Intravitreal triamcinolone acetonide for acute radiation papillopathy

To evaluate intravitreal triamcinolone acetonide for patients with visually symptomatic acute radiation-induced papillopathy.

In a prospective, nonrandomized, single-center case series, intravitreal triamcinolone acetonide (4 mg/0.1 mL) was injected through the pars plana using sterile technique in 9 patients with radiation papillopathy after plaque radiotherapy for choroidal melanoma. Status of radiation papillopathy and final visual acuity were the main outcome measures.

At the time of diagnosis of the choroidal melanoma, visual acuity was 20/20 to 20/40 (n = 6), 20/60 (n = 2), and 20/100 (n = 1). The mean radiation dose to the optic disk was 6,175 cGy (median, 5,994 cGy; range, 3,571-12,760 cGy). Radiation papillopathy developed a mean of 18 months (median, 17 months; range, 6-33 months) after plaque radiotherapy. In all cases, the choroidal melanoma was regressed, and there was no retinal detachment or neovascularization of the retina, optic disk, or iris. Concomitant radiation maculopathy was found in 8 eyes manifesting as macular edema (n = 8), intraretinal dot hemorrhages (n = 6), intraretinal exudation (n = 6), or nerve fiber layer infarction (n = 3). The radiation papillopathy findings included optic disk hyperemia (n = 9), edema (n = 9), and circumpapillary hemorrhage (n = 8). At the time of diagnosis of radiation papillopathy, visual acuity was 20/70 (n = 1), 20/100 (n = 4), 20/200 (n = 1), and counting fingers (n = 3). At 1 week after injection of triamcinolone acetonide, visual acuity improvement was found in seven patients, and resolution of optic disk hyperemia and edema was noted for four and three patients, respectively. At a mean follow-up of 11 months (median, 9 months; range, 6-19 months), visual acuity was stable or improved in 7 patients, and resolution of optic disk hyperemia and edema was found in all 9 patients. The mean time to improvement in visual acuity by > or =2 lines was 3 weeks (median, 1 week; range, 1-12 weeks). The mean time to complete resolution of radiation papillopathy was 4 months. The two patients with worse final visual acuity also had macular hole and central retinal vein obstruction. The only complication of this therapy was possibly related cataract in three patients.

During short-term follow-up, acute radiation-induced papillopathy appears to respond rapidly to intravitreal triamcinolone acetonide injection with resolution of optic disk hyperemia and edema and modest return of visual acuity. The long-term effects remain unknown.