# Outcomes Following Treatment with Notched Proton Beams for Peripapillary Choroidal Melanomas

## TL;DR

Notched proton beams may help preserve vision in patients with eye tumors near the optic disc, though more research is needed.

## Contribution

This study introduces evidence that notched proton beam therapy may reduce long-term vision loss in peripapillary choroidal melanoma.

## Key findings

- Notched beams showed a trend toward slower vision decline and lower complication rates.
- A 0.058 logMAR improvement in vision was observed with notched beams, considered clinically significant.
- No statistically significant reduction in complication rates was found with notched beams.

## Abstract

Peripapillary choroidal melanoma provides a unique challenge; proximity to visually important structures, such as the optic disc and fovea, confers a high risk for the development of maculopathy and optic neuropathy, leading to poorer visual outcomes with most forms of radiotherapy. Ocular proton therapy (OPT) requires an aperture to shape the beam to the tumour. An aperture ‘notch’ may minimise damage to the optic disc and/or the fovea. This study aims to explore if there are any additional advantages to incorporating a notch over the optic nerve beam area. The primary outcomes were longitudinal measurements of visual acuity following proton beam radiotherapy, the occurrence of radiation optic neuropathy, and the tumour recurrence rate. Secondary outcome measures included mortality rates, enucleation rate, and other potentially vision-affecting complications such as radiation maculopathy. Our findings demonstrate that notched proton beam therapy may offer a clinically meaningful reduction in long-term vision loss for tumours located within 3 mm of the optic disc. While not statistically significant, the trend toward slower visual decline and lower complication rates—especially when optic nerve exposure is minimised—supports consideration of this approach in treatment planning. Further validation in prospective, multi-centre studies is warranted.

Purpose: Peripapillary choroidal melanoma provides a unique challenge; proximity to visually important structures, such as the optic disc and fovea, confers a high risk for the development of maculopathy and optic neuropathy, leading to poorer visual outcomes with most forms of radiotherapy. Ocular proton therapy (OPT) requires an aperture to shape the beam to the tumour. An aperture ‘notch’ may minimise damage to the optic disc and/or the fovea. This study aims to explore if there are any additional advantages to incorporating a notch over the optic nerve beam area. Design: Retrospective audit (cohort study). Participants: Participants included eighty-three patients treated at Liverpool with proton beam therapy from January 2012 to March 2020 for their peripapillary choroidal melanoma. All had a minimum of two and a half years of follow-up vision data; this was to ensure there was enough visual acuity assessment data to perform sufficient analysis. Patients excluded had choroidal melanoma situated over 3 mm from the optic disc, as these were unlikely to have an aperture notch. Methods: A retrospective audit was undertaken in accordance with the Declaration of Helsinki, and registered with the Royal Liverpool Hospitals audit department (audit reference number: Ophth/SE/2024-25/25). Data was collated from the Liverpool Ocular Oncology database, clinic letters and the individual proton beam 3D plans. Robust statistical analysis using a mixed effects model was used to explore associations between notched beams and vision loss and complications. Main Outcome Measures: The primary outcome measure is visual acuity loss post-proton beam therapy. Secondary outcome measures were enucleation and other complication rates. Results: Analysis shows that at 10 years post-OPT, there would be an expected 0.058 (p = 0.077) logMAR of vision saved using a notch for the optic disc compared to no notch (normal apertures); this is considered clinically significant. This cohort also loses vision at a slower rate than other cases. No other predictors were found to be statistically significant for loss of vision, and notched beams showed no advantage in reducing rates of complications. Conclusions: There is some evidence of a trend that utilising a notch for optic disc does show long-term vision benefit; it demonstrates a clinically significant benefit in patients with peripapillary choroidal melanoma.