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Mary E Aronow, Jay Wang, Anne Marie Lane, Monica Oxenreiter, Evangelos S Gragoudas, Ivana Kim; Macular perfusion status in eyes with choroidal melanoma treated with prophylactic ranibizumab after proton beam irradiation. Invest. Ophthalmol. Vis. Sci. 2018;59(9):4301.
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The role of anti-vascular endothelial growth factor in preventing radiation retinopathy is evolving. In this prospective study, we measured the extent of macular non-perfusion (NP) in patients with small posterior choroidal melanoma treated with proton beam irradiation (PBI) followed by serial intravitreal injection of ranibizumab.
We analyzed 22 patients with small choroidal melanoma within 2 disc diameters of the disc or fovea who completed a prospective clinical trial of ranibizumab to prevent radiation complications. Tumors had a largest basal diameter (LBD) < 15 mm and height < 5 mm. Patients received PBI (50 or 70 Gy, 5 fractions) followed by ranibizumab (0.5 mg or 1.0 mg) over a 24 month period. Intravitreal ranibizumab was given at the time of tantalum marker placement (baseline), and every 2 months until month 22 (12 injections total). Fluorescein angiograms (venous phase) were analyzed at baseline, 12, and 24 months using ImageJ to determine the total area of macular NP. This research was approved by the institutional review board of the Massachusetts Eye and Ear.
In this series (12 males, 10 females), median age was 59 years (range: 41 - 84 years). Median tumor LBD was 11.0 mm (range: 6.5 - 15.0 mm) and median tumor height was 2.5 mm (range: 1.5 - 4.5 mm). The mean tumor distances to the fovea and disc were 2.0 mm and 2.6 mm, respectively. The average baseline area of macular NP was 0.434 mm2 (95% CI: 0.335 - 0.533 mm2). This increased to 0.999 mm2 (95% CI: 0.570 - 1.428 mm2) and to 2.934 mm2 (95% CI: 1.717 - 4.151 mm2) at 12 and 24 months, respectively. Overall, there was a significant increase in the mean area of NP of 2.500 mm2 at 24 months compared to baseline (p < 0.0001). Tumors closer to the fovea (< 3 mm), had a greater mean area of macular NP at 24 months (4.084 mm2, 95% CI: 0.996 -7.401) compared to those > 3 mm (0.876 mm2, CI: 0.296-1.487) from the fovea (p=0.012). Tumors < 3 mm from the fovea also had a greater median change in macular NP (2.661 mm2, SD +/- 2.989), compared to those > 3 mm away (0.360 mm2, SD +/- 0.512) at 24 months (p=0.003). Average VA was 20/26, 20/28, and 20/30 at baseline, 12, and 24 months.
Despite regular treatment with ranibizumab, macular NP increased over the course of 24 months. However, visual acuity remained excellent, and may be the result of adjuvant ranibizumab.
This is an abstract that was submitted for the 2018 ARVO Annual Meeting, held in Honolulu, Hawaii, April 29 - May 3, 2018.
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