Eye Salvage with Combination of Intravitreal and Intracameral Melphalan Injection for Recurrent Retinoblastoma with Anterior Chamber Involvement: Report of a Case

Abstract

Aims: Herein we report successful eye salvage following combined intravitreal and intracameral administration of melphalan for anterior chamber recurrence of retinoblastoma. Methods: A 12-month-old boy was referred with a sporadic bilateral retinoblastoma staged as group D and V in the right eye and group E and V in the left eye. Treatment initially involved 6 cycles of 3 drugs followed by focal treatments. The left eye was enucleated. Three months after the end of systemic chemotherapy, multiple recurrent lesions were noted in the ciliary body and the anterior chamber. A series of intravitreal (IVT) and intracameral (IC) injections of melphalan combined with a 7th cycle of systemic chemotherapy was performed. The therapeutic schedule alternated: week A an IVT of melphalan (30 μg/0.1 mL) for a total of 4 versus week B IC injections of melphalan (15 μg/0.05 mL) 4 IC in total. Each injection was preceded by an anterior chamber. Cryotherapy to the injection punctures was systematically performed. Results: Rapidly, iris and ciliary body nodules regressed completely based on clinical and ultrasound biomicroscopic examinations. After 3 years of follow-up, the patient has shown no evidence of recurrence. Conclusion: In our patient, combined IVT and IC administration of melphalan proved highly efficacious in eradicating the ciliary body and anterior chamber disease and salvage of his one remaining functional eye.

Conservative management of retinoblastoma: Challenging orthodoxy without compromising the state of metastatic grace. “Alive, with good vision and no comorbidity”

“…Alternatively, it is also possible to inject very small volumes of highly concentrated drug without prior anterior chamber tap, i.e. 0.015 ml at 500 μg/ml (7.5 μg) of topotecan (Paez-Escamilla et al, 2017), or 0.05 ml at 30 μg/ml (15 μg) of melphalan (Cassoux et al, 2017). This technique, however, is suboptimal regarding the drug concentration achieved in the aqueous humor, with a risk of underexposure at the level of the posterior chamber.…”

Current Indications of Secondary Enucleation in Retinoblastoma Management: A Position Paper on Behalf of the European Retinoblastoma Group (EURbG)

“…Similarly, the use of intravitreal anti-VEGF injections performed according to the same technique as intravitreal chemotherapy has permitted the eye-preserving management of treatment- or tumor-related neovascular complications, earlier commonly treated with immediate enucleation [ 80 ]. Finally, the more recent inception in 2015 of a technique adapted to inject safely into the anterior and posterior chambers, namely intracameral chemotherapy [ 81 , 82 ], has shown promising results for the control of aqueous seeding [ 57 , 83 , 84 ], previously also treated with immediate enucleation.…”

Aqueous seeding in intraocular retinoblastoma: A review

“…Two intravitreal injections of topotecan subsequently achieved complete tumour control, 33 suggesting the possible role of intravitreal chemotherapy as an adjunct treatment modality in such cases. Similarly, Cassoux et al achieved complete tumour control in an eye with recurrent RB with AC seeds and ciliary body disease, by alternating use of intravitreal chemotherapy (four injections of melphalan 30 μg/0.1 ml) and intracameral chemotherapy (four injections of melphalan 15 μg/0.05 ml) 37 . In this eye, both intravitreal and intracameral chemotherapy would have helped in achieving the tumour control.…”