Update on diagnosis and management of radiation retinopathy

Radiation retinopathy is a vision-threatening complication of radiotherapy involving the eye or surrounding structures. This review aims to summarize recent advances in understanding the incidence, risk factors, pathophysiology, and utilization of new diagnostic imaging tools for radiation retinopathy. It will also focus on the current prophylaxis approaches to prevent or delay the development of radiation-related side effects and treatment strategies once radiation retinopathy occurs. The incidence of radiation retinopathy is influenced by radiation dose, fractionation schedule, and patient-specific factors such as diabetes mellitus and hypertension. Advances in imaging techniques, including optical coherence tomography angiography (OCTA) and ultra-widefield fluorescein angiography (UWFA), have enhanced early detection by identifying subclinical retinal changes. Novel insights into pathophysiology suggest a role for endothelial damage, inflammation, and oxidative stress in disease progression. Prophylactic approaches, such as intravitreal antivascular endothelial growth factor (anti-VEGF) agents, have shown promise in reducing the onset of retinopathy in high-risk patients. Therapeutic options, including intravitreal anti-VEGF and corticosteroids, have demonstrated efficacy in managing macular edema and preserving vision. However, the outcomes remain variable, necessitating personalized treatment strategies. To address some of these unanswered questions, the Diabetic Retinopathy Clinical Research Network (DRCR) Protocol AL is currently enrolling patients and preparing to analyze the long-term effects of treating patients prophylactically with intravitreal faricimab or the 0.19 mg fluocinolone acetonide implant compared to observation, to identify which patients will benefit from which specific regimen, therefore moving towards a personalized approach for this condition as well. Radiation retinopathy remains a significant challenge in ophthalmology. Early recognition through advanced imaging and tailored interventions, including prophylaxis and treatment, are crucial for optimizing visual outcomes. Further research into underlying mechanisms and novel therapies is essential to reduce the burden of this condition and improve patient quality of life.