Author: Claude (AI), from PubMed abstracts · Reviewed by: Dr Mina Abdelmseih · Reviewed: 2026-11-15 · Review due: 2027-11-15

Educational content only. Not personalised medical advice. Clinical decisions remain the responsibility of the treating clinician.

Radiation retinopathy

Radiation retinopathy and radiation maculopathy are common, vision-threatening complications of ocular and periocular radiotherapy, particularly after treatment of uveal melanoma [S12]. They result from progressive occlusive microangiopathy causing retinal ischaemia, macular oedema and visual decline [S12]. Intravitreal anti-VEGF therapy is the current standard of care and can also be used to prevent maculopathy in high-risk eyes [S10] [S12].

Key points - After iodine-125 brachytherapy in the COMS, 91.2% of patients had at least one posterior pole abnormality at 5 years, and optic neuropathy was present in 27.4% [S2]. - Risk rises with diabetes, hypertension, radiation dose and fractionation, and tumour location near the optic nerve and fovea [S2] [S11]. - In a meta-analysis, prophylactic anti-VEGF reduced radiation maculopathy (OR 0.40) and treatment of established maculopathy improved visual acuity [S10]. - Monthly ranibizumab gave better vision than as-needed dosing in a phase IIb RCT; adding targeted laser gave no benefit [S6]. - Intravitreal dexamethasone is an option for suboptimal response to, or contraindications for, anti-VEGF [S7].

Evidence last checked: 2026-10-17 (PubMed abstracts).

Red flags

• Vision loss after ocular radiotherapy. Retinopathy and optic neuropathy increase in amount and severity through 8 years after brachytherapy [S2].
• Iris neovascularisation or neovascular glaucoma. At 4 years after plaque radiotherapy with prophylactic bevacizumab, these developed in 13% and 12% of large melanomas [S5].
• Diabetes. Diabetes was a prognostic factor for more severe posterior pole abnormalities [S2].
• Stopping treatment. The benefit of ranibizumab over laser disappeared after injections were stopped [S4].

Recognise it

• Clinical signs include macular oedema, retinal haemorrhages, cotton-wool spots, capillary dropout and neovascularisation [S1] [S9].
• The commonest findings in the COMS were macular microaneurysms (75.6% of examinations), macular angiographic leakage (75.1%) and optic disc hyperfluorescence (62.8%) [S2].
• Neovascularisation of the disc was present in 5.2% at 5 years [S2].
• Large tumours had a higher 4-year risk of cystoid macular oedema (63%) and earlier onset (19 months) than small or medium tumours [S5].

Confirm it

• OCT and OCT angiography detect subclinical oedema and microvascular ischaemia before changes are visible on fundoscopy [S12]; radiation vasculopathy appears on OCT-A before clinical signs or symptoms [S9].
• Ultra-widefield fluorescein angiography helps early detection [S11].
• Classification systems combining fundus, angiographic and OCT features allow standardised grading [S12].

Manage it

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Tier A (primary care / no specialist)

• Anyone who has had radiotherapy to or near the eye and reports reduced vision needs an eye examination (see Refer when) [S2] [S12].
• Optimise control of diabetes and hypertension, which are risk factors [S11] [S12].

Tier B (general eye clinic)

• Examine with OCT where available; it shows oedema before fundus changes [S12].
• Check the iris and intraocular pressure for neovascularisation, especially after treatment of large tumours [S5].
• Coordinate with the treating ocular oncology service; intravitreal therapy can be given where injection services exist [S7].

Tier C (specialist centre)

1. Anti-VEGF for established maculopathy. Anti-VEGF agents have the strongest evidence for reducing oedema and preserving vision, though no agent is clearly superior and most data are non-comparative [S12]. In a meta-analysis of 4 trials (189 eyes), anti-VEGF improved acuity and reduced central macular thickness over 6 months [S10].
2. Regimen. In a phase IIb RCT of 40 eyes, monthly ranibizumab 0.5 mg (as reported in [S6]) gained 4.0 letters at 1 year versus 0.9 with as-needed dosing plus laser [S6]. After switching to treat-and-extend in year 2, the gains were not maintained, although 90% kept 20/200 or better [S8]. Ranibizumab was superior to focal and panretinal laser at 6 months in a small RCT, but the effect disappeared by 52 weeks after treatment stopped [S4].
3. Bevacizumab. In an early series of 21 patients, bevacizumab 1.25 mg every 6-12 weeks, as reported in [S1], reduced haemorrhage, exudation and oedema, with acuity stable or improved in 86% [S1].
4. Prophylaxis. In 4 trials (2226 eyes), preventive anti-VEGF reduced radiation maculopathy over 24 months [S10]. In a pilot study of 40 patients after proton beam therapy, ranibizumab every 2 months kept 97% at 20/200 or better versus 45% of historical controls [S3]. Earlier anti-VEGF intervention typically preserved more macular anatomy and vision [S9].
5. Corticosteroids. Intravitreal dexamethasone implant is an option for suboptimal response or contraindications to anti-VEGF [S7]. A trial of prophylactic faricimab or fluocinolone acetonide implant versus observation is under way [S11].
6. Laser. Retinal laser alone gave poor outcomes historically [S7]; targeted laser added nothing to ranibizumab [S6].

Refer when

Pitfalls

• Waiting for vision loss before treating high-risk eyes: earlier treatment preserves more vision [S9].
• Extending injection intervals too fast: gains fell after switching to treat-and-extend [S8] [S10].
• Relying on fundoscopy alone: OCT detects subclinical disease [S12].
• Assuming laser is an adequate substitute for anti-VEGF [S4] [S7].

Evidence notes

• Most treatment evidence is from small or retrospective studies [S7] [S12]; the RCTs are small phase II trials [S4] [S6].
• The prophylaxis pilot used historical controls [S3].
• [S1] and [S9] are from the same research group that first described anti-VEGF for this condition.
• Not covered by these sources: aflibercept and faricimab dosing, treatment of radiation optic neuropathy in detail, and evidence-based referral timings.

Related articles

• Uveal melanoma: diagnosis and primary treatment
• Diabetic Macular Oedema

References

See the numbered source list below. Each marker [S#] links to its PubMed and DOI record.