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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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