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Radiation retinopathy secondary to treatment of maxillary sinus carcinoma: A dramatic case
Retinopatía por radiación secundaria a tratamiento de carcinoma de seno maxilar: un caso dramático
J. Galindo-Boceroa,
Corresponding author
javiergalindobocero@hotmail.com

Corresponding author.
, S. Macías-Francob, S. Sánchez-Garcíac, M. Fonollá-Gilb, A. García-Alonsob
a Servicio de Oftalmología, Fundación Hospital de Jove, Gijón, Asturias, Spain
b Servicio de Oftalmología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
c Servicio de Radiodiagnóstico, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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with a size of approximately 60<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>55<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>mm &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The tumor is considered to be non-resectable and it was decided to apply 4 chemotherapy cycles with the TPF regime &#40;docetaxel<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>cisplatin<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>fluorouracyl&#41; with minimum response&#44; which led to the application of radical radiotherapy with a total dose of 70<span class="elsevierStyleHsp" style=""></span>Gy &#40;divided in 35 sessions of 2<span class="elsevierStyleHsp" style=""></span>Gy each&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The patient began to exhibit progressive visual acuity &#40;VA&#41; loss in the right eye 18 months after irradiation&#46; Exploration confirmed diminished VA in right eye &#40;0&#46;6&#41; when compared to the left eye &#40;1&#46;0&#41;&#46; Right eye examination revealed scleral vessel dilatation&#44; posterior subcapsular cataracts&#44; incipient macular edema&#44; cotton wool hemorrhages and exudates in the nasal and inferior retina as well as inferior peripheral ischemia in angiography &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; No alterations were observed in the left eye&#46; Computerized action tomography and magnetic nuclear angioresonance discarded progression of the tumor and other possible causes&#46; Accordingly&#44; clinic pointed to ocular toxicity secondary to radiation&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Retinal panphotocoagulation and focal laser were performed sequentially&#44; followed by cataract surgery with intraocular lens implant in posterior chamber and 4 intravitreal injections of bevacizumab&#46; Despite said treatment&#44; VA progressively deteriorated in the course of 12 months follow-up&#44; with panretinal ischemia extension and macular edema worsening&#44; with VA diminishing to &#60;0&#46;01&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Evolution was torpid and evolved to massive subretinal exudation in posterior pole and nasal retina &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; leading to complete exudative retina detachment&#44; hemophthalmos and secondary malign glaucoma&#46; The patient did not perceive light and medical treatment failed to control intraocular pressure&#46; Accordingly&#44; evisceration was decided due to painful blind eye 4 years after onset of symptoms and nearly 6 years after irradiation&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Radiation retinopathy was described by H&#46;B&#46; Stallard in 1933&#46; At that time&#44; the retina was considered to be radio-resistant tissue together with the central nervous system&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The time interval between exposure to radiation energy and the appearance of retinal lesions is variable and unpredictable&#46; Clinical changes were observed in laboratory retinas after 3 weeks&#44; although typically retinopathy appears between 6 months and 3 years after treatment<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> although some reports describe retinopathy cases appearing up to 15 years after irradiation&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Incidence mainly depends on the overall dose and the size of the administered fraction&#46; Some studies demonstrate clear increased risk with total dosages above 45&#8211;50<span class="elsevierStyleHsp" style=""></span>Gy or fractions exceeding 1&#46;8&#8211;2&#46;0<span class="elsevierStyleHsp" style=""></span>Gy&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">As in diabetic retinopathy&#44; histopathological and ultrastructural studies confirmed that the first event in radiation retinopathy is occlusive microvasculopathy with loss of endothelial cells and closure of capillaries<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> which in the long-term induce ischemic and vasoproliferative changes&#46; The retina posterior pole is more sensitive than the periphery&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;7</span></a> Patients with previous chemotherapy treatment could exhibit more severe forms of retinopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Macular edema is the main cause of visual impairment&#44; although with less frequency it can appear as acute optical neuropathy&#46; In late stages of the disease&#44; the ischemic component predominates and accounts for the appearance of neovascular complications that could significantly influence prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;7</span></a> In these cases evisceration or enucleation could be necessary due to painful blind eye&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Diagnostic is predominantly clinic&#44; with optical coherence tomography and fluorescein angiography being very useful to determine the degree of subretinal exudation and ischemia&#46; In the presence of the latter&#44; retinal photocoagulation is an attempt to prevent the appearance of neovascular complications&#46; Therapeutic options for macular edema include laser and intravitreal injections of triamcinolone or anti-VEGF&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;7</span></a> Recently&#44; intravitreal dexamethasone implants have demonstrated good results in refractory maculopathy cases&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Radiation retinopathy is an infrequent pathology which nonetheless must be taken into account in the presence of vision loss in patients with neck and head irradiation&#46; Radiotherapy is increasingly used for treating ocular and orbital tumors&#44; for which reason the prevalence and incidence of this disease are on the increase&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Long-term ophthalmological follow-up is crucial for early diagnostic&#44; which in turn is essential to halt the progression of the disease&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interests</span><p id="par0060" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Clinical case</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 53-year old male presented with visual impairment in right eye after irradiation of right maxillary sinus carcinoma&#46; Funduscopy shows radiation retinopathy&#58; hemorrhages&#44; exudates&#44; macular edema&#44; and peripheral retinal ischemia&#46; A poor outcome was achieved despite laser treatment and intravitreal injections of bevacizumab&#44; resulting in evisceration of the affected eye&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Radiation retinopathy must be considered in any loss of vision after head and neck irradiation&#46; Ophthalmological long-term follow-up of these patients is essential for an early diagnosis&#46;</p></span>"
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        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Caso cl&#237;nico</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Un var&#243;n de 53 a&#241;os consulta por p&#233;rdida de visi&#243;n en ojo derecho tras irradiaci&#243;n de carcinoma de seno maxilar derecho&#46; La exploraci&#243;n fundusc&#243;pica muestra hemorragias&#44; exudados&#44; edema macular e isquemia retiniana perif&#233;rica&#44; compatibles con una retinopat&#237;a por radiaci&#243;n&#46; La evoluci&#243;n es t&#243;rpida a pesar de tratamiento con l&#225;ser e inyecciones intrav&#237;treas de bevacizumab&#44; finalizando en evisceraci&#243;n del ojo afecto&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discusi&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La retinopat&#237;a por radiaci&#243;n debe tenerse en cuenta ante cualquier p&#233;rdida de visi&#243;n tras irradiaci&#243;n de cabeza y cuello&#46; El seguimiento oftalmol&#243;gico a largo plazo de estos pacientes es fundamental para conseguir un diagn&#243;stico precoz&#46;</p></span>"
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ISSN: 21735794
Original language: English
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