Eye brachytherapy, where a small radioactive plaque is temporarily sutured to the outer wall of the eye to treat a tumor, typically controls the cancer in roughly 96% of cases, but the weeks and months that follow surgery bring a mix of short-term discomforts and longer-term visual changes that most patients are not fully prepared for. The plaque itself stays on the eye for about three to seven days before a second brief procedure to remove it, and recovery from there unfolds over a timeline that stretches from days to years depending on which effects develop. Knowing what is normal, what deserves a call to your doctor, and what the latest research says about managing complications can take some of the uncertainty out of a stressful experience.
The First Week With the Plaque In Place
During surgery, the ocular oncologist sutures a small radioactive disc, usually carrying iodine-125 or ruthenium-106, directly onto the sclera (the white outer shell of the eye) over the tumor. The plaque stays there for a prescribed number of days, generally three to seven, until it delivers the target radiation dose, and then it is removed in a second, shorter procedure.
While the plaque is in place, your eye will be patched with a lead-lined shield. The shield serves double duty: it protects the eye and limits radiation exposure to the people around you. Written and verbal instructions typically require you to stay at a single location for the duration of the implant, wear the shielding patch whenever you are near other people, avoid close contact with children and anyone who may be pregnant, and sleep in a separate bed. A hospital bracelet labeled “Caution. Radioactive Material, Temporary Implant” stays on your wrist as a reminder to medical staff if you need care for an unrelated reason during those days.
Soreness, tearing, and a feeling of pressure behind the eye are common during this window. Your doctor will usually prescribe antibiotic and anti-inflammatory eye drops, and sometimes oral pain medication. The discomfort tends to peak in the first day or two after plaque placement and gradually eases once the plaque comes out.
The First Few Weeks After Plaque Removal
Once the plaque is removed, the eye is typically red, swollen, and light-sensitive. Most of this settles down over two to four weeks as the surgical site heals. You will likely continue using antibiotic and steroid drops on a tapering schedule. Double vision, or diplopia, is fairly common in the early postoperative period because surgeons often need to temporarily detach one of the eye muscles to position the plaque. In one study of over 300 patients, about 13% reported diplopia at their first postoperative visit. In most cases it resolved on its own: roughly 44% cleared within a month and another 29% resolved within six months. Only about 2% experienced persistent double vision that did not go away.
The lateral rectus muscle, which pulls the eye outward, is the one most frequently detached during surgery, followed by the superior rectus, which pulls the eye upward. If your plaque required repositioning one of these muscles, your surgeon will reattach it at the end of the procedure, but the muscle can take weeks to regain its full coordination with the other eye. During that time you may notice the images from your two eyes drifting apart, especially when looking in certain directions. Prism glasses or an eye patch on the treated side can help while the muscle heals.
Radiation Cataracts
A cataract, the clouding of the eye’s natural lens, is one of the most predictable long-term side effects of eye brachytherapy. In a study of 384 patients treated with palladium-103 plaques, radiation cataracts developed in about 24% at an average follow-up of roughly 40 months. Tumors sitting closer to the front of the eye pushed that rate considerably higher, to around 43%, compared with about 18% for tumors farther back, because the lens receives a larger radiation dose when the plaque is positioned nearby.
A separate large study comparing brachytherapy patients to the general population found that the 12-year incidence of cataract surgery after plaque treatment was 27%, markedly higher than the 16% seen in matched members of the general population. Patients treated with iodine-125 plaques had a higher cataract-surgery rate than those treated with ruthenium-106, though even the ruthenium group exceeded the general-population rate. Older age and the use of iodine-125 were the strongest predictors of needing surgery. The encouraging finding is that cataract surgery after brachytherapy generally goes well, with outcomes similar to routine cataract operations.
Cataracts are treatable, but the timing matters. One case report described a 36-year-old woman who developed a radiation cataract four years after successful plaque therapy for choroidal melanoma. The cataract not only blurred her vision but also blocked the oncologist’s ability to examine the tumor during follow-up. Prompt cataract surgery restored her visual acuity and made it possible to resume tumor surveillance, which underscores why you should not put off reporting vision changes to your care team.
Radiation Retinopathy and Maculopathy
Radiation retinopathy is a slow-developing blood-vessel disease in the retina caused by radiation damage to the tiny capillaries that nourish it. It can appear anywhere from one month to 15 years after treatment, though it most commonly shows up within the first few years. The blood vessels leak, close off, or grow abnormally, leading to swelling, bleeding, and sometimes permanent vision loss in the affected area. When the damage centers on the macula, the part of the retina responsible for sharp central vision, it is called radiation maculopathy, and it poses the greatest threat to functional vision.
Not everyone who undergoes eye brachytherapy develops retinopathy. The risk depends heavily on how much radiation the retina and optic nerve received, which in turn depends on the tumor’s size and location. Tumors that sit near the macula or optic disc deliver higher doses to those critical structures. Your oncologist will have estimated these doses during treatment planning, and those numbers help predict your individual risk.
The good news is that treatment options have improved substantially. Anti-VEGF injections, the same drugs used for age-related macular degeneration, have become the standard approach. A systematic review and meta-analysis found that anti-VEGF therapy produced better visual-acuity results and greater reductions in retinal swelling compared with other treatment options for radiation retinopathy. Ten-year data from one research group showed that continuous anti-VEGF injections every 4 to 12 weeks preserved vision in a large majority of patients: about 80% of 120 patients kept their vision within two lines of where they started, and the probability of maintaining that level of vision was around 69% at five years and 38% at eight years of treatment. Clinical signs of radiation maculopathy often decreased or resolved with ongoing injections. The catch is that the treatment requires regular, indefinite injections, which can be burdensome, but for many patients it is the difference between functional and nonfunctional vision in the treated eye.
Radiation Optic Neuropathy
When the optic nerve itself absorbs a significant radiation dose, a condition called radiation optic neuropathy can develop. The clinical picture includes swelling of the optic disc, small hemorrhages around it, and cotton-wool spots, and vision is usually substantially reduced by the time the diagnosis is made. This complication tends to occur in patients whose tumors were located near the optic nerve head, delivering a high cumulative dose to that structure.
Radiation optic neuropathy is less common than retinopathy, but it can be more devastating because the optic nerve has limited capacity to recover once damaged. Treatment strategies overlap with those for radiation retinopathy and include anti-VEGF injections and sometimes corticosteroids, though the evidence base is thinner. The same research group that reported 10-year data on anti-VEGF for maculopathy has also advocated early treatment to slow progression, but the results are more variable for optic neuropathy than for maculopathy.
Glaucoma After Brachytherapy
Elevated eye pressure and glaucoma represent another category of complications, and they come in more than one form. Secondary open-angle glaucoma, where the eye’s drainage system gradually becomes less efficient, was diagnosed in about 9% of eyes in one study of iodine-125 brachytherapy patients. Neovascular glaucoma, a more aggressive variant driven by abnormal new blood vessels that physically block the drainage angle, occurred in about 7% of eyes in the same cohort. Risk factors for neovascular glaucoma included larger tumor size, a history of smoking, and more severe radiation retinopathy, which makes sense because the same leaky, abnormal blood vessels that cause retinopathy can also invade the drainage structures.
There is evidence that neovascular glaucoma tends to appear relatively quickly, within a few years of high-dose radiation, and it behaves somewhat like a threshold effect: below a certain radiation dose to the relevant structures, the risk appears low, but above that threshold it rises sharply. Open-angle glaucoma, by contrast, can develop more insidiously over a longer timeframe. Both forms are treatable with pressure-lowering drops, laser procedures, or surgery, but catching them early through regular pressure checks is critical to preserving vision.
Scleral Necrosis and Other Rare Complications
Scleral necrosis, where the tissue under the plaque thins and breaks down, is uncommon but worth knowing about. In a large series of over 5,000 patients, about 1% developed clinically evident scleral necrosis. The risk was far from uniform, though. Tumors involving the ciliary body, the ring of tissue just behind the iris, carried a strikingly higher rate of roughly 29%, while tumors limited to the choroid (the most common location) had a rate below 1%. Thicker tumors and higher scleral radiation doses also increased the risk. A second large analysis of nearly 4,000 patients found a somewhat higher overall rate of about 3%, with necrosis appearing on average around 30 months after treatment. Younger age, ciliary body involvement, and certain plaque types were independent risk factors.
When scleral necrosis does occur, it can occasionally set off a rare autoimmune reaction called sympathetic ophthalmia, where the immune system begins attacking the uninjured fellow eye. This is an ophthalmologic emergency requiring prompt immunosuppressive treatment. Fortunately, the combination of scleral necrosis leading to sympathetic ophthalmia is exceedingly rare, but it is the reason your care team monitors both eyes during follow-up, not just the treated one.
Dry eye has also been reported after brachytherapy, though at low rates. In one multi-modality study, only about 1% of patients developed clinically significant dry eye during follow-up. It was slightly more common after proton-beam therapy than after ruthenium-106 brachytherapy.
Tumor Monitoring After Treatment
One of the most important parts of post-brachytherapy life is regular imaging to confirm that the tumor is shrinking and not regrowing. Ultrasound is the workhorse tool: it measures the tumor’s height and base dimensions over time. After brachytherapy, the vast majority of tumors respond. In one study, about 97% of treated tumors showed a decrease in height. The speed at which a tumor shrinks can itself be informative. Tumors that shrank faster than about 10% per month in height were paradoxically associated with higher five-year melanoma-related mortality, likely because more aggressive tumors both respond quickly to radiation and are more prone to having already seeded distant metastases.
Local tumor control rates are high. A large review covering multiple radiation modalities found that local control was achieved in about 96% of cases, with recurrence rates of roughly 4% to 5% regardless of whether ruthenium-106 plaques, iodine-125 plaques, or proton-beam radiotherapy was used. Eye retention rates were similarly encouraging, exceeding 94% across all modalities. A single-institution series using ruthenium-106 reported somewhat higher recurrence over longer follow-up, with estimated local recurrence of 3% at 12 months, about 8% at two years, and roughly 15% at four years, with older age and worse initial visual acuity as risk factors.
Recurrence, when it happens, can sometimes be retreated with a second plaque or other salvage therapy. But the radiation dose from the first treatment already sits in the tissues, so the threshold for additional complications is lower the second time around. This is one reason why sticking to your follow-up imaging schedule matters.
Systemic Surveillance for Metastasis
Eye brachytherapy treats the primary tumor, but uveal melanoma has a well-known tendency to spread to the liver, sometimes years after the eye has been successfully treated. How aggressively you are monitored for metastasis depends in part on your tumor’s genetic profile. Tumors with certain chromosomal changes, particularly monosomy 3, carry a substantially higher risk of metastasis.
A study comparing different surveillance schedules found that enhanced protocols, using more frequent liver imaging, detected metastatic lesions when they were much smaller: about 1.5 to 1.6 centimeters on average for patients on more intensive monitoring compared with 6.1 centimeters for those on standard protocols. Patients on enhanced monitoring had a lower 24-month incidence of large metastases and a meaningfully reduced hazard of death after metastasis was found. However, overall survival did not significantly differ between groups, possibly because effective systemic treatments for metastatic uveal melanoma remain limited. The takeaway is that enhanced surveillance catches problems earlier and gives you more options, even if the survival benefit is still being quantified.
Your oncology team will typically schedule liver ultrasounds or MRI scans every three to six months in the first years after treatment, with the interval potentially lengthening if your genetic risk profile is favorable. Blood tests for liver function are often included but are less sensitive for detecting small metastases than imaging.
Emotional and Quality-of-Life Effects
A cancer diagnosis involving the eye carries a psychological weight that goes beyond the physical symptoms. Anxiety and depressive symptoms are relatively common in the first year after treatment but tend to decrease over time, particularly after the six-month mark. One study following patients for a year after treatment with ruthenium plaque therapy found that anxiety levels gradually fell during that period, though they remained elevated compared with the general population.
A review pooling multiple studies on quality of life, depression, and anxiety in uveal melanoma patients found that the choice of treatment, whether brachytherapy or enucleation (complete eye removal), did not produce significant long-term differences in depression, anxiety, or overall quality of life. In a large cohort of nearly 1,600 patients, about 20% of those treated with radiotherapy attributed poor quality of life to their ocular disease, a proportion almost identical to the 21% reported by patients who had their eye removed. That might seem surprising, but it reflects the fact that both treatments carry their own burdens: enucleation brings cosmetic and depth-perception challenges, while brachytherapy brings the ongoing uncertainty of tumor monitoring and the possibility of progressive visual complications in the treated eye.
If you find yourself struggling with worry about recurrence or feeling down about vision changes, those reactions are well within the normal range for this diagnosis. Many cancer centers have psycho-oncology services, and connecting with a support group of other uveal melanoma patients can help normalize an experience that most people in your daily life will have never heard of.
What a Typical Follow-Up Schedule Looks Like
There is no single universal protocol, but most centers follow a pattern something like this during the first years after treatment:
- First month: One or two visits to check wound healing, eye pressure, and early signs of inflammation or diplopia. Drops are adjusted.
- Months two through six: Visits every one to two months with ultrasound measurements of tumor height. This is when early radiation retinopathy or optic neuropathy might first be detected.
- Months six through twelve: Visits roughly every two to three months. Cataract formation may begin to be noticeable. Liver imaging for metastasis surveillance is underway per your risk category.
- Years two through five: Visits every three to six months. Tumor regression is tracked, and any late-onset complications like glaucoma or progressive retinopathy are managed. Anti-VEGF injections may begin if maculopathy appears.
- Beyond five years: Many patients transition to annual or semi-annual visits for the eye, though metastasis surveillance may continue longer depending on genetic risk.
Each visit typically includes a dilated eye exam, eye-pressure measurement, ultrasound of the tumor, and sometimes optical coherence tomography (a painless scan of the retinal layers) to check for subtle maculopathy. Your doctors are looking for tumor regrowth, new complications, and changes that warrant intervention. Keeping every appointment, even when your eye feels fine, is the single most practical thing you can do to protect both your vision and your overall health after brachytherapy.