Eye

**Approximately the other 25% of eye tumors are retinoblastomas, but these tumors present more than any other eye tumor in children.3 ** Spindle Cell(30%):  Type A - Best prognosis, 5-yr OS rate = 95% Type B - Intermediate prognosis, 5-yr OS rate = 85%  * Mixed Cell (65%): Contains spindle and epithelioid cells, 5-yr OS rate = 83% * Epithelioid Cell (5%): Worse prognosis, 5-yr OS rate = 60% [4] **__Retinoblastoma: __ **is a small round blue cell tumor derived from cells of neural crest origin. [3] <span style="background-color: transparent; color: lime; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">__<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: underline; vertical-align: auto;">Eyelid: __ **<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">The histology of cancers of the eyelid can be basal cell<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;"> or squamous cell<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">. [3] <span style="background-color: transparent; color: lime; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">__<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: underline; vertical-align: auto;">Intraocular Melanoma: __ ** * <span style="background-color: transparent; color: lime; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: windowtext; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Spindle cell melanoma (cells are longer and tapered at the ends) * <span style="background-color: transparent; color: lime; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: windowtext; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Epithelioid melanoma (cells are oval-shaped) * <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Mixed cell melanoma<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;"> (both spindle and epithelioid)[4] || <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">[5] || <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">T1-5 mm or less in greatest dimension <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">T2->5mm in greatest dimension, without invasion of adjacent structure  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">T3-Tumor invades adjacent structures, excluding orbit  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">T4-Tumor invades orbit  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">TNM classification for melanoma of the conjunctiva <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; text-indent: 0.25in; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">T1-Tumors of bulbar conjunctiva occupying one quadrant or less  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; text-indent: 0.25in; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">T2-Tumors of bulbarf conjunctiva occupying more than one quadrant  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; text-indent: 0.25in; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">T3-Tumors of conjunctival fornix and/or palpebral conjunctiva and/or caruncle  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; text-indent: 0.25in; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">T4-Tumor invades eyelid, cornea and/or orbit  **International classification of retinoblastoma** <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;">Group A- Small tumor<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">- retinoblastoma less than or equal to 3mm  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;">Group B- Larger tumor<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">-Retinoblastoma >3mm or  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Macular retinoblastoma location or  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Juxtapupillary retinoblastoma location or  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Subretinal fluid  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;">Group C- Focal seeds- <span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Retinoblastoma with subretinal seeds < or equal to 3mm or  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Vitreous seeds < or equal to 3mm from retinoblastoma  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Vitreous seeds < or equal to 3mm from retinoblastoma  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Both subretinal and vitreous seeds < or equal to 3mm from retinoblastoma  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;">Group D- Diffused Seeds<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">-  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Retinblastoma with subretinal seeds >3mm from retinoblastoma  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Vitreous seeds >3mm from retinoblastoma  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Both subretinal and vitreous seeds 3mm from retinoblastoma  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;">Group E- Extensive- <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Neovascular glaucoma  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Opaque media from hemorrhage in ant. Chamber, vitreous, or subretinal space <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Invasion of postlaminar optic nerve, choroid (>2mm), sclera, orbit, ant chamber  <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; margin-left: 0.25in; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">[7]  || The AJCC has developed staging systems for iris melanoma, ciliary body and choroidal melanoma, and intra-ocular lymphoma. This staging system is very detailed and an in depth explanation can be found at: []. Several different staging systems exist for retinoblastomas, but the most commonly used system is the Reese-Ellsworth Classification.[1] This system entails: The TGNM staging system is used for Rhabdomyosarcomas and takes into account histology.[1] The TGNM staging system looks like: Stage groupings for this staging system include:
 * Epidemiology: || **<span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Seventy-five percent of malignant eye tumors are formed from malignant melanoma.3 This is often presented in the uvea (middle coat) of the eye. The anterior uvea cases are more easily detected, thus diagnosed earlier than posterior uvea cases. Anterior uvea cases are often resected by iridectomy or iridocyclectomy, and posterior cases often need more extensive surgery, which can often include total removal of the eye. The uvea is a common site for metastatic spread of breast, lung and gastrointestinal primary disease. **
 * <span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">There are many types of cancer that affects the surrounding tissue of the eye. The eyelid is susceptible to basal and squamous cell carcinoma, and also the meibomian gland is a sebaceous gland, producing sebaceous gland carcinoma.3 Optic gliomas are tumors of the nervous system tumors (approximately 1%) and is common in children under the age of 15 years. This type of tumor involves the optic chiasm 50% of the time. Lacrimal glad tumors also occur. The orbit can be a site of malignant lymphoma or produce a tumor known as a rhabdomyosarcoma. ** ||
 * Etiology: || **<span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Retinoblastomas are a recessive hereditary trait in approximately 40% of cases, formed by a deletion on the long arm of chromosome 13.3 Melanoma of the eye can be a result ultraviolet ray exposure and is more likely to occur in people that have a high risk of burning such as people with lighter skin.11 ** ||
 * Signs & Symptoms: || **<span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Malignant melanoma can often be seen as a discoloration or possibly iris deformation if the disease affects the anterior portion of the eye.9 Other symptoms include bulging of the eye, pain in or around eye due to swelling, declining vision. Retinoblastomas initially present themselves through symptoms such as squinting and white papillary reflex (leukochoria), along with a mass in the fundus.3 These symptoms present between 6-24 months. Rhabdomyosarcomas presents with swelling of the tissue surrounding the eye or bulging of the eye. ** ||
 * Diagnostic Procedures: || **<span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Retinal drawings and photographs, along with ultrasound studies and a complete examination of the eye preformed for diagnosis for retinoblastomas.3 Diagnosis of malignant melanoma is also preformed similarly, but may include a biopsy.9 ** ||
 * Histology: || **<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">__<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: underline; vertical-align: auto;">Ocular Melanoma: __ ** *
 * Lymph Node Drainage: || <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Research is still underway to determining the role of lymphatics of eye cancer. Studies to identify lymphatic channels are being performed. Molecular biology and endothelial cell markers are being used to determine lymphatics <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">[[image:schlemms_canal.jpg width="293" height="272" caption="Schlemm’s canal"]] <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Schlemm's canal **<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">, also known as **<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">canal ****<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"> of Schlemm ** or the **<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">scleral venous sinus **, acts as a lymph node, is a circular channel in the eye that collects aqueous humor from the anterior chamber and delivers it into the bloodstream via the anterior ciliary veins. .[6]  ||
 * Metastatic Spread: || <span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">Most malignant melanomas metastasize through a hematogenous route <span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">to distant organs. Eighty-five percent <span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;">of metastatic choroidal melanoma will be initially found in the liver.<span style="background-color: transparent; color: lime; font-family: Times New Roman; font-size: 16px; text-decoration: none; vertical-align: auto;"> Metastases can be discovered by blood tests (liver function studies) when a patient has no symptoms. Other sites include the subcutaneous nodules, lung, bone and brain metastasis.
 * Grading: || TNM classification for squamous cell carcinoma of conjunctiva
 * Staging: || The American Joint Commission on Cancer (AJCC) utilized the "TNM" staging system for eye cancers. The staging system is used to provide simple terminology to the extent of a person's disease. Several different staging systems exist for eye cancers.
 * Group 1: Very Favorable
 * A. Solitary tumor, less than 4 disc diameters, at or behind the equator
 * B. Multiple tumors, none greater than 4 disc diameters, all behind the equator
 * Group 2: Favorable
 * A. Solitary tumor, 4-10 disc diameters in size, at or behind the equator
 * B. Multiple tumors, 4-10 disc diameters in size, at or behind the equator
 * Group 3: Doubtful
 * A. Any lesion anterior to the equator
 * B. Solitary tumors greater than 10 disc diameters behind the equator
 * Group 4: Unfavorable
 * A. Multiple tumors, some greater than 10 disc diameters
 * B. Any lesion extending anterior to the ora serrata
 * Group 5: Very Unfavorable
 * A. Tumors involving more than half the retina
 * B. Vitreous seeding
 * T1: Confined to anatomic site of origin
 * T1a: less than 5 cm in diameter
 * T1b: greater than 5 cm in diameter
 * T2: Extension and/or fixation to surrounding tissue
 * T2a: less than 5 cm in diameter
 * T2b: greater than 5 cm in diameter
 * G1: favorable histology
 * G2: unfavorable histology
 * GX: insufficient tumor for histologic classification
 * N0: regional nodes not involved
 * N1: regional nodes involved
 * M0: no distant metastasis
 * M1: distant metastasis
 * Stage 1: T1 (a or b), G1, N0, M0
 * Stage 2: T2 (a or b), G1, N0, M0
 * Stage 3: T1 or T2, N1, M0
 * Stage 4: Any M1 ||
 * Radiation Side Effects: ||  || **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">deficiency3 ** ||

<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;"> <span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;"> <span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;"> **__<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Figure 3 __** <span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;"> **__<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Figure 4. __** **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">The NTTDs of organs in the involved field according to mild to moderate and severe to fatal morbidity combined are demonstrated in Table 1. ** || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Table 1 ****<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 13px; line-height: 150%;">2 ** |||||||| **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">NTTDs of Organs within the Involved Eye Irradiated Fields ** || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Veins ** || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Sclerosis **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">>8000 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">>10,000 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">100cm **  || References: <span style="background-color: transparent; color: lime; font-family: 'Times New Roman',Times,serif; font-size: 70%; text-decoration: none; vertical-align: auto;">
 * Prognosis: || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Ocular melanomas that are anteriorly located in the anterior choroid or ciliary body have the worst prognosis. Extraocular extension of melanomas of the uvea implies a poor prognosis as well. Ocular melanomas of the spindle cell type have a better survival prognosis, mixed cell types have an intermediate survival rate, and epitheliod & necrotic melanomas have the poorest survival prognosis. In addition to the these prognostic factors, larger & thicker tumors indicate poor prognosis.1 ****<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">The prognosis of orbital lymphomas is dependent of histological subtype. Ocular lymphomas that involve the central nervous system have a dismal prognosis.Lacrimal gland tumor prognosis is related to the presence of necrosis, perineural invasion, hemorrhage, and high miotic counts. Orbital meningiomas have a similar prognosis as intracranial meningiomas due to similar histology.1 ** ||
 * Treatments: || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Radiation treatment techniques for cancers of the eye include: plaque therapy for ocular melanomas, electron therapy for skin lesions near the eye, wedged pair for unilateral orbit, opposed laterals for bilateral orbits, enface globe electron with a hanging lens block and IMRT for optic nerve gliomas and meningiomas. **
 * <span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Plaque Therapy is often used for treatment of ocular melanomas. **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Several isotopes can be utilized in this modality of treatment. Some common isotopes used are Cobalt-60, Gold-198, Palladium-103, Iodine-125 and Irridium-192. The advantage of using radioactive isotopes is the low energy gamma rays and their decreased need for shielding there are many types of applicators that can be used for plaque therapy. The most often used applicator is the COMS plaque which offers shielding of lateral and posterior structures.1 **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Electron Therapy is used when there is skin involvement close to the eye. A tungsten shield may be used to preserve the globe when 6MeV electrons are used. 1 Typical dose ranges from 4500cGy-6000cGy. **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Wedged Pair technique is used when only one eye is involved. This unilateral approach utilizes a wedged pair technique which allows for conformity around the area of interest being treated while minimizing dose to normal tissues.1 **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Opposed Lateral field arrangement with non-divergent beams posteriorly or split beam techniques are used when both eyes are involved. Examples of when this technique would be used are for treatment of Grave’s disease, bilateral choroid metastasis, and lymphomas in both eyes.1 An isodose plan for opposed lateral ports is demonstrated in Figure 1. **
 * __<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Figure 1. __**
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Enface Electron with a Hanging Eye Block techniques are used when the conjunctiva requires only the anterior structures of the eye to be treated. The beam can be set en face to the cornea. A hanging eye block can be employed and the patient instructed to stare at it during treatment in order to preserve the lens of the eye. 1 An example of a hanging eye block technique is demonstrated in Figures 2-4. **
 * __<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Figure 2 __****<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">. Viewthrough the electron cone with hanging eye block blocking the lens. **
 * <span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">IMRT technique of radiotherapy offers an advantage when treating the optic nerve. Critic structures can be identified so that dose constraints **
 * <span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">can be applied.1 ** ||
 * TD5/5: || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">The TD 5/5 is the total dose delivered via a conventional radiation fractionation schema that will cause a minimum of 5% complication rate within 5 years. The TD 50/5 is the total dose delivered via a conventional fractionation schema that will cause a minimum of 50% complication rate within 5 years. These doses are known as normal tissue tolerance doses (NTTDs) The NTTDs are classified into mild to moderate and severe to fatal categories.2 **
 * <span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">The volume of tissue being irradiated and the fractionation size directly affects NTTDs. Generally the whole organ can tolerate larger doses if the volume of the organ receiving dose is small. As volume increases tolerance decreases. 2 **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">ORGAN ** || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">INJURY **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">TD 5/5 (cGy) **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">TD50/5 **   **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">(cGy) **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">WHOLE/ **   **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">PARTIAL ORGAN **  ||
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Eye ** ||  ||   ||   ||   ||
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Retina ** || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Blindness **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">5500 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">7000 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Whole **  ||
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Cornea ** || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Blindness **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">5000 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">>6000 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Whole **  ||
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Lens ** || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Blindness **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">500 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">1200 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Whole/Part **  ||
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Optic Chiasm ** || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Blindness **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">4500 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">6500 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Whole **  ||
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Optic Nerve ** || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Blindness **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">5000 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">6500 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Whole **  ||
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Peripheral Nerves ** || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Neuritis **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">6000 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">10,000 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">10cm **  ||
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Arteries/ **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Brain ** || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Infarction/ **   **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Necrosis **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">5000-6000 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">6000-7000 **  ||  **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Whole **  ||   ||
 * 1) **<span style="color: #215868; font-family: 'Cambria','serif'; font-size: 16px; line-height: 150%;">1 ** **<span style="color: #215868; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Gunderson & Tepper. Orbital, Ocular, and Optic Nerve Tumors. In //Clinical Radiation Oncology.// 2nd ed. Philadelphia, PA: Elsevier, Churchill & Livingstone: 2007: 616-623. **
 * 2) **<span style="color: #7030a0; font-family: 'Cambria','serif'; font-size: 16px; line-height: 150%;">2 ** **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Washington, C.M. & Leaver, D. Overview of Radiobiology. In //Principles and Practice of Radiation Therapy.// 3rd ed. St. Louis, MO: Elsevier; 2010:80-82. **
 * 3) **<span style="color: #002060; font-family: 'Cambria','serif'; font-size: 16px; line-height: 115%;">3 ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Chao KSC, Perez CA, Brady LW. Pituitary. In: Chao KSC, Perez CA, Brady LW, eds. //Radiation Oncology Management Decisions.// Philadelphia, PA: Lippincott Williams & Wilkins; 2002:223-233. **
 * 4) **<span style="color: #00b050; font-family: 'Cambria','serif'; font-size: 16px; line-height: 150%;">4 ** **<span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Perez and Brady’s Principles and Practice of Radiation Oncology. 5th Edition. PA 2008: 778-796. Lippincott Williams and Wilkins **
 * 5) **<span style="color: #00b050; font-family: 'Cambria','serif'; font-size: 16px; line-height: 150%;">5 ** **<span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Dasher, BG & Vann, AM. //Portal Design in Radiation Therapy//. 2nd edition. Philadelphia, PA: DWV Enterprises. 2006: 64-65. **
 * 6) **<span style="color: #00b050; font-family: 'Cambria','serif'; font-size: 16px; line-height: 150%;">6 ** **<span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Washington, C.M & Leaver, D.(Eds.).(2004). //Principles and Practice of Radiation Therapy// (Second ed). Pg.640-641.St. Louis, Missouri; Mosby Inc **
 * 7) **<span style="color: #00b050; font-family: 'Cambria','serif'; font-size: 16px; line-height: 150%;">7 ** **<span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Radiation Oncology/Eye, Wikibooks, Available at: ** [|**http://en.wikibooks.org/wiki/Radiation_Oncology/Eye**] **<span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">. Accessed: June 3, 2011 **
 * 8) **<span style="color: #00b050; font-family: 'Cambria','serif'; font-size: 16px; line-height: 150%;">8 ** **<span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">EyeCancernetwork/overview of the treatment of metastatic melanoma, available at: ** [|**http://www.eyecancer.com/Research/Research.aspx?nID=73&Research=Overview+of+the+Treatment+of+Metastatic+Melanoma&nResearchCategoryID=1&sResearchCategory=Articles**] **<span style="color: #00b050; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">. Accessed: June 3, 2011. **
 * 9) **<span style="color: #e36c0a; font-family: 'Cambria','serif'; font-size: 16px; line-height: 115%;">9 ** **<span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Medline Plus Website.http://www.nlm.nih.gov/medlineplus/ency/article/001022.htm. Accessed June 4, 2011. **
 * 10) **<span style="color: #e36c0a; font-family: 'Cambria','serif'; font-size: 16px; line-height: 115%;">10 ** **<span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation. //Int J Radiat Oncol Biol Phys//.1991;21(1):109-122. **
 * 11) **<span style="color: #e36c0a; font-family: 'Cambria','serif'; font-size: 16px; line-height: 115%;">11 ** **<span style="color: #e36c0a; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">MacMillan Caner Support Website. http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Eye/Melanomaoftheeye.aspx. Accessed June 5, 2011. **

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