Radiation retinopathy: a review

Radiation retinopathy (RR) and radiation maculopathy (RM) are common, vision-threatening complications of ocular and periocular radiotherapy, particularly after treatment of uveal melanoma. They result from progressive occlusive microangiopathy leading to retinal ischemia, macular edema, and visual decline. With the increasing use of plaque brachytherapy and proton beam therapy, understanding their epidemiology, risk factors, and management is essential to improve outcomes.

RR and RM arise from radiation-induced endothelial and pericyte injury causing blood-retinal barrier breakdown, ischemia, and neuronal loss. Risk is influenced by patient factors (diabetes, hypertension, chemotherapy), tumor characteristics (size, location), and radiation parameters (dose, isotope, fractionation). Advances in imaging, especially OCT and OCT angiography, permit early detection of subclinical edema and microvascular ischemia before funduscopic changes. Classification systems integrating fundus, angiographic, and OCT features provide standardized grading. Treatment remains challenging, though anti-VEGF agents (bevacizumab, ranibizumab, aflibercept) demonstrate the strongest evidence for reducing edema, stabilizing anatomy, and preserving vision; however, no treatment has demonstrated clear superiority, and outcomes are largely derived from non-comparative studies. Early and sustained therapy yields better outcomes, though recurrence is common. Emerging agents such as faricimab are under investigation.

RR and RM remain major obstacles to long-term visual preservation after ocular radiotherapy. Multimodal imaging enables earlier diagnosis, while anti-VEGF therapy is the current standard of care. Clinicians should maintain vigilance in at-risk patients, initiate timely treatment, and use imaging biomarkers to guide follow-up. Future research should optimize treatment regimens and evaluate novel therapeutics to further improve visual outcomes.