Modorati Giulio Maria, Dagan Roi, Mikkelsen Lauge Hjorth, Andreasen Simon, Ferlito Alfio, Bandello Francesco
Department of Ophthalmology, University Vita-Salute, IRCCS San Raffaele, Milan, Italy.
Radiation Oncology, University of Florida Proton Therapy Institute, Jacksonville, Florida, USA.
Ocul Oncol Pathol. 2020 Mar;6(2):115-122. doi: 10.1159/000501971. Epub 2019 Sep 3.
Gamma knife radiosurgery (GKR) has shown promising results in the treatment of intraocular uveal melanoma (UM) in terms of local tumor control. However, GKR is not free from potentially sight-threatening side effects, including cataract, dry eye disease, vitreous hemorrhage, radiation retinopathy (RR), radiation maculopathy (RM), optic neuropathy, and neovascular glaucoma. The aim of this paper is to report our 20-year experience in UM management with GKR focusing on the rate of clinical treatment-induced complications.
Single-center, retrospective, observational study, including all patients with UM treated at the Ocular Oncology and Uveitis Service, in the Department of Ophthalmology of the San Raffaele Scientific Institute, Milan from September 1993 to September 2018. Clinical charts comprised complete ophthalmological examination with measurement of best-corrected visual acuity, slit-lamp biomicroscopy, intraocular pressure measurement, gonioscopy, and indirect ophthalmoscopy at each visit. B-scan ultrasound (Aviso S, 10 MHz probe; Paris, France), optical coherence tomography (Heidelberg Spectralis; Heidelberg Engineering, Heidelberg, Germany), retinography, and fundus fluorescein angiography (standard or ultra-widefield [UWF; California, Optos, Dunfermline, Scotland, UK]) were performed aiding in the diagnosis of complications.
Overall, 194 patients (100 males, 51.6%) were reviewed. The median age at the time of the treatment was 65 years (range 27-89) and all participants were Caucasian. In 185 eyes (95.4%), the tumor was primarily located at the choroid. The median follow-up was 57.6 months; radiation-induced complications were found in 145 eyes (74.7%). Radiation-induced cataract and RR were the most frequent events, with a relative incidence of 41.2 and 34.5%, respectively, followed by neovascular glaucoma (27.3%), optic neuropathy (18.6%), RM (11.4%), vitreous hemorrhage (14.4%), phthisis bulbi (7.7%), hyphema (0.5%), and corneal melting (0.5%). The shorter onset of side effects involved the optic nerve (median 14.9 months) and the macula (median 13.7 months).
Despite modern and advanced strategies introduced to limit GKR side effects, cataract and RR still represent a serious limitation of this treatment. Incidence of RR was higher in our cohort compared to other reports, probably due to increased diagnosis rate permitted by UWF retinal imaging.
伽玛刀放射外科手术（GKR）在眼内葡萄膜黑色素瘤（UM）的局部肿瘤控制方面已显示出有前景的结果。然而，GKR并非没有潜在的威胁视力的副作用，包括白内障、干眼症、玻璃体积血、放射性视网膜病变（RR）、放射性黄斑病变（RM）、视神经病变和新生血管性青光眼。本文的目的是报告我们20年来使用GKR治疗UM的经验，重点关注临床治疗引起的并发症发生率。
单中心、回顾性、观察性研究，纳入1993年9月至2018年9月在米兰圣拉斐尔科学研究所眼科的眼肿瘤与葡萄膜炎科接受治疗的所有UM患者。临床病历包括每次就诊时的完整眼科检查，测量最佳矫正视力、裂隙灯生物显微镜检查、眼压测量、前房角镜检查和间接检眼镜检查。进行B超扫描（Aviso S，10 MHz探头；法国巴黎）、光学相干断层扫描（海德堡Spectralis；德国海德堡工程公司，海德堡）、视网膜造影和眼底荧光血管造影（标准或超广角[UWF；加利福尼亚州，Optos公司，英国邓弗姆林，苏格兰]）以辅助并发症的诊断。
总体而言，共回顾了194例患者（100例男性，占51.6%）。治疗时的中位年龄为65岁（范围27 - 89岁），所有参与者均为白种人。在185只眼（95.4%）中，肿瘤主要位于脉络膜。中位随访时间为57.6个月；145只眼（74.7%）发现了放射诱发的并发症。放射性白内障和RR是最常见的事件，相对发生率分别为41.2%和34.5%，其次是新生血管性青光眼（27.3%）、视神经病变（18.6%）、RM（11.4%）、玻璃体积血（14.4%）、眼球痨（7.7%）、前房积血（0.5%）和角膜溶解（0.5%）。副作用出现较快的累及视神经（中位时间14.9个月）和黄斑（中位时间13.7个月）。
尽管引入了现代先进策略来限制GKR的副作用，但白内障和RR仍然是这种治疗的严重限制。与其他报告相比，我们队列中RR的发生率更高，可能是由于UWF视网膜成像提高了诊断率。
