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García-O'Farrill N, Pugazhendhi S, Karth PA, Hunter AA. Radiation retinopathy intricacies and advances in management. Semin Ophthalmol 2021; 37:417-435. [PMID: 34874814 DOI: 10.1080/08820538.2021.2000623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background: Radiation retinopathy is a chronic, progressive, vision-threatening complication from exposure to various radiation sources. While several treatment modalities are available, proper management for this disease is a continuing challenge with no consensus on the most efficacious.Objective: The aim of this article is to provide an updated review of the published literature on the course of the disease, available treatments and their efficacies, frequency of regimen, core issues in patient management, and additional newer treatment modalities, including possible prophylactic approaches.Value: We also highlighted the challenges encountered with managing chronically treated patients through an analysis of a clinical case report on a patient who was treated for several years with different modalities after a diagnosis of radiation retinopathy.
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Affiliation(s)
- Noraliz García-O'Farrill
- Oregon Eye Consultants, Eugene, OR, USA.,Department of Ophthalmology, School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA
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Azzam P, Mroueh M, Francis M, Daher AA, Zeidan YH. Radiation-induced neuropathies in head and neck cancer: prevention and treatment modalities. Ecancermedicalscience 2020; 14:1133. [PMID: 33281925 PMCID: PMC7685771 DOI: 10.3332/ecancer.2020.1133] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Indexed: 12/24/2022] Open
Abstract
Head and neck cancer (HNC) is the sixth most common human malignancy with a global incidence of 650,000 cases per year. Radiotherapy (RT) is commonly used as an effective therapy to treat tumours as a definitive or adjuvant treatment. Despite the substantial advances in RT contouring and dosage delivery, patients suffer from various radiation-induced complications, among which are toxicities to the nervous tissues in the head and neck area. Radiation-mediated neuropathies manifest as a result of increased oxidative stress-mediated apoptosis, neuroinflammation and altered cellular function in the nervous tissues. Eventually, molecular damage results in the formation of fibrotic tissues leading to susceptible loss of function of numerous neuronal substructures. Neuropathic sequelae following irradiation in the head and neck area include sensorineural hearing loss, alterations in taste and smell functions along with brachial plexopathy, and cranial nerves palsies. Numerous management options are available to relieve radiation-associated neurotoxicities notwithstanding treatment alternatives that remain restricted with limited benefits. In the scope of this review, we discuss the use of variable management and therapeutic modalities to palliate common radiation-induced neuropathies in head and neck cancers.
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Affiliation(s)
- Patrick Azzam
- Department of Anatomy, Cell Biology and Physiology, Faculty of Medicine, American University of Beirut, Beirut 1107 2020, Lebanon
| | - Manal Mroueh
- Department of Anatomy, Cell Biology and Physiology, Faculty of Medicine, American University of Beirut, Beirut 1107 2020, Lebanon
| | - Marina Francis
- Department of Anatomy, Cell Biology and Physiology, Faculty of Medicine, American University of Beirut, Beirut 1107 2020, Lebanon
| | - Alaa Abou Daher
- Department of Anatomy, Cell Biology and Physiology, Faculty of Medicine, American University of Beirut, Beirut 1107 2020, Lebanon
| | - Youssef H Zeidan
- Department of Anatomy, Cell Biology and Physiology, Faculty of Medicine, American University of Beirut, Beirut 1107 2020, Lebanon
- Department of Radiation Oncology, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon
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DiFrancesco T, Khanna A, Stubblefield MD. Clinical Evaluation and Management of Cancer Survivors with Radiation Fibrosis Syndrome. Semin Oncol Nurs 2020; 36:150982. [PMID: 32008860 DOI: 10.1016/j.soncn.2019.150982] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To define radiation fibrosis and radiation fibrosis syndrome; review the basics of radiotherapy, the pathophysiology of radiation injury, and the principles of clinical evaluation and management of the common late effects resulting from radiation therapy for cancer treatment. DATA SOURCES Peer-reviewed journal articles, book chapters, Internet. CONCLUSION There is no cure for radiation fibrosis syndrome, but supportive treatment of its clinical sequelae can potentially result in improved function and quality of life. IMPLICATIONS FOR NURSING PRACTICE The sequelae of radiation fibrosis syndrome can often be improved with early detection and supportive care by a multidisciplinary team including cancer rehabilitation physiatrists, oncologists, oncology nurses, nurse practitioners, physical therapists, occupational therapists, and speech and language pathologists.
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Affiliation(s)
- Tanya DiFrancesco
- PGY-4 Physical Medicine & Rehabilitation, Kingsbrook Rehabilitation Institute, Brooklyn, NY
| | - Ashish Khanna
- Cancer Rehabilitation Medicine, The Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ
| | - Michael D Stubblefield
- Cancer Rehabilitation Medicine, The Kessler Institute for Rehabilitation, West Orange, NJ.
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Özer MA, Polat N, Özen S, Parlakpınar H, Ekici K, Polat A, Vardı N, Tanbek K, Yildiz A. Effects of Molsidomine on Retinopathy and Oxidative Stress Induced by Radiotheraphy in Rat Eyes. Curr Eye Res 2016; 42:803-809. [PMID: 27897441 DOI: 10.1080/02713683.2016.1238943] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE To determine the role of Molsidomine in preventing radiation-induced retinopathy after head and neck region irradiation of rats with a single radiation dose of 15 Gy. MATERIALS AND METHODS Male Wistar albino rats were randomly grouped into five as follows: (1) control group rats, which were applied through an intraperitoneal (i.p.) vehicle without radiotherapy (RT); (2) RT group rats received a single dose of 15 Gy irradiation and after daily 0.1 ml vehicle i.p. for 5 consecutive days; (3) molsidomine (MOL) group rats were treated for 5 consecutive days by i.p. with 4 mg/kg/day MOL; (4) irradiation plus MOL group (RT+MOL) rats received irradiation and after 10 days single daily i.p. dose of MOL for 5 consecutive days; and (5) MOL+RT group rats were treated for 5 consecutive days by i.p. with MOL before RT. At the end of the work the rats were sacrificed under high-dose anesthesia on the 16th day and then eye tissues were taken for histopathological, immunohistochemical (caspase-3), and biochemical analyses (superoxide dismutase [SOD], glutathione peroxidase [GSH], and malondialdehyde [MDA]). RESULTS RT significantly decreased both the content of GSH and the activity of SOD, and significantly increased the production of MDA level in the rat eyes. MOL treatment significantly increased the SOD and GSH levels and significantly decreased the MDA production (p < 0.0001). In addition, RT significantly increased the number of ganglion cells (GCs; p = 0.001), whereas especially pretreatment with MOL improved (p = 0.013). RT led to significant retinopathy formation, and MOL therapy protected the retina from radiation-induced retinopathy (p < 0.0001). CONCLUSIONS We suggest that MOL is a powerful antioxidant and free radical scavenger that prevents the rat eyes from radiation-induced retinopathy and oxidative stress.
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Affiliation(s)
- Murat Atabey Özer
- a Department of Ophthalmology, Medical Faculty , Giresun University , Giresun , Turkey
| | - Nihat Polat
- b Department of Ophthalmology, Medical Faculty , Inonu University , Malatya , Turkey
| | - Serkan Özen
- a Department of Ophthalmology, Medical Faculty , Giresun University , Giresun , Turkey
| | - Hakan Parlakpınar
- c Department of Pharmacology, Medical Faculty , Inonu University , Malatya , Turkey
| | - Kemal Ekici
- d Department of Radiation Oncology, Medical Faculty , Inonu University , Malatya , Turkey
| | - Alaaddin Polat
- e Department of Physiology, Medical Faculty , Inonu University , Malatya , Turkey
| | - Nigar Vardı
- f Department of Histology and Embryology, Medical Faculty , Inonu University , Malatya , Turkey
| | - Kevser Tanbek
- e Department of Physiology, Medical Faculty , Inonu University , Malatya , Turkey
| | - Azibe Yildiz
- f Department of Histology and Embryology, Medical Faculty , Inonu University , Malatya , Turkey
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Hsu CR, Tai MC, Chang YH, Chien KH. Rapid onset of radiation maculopathy after whole-brain radiation therapy: A case report. Medicine (Baltimore) 2016; 95:e4830. [PMID: 27684815 PMCID: PMC5265908 DOI: 10.1097/md.0000000000004830] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Radiation maculopathy is a phenomenon that occurs after radiation exposure. The rapid onset of unilateral macular atrophy without peripheral retinopathy after radiation has rarely been described. METHODS A case report and literature review. RESULTS We report a case of stage 4 non-small cell lung cancer under targeted therapy using Gefitinib who presented with severely impaired visual acuity related to rapid onset of unilateral macular atrophy and diminished photoreceptor inner segment/outer segment (IS/OS) junction 1 month after whole-brain radiation therapy. The fundus fluorescein angiography revealed an enlarged diamond-shaped clear-cut foveal avascular zone in the macula without peripheral retinal vascular changes that differed from typical radiation retinopathy. We confirmed the diagnosis by evaluating the total radiation dosage and by excluding target therapy-induced maculopathy based on a review of the medical literature. CONCLUSION Current therapeutic interventions for macular atrophy after radiation therapy remain a challenge. Vasodilators or antiplatelet medication may be beneficial; however, long-term follow-up is needed. Further studies are required to support the use of early aggressive therapy for the prevention of radiation retinopathy.
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Affiliation(s)
| | | | | | - Ke-Hung Chien
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Correspondence: Ke-Hung Chien, Department of Ophthalmology, Tri-Service General Hospital, Neihu Dist, Taipei City, Taiwan (R.O.C.) (e-mail: )
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Correspondence. Retina 2015; 35:e70-1. [DOI: 10.1097/iae.0000000000000864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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INTRAVITREAL DEXAMETHASONE 0.7-MG IMPLANT FOR RADIATION MACULAR EDEMA AFTER PROTON BEAM THERAPY FOR CHOROIDAL MELANOMA. Retina 2013; 33:1784-90. [DOI: 10.1097/iae.0b013e31829234fa] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Groenewald C, Konstantinidis L, Damato B. Effects of radiotherapy on uveal melanomas and adjacent tissues. Eye (Lond) 2012. [PMID: 23196647 DOI: 10.1038/eye.2012.249] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Most uveal melanomas are treated with radiotherapy. An adequate understanding of the effects of radiation on the tumour and the healthy ocular tissues is necessary. Ionizing radiation damages cell membranes, organelles, and DNA. Irradiated cells are lysed or undergo apoptosis, necrosis, and senescence. These effects occur in tumour cells and vascular endothelial cells, resulting in tumour shrinkage, ischaemia, infarction, exudation, and fibrosis, which can cause exudative maculopathy, serous retinal detachment, rubeosis, and neovascular glaucoma (ie, 'toxic tumour syndrome'). Such abnormalities must be distinguished from collateral damage to healthy ocular tissues that receive high doses of radiation, and these include radiation-induced retinopathy, optic neuropathy, choroidopathy, cataract, and scleral necrosis. Radiation retinopathy can be treated effectively with photodynamic therapy, anti-angiogenic agents, and intravitreal steroid injections. In some patients, optic neuropathy may improve with intravitreal steroids or anti-angiogenic agents. Neovascular glaucoma resolves with intra-cameral bevacizumab. Exudative retinal detachment can regress with intra-vitreal steroid injections. Cataract is treated in the usual manner. Scleral necrosis, if severe, may require grafting, possibly using a lamellar flap from the same eye. Depending on the bulk of the residual toxic tumour, treatment can consist of intra-vitreal steroids and/or anti-angiogenic agents, transpupillary thermotherapy or photodynamic therapy to the tumour, or surgical removal of the tumour by endo- or exo-resection. Measures aimed at preventing collateral damage include eccentric placement of ruthenium plaques or iodine seeds and delivery of a notched proton beam. The decision to treat a uveal melanoma with radiotherapy requires the ability to manage iatrogenic side effects and complications.
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Affiliation(s)
- C Groenewald
- Ocular Oncology Service, St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
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Whipple KM, Levi L, Lee MS. The delayed cost of treatment. Surv Ophthalmol 2012; 58:370-6. [PMID: 22784679 DOI: 10.1016/j.survophthal.2012.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 01/27/2012] [Accepted: 01/31/2012] [Indexed: 11/19/2022]
Abstract
A 78-year-old woman presented with acute decreased vision in both eyes. She had been treated for a pituitary mass with a total of 4,500 centigray of external beam radiation 8 months prior to presentation. She was diagnosed with radiation optic neuropathy. Treatment with hyperbaric oxygen and intravenous steroids were initiated but vision remained poor.
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Affiliation(s)
- Katherine M Whipple
- University of California at San Diego Health System, Department of Ophthalmology-Shiley Eye Center, La Jolla, California 92093, USA.
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Russo A, Avitabile T, Uva M, Faro S, Franco L, Sanfilippo M, Gulisano S, Toro M, De Grande V, Rametta S, Foti L, Longo A, Reibaldi M. Radiation Macular Edema after Ru-106 Plaque Brachytherapy for Choroidal Melanoma Resolved by an Intravitreal Dexamethasone 0.7-mg Implant. Case Rep Ophthalmol 2012; 3:71-6. [PMID: 22529805 PMCID: PMC3331877 DOI: 10.1159/000337144] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Purpose To report the effective treatment of radiation macular edema following ruthenium-106 plaque brachytherapy for a choroidal melanoma with a dexamethasone 0.7-mg (Ozurdex®) intravitreal implant. Methods An interventional case report with optical coherence tomography (OCT) scans. Results A 65-year-old Caucasian woman was suffering from radiation macular edema following ruthenium-106 plaque brachytherapy for a choroidal melanoma on her left eye. She had undergone one intravitreal injection of 0.5 mg bevacizumab (Avastin®, Genentech/Roche) in the following months without functional or anatomical improvement. Seven months after the development of radiation macular edema, she received a single intravitreal injection of dexamethasone 0.7 mg (Ozurdex). Four weeks following the injection, her best-corrected visual acuity improved from 0.3 to 0.5. Radiation macular edema resolved with a reduction of central retinal thickness from 498 μm before Ozurdex injection to 224 μm after Ozurdex injection, as measured by OCT scan. Conclusion Dexamethasone 0.7 mg (Ozurdex) has proven to be an effective treatment option in retinal vein occlusion and noninfectious uveitis. It can also be considered as off-label treatment in radiation macular edema following ruthenium-106 plaque brachytherapy for a choroidal melanoma.
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Affiliation(s)
- Andrea Russo
- Department of Ophthalmology, University of Catania, Catania, Italy
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Abstract
BACKGROUND to review the currently available therapeutic modalities for radiation retinopathy (RR), including newer investigational interventions directed towards specific aspects of the pathophysiology of this refractory complication. METHODS a review of the literature encompassing the pathogenesis of RR and the current therapeutic modalities available was performed. RESULTS RR is a chronic and progressive condition that results from exposure to any source of radiation. It might be secondary to radiation treatment of intraocular tumors such as choroidal melanomas, retinoblastomas, and choroidal metastasis, or from unavoidable exposure to excessive radiation from the treatment of extraocular tumors like cephalic, nasopharyngeal, orbital, and paranasal malignancies. After the results of the Collaborative Ocular Melanoma Study, most of the choroidal melanomas are being treated with plaque brachytherapy increasing by that the incidence of this radiation complication. RR has been reported to occur in as many as 60% of eyes treated with plaque radiation, with higher rates associated with larger tumors. Initially, the condition manifests as a radiation vasculopathy clinically seen as microaneurysms and telangiectases, with posterior development of retinal hard exudates and hemorrhages, macular edema, neovascularization and tractional retinal detachment. Regrettably, the management of these eyes remains limited. Photodynamic therapy, laser photocoagulation, oral pentoxyphylline and hyperbaric oxygen have been attempted as treatment modalities with inconclusive results. Intravitreal injections of anti-vascular endothelial growth factor such as bevacizumab, ranibizumab and pegaptanib sodium have been recently used, also with variable results. DISCUSSION RR is a common vision threatening complication following radiation therapy. The available therapeutic options are limited and show unsatisfactory results. Further large investigative studies are required for developing better therapeutic as well as preventive treatment strategies.
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Affiliation(s)
- Gian Paolo Giuliari
- Princess Margaret Hospital, University of Toronto, Department of Ophthalmology and Vision Sciences, Hospital Health Network, Toronto, Ontario, Canada.
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Treatment of radiation retinopathy following plaque brachytherapy for choroidal melanoma. Curr Opin Ophthalmol 2009; 20:200-4. [DOI: 10.1097/icu.0b013e328329b62d] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Monroe AT, Bhandare N, Morris CG, Mendenhall WM. Preventing radiation retinopathy with hyperfractionation. Int J Radiat Oncol Biol Phys 2005; 61:856-64. [PMID: 15708266 DOI: 10.1016/j.ijrobp.2004.07.664] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2004] [Revised: 06/25/2004] [Accepted: 07/02/2004] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this study was to determine factors associated with the development of radiation retinopathy in a large series of patients with head-and-neck cancer. In particular, we addressed whether the use of hyperfractionated radiation therapy was effective in reducing the risk of retinopathy. METHODS AND MATERIALS One hundred eighty-six patients received a significant dose to the retina as part of curative radiotherapy. Primary sites included: nasopharynx, 46; paranasal sinus, 64; nasal cavity, 69; and palate, 7. Prescription doses varied depending on primary site and histology. Hyperfractionated (twice-daily) radiation was delivered to 42% of the patients in this study, typically at 1.10 to 1.20 Gy per fraction. The remainder were treated once-daily. Retinal doses were determined from computerized dosimetry plans when available. For all other patients, retinal doses were retrospectively calculated using reconstructed off-axis dosimetry taken from contours through the center of the globes. Retinal dose was defined as the minimum dose received by at least 25% of the globe. The median retinal dose was 56.85 Gy. Patients were followed for a median of 7.6 years. RESULTS Thirty-one eyes in 30 patients developed radiation retinopathy, resulting in monocular blindness in 25, bilateral blindness in 1, and decreased visual acuity in 4. The median time to the diagnosis of retinopathy was 2.6 years (range, 11 months to 5.3 years). The actuarial incidence of developing radiation retinopathy was 20% at both 5 and 10 years. The incidence of developing ipsilateral blindness due to retinopathy was 16% at 5 years and 17% at 10 years. Site-specific incidences varied considerably, with ethmoid sinus (9 of 25, 36%), nasal cavity (13 of 69, 19%), and maxillary sinus (6 of 35, 17%) being the most common sites associated with radiation retinopathy. Three of 72 patients (4%) receiving retinal doses less than 50 Gy developed retinopathy. Higher retinal doses resulted in a steady increase in the incidence of retinopathy, with 25 of the 30 cases occurring after 60 Gy or more. Of the patients receiving more than 50 Gy to the retina, hyperfractionation was associated with a significantly lower incidence of radiation retinopathy (37% vs. 13%; p = 0.0037). On multivariate analysis, retinal dose (p < 0.0001), fractionation schedule (p = 0.0003), age (p = 0.0365), and prolonged overall treatment time (p = 0.0213) were significant predictors of radiation retinopathy. CONCLUSION The incidence of ipsilateral radiation retinopathy after treatment of nasal cavity/paranasal tumors is 20% at 5 and 10 years. Retinal dose and fractionation schedule are the strongest predictors of retinopathy. Hyperfractionated radiotherapy is associated with a significant reduction in the incidence of radiation retinopathy, especially when the retina receives more than 50 Gy.
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Affiliation(s)
- Alan T Monroe
- Department of Radiation Oncology, University of Florida College of Medicine, Health Science Center, 2000 SW Archer Road, Gainesville, FL 32608, USA
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