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Original Investigation |

Vision Loss Following Episcleral Brachytherapy for Uveal Melanoma Development of a Vision Prognostication Tool

Hassan A. Aziz, MD1; Nakul Singh, MS2; James Bena, MS3; Allan Wilkinson, PhD4; Arun D. Singh, MD1
[+] Author Affiliations
1Department of Ophthalmic Oncology, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
2Case Western Reserve University School of Medicine, Cleveland, Ohio
3Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
4Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
JAMA Ophthalmol. 2016;134(6):615-620. doi:10.1001/jamaophthalmol.2016.0104.
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Importance  Vision loss following episcleral brachytherapy for uveal melanoma is difficult to predict for individual patients.

Objective  To generate a risk calculator for vision loss following episcleral brachytherapy for uveal melanoma.

Design, Setting, and Participants  A retrospective review of data was conducted at a multispecialty tertiary care center in Cleveland, Ohio. All patients with primary ciliary body or choroidal melanoma treated with iodine 125 or ruthenium 106 episcleral brachytherapy between January 1, 2004, and December 30, 2013, were included. Univariate and multivariable Cox proportional hazards were used to determine the influence of baseline patient factors on vision loss. Kaplan-Meier curves (log-rank analyses) were used to estimate freedom from vision loss. Bootstrap resampling was performed to bias correct this estimate.

Main Outcomes and Measures  Vision loss (to visual acuity [VA] worse than 20/50 and worse than 20/200).

Results  A total of 311 patients were included in the study, with a mean (SD) age of 62 (14.7) years at start of treatment and a median follow-up of 36 months (interquartile range, 18-60 months). At presentation, VA was better than or equal to 20/50 in 199 patients (64%) and better than or equal to 20/200 in 289 patients (93%). By Kaplan-Meier analysis, VA less than 20/200 at 3 years was not associated with sex, diabetes, systemic hypertension, or hypercholesterolemia but was associated with history of ocular comorbidities, type of isotope (ruthenium 106 or iodine 125), and initial VA ( >20/50 or <20/50). By multivariable analysis, age (hazard ratio [HR], 0.97; 95% CI, 0.94-1.00; P = .06), largest basal diameter (HR, 1.25; 95% CI, 1.16-1.34; P = <.001), total radiation dose to the fovea (HR, 1.03; 95% CI, 1.01-1.04; P = .001) and optic disc (HR, 1.01; 95% CI, 1.00-1.01; P = .005), and initial VA worse than 20/50 (HR, 1.85; 95% CI, 1.20-2.85; P = .005) were predictive of vision loss to a VA of less than 20/200. The concordance index for the full data set was 0.77. Using these data, an online risk calculator was developed to predict vision loss following episcleral brachytherapy.

Conclusions and Relevance  The vision prognostication tool presented herein needs to be validated by independent data sets. This tool may improve counseling for patients being evaluated for episcleral brachytherapy. At-risk individuals identified by this tool could be considered for inclusion into trials exploring prevention or treatment of radiation retinopathy and alternative therapies of uveal melanoma.

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Figure 1.
Nomogram for Prediction of Visual Acuity

Nomogram for prediction of visual acuity better than or equal to 20/200 at 1 and 3 years.

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Figure 2.
Actual vs Predicted 1-Year Vision Retention

The calibration plot for visual acuity better than or equal to 20/200 (sample size = 289; 100 patients with vision loss; 7 parameters in the model; 1000 bootstrap sample). Ideally, the plots of predicted and actual risk measures would be close to the “ideal” line (black line). The concordance index for the full data set was 0.77. These statistics reflect that approximately 77% of the time, those with vision loss were correctly identified by the model. The steady increase in the points on the calibration curve indicate that actual and predicted risk levels are generally well matched, except at the very high end of distribution, where predicted vision retention exceeds the actual vision retention. Error bars indicate 95% CIs. Filled points indicate model-predicted vision retention rates; empty points indicate bootstrap (optimism)-adjusted vision retention rates. Tick marks at the top of the graph indicate the distribution of participants.

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