When intraocular lymphoma (IOL) is present at diagnosis, there is usually concomitant cerebral involvement. If WBXRT is being used in the primary treatment, the eyes should also be included in the irradiation field. The long term side-effects of orbital irradiation include the development of cataracts, retinal detachment, and optic nerve atrophy. High-dose intravenous MTX alone can achieve therapeutic concentrations in the vitreous humour.65 One study reported a complete response in four of five patients with IOL treated with this approach.66 This suggests that orbital XRT can be deferred in patients with stable visual findings who receive MTX. One approach is to assess for persistent disease after four cycles of chemotherapy. If IOL is still detected, then orbital irradiation can be administered.
It is rare for patients to present with IOL alone. Ninety percent of these patients will eventually relapse in the brain, and any treatment approach should keep this in mind. Chemotherapy alone, with orbital and/or WBXRT reserved for persistent or progressive disease, is an attractive option that minimizes toxicity.
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