Abstract
Radiation is the most common life and sight-sparing treatment for eye cancer patients. However, it can subsequently lead to a dose-dependent, progressive radiation vasculopathy, which results in retinopathy- or optic neuropathy-related vision loss. Before the advent of intravitreal drug therapy, laser destruction of the ischemic retina was found to be effective for select patients. However, in 2006, the anti-vascular endothelial growth factor bevacizumab was found to trigger regression and suppress radiation maculopathy and optic neuropathy. Anti-vascular endothelial growth factor drugs were administered initially to forestall vision loss in patients with clinically significant disease. Advancements in retinal imaging and a better understanding of their capabilities resulted in earlier intervention with anti-vascular endothelial growth factor treatment. Still, not all the radiation damage to the retina was reversible. To prevent this irreversible injury, periodic anti-vascular endothelial growth factor therapy was given to those patients at the highest risk of developing radiation-related maculopathy within six months of high-dose foveal plaque radiation therapy. This research found that treating patients before clinically evident radiation maculopathy prevented or delayed the onset of radiation maculopathy with preservation of vision. Other strategies to prevent vision loss due to progressive, recalcitrant retinopathy have included the off-label use of alternative therapeutic agents and polypharmacy with intravitreal steroids. These therapeutic agents should be evaluated in protocols where intervention can be guided by optical coherence tomography angiography as subclinical obliterative retinal microangiopathy appears to start at the time of or soon after ocular irradiation. Treatment strategies have evolved, especially as our understanding of the condition has improved. We propose that future protocols take advantage of new therapies, use advances in retinal imaging, and employ novel technologies to establish optimal treatment regimens.