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Kelly Bui, Mark Dikopf, Joelle Hallak, Daniel Kiernan, Clement Chow, William Mieler; Treatment of Radiation Maculopathy with Bevacizumab versus Alternating Bevacizumab and Intravitreal Triamcinolone. Invest. Ophthalmol. Vis. Sci. 2013;54(15):3841.
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© ARVO (1962-2015); The Authors (2016-present)
Radiation maculopathy (RM) is the most common cause of severe vision loss following radiotherapy for uveal melanoma. To date, no proven therapy for RM exists. This study compares the treatment efficacy of bevacizumab to alternating therapy with bevacizumab and intravitreal triamcinolone (IVTA).
This was a retrospective case series of patients who underwent I-125 brachytherapy for uveal melanoma and were treated for RM by one surgeon, WFM, from February 2009 to May 2012. Radiation maculopathy was defined as macular edema with associated exudation and capillary bed disruption. Outcome measures were changes in logMar visual acuity (VA) and central foveal thickness (CFT) between bevacizumab group and IVTA group on a monthly basis and between monotherapy group (bevacizumab) and alternating therapy group (bevacizumab and IVTA) at 6 months.
Forty-eight patients underwent I-125 brachytherapy and 5 developed RM. Four additional patients were referred to WFM for treatment of RM (total N=9). Five patients received monotherapy and 4 received alternating therapy after failing an initial bevacizumab monotherapy trial. The mean age was 63 years (39-79); all were Caucasians. Average tumor basal diameter was 10.6mm; height 5mm. Mean apex dose was 88.6 Gray. Patients developed RM at a mean of 21 months following brachytherapy. The mean change in VA was 0.12 logMar in both the bevacizumab and IVTA groups (p=0.49); the mean reduction in CFT was 68 microns in the bevacizumab group compared to 200 microns in the IVTA group (p=0.048). At 6 months, the monotherapy group had a 0.34 logMar change in VA compared to 0.067 in the alternating therapy group (p=0.17). Mean reduction in CFT was 174 microns in the monotherapy group compared to 151 microns in the alternating therapy group (p=0.38). Adverse events included increased intraocular pressure controlled on topical glaucoma agents and posterior subcapsular cataracts.
The use of IVTA resulted in a statistically significant reduction in CFT without corresponding change in VA. Alternating therapy did not lead to statistically significant improvement in VA or CFT compared to monotherapy. However, the results are confounded by a selection bias as patients in the alternating therapy group had failed initial bevacizumab monotherapy. Alternating bevacizumab and IVTA may be beneficial in recalcitrant cases of RM.
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