five days' to one year's duration. The IRBP concentration in subretinal fluid showed no correlation with visual outcome and may be influenced by IRBP turnover in the vitreous cavity. Most strikingly, none of the 17 samples from patients with retinopathy of prematurity contained detectable amounts of IRBP.

Grid photocoagulation for macular edema in patients with retinitis pigmentosa.

We performed a pilot study of grid laser photocoagulation in 16 patients with fluorescein angiographically demonstrable macular edema associated with retinitis pigmentosa. Six of the treated eyes showed a positive response, while none of the fellow untreated eyes did. Seven of the untreated eyes lost one or more lines of vision, while none of the treated eyes did. Overall, 13 of 16 eyes showed decreased dye accumulation in the macula after treatment. In some eyes, the area showing reduced dye accumulation was more extensive than the area that received treatment directly.

Thrombin infusion to control bleeding during vitrectomy for stage V retinopathy of prematurity.

We prospectively studied 36 consecutive premature infants with the diagnosis of retinopathy of prematurity stage V with total traction retinal detachment who underwent lensectomy/vitrectomy and epiretinal membrane delamination. The first 26 patients underwent vitrectomy using thrombin mixed with Balanced Salt Solution Plus at a concentration of 100 U/mL and the remaining ten patients had pure Balanced Salt Solution Plus used. Intraoperative and postoperative bleeding were monitored. The overall intraoperative bleeding rate was 92% (33/36). Intraoperative bleeding (19% vs 80%) and bleeding at the time of wound closure (4% vs 30%) were both significantly reduced in the thrombin vs no thrombin group.

Surgical instrumentation cart.

We describe the design of a surgical equipment/instrumentation cart that provides accessibility, mobility, convenience, conservation of floor space, and efficient use of vertical air space. This multiple-shelf cart allows organization and coordination of multiple pieces of equipment. The attached working shelves replace the multiple Mayo stands and free up needed floor space. This cart provides for easy storage and unnecessary movement of equipment and potential damage. The power strips on the rear of the cart eliminate the multiple electrical cords and potential injury to operating personnel and equipment malfunction.