Posterior Vitreous Detachment and the Associated Risk of Retinal Toxicity with Intravitreal Melphalan Treatment for Retinoblastoma

Abstract

Background/Aims: The presence of a posterior vitreous detachment (PVD) may play a role in the development of severe retinal toxicity following intravitreal melphalan (IVM) injection for vitreous seeding. We aimed to evaluate the incidence of PVD in retinoblastoma eyes and its association with retinal toxicity after IVM. Methods: We reviewed 112 eyes of 81 retinoblastoma patients with B-scan images available for review from 2010 to 2017. A cohort with vitreous seeding treated with IVM was compared to a cohort that did not undergo injection. The primary outcome measure was the presence of PVD at diagnosis and after treatment. Secondary measures included IVM-associated retinal toxicity and other ocular complications. Results: The incidence of PVD was 20% at diagnosis, and in eyes with B-scans available both at diagnosis and after treatment 18% of eyes developed a PVD over the course of therapy, more frequently after IVM (p = 0.05). Of 34 eyes receiving IVM treatment, the incidences of posterior segment toxicity and globe salvage were similar between eyes with and without PVD (p = 0.4015 and 0.52, respectively). Conclusion: In this cohort of patients, there did not appear to be an association with the presence of PVD during IVM and the development of retinal toxicity.

A Rare Case of Acute Hemorrhagic Retinopathy Following Intravitreal Melphalan Injection for Persistent Vitreous Seeds in Retinoblastoma

“…12,13 The proposed mechanisms reported in the literature include the induction of a posterior vitreous detachment following a prior intravitreal injection and/or an endophytic tumor with vitreous seeds that causes apical disruption of the internal limiting membrane–posterior hyaloid complex. 12,14 Hence, severe hemorrhagic occlusive retinal vasculopathy can potentially be avoided by visualizing the needle tip behind the lens under the operating microscope and injecting slowly to form a cloud of drug in the midvitreous cavity. Ultrasonography to identify a posterior hyaloid detachment as well as shaking of the eyeball with 2 forceps or a cotton-tip applicator post injection to diffuse the drug uniformly into the vitreous cavity have been proposed to avoid this complication.…”

Vitreous Seed Classification and Regression Patterns in Eyes With Retinoblastoma

“…Only a few reports of hemorrhagic retinal toxicity following intravitreal melphalan has been reported to date. [21][22][23] In general, there are some safety concerns with IvitC that warrant a review of the current recommendations. First, this procedure should be performed under the direction of an expert pediatric ocular oncologist.…”

“…Only a few reports of hemorrhagic retinal toxicity following intravitreal melphalan has been reported to date. 21 -23…”

Intravitreal Melphalan for Retinoblastoma: The Impact of Toxicity on Recurrence and Ultimate Globe Salvage

“…While rare, severe hemorrhagic toxicity leading to diffuse chorioretinal and optic atrophy has also been described [9]. Although severe toxicity was initially thought to be associated with posterior vitreous detachment, thus concentrating the chemotherapy to the retina, a review of a larger cohort of patients failed to find an association between posterior vitreous detachment and toxicity [10]. A recent publication from a Chinese cohort described significant toxicity: 40% of patients with grade 3 or higher toxicity, 40% with vascular occlusion (similar to the acute hemorrhagic presentation), 40% anterior toxicity, and upwards of 20% with optic atrophy [11].…”