title: Acute Hemorrhagic Retinopathy following Intravitreal Melphalan Injection for Retinoblastoma: A Report of Two Cases and Technical Modifications to Enhance the Prevention of Retinal Toxicity.
abstract: OBJECTIVE
  To report the occurrence of acute hemorrhagic retinopathy following intravitreal melphalan injection for retinoblastoma.
  
  
  METHODS
  This is a retrospective case series of 2 patients with retinoblastoma treated with intravitreal melphalan for vitreous seeding who developed acute hemorrhagic retinopathy.
  
  
  RESULTS
  Patient 1 is a 6-month-old female with bilateral retinoblastoma (Group D right eye and Group B left eye) treated with 4 cycles of systemic chemotherapy and 2 intravitreal melphalan injections in each eye. Patient 2 is a 10-month-old male with unilateral Group D retinoblastoma treated with 6 cycles of systemic chemotherapy and 2 injections of intravitreal melphalan. At the 1-week follow-up after the second injection, both patients had an acute hemorrhagic retinopathy that resulted in chorioretinal toxicity with a sharp demarcation line between the normal and abnormal retina. At the last follow-up (22 and 12 months, respectively), there was total tumor control and resolution of vitreous seeding in both patients.
  
  
  CONCLUSIONS
  Although intravitreal melphalan injection is effective for vitreous seeding in eyes with retinoblastoma, acute hemorrhagic retinopathy and diffuse chorioretinal atrophy is a possible complication of this treatment modality. Given the clinical findings observed in these patients, the development of this retinal toxicity most likely results from a retrohyaloid overdose. Consequently we suggest preventive measures aimed at limiting the risk of retrohyaloid injection.
authors.affiliation: The Vision Center at Children's Hospital Los Angeles, USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, Calif., USA.
authors.forename: Hassan A
authors.initials: HA
authors.lastname: Aziz
authors.affiliation: The Vision Center at Children's Hospital Los Angeles, USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, Calif., USA.
authors.forename: Jonathan W
authors.initials: JW
authors.lastname: Kim
authors.affiliation: Department of Ophthalmology, Jules Gonin Eye Hospital, Lausanne, Switzerland.
authors.forename: Francis L
authors.initials: FL
authors.lastname: Munier
authors.affiliation: The Vision Center at Children's Hospital Los Angeles, USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, Calif., USA.
authors.forename: Jesse L
authors.initials: JL
authors.lastname: Berry
keywords: Chorioretinal toxicity; Intravitreal melphalan; Retinoblastoma; Vascular occlusion; Vitreous seeding