Radiation-induced optic neuropathy, is a devastating late complication of radiotherapy to the anterior visual pathway resulting in acute, profound, irreversible visual loss. It is thought to be a result of radiation necrosis of the anterior visual pathway. Visual loss may be unilateral or bilateral; simultaneous or sequential. RION occurs commonly between 10-20 months, with an average of 18 months after treatment; but the onset may range from three months to 9 years. Cumulative doses of radiation that exceed 50 Gy or single doses to the anterior visual pathway or greater than 10 Gy are usually required for RION to develop. Several factors are associated with a higher risk for developing RION or for RION occurring with lower total doses of radiation. These include age, pre-existing compression of the optic nerve and chiasm by tumour, concurrent chemotherapy or previous external beam radiation.

MRI, the investigation of choice for identifying radiation injury to the visual pathway, may show abnormalities before the loss of vision. Typically, the unenhanced T1- and T2-weighted images show no abnormality, but the optic nerve will show enhancement on T1-weighted images with MRI.

Treatment with systemic corticosteroids, anticoagulation and hyperbaric oxygen has been generally unsuccessful and disappointing. If visual dysfunction is detected early, hyperbaric oxygen might be beneficial if treatment is initiated within 72 hours of visual loss. Because of the poor prognosis associated with RION, the risk of its potential development should be factored into the decision to irradiate the brain 1).

Good local control rate and a low risk indicate that multisession radiosurgery (mRS) is a safe and effective treatment option in cases of large meningiomas 2).

In patients without prior radiation treatments can safely receive radiation doses up to 12 Gy with a low risk of radiation induced optic neuropathy (RION). Although additional studies are needed to better delineate the normal tissue complication probability (NTCP) of the AVP, adherence to the AVP radiation tolerance guidelines developed 20 years ago (8 Gy) limits the applicability and potentially the effectiveness of single-fraction stereotactic radiosurgery (SRS) for patients with lesions in the parasellar region 3).

Danesh-Meyer HV. Radiation-induced optic neuropathy. J Clin Neurosci. 2008 Feb;15(2):95-100. Review. PubMed PMID: 18068989.
Marchetti M, Bianchi S, Pinzi V, Tramacere I, Fumagalli ML, Milanesi IM, Ferroli P, Franzini A, Saini M, DiMeco F, Fariselli L. Multisession Radiosurgery for Sellar and Parasellar Benign Meningiomas: Long-term Tumor Growth Control and Visual Outcome. Neurosurgery. 2016 May;78(5):638-46. doi: 10.1227/NEU.0000000000001073. PubMed PMID: 26492428.
Pollock BE, Link MJ, Leavitt JA, Stafford SL. Dose-Volume Analysis of Radiation-Induced Optic Neuropathy After Single-Fraction Stereotactic Radiosurgery. Neurosurgery. 2014 Jun 4. [Epub ahead of print] PubMed PMID: 24902082.
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