Radiation cataractogenesis: epidemiology and biology

Radiation cataract in Heterogeneous Stock mice after γ-ray or HZE ion exposure

Health effects of space radiation are a serious concern for astronauts on long-duration missions. The lens of the eye is one of the most radiosensitive tissues in the body and, therefore, ocular health risks for astronauts is a significant concern. Studies in humans and animals indicate that ionizing radiation exposure to the eye produces characteristic lens changes, termed "radiation cataract," that can affect visual function. Animal models of radiation cataractogenesis have previously utilized inbred mouse or rat strains. These studies were essential for determining morphological changes and dose-response relationships between radiation exposure and cataract. However, the relevance of these studies to human radiosensitivity is limited by the narrow phenotypic range of genetically homogeneous animal models. To model radiation cataract in genetically diverse populations, longitudinal cataract phenotyping was nested within a lifetime carcinogenesis study in male and female heterogeneous stock (HS/Npt) mice exposed to 0.4 Gy HZE ions (n = 609) or 3.0 Gy γ-rays (n = 602) and in unirradiated controls (n = 603). Cataractous change was quantified in each eye for up to 2 years using Merriam-Focht grading criteria by dilated slit lamp examination. Virtual Optomotry™ measurement of visual acuity and contrast sensitivity was utilized to assess visual function in a subgroup of mice. Prevalence and severity of posterior lens opacifications were 2.6-fold higher in HZE ion and 2.3-fold higher in γ-ray irradiated mice compared to unirradiated controls. Male mice were at greater risk for spontaneous and radiation associated cataracts. Risk for cataractogenesis was associated with family structure, demonstrating that HS/Npt mice are well-suited to evaluate genetic determinants of ocular radiosensitivity. Last, mice were extensively evaluated for cataract and tumor formation, which revealed an overlap between individual susceptibility to both cancer and cataract.

Individual response of the ocular lens to ionizing radiation

PURPOSE

Cataract (opacification of the ocular lens) is a typical tissue reaction (deterministic effect) following ionizing radiation exposure, for which prevention dose limits have been recommended in the radiation protection system. Manifestations of radiation cataracts can vary among individuals, but such potential individual responses remain uncharacterized. Here we review relevant literature and discuss implications for radiation protection. This review assesses evidence for significant modification of radiation-induced cataractogenesis by age at exposure, sex and genetic factors based on current scientific literature.

CONCLUSIONS

In addition to obvious physical factors (e.g. dose, dose rate, radiation quality, irradiation volume), potential factors modifying individual responses for radiation cataracts include sex, age and genetics, with comorbidity and coexposures also having important roles. There are indications and preliminary data identifying such potential modifiers of radiation cataract incidence or risk, although no firm conclusions can yet be drawn. Further studies and a consensus on the evidence are needed to gain deeper insights into factors determining individual responses regarding radiation cataracts and the implications for radiation protection.

Insights into the biochemical and biophysical mechanisms mediating the longevity of the transparent optics of the eye lens

In the human eye, a transparent cornea and lens combine to form the "refracton" to focus images on the retina. This requires the refracton to have a high refractive index "n," mediated largely by extracellular collagen fibrils in the corneal stroma and the highly concentrated crystallin proteins in the cytoplasm of the lens fiber cells. Transparency is a result of short-range order in the spatial arrangement of corneal collagen fibrils and lens crystallins, generated in part by post-translational modifications (PTMs). However, while corneal collagen is remodeled continuously and replaced, lens crystallins are very long-lived and are not replaced and so accumulate PTMs over a lifetime. Eventually, a tipping point is reached when protein aggregation results in increased light scatter, inevitably leading to the iconic protein condensation-based disease, age-related cataract (ARC). Cataracts account for 50% of vision impairment worldwide, affecting far more people than other well-known protein aggregation-based diseases. However, because accumulation of crystallin PTMs begins before birth and long before ARC presents, we postulate that the lens protein PTMs contribute to a "cataractogenic load" that not only increases with age but also has protective effects on optical function by stabilizing lens crystallins until a tipping point is reached. In this review, we highlight decades of experimental findings that support the potential for PTMs to be protective during normal development. We hypothesize that ARC is preventable by protecting the biochemical and biophysical properties of lens proteins needed to maintain transparency, refraction, and optical function.

Assessment of Health Professionals' Attitudes on Radiation Protection Measures

(1) Background: Health professionals' knowledge, beliefs and perceptions concerning radiation protection may affect their behaviour during surgery and consequently influence the quality of health services. This study highlights the health professionals' average knowledge level and captures the beliefs, perceptions, and behaviours in a large public Greek hospital. (2) Materials and Methods: A cross-sectional study was carried out, including health professionals working in operating rooms. One hundred thirty-two staff members participated by responding to an original questionnaire. The sample consisted of nurses, radiographers and medical doctors of various specialties involved daily in surgical procedures where ionizing radiation is required. The survey was conducted from March to June 2021, and the response rate was 97%. (3) Results: The level of overall knowledge of health professionals regarding radiation protection safety was not satisfactory. Females and employees with a lower level of education had more misconceptions about radiation and radiation protection. Employees of younger ages and with less previous experience were more likely to have negative emotions towards radiation exposure. Finally, employees with fewer children tended to express physical complaints caused by their negative emotions due to radiation exposure. (4) Conclusions: Health professionals' lack of basic and specialized knowledge concerning radiation protection safety had a negative impact on the provision of health services. The continuing training of the staff seemed to be the only solution to reverse this trend. The training should highlight how radiation exposure can be minimized, safeguarding health professionals' trust and sense of security by significantly improving their working environment.

Out-of-field dose assessment for a 1.5 T MR-Linac with optically stimulated luminescence dosimeters

PURPOSE

To assess the out-of-field surface and internal dose of the 1.5 T MR-Linac compared to the conventional external beam linac using optically stimulated luminescence dosimeters (OSLDs), and evaluate the out-of-field dose calculation accuracy of the Monaco treatment planning system (TPS) of the 1.5T MR-Linac.

METHODS

A cubic solid water phantom, with OSLDs on the surface, was vertically irradiated by MR-Linac square fields with different sizes. In addition, OSLDs were arranged out of the beam edges in four directions. An anthropomorphic adult phantom, with 125 cm³ simulated volume, was irradiated in four orthogonal directions by both MR-Linac and conventional linac at the head, thoracic, and pelvic sites. Out-of-field doses were measured by OSLDs on both the surface and internal emulational organs at risk (OARs). The results were compared to the simulated dose from Monaco TPS.

RESULTS

At different field sizes (5 × 5 to 20 × 20 cm² ) and distances (1 to 10 cm) to beam edge, the out-of-field surface dose measured on MR-Linac varied from 0.16 % (10 cm to 5 × 5 cm² edge) to 7.02 % (1 cm to 20 × 20 cm² edge) of the maximum dose laterally and from 0.14 % (10 cm to 5 × 5 cm² edge) to 8.56 % (1 cm to 20 × 20 cm² edge) of the maximum dose longitudinally. Compared to the OSLDs measured data, the Monaco TPS presented an overestimate of the out-of-field dose of OARs at 0-2 % isodose area on both surface and internal check points, and the overestimation gets greater as the distance increases. The underestimation was found to be 0-35% at 2-5% isodose area on both surface and internal check points. Compared to the conventional linac, MR-Linac delivered higher average values of out-of-field dose on surface check points (20%, 19%, 21%) and internal simulated OARs (42%, 37%, 9%) of the anthropomorphic phantom at head, thoracic, and pelvic irradiations, respectively.

CONCLUSIONS

Compared to the conventional linac, MR-Linac has the same out-of-field dose distribution. However, considering the absolute dose values, MR-Linac delivered relatively higher out-of-field doses on both surface and internal OARs. Additional radiation shielding to patients undergoing MR-Linac may provide protection from out-of-field exposure.

Eye lens and thyroid gland radiation exposure for patients undergoing brain computed tomography examination

This study aims to estimate the effective radiation dose and organ dose from head CT procedures. It was conducted in three main private hospitals in Khartoum State-Sudan, using Toshiba machines with 64 slices. The total number of patients included in this study was 142 patients (82 males and 60 females). The effective dose and organ dose were calculated by CT Expo software. The effective dose slightly varied among patients according to gender and age. The effective dose for female patients (5.99 mSv) was higher than that for male patients (5.84 mSv), and the pediatric dose (5.46 mSv) was lower than the adults' dose (5.94 mSv). The dose for eye lens was found lower for male patients (89.117 mSv) than the dose for female patients (94.62) mSv). According to patients' age: the dose received by the lens of the eye was much lower in pediatric (79.93 mSv) than the adults (92.41 mSv). The dose for thyroid in female patients (33.52 mSv) was higher than the male patients (28 mSv). The pediatric dose (28.34 mSv) was lower than the adults' dose (30.64 mSv). Departmental imaging protocol and lack of training among hospital staff are expected to be responsible for these variations. Therefore, this study recommends that the CT technologists be trained on suitable strategies to achieve dose optimization. Moreover, patients' doses must be monitored regularly.

Ionizing Radiation-Induced Epigenetic Modifications and Their Relevance to Radiation Protection

The present system of radiation protection assumes that exposure at low doses and/or low dose-rates leads to health risks linearly related to the dose. They are evaluated by a combination of epidemiological data and radiobiological models. The latter imply that radiation induces deleterious effects via genetic mutation caused by DNA damage with a linear dose-dependence. This picture is challenged by the observation of radiation-induced epigenetic effects (changes in gene expression without altering the DNA sequence) and of non-linear responses, such as non-targeted and adaptive responses, that in turn can be controlled by gene expression networks. Here, we review important aspects of the biological response to ionizing radiation in which epigenetic mechanisms are, or could be, involved, focusing on the possible implications to the low dose issue in radiation protection. We examine in particular radiation-induced cancer, non-cancer diseases and transgenerational (hereditary) effects. We conclude that more realistic models of radiation-induced cancer should include epigenetic contribution, particularly in the initiation and progression phases, while the impact on hereditary risk evaluation is expected to be low. Epigenetic effects are also relevant in the dispute about possible "beneficial" effects at low dose and/or low dose-rate exposures, including those given by the natural background radiation.

A randomized comparison of estimated radiation exposure between Low and conventional dose protocol during invasive coronary angiography (ERICA trial): Pilot study

PURPOSE

Radiation exposure during coronary angiography is potentially harmful to patients and operators. However, there are limited data on the effects of a low-dose radiation angiography. We evaluated the feasibility and effectiveness of a reduced radiation dose protocol during invasive coronary angiography.

METHODS

One hundred three consecutive patients who underwent coronary angiography were enrolled and randomized to low- or conventional dose protocols (LDP versus CDP). The LDP consists of 10 frames per second during fluoroscopy and half the radiation dose of CDP during cineangiography. Image quality was assessed using a Likert rating scale by an independent radiologist. The radiation dose was estimated with dose-area product (DAP) and air-kerma (AK).

RESULTS

Body weight and waist circumference are well correlated with the level of DAP and AK. Exposure time and total images and frame counts in cineangiography were similar in both groups. There was a marked reduction of the estimated radiation dose (DAP and AK) in the LDP group compared to the CDP group without significant compromise in image quality (total DAP: LDP 1980.1 ± 1163.7 vs. CDP 3434.2 ± 2188.1 μGym² p = 0.001; total AK: 279.6 ± 159.3 vs. 493.8 ± 280.6 mGy, p < 0.001).

CONCLUSION

The LDP reduced the total estimated radiation dose compared to the CDP without a significant loss of diagnostic information. A LDP may be a viable strategy to protect patients and medical staff from the hazards of radiation in the cardiac catheterization laboratory.

Effects of chronic low-dose radiation on cataract prevalence and characterization in wild boar (Sus scrofa) from Fukushima, Japan

This study evaluated cataracts in wild boar exposed to chronic low-dose radiation. We examined wild boar from within and outside the Fukushima Exclusion Zone for nuclear, cortical, and posterior subcapsular (PSC) cataracts in vivo and photographically. Plausible upper-bound, lifetime radiation dose for each boar was estimated from radioactivity levels in each animal's home range combined with tissue concentrations of 134+137Cesium. Fifteen exposed and twenty control boar were evaluated. There were no significant differences in overall prevalence or score for cortical or PSC cataracts between exposed and control animals. Nuclear (centrally located) cataracts were significantly more prevalent in exposed boar (p < 0.05) and had statistically higher median scores. Plausible upper-bound, lifetime radiation dose ranged from 1 to 1,600 mGy in exposed animals, with no correlation between dose and cortical or PSC score. While radiation dose and nuclear score were positively associated, the impact of age could not be completely separated from the relationship. Additionally, the clinical significance of even the highest scoring nuclear cataract was negligible. Based on the population sampled, wild boar in the Fukushima Exclusion Zone do not have a significantly higher prevalence or risk of cortical or PSC cataracts compared to control animals.

Ionising radiation and lens opacities in interventional physicians: results of a German pilot study

We assessed the feasibility of an epidemiological study on the risk of radiation-related lens opacities among interventional physicians in Germany. In a regional multi-centre pilot study associated with a European project, we tested the recruitment strategy, a European questionnaire on work history for the latter dosimetry calculation and the endpoint assessment. 263 interventional physicians and 129 non-exposed colleagues were invited. Questionnaires assessed eligibility criteria, risk factors for cataract, and work history relating to occupational exposure to ionising radiation, including details on type and amount of procedures performed, radiation sources, and use of protective equipment. Eye examinations included regular inspection by an ophthalmologist, digital slit lamp images graded according to the lens opacities classification system, and Scheimpflug camera measurements. 46 interventional (17.5%) and 30 non-exposed physicians (23.3%) agreed to participate, of which 42 and 19, respectively, met the inclusion criteria. Table shields and ceiling suspended shields were used as protective equipment by 85% and 78% of the interventional cardiologists, respectively. However, 68% of them never used lead glasses. More, although minor, opacifications were diagnosed among the 17 interventional cardiologists participating in the eye examinations than among the 18 non-exposed (59% versus 28%), mainly nuclear cataracts in interventional cardiologists and cortical cataracts in the non-exposed. Opacification scores calculated from Scheimpflug measurements were higher among the interventional cardiologists, especially in the left eye (56% versus 28%). Challenges of the approach studied include the dissuading time investment related to pupil dilatation for the eye examinations, the reliance on a retrospective work history questionnaire to gather exposure-relevant information for dose reconstructions and its length, resulting in a low participation rate. Dosimetry data are bound to get better when the prospective lens dose monitoring as foreseen by 2013 European Directives is implemented and doses are recorded.

Lens Dose-Response Prediction Modeling and Cataract Incidence in Patients With Retinoblastoma After Lens-Sparing or Whole-Eye Radiation Therapy

PURPOSE

We retrospectively assessed the incidence of cataracts in patients with retinoblastoma (Rb) treated with either lens-sparing radiation therapy (LSRT) or whole-eye radiation therapy (WERT). A secondary aim of this study was to model the dose-response risk of cataract.

METHODS AND MATERIALS

We reviewed 65 patients with Rb treated with radiation therapy (RT) at Children's Hospital, Los Angeles from 1997 to 2015. Eyes that were enucleated before RT or lacked follow-up eye examinations were excluded. All patients underwent computed tomography simulation, and mean lens dose data were collected. Follow-up ophthalmologic examinations and intraocular lens implant history were reviewed for cataracts. The primary event-free survival (EFS) outcome was cataract development. Eyes without cataracts were censored on the last date of eye examination or post-RT enucleation, if applicable. Kaplan-Meier estimates were used to compare EFS outcomes, and dose response was projected with Cox regression and logistic regression models.

RESULTS

Sixty-one patients (94 eyes) were analyzed with a median follow-up of 51.8 months. For eyes treated with WERT, cataracts developed in 71.7% versus 35.3% for LSRT. Median EFS for WERT and LSRT were 20.8 and 67.9 months, respectively. Compared with WERT, a significant EFS benefit was demonstrated for LSRT (P < .001). Mean lens dose had a significant effect on cataracts in both Cox regression and logistic regression models (P < .01). The mean lens dose of 7 Gy was projected to have a 5-year cataract incidence of 20% and 25% with the logistic and Cox regression models, respectively.

CONCLUSIONS

We report the first clinical data demonstrating significantly improved EFS in patients with Rb treated with LSRT. Through lens dose-response modeling, we validate a mean lens dose threshold of 7 Gy to keep cataract risk below 25%. Although RT is used less often for Rb owing to advances in chemotherapy delivery options, these findings are relevant for refining lens dose constraints, particularly in children who have received radiation dose near the orbit.

Risk of radiation-induced lens opacities among surgeons and interventional medical staff

The main effect of ionizing radiation on the eyes is the onset of posterior cortical and subcapsular cataracts. Recent studies have raised questions about the mechanism of ocular damage and the threshold dose for the onset of such effects. Currently, operators may be exposed to ionizing radiation during surgical procedures. It has been estimated that urologists can be exposed to an annual dose close to or above 20 mSv/year. The aim of our study was to evaluate the frequency of cataracts in a group of professional radiological operators to verify their possible association with the radiation dose to the crystalline lens and the tasks performed. The records of 73 health workers exposed to ionizing radiation were reviewed. The average annual dose to the crystalline lens, the number of years of exposure, and the presence of radiation-compatible opacities were assessed for all operators. Lenticular opacities were observed in 16.4% of subjects. The presence of alterations was associated with exposure doses below 10 mSv and > 10 years' experience in fluoroscopically guided procedures. Based on our results, protection of the crystalline lens against exposure to ionizing radiation by means of goggles is recommended. In addition, examination of the lens via slit lamp examination is recommended for all operators involved in interventional procedures with the current levels of radiation exposure.

Alterations in synaptic density and myelination in response to exposure to high-energy charged particles

High-energy charged particles are considered particularly hazardous components of the space radiation environment. Such particles include fully ionized energetic nuclei of helium, silicon, and oxygen, among others. Exposure to charged particles causes reactive oxygen species production, which has been shown to result in neuronal dysfunction and myelin degeneration. Here we demonstrate that mice exposed to high-energy charged particles exhibited alterations in dendritic spine density in the hippocampus, with a significant decrease of thin spines in mice exposed to helium, oxygen, and silicon, compared to sham-irradiated controls. Electron microscopy confirmed these findings and revealed a significant decrease in overall synapse density and in nonperforated synapse density, with helium and silicon exhibiting more detrimental effects than oxygen. Degeneration of myelin was also evident in exposed mice with significant changes in the percentage of myelinated axons and g-ratios. Our data demonstrate that exposure to all types of high-energy charged particles have a detrimental effect, with helium and silicon having more synaptotoxic effects than oxygen. These results have important implications for the integrity of the central nervous system and the cognitive health of astronauts after prolonged periods of space exploration.

Modifiers of radiation effects in the eye

World events, including the threat of radiological terrorism and the fear of nuclear accidents, have highlighted an urgent need to develop medical countermeasures to prevent or reduce radiation injury. Similarly, plans for manned spaceflight to a near-Earth asteroid or journey to Mars raise serious concerns about long-term effects of space radiation on human health and the availability of suitable therapeutic interventions. At the same time, the need to protect normal tissue from the deleterious effects of radiotherapy has driven considerable research into the design of effective radioprotectors. For more than 70 years, animal models of radiation cataract have been utilized to test the short and long-term efficacy of various radiation countermeasures. While some compounds, most notably the Walter Reed (WR) class of radioprotectors, have reported limited effectiveness when given before exposure to low-LET radiation, the human toxicity of these molecules at effective doses limits their usefulness. Furthermore, while there has been considerable testing of eye responses to X- and gamma irradiation, there is limited information about using such models to limit the injurious effects of heavy ions and neutrons on eye tissue. A new class of radioprotector molecules, including the sulfhydryl compound PrC-210, are reported to be effective at much lower doses and with far less side effects. Their ability to modify ocular radiation damage has not yet been examined. The ability to non-invasively measure sensitive, radiation-induced ocular changes over long periods of time makes eye models an attractive option to test the radioprotective and radiation mitigating abilities of new novel compounds.

Actual and Potential Radiation Exposures in Digital Radiology: Analysis of Cumulative Data, Implications to Worker Classification and Occupational Exposure Monitoring

Radiation worker categorization and exposure monitoring are principal functions of occupational radiation safety. The aim of this study was to use the actual occupational exposure data in a large university hospital to estimate the frequency and magnitude of potential exposures in radiology. The additional aim was to propose a revised categorization and exposure monitoring practice based on the potential exposures. The cumulative probability distribution was calculated from the normalized integral of the probability density function fitted to the exposure data. Conformity of the probabilistic model was checked against 16 years of national monitoring data. The estimated probabilities to exceed annual effective dose limits of 1 mSv, 6 mSv and 20 mSv were 1:1000, 1:20 000 and 1:200 000, respectively. Thus, it is very unlikely that the class A categorization limit of 6 mSv could be exceeded, even in interventional procedures, with modern equipment and appropriate working methods. Therefore, all workers in diagnostic and interventional radiology could be systematically categorized into class B. Furthermore, current personal monitoring practice could be replaced by use of active personal dosemeters that offer more effective and flexible means to optimize working methods.

THE IMPACT OF CIRCADIAN RHYTHMS ON MEDICAL IMAGING AND RADIOTHERAPY REGIMES FOR THE PAEDIATRIC PATIENT

Daily rhythmic changes are found in cellular events in cell cycle, DNA repair, apoptosis and angiogenesis in both normal and tumour tissue, as well as in enzymatic activity and drug metabolism. In this paper, we hypothesize that circadian rhythms need to be considered in radiation protection and optimization in personalized medicine, especially for paediatric care. The sensitivity of the eye lens to ionizing radiation makes the case for limiting damage to the lens epithelium by planning medical radio-imaging procedures for the afternoon, rather than the morning. Equally, the tumour and normal tissue response to radiotherapy is also subject to diurnal variation enabling optimization of time of treatment.

Radiobiology in Cardiovascular Imaging

The introduction of ionizing radiation in medicine revolutionized the diagnosis and treatment of disease and dramatically improved and continues to improve the quality of health care. Cardiovascular imaging and medical imaging in general, however, are associated with a range of radiobiologic effects, including, in rare instances, moderate to severe skin damage resulting from cardiac fluoroscopy. For the dose range associated with diagnostic imaging (corresponding to effective doses on the order of 10 mSv [1 rem]), the possible effects are stochastic in nature and largely theoretical. The most notable of these effects, of course, is the possible increase in cancer risk. The current review addresses radiobiology relevant to cardiovascular imaging, with particular emphasis on radiation induction of cancer, including consideration of the linear nonthreshold dose-response model and of alternative models such as radiation hormesis.

ON-FIELD EVALUATION OF OPERATOR LENS PROTECTIVE DEVICES IN INTERVENTIONAL RADIOLOGY

The recent publication of the Euratom Directive 2013/59, adopting the reduction of eye lens dose limits from 150 to 20 mSv y^-1, calls for the development of new tools and methodologies for evaluating the eye lens dose absorbed by the medical staff involved in interventional radiology practices. Moreover, the effectiveness of the protective devices, like leaded glasses, which can be employed for radiation protection purposes, must be tested under typical exposure scenarios. In this work, eye lens dose measurements were carried out on an anthropomorphic phantom simulating a physician bound to perform standard interventional neuroradiology angiographic procedures. The correlation between eye lens doses, in terms of Hp(0.07), and the equivalent dose [again in terms of Hp(0.07)] monthly measured with thermoluminescent dosemeters placed above the lead apron at the chest level was studied, in the presence and in the absence of different types of leaded glasses.

Individual response to ionizing radiation

The human response to ionizing radiation (IR) varies among individuals. The first evidence of the individual response to IR was reported in the beginning of the 20th century. Considering nearly one century of observations, we here propose three aspects of individual IR response: radiosensitivity for early or late adverse tissue events after radiotherapy on normal tissues (non-cancer effects attributable to cell death); radiosusceptibility for IR-induced cancers; and radiodegeneration for non-cancer effects that are often attributable to mechanisms other than cell death (e.g., cataracts and circulatory disease). All the molecular and cellular mechanisms behind IR-induced individual effects are not fully elucidated. However, some specific assays may help their quantification according to the dose and to the genetic status. Accumulated data on individual factors have suggested that the individual IR response cannot be ignored and raises some clinical and societal issues. The individual IR response therefore needs to be taken into account to better evaluate the risks related to IR exposure.

Status of NCRP Scientific Committee 1-23 Commentary on Guidance on Radiation Dose Limits for the Lens of the Eye

Previous National Council on Radiation Protection and Measurements (NCRP) publications have addressed the issues of risk and dose limitation in radiation protection and included guidance on specific organs and the lens of the eye. NCRP decided to prepare an updated commentary intended to enhance the previous recommendations provided in earlier reports. The NCRP Scientific Committee 1-23 (SC 1-23) is charged with preparing a commentary that will evaluate recent studies on the radiation dose response for the development of cataracts and also consider the type and severity of the cataracts as well as the dose rate; provide guidance on whether existing dose limits to the lens of the eye should be changed in the United States; and suggest research needs regarding radiation effects on and dose limits to the lens of the eye. A status of the ongoing work of SC 1-23 was presented at the Annual Meeting, "Changing Regulations and Radiation Guidance: What Does the Future Hold?" The following represents a synopsis of a few main points in the current draft commentary. It is likely that several changes will be forthcoming as SC 1-23 responds to subject matter expert review and develops a final document, expected by mid 2016.

Emerging issues in radiogenic cataracts and cardiovascular disease

In 2011, the International Commission on Radiological Protection issued a statement on tissue reactions (formerly termed non-stochastic or deterministic effects) to recommend lowering the threshold for cataracts and the occupational equivalent dose limit for the crystalline lens of the eye. Furthermore, this statement was the first to list circulatory disease (cardiovascular and cerebrovascular disease) as a health hazard of radiation exposure and to assign its threshold for the heart and brain. These changes have stimulated various discussions and may have impacts on some radiation workers, such as those in the medical sector. This paper considers emerging issues associated with cataracts and cardiovascular disease. For cataracts, topics dealt with herein include (i) the progressive nature, stochastic nature, target cells and trigger events of lens opacification, (ii) roles of lens protein denaturation, oxidative stress, calcium ions, tumor suppressors and DNA repair factors in cataractogenesis, (iii) dose rate effect, radiation weighting factor, and classification systems for cataracts, and (iv) estimation of the lens dose in clinical settings. Topics for cardiovascular disease include experimental animal models, relevant surrogate markers, latency period, target tissues, and roles of inflammation and cellular senescence. Future research needs are also discussed.

New challenges in high-energy particle radiobiology

Densely ionizing radiation has always been a main topic in radiobiology. In fact, α-particles and neutrons are sources of radiation exposure for the general population and workers in nuclear power plants. More recently, high-energy protons and heavy ions attracted a large interest for two applications: hadrontherapy in oncology and space radiation protection in manned space missions. For many years, studies concentrated on measurements of the relative biological effectiveness (RBE) of the energetic particles for different end points, especially cell killing (for radiotherapy) and carcinogenesis (for late effects). Although more recently, it has been shown that densely ionizing radiation elicits signalling pathways quite distinct from those involved in the cell and tissue response to photons. The response of the microenvironment to charged particles is therefore under scrutiny, and both the damage in the target and non-target tissues are relevant. The role of individual susceptibility in therapy and risk is obviously a major topic in radiation research in general, and for ion radiobiology as well. Particle radiobiology is therefore now entering into a new phase, where beyond RBE, the tissue response is considered. These results may open new applications for both cancer therapy and protection in deep space.

Biological Effects of Space Radiation and Development of Effective Countermeasures

As part of a program to assess the adverse biological effects expected from astronaut exposure to space radiation, numerous different biological effects relating to astronaut health have been evaluated. There has been major focus recently on the assessment of risks related to exposure to solar particle event (SPE) radiation. The effects related to various types of space radiation exposure that have been evaluated are: gene expression changes (primarily associated with programmed cell death and extracellular matrix (ECM) remodeling), oxidative stress, gastrointestinal tract bacterial translocation and immune system activation, peripheral hematopoietic cell counts, emesis, blood coagulation, skin, behavior/fatigue (including social exploration, submaximal exercise treadmill and spontaneous locomotor activity), heart functions, alterations in biological endpoints related to astronaut vision problems (lumbar puncture/intracranial pressure, ocular ultrasound and histopathology studies), and survival, as well as long-term effects such as cancer and cataract development. A number of different countermeasures have been identified that can potentially mitigate or prevent the adverse biological effects resulting from exposure to space radiation.

Occupational exposure to low doses of ionizing radiation and cataract development: a systematic literature review and perspectives on future studies

Ionizing radiation is a well-known but little understood risk factor for lens opacities. Until recently, cataract development was considered to be a deterministic effect occurring at lens doses exceeding a threshold of 5-8 Gy. Substantial uncertainty about the level and the existence of a threshold subsists. The International Commission on Radiation Protection recently revised it to 0.5 Gy. Based on a systematic literature review of epidemiological studies on exposure to low levels of ionizing radiation and the occurrence of lens opacities, a list of criteria for new epidemiological studies was compiled, and a list of potential study populations was reviewed. Among 24 publications finally identified, six report analyses of acute exposures in atomic bomb survivors and Chernobyl liquidators, and the others report analyses of protracted exposures in occupationally, medically or accidentally exposed populations. Three studies investigated a dose threshold: in atomic bomb survivors, the best estimates were 1 Sv (95 % CI <0-0.8 Sv) regarding lensectomies; in survivors exposed as children, 0.6 Sv (90 % CI <0.0-1.2 Sv) for cortical cataract prevalence and 0.7 Sv (90 % CI 0.0-2.8 Sv) for posterior subcapsular cataract; and in Chernobyl liquidators, 0.34 Sv (95 % CI 0.19-0.68 Sv) for stage 1 cataract. Current studies are heterogeneous and inconclusive regarding the dose-response relationship. Protracted exposures and high lens doses occur in several occupational groups, for instance, in physicians performing fluoroscopy-guided interventional procedures, and in accidentally exposed populations. New studies with a good retrospective exposure assessment are feasible and should be initiated.

Non-targeted effects of ionising radiation--implications for low dose risk

Non-DNA targeted effects of ionising radiation, which include genomic instability, and a variety of bystander effects including abscopal effects and bystander mediated adaptive response, have raised concerns about the magnitude of low-dose radiation risk. Genomic instability, bystander effects and adaptive responses are powered by fundamental, but not clearly understood systems that maintain tissue homeostasis. Despite excellent research in this field by various groups, there are still gaps in our understanding of the likely mechanisms associated with non-DNA targeted effects, particularly with respect to systemic (human health) consequences at low and intermediate doses of ionising radiation. Other outstanding questions include links between the different non-targeted responses and the variations in response observed between individuals and cell lines, possibly a function of genetic background. Furthermore, it is still not known what the initial target and early interactions in cells are that give rise to non-targeted responses in neighbouring or descendant cells. This paper provides a commentary on the current state of the field as a result of the non-targeted effects of ionising radiation (NOTE) Integrated Project funded by the European Union. Here we critically examine the evidence for non-targeted effects, discuss apparently contradictory results and consider implications for low-dose radiation health effects.

Update on imaging of the lacrimal drainage system

Epiphora is a common problem seen by the ophthalmologist. There are numerous etiologies of a watering eye, and the underlying diagnosis is not always clear. A variety of in-office examination techniques and procedures exist to aid with diagnosis and determination of appropriate therapy, but sometimes the diagnosis remains elusive, or an instituted therapy fails. Lacrimal imaging, particularly in these cases, can be helpful in assessing the function and anatomy of the lacrimal drainage system. This review serves to examine the literature of the last 10 years concerning imaging of the lacrimal drainage system.

Radiation cataract: clinicopathologic report

We report the case of a 52-year-old woman who developed bilateral anterior and posterior subcapsular cataracts with anterior capsule fibrosis 12 years after exposure to intensive radiation therapy. The woman had uneventful cataract surgery and gained 20/20 corrected distance visual acuity in both eyes. Hematoxylin-eosin staining of the anterior capsule revealed significant subcapsular scar formation in the context of fibroblast proliferation.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Eighth Warren K. Sinclair keynote address: Heavy ions in therapy and space: benefits and risks

Heavy charged particles produce biological damage that is different from that normally produced by sparsely ionizing radiation, such as x- or gamma-rays, which are a large component of the natural radiation background. In fact, as a result of the different spatial distribution of the energy deposited along the core and penumbra of the track, DNA lesions are exquisitely complex and difficult to repair. Relative biological effectiveness (RBE) factors are normally used to scale from x-rays to heavy ion damage, but it should be kept in mind that RBE depends on several factors (dose, dose rate, endpoint, particle energy, and charge, etc.), and sometimes heavy ions produce special damages that just cannot be scaled by x-ray damage alone. These special characteristics of heavy ions can be used to treat tumors efficiently, as it is currently done in Japan and Germany, but they represent a threat for human space exploration.

Space radiation protection issues

The complex charged particle environments in space pose considerable challenges with regard to potential health consequences that can impact mission design and crew selection. The lack of knowledge of the biological effects of different ions in isolation and in combination is a particular concern because the risk uncertainties are very high for both cancer and non-cancer late effects. Reducing the uncertainties is of high priority. Two principal components of space radiation each raise different concerns. Solar particle events (SPE) occur sporadically and are comprised primarily of low- to moderate-energy protons. Galactic cosmic radiation (GCR) is isotropic and relatively invariant in dose rate. GCR is also dominated by protons, but the energy range is wider than in SPE. In addition, the contribution of other light and heavy ions to the health risks from GCR must be addressed. This paper will introduce the principal issues under consideration for space radiation protection.

Radiation cataract

Until very recently, ocular exposure guidelines were based on the assumption that radiation cataract is a deterministic event requiring threshold doses generally greater than 2 Gy. This view was, in part, based on older studies which generally had short follow-up periods, failed to take into account increasing latency as dose decreased, had relatively few subjects with doses below a few Gy, and were not designed to detect early lens changes. Newer findings, including those in populations exposed to much lower radiation doses and in subjects as diverse as astronauts, medical workers, atomic bomb survivors, accidentally exposed individuals, and those undergoing diagnostic or radiotherapeutic procedures, strongly suggest dose-related lens opacification at significantly lower doses. These observations resulted in a recent re-evaluation of current lens occupational exposure guidelines, and a proposed lowering of the presumptive radiation cataract threshold to 0.5 Gy/year and the occupational lens exposure limit to 20 mSv/year, regardless of whether received as an acute, protracted, or chronic exposure. Experimental animal studies support these conclusions and suggest a role for genotoxicity in the development of radiation cataract. Recent findings of a low or even zero threshold for radiation-induced lens opacification are likely to influence current research efforts and directions concerning the cellular and molecular mechanisms underlying this pathology. Furthermore, new guidelines are likely to have significant implications for occupational and/or accidental exposure, and the need for occupational eye protection (e.g. in fields such as interventional medicine).

NASCA report 2: Longitudinal study of relationship of exposure to space radiation and risk of lens opacity

The NASA Study of Cataract in Astronauts (NASCA) was designed to measure the impact of exposure to space radiation on progression rates of cortical, nuclear, and posterior subcapsular cataract in U.S. astronauts who have flown in space and comparison groups of astronauts who had not flown in space, and subjects with a history of military aviation. We present our analyses of 5 years of data with an average of 3.8 exams per subject. All subjects had digital lens images with the Nidek EAS 1000 Lens Imaging System. Because of high variability and skewness of opacity measures, nonparametric methods were used to test for association between rates of opacification and space radiation exposure. First, median regression was used to collapse longitudinal data into robust estimates of progression rates (opacity severity compare to time for each eye of each subject). To quantify and test for a radiation effect, median regression with the dependent variable being the maximum of the two slopes (OD and OS) per subject was then used, adjusting for the confounding variables of age, nutritional, and sun-exposure histories. Median regression showed evidence of an association between the rate of cortical progression in the worse eye with radiation dose and age. The estimated median progression rate from space radiation being 0.25 ± 0.13% lens area/Sv/year (P = 0.062). We found no relationship between radiation exposure and progression of aggregate area of posterior subcapsular cataract or nuclear progression rates. However, longer follow-up may be needed to further understand any impact of space radiation on progression rates for posterior subcapsular cataracts and nuclear cataracts, and to characterize changes to visual acuity.

Implication of the miR-184 and miR-204 competitive RNA network in control of mouse secondary cataract

The high recurrence rate of secondary cataract (SC) is caused by the intrinsic differentiation activity of residual lens epithelial cells after extra-capsular lens removal. The objective of this study was to identify changes in the microRNA (miRNA) expression profile during mouse SC formation and to selectively manipulate miRNA expression for potential therapeutic intervention. To model SC, mouse cataract surgery was performed and temporal changes in the miRNA expression pattern were determined by microarray analysis. To study the potential SC counterregulative effect of miRNAs, a lens capsular bag in vitro model was used. Within the first 3 wks after cataract surgery, microarray analysis demonstrated SC-associated expression pattern changes of 55 miRNAs. Of the identified miRNAs, miR-184 and miR-204 were chosen for further investigations. Manipulation of miRNA expression by the miR-184 inhibitor (anti-miR-184) and the precursor miRNA for miR-204 (pre-miR-204) attenuated SC-associated expansion and migration of lens epithelial cells and signs of epithelial to mesenchymal transition such as α-smooth muscle actin expression. In addition, pre-miR-204 attenuated SC-associated expression of the transcription factor Meis homeobox 2 (MEIS2). Examination of miRNA target binding sites for miR-184 and miR-204 revealed an extensive range of predicted target mRNA sequences that were also a target to a complex network of other SC-associated miRNAs with possible opposing functions. The identification of the SC-specific miRNA expression pattern together with the observed in vitro attenuation of SC by anti-miR-184 and pre-miR-204 suggest that miR-184 and miR-204 play a significant role in the control of SC formation in mice that is most likely regulated by a complex competitive RNA network.

[Measurement of ocular lens ionizing radiation exposure after radioiodine therapy]

AIM

Current reports for the radiation cataracts contained a warning for deterministic effects at 1-2 Gy radiation single exposure for lens. Recently, the German Radiation Protection Board (SSK) published a document (234. SSK-Board) in that threshold dose for radiation cataracts is claimed at 0.5 Gy. The lens of the eye is recognized as one of the most radiosensitive tissues in the human body, and the International Commission on Radiological Protection (ICRP 103) has defined a limit of 150 mSv for its exposure.Recently, the ICRP lowered this limit down to 20 mSv per year.However, this limit does not apply to patients. Therefore, the question of the lens radiation exposure for patients underwent a radioiodine therapy (RIT) is a point at issue.

PATIENTS, METHODS

A total of 41 patients (age: 22-92 years) underwent a radioiodine therapy were included in the study. Optical stimulated luminescence dosimeters were used to measure the radiation exposure. The dosimeters were fastened nearby the patient's eye lens. The measurement was carried out up to 48 h after radioiodine application and the patients were divided into three groups. Group 1: patients underwent a diagnostic 131I whole body scan (mean activity: 370 MBq); group 2: thyriod carcinoma patients under RIT (mean activity: 3700 MBq); group 3: hyperthyroid patients under RIT (activity: 180-1237 MBq).

RESULTS

The cumulative exposure of the eye lens during the stay at the therapy unit (48 h) was 4.8 ± 0.7 mGy in group 1, 24.5-50.5 mGy in group 2 and 2.7-26.3 mGy in group 3, respectively. For the calculation of the expected cumulative dose, including follow-up after patient's dismissal, the effective half-lives were involved. The cumulative doses were obtained to be 6 ± 1 mGy in the first group, 63 ± 15 mGy in the second and 5-148 mGy in the third.

CONCLUSION

The results show that there exists a low risk for radiation cataract in a nuclear medicine therapy unit. After serial radioiodine therapies radiation-induced lens opacity cannot be expected.

ICRP publication 118: ICRP statement on tissue reactions and early and late effects of radiation in normal tissues and organs--threshold doses for tissue reactions in a radiation protection context

This report provides a review of early and late effects of radiation in normal tissues and organs with respect to radiation protection. It was instigated following a recommendation in Publication 103 (ICRP, 2007), and it provides updated estimates of 'practical' threshold doses for tissue injury defined at the level of 1% incidence. Estimates are given for morbidity and mortality endpoints in all organ systems following acute, fractionated, or chronic exposure. The organ systems comprise the haematopoietic, immune, reproductive, circulatory, respiratory, musculoskeletal, endocrine, and nervous systems; the digestive and urinary tracts; the skin; and the eye. Particular attention is paid to circulatory disease and cataracts because of recent evidence of higher incidences of injury than expected after lower doses; hence, threshold doses appear to be lower than previously considered. This is largely because of the increasing incidences with increasing times after exposure. In the context of protection, it is the threshold doses for very long follow-up times that are the most relevant for workers and the public; for example, the atomic bomb survivors with 40-50years of follow-up. Radiotherapy data generally apply for shorter follow-up times because of competing causes of death in cancer patients, and hence the risks of radiation-induced circulatory disease at those earlier times are lower. A variety of biological response modifiers have been used to help reduce late reactions in many tissues. These include antioxidants, radical scavengers, inhibitors of apoptosis, anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, growth factors, and cytokines. In many cases, these give dose modification factors of 1.1-1.2, and in a few cases 1.5-2, indicating the potential for increasing threshold doses in known exposure cases. In contrast, there are agents that enhance radiation responses, notably other cytotoxic agents such as antimetabolites, alkylating agents, anti-angiogenic drugs, and antibiotics, as well as genetic and comorbidity factors. Most tissues show a sparing effect of dose fractionation, so that total doses for a given endpoint are higher if the dose is fractionated rather than when given as a single dose. However, for reactions manifesting very late after low total doses, particularly for cataracts and circulatory disease, it appears that the rate of dose delivery does not modify the low incidence. This implies that the injury in these cases and at these low dose levels is caused by single-hit irreparable-type events. For these two tissues, a threshold dose of 0.5Gy is proposed herein for practical purposes, irrespective of the rate of dose delivery, and future studies may elucidate this judgement further.

Radiation and cataract

When this paper was about to go to press, the International Commission on Radiological Protection released a statement recommending a change in the threshold dose for the eye lens and dose limits for eye for occupationally exposed persons. It is clear that the earlier published threshold for radiation cataract is no longer valid. Epidemiological studies among Chernobyl clean-up workers, A bomb survivors, astronauts, residents of contaminated buildings, radiological technicians and recent surveys of staff in interventional rooms indicate that there is an increased incidence of lens opacities at doses below 1 Gy. Nevertheless, eye lens dosimetry is at a primitive stage and needs to be developed further. Despite uncertainties concerning dose threshold and dosimetry, it is possible to significantly reduce the risk of radiation cataract through the use of appropriate eye protection. By increasing awareness among those at risk and better adoption and increased usage of protective measures, radiation cataract can become preventable despite lowering of dose limits.

Significant reduction in dental cone beam computed tomography (CBCT) eye dose through the use of leaded glasses

OBJECTIVE

In light of the increased recognition of the potential for lens opacification after low-dose radiation exposures, we investigated the effect of leaded eyeglasses worn during dental cone-beam computerized tomography (CBCT) procedures on the radiation absorbed dose to the eye and suggest simple methods to reduce risk of radiation cataract development.

STUDY DESIGN

Dose measurements were conducted with the use of 3 anthropomorphic phantoms: male (Alderson radiation therapy phantom), female (CIRS), and juvenile male (CIRS). All exposures were performed on the same dental CBCT machine (Imtec, Ardmore, OK) using 2 different scanning techniques but with identical machine parameters (120 kVp, 3.8 mA, 7.8 s). Scans were performed with and without leaded glasses and repeated 3 times. All measurements were recorded using calibrated thermoluminescent dosimeters and optical luminescent dosimetry.

RESULTS

Leaded glasses worn by adult and pediatric patients during CBCT scans may reduce radiation dose to the lens of the eye by as much as 67% (from 0.135 ± 0.004 mGy to 0.044 ± 0.002 mGy in pediatric patients).

CONCLUSIONS

Leaded glasses do not appear to have a deleterious effect on the image quality in the area of clinical significance for dental imaging.

Risk for radiation-induced cataract for staff in interventional cardiology: is there reason for concern?

OBJECTIVES

To examine the prevalence of radiation-associated lens opacities among interventional cardiologists and nurses and correlate with occupational radiation exposure.

BACKGROUND

Interventional cardiology personnel are exposed to relatively high levels of X-rays and based on recent findings of radiation-associated lens opacities in other cohorts, they may be at risk for cataract without use of ocular radiation protection.

METHODS

Eyes of interventional cardiologists, nurses, and age- and sex-matched unexposed controls were screened by dilated slit lamp examination and posterior lens changes graded using a modified Merriam-Focht technique. Individual cumulative lens X-ray exposure was calculated from responses to a questionnaire and personal interview.

RESULTS

The prevalence of radiation-associated posterior lens opacities was 52% (29/56, 95% CI: 35-73) for interventional cardiologists, 45% (5/11, 95% CI: 15-100) for nurses, and 9% (2/22, 95% CI: 1-33) for controls. Relative risks of lens opacity was 5.7 (95% CI: 1.5-22) for interventional cardiologists and 5.0 (95% CI: 1.2-21) for nurses. Estimated cumulative ocular doses ranged from 0.01 to 43 Gy with mean and median values of 3.4 and 1.0 Gy, respectively. A strong dose-response relationship was found between occupational exposure and the prevalence of radiation-associated posterior lens changes.

CONCLUSIONS

These findings demonstrate a dose dependent increased risk of posterior lens opacities for interventional cardiologists and nurses when radiation protection tools are not used. While study of a larger cohort is needed to confirm these findings, the results suggest ocular radio-protection should be utilized.