The evolving role of interventional radiology in ophthalmology: advancements in imaging, therapeutic applications, and future prospects, a narrative review

Abstract

Since its establishment, interventional radiology (IR) has played a crucial role in various medical fields, including ophthalmology, in treating various ocular conditions and improving patient outcomes. This review discusses the recent innovations, therapeutic applications, and existing challenges of IR in the ophthalmology field. Multiple modalities of IR, including magnetic resonance imaging, computed tomography (CT), ultrasound, fluorescein angiography, indocyanine green angiography, and optical coherence tomography angiography (OCTA), play a crucial role in diagnosing ocular diseases and tumors. Among them, OCTA, being non-invasive, is preferred over traditional methods for better visualization of ocular microvasculature. IR in eye care offers a less invasive treatment approach and high precision with procedures like targeted chemotherapy, embolization, and CT-guided biopsies. Application of IR in the eye demands high precision, but limitations include limited access to equipment, trained specialists, and high costs. By fusing advanced imaging, artificial intelligence, and nanotechnology for effective treatments, IR has proved revolutionary for eye care. As collaboration between specialists grows and new tools like simulation training and augmented reality/virtual reality improve precision and safety, challenges such as high costs and limited access to technology still need to be addressed. This review will highlight the role of IR in ophthalmology, including minimally invasive procedures and therapeutic approaches. The integration of IR has led to improvements in the management of ocular conditions, with better outcomes and minimal side effects, by enhancing precision and improving recovery time.

Introduction

Charles Dotter established interventional radiology (IR) in 1963, and since then, IR has been a crucial component of patient care[1]. The use of visually guided, minimally invasive procedures to enhance patient outcomes has expanded due to advancements in imaging technologies. Reducing trauma through minimally invasive access is the foundation of IR, which aims to improve clinical outcomes while lowering surgical complications, recovery times, and medical expenses. IR maximizes the “triple aim” of contemporary healthcare, which includes lowering per-capita costs, enhancing population health, and improving patient experience (both in quantity and quality)[2]. IR plays a crucial role across multiple medical fields. For example, in oncology, IR techniques like radioembolization provide targeted radiation therapy for liver tumors, improving treatment options for cancer patients[3]; in vascular medicine, angioplasty and stenting help restore blood flow in conditions like peripheral artery disease; and in gastroenterology, procedures like transjugular intrahepatic portosystemic shunt manage portal hypertension in liver cirrhosis patients, among others.

HIGHLIGHTS

• Interventional radiology helps in the precise, minimally invasive diagnosis and treatment of eye disease, with optical coherence tomography angiography offering clear, non-invasive visualization of ocular microvasculature.

• Image-guided procedures, such as chemotherapy, embolization, and biopsies, improve treatment accuracy and reduce complications.

• Advances in imaging, artificial intelligence, and emerging technologies are boosting ophthalmic care, though high costs and limited access remain key challenges.

Minimally invasive techniques in modern medicine have revolutionized ophthalmology, offering significant benefits over traditional methods. In cataract surgery, microincisions smaller than 2 mm have replaced larger cuts, leading to faster visual recovery and reduced complications. Similarly, vitreoretinal surgeries now employ sutureless small-gauge vitrectomy (25–27 gauge). Minimally Invasive Glaucoma Surgery procedures, such as the Preserflo® MicroShunt, iStent, XEN Gel Stent, and Hydrus Microstent, have also been introduced to reduce intraocular pressure with minimal tissue disruption. These devices are implanted through microscopic incisions, enhancing aqueous humor drainage while reducing the need for long-term medication[4]. Coming to the key focus of our discussion, in ophthalmology, IR therapy has emerged as the preferred approach for managing various ocular conditions previously treated with conventional neurosurgical techniques. By using minimally invasive embolization techniques, IR is crucial in treating multiple ocular conditions such as carotid-cavernous sinus fistulas, which can cause vision loss and eye swelling. It is also being explored for conditions like idiopathic intracranial hypertension (pseudotumor cerebri), where cerebral venous sinus stenting may help reduce optic nerve pressure and prevent vision impairment[5]. Additionally, IR plays a significant role in treating nasolacrimal duct obstruction. Techniques such as fluoroscopically guided balloon dacryocystoplasty and nasolacrimal stent placement provide minimally invasive alternatives to conventional surgery, leading to fewer complications and faster recovery. These methods improve tear drainage while reducing the risks linked to external dacryocystorhinostomy[6]. It is also used to treat ocular tumors like intraocular retinoblastoma through ophthalmic artery chemosurgery (OAC), which delivers chemotherapy directly to the tumor via a microcatheter. This targeted approach enhances effectiveness while reducing systemic side effects, preserving the eye, and minimizing the need for radiation or enucleation[7]. IR imaging methods also play a crucial role in diagnosing ophthalmic disorders by providing high-resolution, real-time visualization of ocular and orbital structures, such as digital subtraction angiography (DSA).

This review article will explore recent innovations in imaging techniques, the expanding therapeutic applications of IR in ophthalmology, and the role of minimally invasive procedures in improving patient outcomes. Additionally, it highlights current challenges and future directions in integrating IR into ophthalmic care, paving the way for more precise and effective treatments.

In line with current best practices for transparency and accountability in scientific reporting, this manuscript adheres to the TITAN guidelines for responsible disclosure of artificial intelligence (AI) assistance in research and writing[8].

Imaging innovations in ophthalmology

IR incorporates various imaging modalities such as magnetic resonance imaging (MRI), computed tomography (CT) scanning, ultrasound, and fluoroscopy. This discipline employs specialized methods to take pictures of the relevant organ to diagnose and treat disorders. More often, specialized imaging techniques like fundus photography and optical coherence tomography (OCT) are employed to analyze and track malignancies and eye disorders[9].

CT scans are also beneficial in identifying the underlying cause of orbital cellulitis, distinguishing between pre-septal and post-septal orbital cellulitis. CT is highly effective in ocular and orbital trauma, providing detailed visualization of soft tissues, bony structures, and foreign bodies[10] as well as assessing bony involvement in orbital tumors[11]. CT scans can still play a role in evaluating choroidal tumors, though they are typically supplanted by ultrasound and MRI for initial diagnosis and staging due to their superior diagnostic precision. MRI plays a crucial role in diagnosing the extent of local tumor involvement in advanced retinoblastoma and has been informally shown to identify various inflammatory conditions affecting the globe, including posterior scleritis, endophthalmitis, and posterior uveitis associated with Vogt–Koyanagi–Harada disease[12].

Fundus fluorescein angiography (FA), an invasive diagnostic procedure, helps to assess the anatomy and physiology of retinal and choroidal circulation, which aids in the diagnosis of various ocular pathologies. The fundus camera is equipped with two filters: an excitation filter and a barrier filter. Injection of the dye is timely coordinated with the process of taking photographs. The technique can distinguish between diabetic macular edema and Irvine–Gass syndrome, confirm the diagnosis of myopic choroidal neovascular membrane, and identify and document the activity of choroidal neovascular membrane in various retinal diseases, including age-related macular degeneration[13].

Indocyanine green (ICG) angiography is an important invasive imaging modality used to study choroidal and retinal circulation, visualized via a fundus camera with excitation, and a barrier filter is used to take photographs. The moment the dye is injected, control photographs are taken, which automatically switch on the timer. ICG angiography is used to image the choroidal circulation and its abnormalities, including retinal angiomatous proliferation, central serous chorioretinopathy, choroidal tumors, choroidal melanoma, choroidal hemangioma, birdshot chorioretinopathy, multifocal choroiditis, multiple evanescent white dot syndrome, serpiginous choroidopathy, punctate inner chorioretinopathy, acute zonal occult outer retinopathy, chorioretinal atrophy, and Vogt–Koyanagi–Harada syndrome[13].

Optical coherence tomography angiography (OCTA), as a non-invasive, depth-resolved imaging tool, can provide qualitative and quantitative information about the status of retinal and choroidal vessels. OCTA seems to be important in revealing capillary non-perfusion areas in retinal vasculitis. It can be used in serpiginous choroiditis to detect subclinical or persistent choroidal non-perfusion, multifocal choroiditis, punctate inner choroidopathy, birdshot retinochoroidopathy, acute zonal occult outer retinopathy, intraocular tuberculosis, and Herpesviridae. OCTA was even estimated to be superior to FA in detecting ischemic retinal capillary changes, diagnosing Behçet’s retinal vasculitis, and helping detect choroidal neovascularization, whereas FA did not provide any hints, especially when considering type 1 choroidal neovascularization[14].

Traditional imaging methods, such as fundus photography, offer a two-dimensional, wide-field view of the retina, with confocal scanning laser ophthalmoscopy (cSLO) and digital fundus photography being more prone to color distortion, motion artifacts, and media opacities[15]. In comparison, FA and ICG angiography use dyes to visualize retinal and choroidal vasculature, respectively. In addition, OCTA is a non-invasive, dye-free technique that provides high-resolution, three-dimensional images of the microvasculature[16].

Diagnostic imaging, particularly its role in IR, signifies the clinical utility of advanced imaging techniques, such as OCT, high-resolution CT, and MRI, as a real-time navigational tool in interventional procedures, enhancing precision in ophthalmic and neuro-ophthalmic interventions[17].

Therapeutic applications of IR in ophthalmology

In ophthalmology, Perlmutter Cancer Center describes the role of interventional therapy using IR in diagnosing and treating intraocular melanoma. The technique of chemoembolization uses catheters to insert chemotherapy or anti-cancer drugs into vessels that feed the tumor or directly into the liver, which is the site of metastasis for intraocular tumors. Tumor ablation techniques involve thermal, laparoscopic, and ethanol ablation. Radioembolization is used to treat secondary growth areas in the liver due to ocular cancers. OAC uses chemotherapy drugs inserted into the ophthalmic artery using a catheter. OAC is a very effective treatment and can be performed several times intra-arterially to cure Group D retinoblastoma. In this review, interventional oncology has proven to be one of the major therapeutic applications of IR.

Cross-sectional imaging with CT and MRI complements clinical eye exams and fundoscopy in patients with orbital tumors, offering valuable diagnostic insights and aiding treatment planning by enabling accurate assessment of tumor size and spread[18]. Imaging modalities are used for the assessment of retinal vein occlusion. Diabetic retinopathy is one of the alarming health conditions. Ophthalmologists use FA, OCT, OCTA, and FP imaging in grading diseases. These automated systems have helped analyze a huge amount of data[19]. OCT is a gold standard that determines the eligibility of other medical therapies used for RVO. Keizer performed balloon embolization in patients with carotid-cavernous and orbital arteriovenous fistulas with 94.5% success[20].

OCT is being used in the evaluation of uveitis. Complications of uveitis are easily seen and tracked using OCT[21]. Contrast-enhanced MRI patterns in the post-laminar optic nerve can help distinguish between tumor invasion and inflammation, leading to a more accurate assessment of metastatic risk[21].

Central venous catheters and subcutaneous ports provide flexible options for short- and long-term delivery of intravenous therapy. According to the article published in American Family physician, arterial interventions, aortic aneurysm repair, venous interventions, transarterial embolization for the treatment of hemorrhage, reproductive interventions, treatment of deep vein thrombosis, and interventional oncology have all benefited from IR. Alongside medical procedures, the approach of IR to develop new, less invasive strategies to benefit patients has evolved as a young, emerging field in research and innovation.

Advances in IR have led to innovative procedures that offer cost-effective, minimally invasive alternatives with shorter recovery times and fewer complications compared to traditional medical and surgical treatments[1]. Integrated IR robotic systems can be guided by various imaging modalities, including CT, MRI, ultrasound, and fluoroscopy, allowing for precise and flexible procedural guidance[22]. IR offers a range of minimally invasive techniques that can be applied to various body structures to achieve diverse objectives, such as draining fluids, restoring blood flow, repairing damaged tissues, and blocking or destroying abnormal blood vessels. It is especially important for poor surgical candidates and critically ill patients.

Minimally invasive approaches in ophthalmology

In 1989, Becker and Berry introduced a minimally invasive technique to treat epiphora. It was named the Balloon Dacryocystoplasty. It is considered a recent advancement in the field of IR. Currently, the procedure is performed by an IR doctor and involves the resolution of an obstructed nasolacrimal duct. The Balloon Dacryocystoplasty employs a specific purpose-built balloon catheter, which can apply a radial force on the thickened duct wall, thereby relieving the obstruction. Another recent advancement is the embolization technique (fluoroscopy, CT-guided, etc.). Concerning ophthalmology, interventional radiologists can embolize very large non-involuting congenital hemangiomas (in areas surrounding the orbit) before surgical excision to prevent excessive loss of blood during the surgery[23].

Carotid-cavernous fistula (CCF), which mostly produces ocular symptoms, is also one of the diseases whose management has been provided by IR. Prolo and Hanberry demonstrated the usage of a fixed balloon catheter to block a CCF in 1971, followed by Serbinenko et al, who reported the first case of successful embolization of a CCF from an endovascular approach using a detachable silicone balloon with preservation of the internal carotid artery. Now, the transarterial obliteration of the fistula with a detachable balloon, transarterial or transvenous obliteration of the ipsilateral cavernous sinus with coils or other embolic material (for high-flow direct CCFs), or deployment of a polyfluorotetraethylene-covered stent across the fistula (for immediate obliteration, especially in the setting of an unsuccessful balloon test occlusion study) are considered standard options for the treatment of direct CCF since the 1980s. While indirect fistulas can be repaired by occluding the cavernous sinus that harbors the fistulous communications (transvenous embolization)[24], multiple staged sessions to reduce arterial inflow before transvenous occlusion for high-flow indirect CCFs are considered a viable alternative after failure of transvenous attempts. In case of a difficult venous approach, an arterialized and dilated superior ophthalmic vein can be cannulated to approach the cavernous sinus. This is made possible by an ophthalmic surgeon establishing the superior ophthalmic vein cannulation through an eyelid or eyebrow incision – an excellent example of IR and ophthalmology collaboration.

Intra-arterial chemotherapy (IAC) is a minimally invasive procedure performed by a skilled interventional radiologist in collaboration with ocular and pediatric oncologists, anesthesiologists, and pharmacists. Under fluoroscopic guidance, the interventional radiologist inserts a 4-French pediatric arterial sheath into the ipsilateral femoral artery, carefully navigating through the aorta, carotid artery, and internal carotid artery to selectively catheterize the ophthalmic artery. This precise technique has revolutionized IAC, making it a key approach for eye salvage in advanced intraocular retinoblastoma and gaining widespread adoption in developed countries. Recent advances in IR have made it possible to selectively catheterize the ophthalmic artery and infuse a fibrinolytic agent close to the obstruction site. Three studies have been reported using this novel technique in patients with central retinal vein occlusion[25]. The application of CT-CNB (core-needle biopsy) guidance for orbital space-occupying lesions is described in another case series. The study found that CT-core needle biopsy can be used as a substitute for open biopsy (orbitotomy – which is a major surgical procedure requiring general anesthesia) when treating mass lesions in the lateral aspect of the orbit, avoiding major surgery and permitting prompt use of radiation therapy when necessary. It may be possible to reduce the risk of complications and make the sampling process easier and more efficient by performing the biopsy under CT guidance (by an interventional radiologist). There are only two reports on small-scale studies of CT being used to acquire core needle biopsy of space-occupying lesions of the orbit.

Intra-arterial thrombolysis employs tissue plasminogen activator (tPA) for thrombus resolution, with its clinical efficacy being critically time-sensitive, necessitating intervention within a 6-hour window post-symptom onset. Delivery of tPA into the ophthalmic artery, when administered before irreversible retinal ischemia, yields superior recanalization rates and visual outcomes (56% vs. 32% improvement rates) compared to standard treatment, although it requires careful patient selection to avoid hemorrhage and systemic complications[26].

A study found that low-dose urokinase with papaverine significantly improved vision in central retinal artery occlusion patients, with no major complications reported in this small group. Despite its efficacy, however, the technique may still carry serious risks, such as intracranial bleeding, stroke, arterial injury, vasospasm, and delayed ocular complications[27].

Interventional neuroendovascular techniques are the preferred treatment for CCFs due to their favorable long-term outcomes. Coils are widely used because they are radiopaque, easy to deploy, and can be repositioned or removed if placement is suboptimal. However, complete occlusion may sometimes be difficult to achieve, particularly in septated cavernous sinuses where adequate volumetric packing is challenging. Moreover, the reported rates of cranial nerve paresis are higher with coil embolization, probably because of their mass effect[28].

In a long-term study of nine patients with palpebral arteriovenous malformations (pAVMs), combined endovascular embolization and surgical treatment achieved greater than 75% lesion devascularization in all cases, with good clinical regression and no permanent visual acuity loss reported during follow-up[29].

Challenges and limitations

Technical challenges

Ophthalmic interventions require exceptional accuracy due to the fragile and complex nature of intricate components. Procedures like occlusion of pAVMs require careful catheter guidance to avoid collateral injury. The small size of ocular vessels and their proximity to vital structures, such as the optic nerve and retina, increase the difficulty. A study involving eight patients with palpebral AVMs emphasized the effectiveness of a combined endovascular and surgical strategy, achieving notable lesion reduction without major complications[29]. This underscores the importance of a multidisciplinary strategy and advanced imaging techniques to optimize outcomes. In another study, a comprehensive treatment plan involving vascular occlusion, sclerotherapy, and surgery was employed for periorbital and palpebral AVMs. Over a 3-year follow-up, complete remission was achieved in patients, with no major complications, such as blindness or ptosis. This underscores the importance of securing the central retinal artery to ensure safer and more effective outcomes[30].

Limited availability of specialized equipment and professionals

The incorporation of IR in ophthalmology is further constrained by the shortage of specialized equipment and skilled professionals. Advanced imaging systems, such as high-resolution OCT and DSA, are crucial for accurate interventions but may not be easily available in all medical centers, especially in low- and middle-income countries. IR integration into contemporary clinical practice is restricted to neuro-ophthalmological conditions. The management of intricate vascular anomalies, particularly CCFs, employs endovascular techniques such as coiling and embolization to alleviate severe ocular symptoms and prevent irreversible visual impairment[31]. Furthermore, the number of specialists competent in both ophthalmology and IR remains limited, impeding the widespread adoption of IR-based treatments[32].

High costs of IR procedures

The economic burden associated with IR procedures is another major barrier. The high expenses stem from costly diagnostic systems, advanced catheterization tools, and the need for specialized training programs. In low-resource settings, financial constraints can delay diagnosis and timely management of ocular conditions, resulting in adverse outcomes. For instance, a study on optic neuritis management in India reported that financial limitations posed challenges for many patients, leading to delayed treatment and poorer visual outcomes[33].

Potential risks and complications

IR in ophthalmology involves intrinsic risks, including radiation exposure, contrast-induced nephropathy, and ischemic complications. While modern imaging reduces radiation, repeated procedures in pediatric patients may elevate the risk of cataracts, radiation retinopathy, or optic neuropathy[34]. Contrast agents used in angiographic procedures can cause contrast-induced nephropathy, particularly in patients with renal impairment, necessitating hydration and dose adjustments[35]. Accidental vascular occlusion during procedures like orbital vascular malformation treatment may lead to retinal artery occlusion or optic nerve ischemia, causing permanent vision loss. For instance, a study reported that during embolization, spasms of the ophthalmic artery occurred, leading to a transient afferent pupillary defect and a decrease in visual acuity[36]. Neurological deficits may occur after embolization[37]. Transient cranial nerve V deficit may occur after trans arterial embolization. Venous hypertension may temporarily worsen ocular symptoms[38].

Ethical considerations and patient selection

Ethical concerns in ophthalmic IR focus on patient selection, risk-benefit assessments, and availability of care. Since many IR-based ophthalmic procedures are still developing, comprehensive patient counseling and informed consent are crucial to ensure awareness of risks, benefits, and alternatives[39].

A significant challenge is the inequality in the availability of IR treatments, which are often restricted to specialized facilities with advanced imaging and trained professionals. This creates concerns about healthcare equity, particularly for underserved populations[40]. Furthermore, pediatric patients need careful radiation risk assessment, as their increased sensitivity requires balancing treatment efficacy with long-term safety, especially in conditions like retinoblastoma.

Future prospects and directions

IR is increasingly recognized as a pivotal component in advancing precision medicine within ophthalmology. By integrating advanced imaging techniques and minimally invasive procedures, IR can enhance diagnostic accuracy and therapeutic interventions tailored to individual patient needs. This approach is particularly relevant in conditions like glaucoma, where early diagnosis and personalized treatment strategies are crucial.

AI is poised to significantly enhance various aspects of IR, fostering advancements in precision medicine through tailored treatment plans based on predictive analytics, thus enabling real-time adaptation to procedural changes and potentially transforming treatment customization[41]. The implementation of AI in retinopathy of prematurity (ROP) has been significant, with Brown et al pioneering the validation of a deep convolutional neural network for automated plus disease diagnosis, utilizing a dataset of 5511 retinal images from the i-ROP study, achieving a sensitivity of 93% and specificity of 94%, thereby matching or surpassing the accuracy of human retinal specialists[42].

Advancements in ocular optical imaging methodologies, including scanning laser polarimetry, cSLO, and OCT, exploit the inherently transparent optical pathway to visualize the internal structures of the eye[43]. Novel therapeutic approaches, such as gene therapy, retinal prosthetics, and localized drug delivery systems, have emerged, enhancing therapeutic efficacy while minimizing side effects.

Radiotherapy serves as a therapeutic approach for the treatment of eyelid and ocular surface neoplasms, which pose significant clinical challenges due to the necessity of delivering substantial radiation doses to the tumor tissues while preserving the radiation-sensitive surrounding ocular structures essential for visual function. Both external radiation therapy and interventional radiotherapy (IRT) – brachytherapy are used, but IRT has the significant advantage of delivering a high target dose limited directly to the primary tumor volume^[44,45^].

Nanotechnology has made rapid progress in various aspects. In medicine, it has brought new prospects for diagnosis and treatment plans, such as the delivery of drugs, peptides, and genes, biomedical imaging, and diagnostics of distinct disorders of the eye, as well as the study of pathogenesis. Cai et al developed ranibizumab-loaded double imaging and therapeutic nanoparticles (S-PEG-ICG-RGD-RBZ) through the conjugation of polyethylene glycol with core cross-linked star polymers, further modified by ICG and RGD to target choroidal neovascularization. In vivo and in vitro assessments revealed that these nanoparticles exhibited no cytotoxicity or genotoxicity, effectively inhibiting vascular endothelial growth factor-induced cellular proliferation and tube formation while demonstrating targeted fluorescence imaging of choroidal neovascularization regions in rodent eyes without significant retention in other tissues[46].

Collaboration between interventional radiologists and ophthalmologists is becoming increasingly important for multidisciplinary care. This partnership can lead to more effective and personalized treatment plans. Simulation-based training has demonstrated enhanced performance and accelerated learning compared to traditional methods, allowing interventional trainees to rehearse and analyze procedures before patient interaction. The provision of this support yields a significant ancillary advantage: a reduction in surgical duration. This time-saving effect leads to several positive outcomes, including minimized radiation exposure for both medical professionals and patients, shortened sedation periods for patients, and enhanced overall procedural efficiency. As augmented reality/virtual reality technologies continue to evolve, we can anticipate improvements in their ease of use and comfort. These advancements will facilitate the smooth incorporation of these technologies into diverse educational environments and clinical practice. Navigation systems for IR procedures are currently costly and not covered by reimbursement in the United States. Nevertheless, these systems could potentially lead to cost reductions through improved procedural efficiency and a decrease in complications, resulting in overall timesaving[47].

Conclusion

This review highlights the expanding role of IR in ophthalmology, particularly in imaging advancements, minimally invasive procedures, and targeted therapeutic approaches. The integration of IR techniques, such as OAC and fluoroscopically guided interventions, has significantly improved the management of complex ocular disorders. These innovations reduce surgical risks, enhance precision, and offer alternative treatments with faster recovery times. However, challenges such as accessibility, specialized training, and long-term efficacy require further exploration. As technology continues to advance, IR is expected to play an increasingly vital role in the future of ophthalmic care.

Ethical approval

Not applicable.

Consent

This article did not involve patients; therefore, consent is not applicable.

Sources of funding

The supporting source/financial relationships had no such involvement.

Author contributions

All authors contributed equally to this work for data collection, review, and article writing.

Conflicts of interest disclosure

No conflicts of interest exist for any of the article’s authors.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Not applicable.

Provenance and peer review

Not commissioned; externally peer-reviewed.

Data availability statement

This review is based on previous literature; therefore, data availability is not applicable.

Literature search strategy

Databases searched: PubMed, PMC (PubMed Central), Google Scholar, and MEDLINE.

Overall Search Window: 1995 to 2025. Search Execution Date: The literature search was initiated and continuously updated up to 2025.