Systemic and ocular follow-up after conservative management of an intraocular tumor

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1 Systemic and ocular follow-up after conservative management of an intraocular tumor 7 th Thessaloniki international Vitreo Retinal Summer School, L. Zografos MD Jules Gonin Eye Hospital

2 Periodic observation following conservative management of uveal melanomas Periodic general check up examination Observation of local tumor control Management of ocular surface and anterior segment complications Prevention and treatment of major complications Neovascular glaucoma Vitreous hemorrage Toxic tumor syndrom Investigation and management of irradiation induce maculopathy

3 Periodic general check up examination Liver US or Liver CT-Scan Liver enzymes SGOT SGPT Gamma GT Alkaline phosphatase Proton beam irradiation 5 years 2x / year 15 years 1x / year

4 Observation of local tumor control Proton beam irradiation 3 years 2x / year 7 years 1x / year 7-15 years 1x / 2 years

5 Observation of local tumor control 106 Ru 106 Rh Brachytherapy Centered / Eccentric

6 100 Ru 106 Rh Brachytherapy Recurrent uveal melanoma 1 year following excentric 106 Ru/ 106 Rh Brachytherapy

7 Observation of local tumor control Obs. per. 6 m. Obs. per. 3 y. Proton beam irradiation

8 Observation of local tumor control Obs. per. 1 y. Obs. per. 6 y.

9 F. 66 ans Choroidal melanoma Proton beam irradiation Obs period 9 years Vis ac 0.1 Irradiation induce maculopathy Peripheral retinal ischemia

10 Obs per 17 years Vis ac 0.03 Extraocular extension Enucleation and irradiation of the orbit

11 Periodic observation following conservative management of uveal melanomas Periodic general check up examination Observation of local tumor control Management and treatment of ocular surface and anterior segment complications Prevention of major complications Neovascular glaucoma Vitreous hemorrage Toxic tumor syndrom Investigation and management of irradiation induce maculopathy

12 Closure of lacrymal puncta Madarosis Skin atrophy Telangiectasia Lesions of eyelids

13 Lesions of eyelids : Madarosis

14 Lesions of the conjonctiva Granulomas Telangiectasia

15 Lesions of the conjonctiva Telangiectasia Laser coagulation

16 Secondary and complicated cataract 1. Sector cortical lens opacities

17 Invasion of the ciliary body Advanced cortical and nuclear cataract

18 Ciliary body melanoma proton beam irradiation H=5.1mm Obs. p. 3y. H=3.1mm

19 Obs. p. 8y. H=2.51mm

20 Advanced cortical and nuclear cataract

21 Advanced cortical and nuclear cataract 1y. after cataract surgery IOL dislocation

22 2. Cataract surgery following irradiation of posterior uveal melanoma Phimosis of anterior capsula

23 Glaucoma following conservative management of uveal melanomas 1. Invasion of the anterior chamber angle

24 Diffuse iris and ciliary body melanoma

25 Lamellar Limbus Autografts Obs. period 2 months N. of cases 82 Survival 95% Local tumor control 100% Obs. period 2 years Eye retention prob. 95%

26 Diffuse iris and ciliary body melanoma Treatment of secondary glaucoma IOP 18 mm Hg

27 Cilliary body melanoma. Proton beam irradiation Obs. p. 3 y. IOP 45mm HG Secondary invasion of anterior chamber angle

28 2. Iris neovascularisation and neovascular glaucoma Anti-VEGF treatment Laser coagulation IOP <20mm Hg 84%

29 Periodic observation following conservative management of uveal melanomas Periodic general check up examination Observation of local tumor control Management of ocular surface and anterior segment complications Prevention and treatment of major complications Neovascular glaucoma Vitreous hemorrage Toxic tumor syndrom Investigation and management of irradiation induce maculopathy

30 Prevention of major complications Neovascular glaucoma Anti-VEGF treatment 6 months 1 inj/2 m. 1 inj/3 m. Laser coagulation of ischemic retina

31 Prophylactic use of anti-vegfs to avoid anterior segment neovascularization following proton beam for uveal melanoma Rubeosis rate AJO 2014, 158,

32 Proton beam irradiation + Anti-VEGF Initial 150 FA Obs. period 1 year

33 Prevention of neovascular glaucoma and vitreous hemorrage Panoramic FA (150 ) Obs. per. 18 months

34 Prevention of neovascular glaucoma and vitreous hemorrage Panoramic FA (150 ) Obs. per. 18 months

35 Prevention of neovascular glaucoma and vitreous hemorrage Panoramic FA (150 ) Obs. per. 24 months

36 Prevention of major complications Toxic tumor syndrom type I Disruption of outer B/R barrier Disruption of inner B/R barrier

37 Toxic tumor syndrome type I Total SRD. 6 months Rupture RPE 10 c. 50% Control group 2 c. 4% iv Triamcinolone 0 c. 0%

38 Proton beam irradiation Triamcinolone + anti VEGF Obs. period! 6 months Vis. Ac. 0.5

39 Toxic tumor syndrome type II Proton beam irradiation + Transvitreal tumor excision

40 Toxic tumor syndrome Type II Proton beam irradiation + Transvitreal tumor excision Vis. Ac Vis. Ac. 0.2

41 Irradiation induced maculopathy Risk factors Irrad. Dose > 20Gy proton beam Irrad. Dose > 30Gy brachytherapy Diabete / high blood pressure

42 Irradiation induced maculopathy N. of cases 132 Disruption of inner B/R barrier Disruption of outer B/R barrier Vaso-occlusif microangiopathy

43 Irradiation induced maculopathy Obs. p. 6 m. Density 40% - 36% Surface 0.661mm mm 2

44 Irradiation induced maculopathy N. of cases 162 FA / OCT A / OCT / OCT en facecomparative study Deep vascular network interrupted Vis. Ac %

45 Deep capillary plexus interrupted Observation period > 6 months N. of cases 54 Absence of previous IV anti-vegf Anti-VEGF 1inj./2months Various protocols N. of cases 28c. 26c. Non flow area 0.570mm mm 2 Mean flow density 39.2% 40.2% CME on OCT en face Abs/minimale 35% 28% Limited 35% 35% Extended 30% 37%

46 IV Anti-VEGF Obs. period = 6 months 1IV / 2 months Vis. Ac. + or stable 26c. / 28 cases M. 68y. 2y. Post irrad. 3x Bevacizumab Vis. Ac Vis. Ac. 0.6

Ac. : loose! 0.1 20c. / 26 c. M. 58y. 1.

47 IV Anti-VEGF Obs. period = 6 months Various protocols Vis. Ac. : loose! c. / 26 c. M. 58y. 1.5y. Post irrad. Obs. period 6 m Vis. Ac. 0.5 Vis. Ac. 0.16

48 Irradiation induce maculopathy Obs. period 1 year 15 cases Mean visual acquity Protocol + Protocol - Anti-VEGF treatment

49 Anti-VEGF 1IV / 2 months Obs. period 6 months Mean non flow area 0.556mm 2 Mean non flow area 0.675mm 2 Variation non flow area 0.099mm 2 / 17%

50 Anti-VEGF various regiments Obs. period 6 months Mean non flow area 0.483mm 2 Mean non flow area 0.950mm 2 Variation non flow area 0.444mm 2 / 89%

51 RANIBIZUMAB FOR THE PREVENTION OF RADIATION COMPLICATIONS IN PATIENTS TREATED WITH PROTON BEAM IRRADIATION FOR CHOROIDAL MELANOMA By Ivana K. Kim, MD, Anne Marie Lane, MPH, Purva Jain, MPH, Caroline Awh, BS, Evangelos S. Gragoudas, MD Trans Am Ophthalmol Soc / 114 / 2016 Cumulative rates of visual acuity retention of!20/200 for overall study cohort. The difference between the curves is statistically significant, P<.001 (Log-rank test). Cumulative rates of visual acuity retention of!20/40 for small/medium tumor group. The difference between the curves is not statistically significant, P=.11 (Log-rank test).

F. 42y. 2y. Post irrad. 3x Ranibizumab 11.2015 Vis.Ac. 0.

52 F. 42y. 2y. Post irrad. 3x Ranibizumab Vis.Ac. 0.9 Whole en face density 35.7 % Whole en face density 47.5 % Vis. Ac. 1.0

Vitreoretinal surgical management In ocular oncology

www.ophtalmique.ch Vitreoretinal surgical management In ocular oncology Pournaras Jean-Antoine C Vitreoretinal Surgery Unit 1. Surgical resection after proton beam therapy 2. Ocular Biopsy 3. RD in advanced