Ocf.wustl.edu
Barnes Jewish Hospital/Siteman Cancer Center
Mallinckrodt Institute of Radiology
Radiation Oncology Department
Eye Plaque Treatment Planning and Special Medical Physics Consultation Form
Patient Name: ____________________________________ DOB:_______________________________
Plaque Insertion Date:___________________ Plaque Extraction Date:_______________________
Total Treatment Time (days) : __________
Treatment Site (circle) : Right Eye Left Eye
Tumor Dimensions (mm x mm) : _______________ Tumor Apex Height(mm):_________________
Posterior Tumor Edge to: Fovea (mm): ___________ Disc (mm):__________________
Plaque Size (mm): _______________ Notch (circle): YES NO
Prescription (Rx) Height (mm): _______________
Included information (circle): Fundus Diagrams Ultra Sound A/B modes
Suggested Treatment Dose: _______________ Gy to the Rx Height
Ophthalmologist Surgeon Physician: _____________________________________________________
Dr William Harbour or Approved Physician
Barnes Retina Institute
Description of Special Physics Consultation:
A special physics consultation was performed for the treatment of the patient’s ocular melanoma using I-125 eye plaque therapy. Tumor dimensions were obtained from the referring physician. Critical organs were identified, their impact on plaque selection and dosimetry evaluated. A eye plaque of the appropriate dimension was selected based on the tumor characteristics, following consultation with the radiation oncologist and the referring physician. Dosimetric planning and calculations are performed to determine the number of I-125 seeds required as well as their strengths. The eye plaque will be fabricated based on the findings of this consultation to be implanted in the patient.
Notes:_________________________________________________________________________________________________________________________________________________________________________________
Medical Physicist Signature: _____________________________ Date: _____________________
Radiation Oncology Physician Signature: ________________________________ Date: _____________________
Dr David Mansur or RO Authorized User
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