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Kimberly J Chin, Paul T Finger, Ekaterina A Semenova, Sonali Nagendran; Long-term Experience with Intravitreal Anti-VEGF Therapy for Radiation Retinopathy. Invest. Ophthalmol. Vis. Sci. 2014;55(13):5095.
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To present a subgroup long-term analysis of patients with uveal melanoma treated with intravitreal anti-VEGF therapy using escalation strategies for radiation retinopathy (RR).
At a single ophthalmic oncology center, 127 patients underwent intravitreal anti-VEGF injections for RR over 7 years. A subgroup analysis was performed on 29 patients who met the following inclusion criteria: diagnosis of uveal melanoma and subsequent RR; pre-anti-VEGF acuity of 20/200 or better; follow-up of at least 6 months and at least 4 intravitreal injections; initial and follow-up OCT central foveal thicknesses (CFT) on a single spectral domain device. In that treatment was initiated at the first sign of RR and/or edema of the macula or optic nerve, patients treated for longstanding RR were not included. Our treatment protocol has been refined over 7 years as follows: patients initially received 1.25 mg bevacizumab at 4 week intervals, increasing to 5-8 weeks if improved. If two successive exams demonstrated worsening of RR (by comparative ophthalmoscopy, photography, fluorescein angiography) or increased CFT, patients were first shortened to a 4-week treatment interval, followed by increased dose to 2.0 mg, 2.5 mg, and lastly 3.0 mg. Best corrected visual acuity (ETDRS), fundus photography, and CFT was recorded at each visit; fluorescein angiography at 6 month intervals.
Our subgroup analysis of 29 patients revealed a mean age of 65 years with mean follow-up 22 months (range 9-48). By AJCC criteria, there were 19 T1, 7 T2, and 3 T3-sized uveal melanomas. Patients were treated with palladium-103 (n=27) or iodine-125 (n=2) to a mean foveal and optic nerve dose of 56 Gy and 43 Gy, respectively. Mean initial and final acuity (logMar) was 0.1 (20/25); acuity did not significantly change at any interval (p>0.05). There was a general trend towards increased dose: at 1 year 68% (19/28) and at 2 years, 42% (8/19) were still on baseline dose. CFT significantly improved at 3 and 12 months (both p=0.04), but not at the longer follow-up intervals (>2 years). This may be due to the small number of patients at these intervals.
Intravitreal anti-VEGF dose escalation strategies may offer patients additional time to forestall vision loss. Long-term stability of visual acuity was achieved despite the progressive, natural course of radiation retinopathy which ultimately leads to subsequent severe vision loss.
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