Vitrectomy for rhegmatogenous or tractional retinal detachment with familial exudative vitreoretinopathy

Familial Exudative Vitreoretinopathy With and Without Pathogenic Variants of Norrin/β-Catenin Signaling Genes

Purpose

To determine the clinical characteristics of familial exudative vitreoretinopathy (FEVR) associated with or without pathogenic variants of the Norrin/β-catenin genes.

Design

This was a multicenter, cross-sectional, observational, and genetic study.

Subjects

Two-hundred eighty-one probands with FEVR were studied.

Methods

Whole-exome sequence and/or Sanger sequence was performed for the Norrin/β-catenin genes, the FZD4, LRP5, TSPAN12, and NDP genes on blood collected from the probands. The clinical symptoms of the probands with or without the pathogenic variants were assessed as well as differences in the inter Norrin/β-catenin genes.

Main Outcome Measures

The phenotype associated with or without pathogenic variants of the Norrin/β-catenin genes.

Results

One-hundred eight probands (38.4%) had 88 different pathogenic or likely pathogenic variants in the genes: 24 with the FZD4, 42 with the LRP5, 10 with the TSPAN12, and 12 with the NDP gene. Compared with the 173 probands without pathogenic variants, the 108 variant-positive probands had characteristics of familial predisposition (63.9% vs. 37.6%, P < 0.0001), progression during infancy (75.0% vs. 53.8%, P = 0.0004), asymmetrical severity between the 2 eyes (50.0% vs. 37.6%, P = 0.0472), and nonsyndromic characteristics (10.2% vs. 17.3%, P = 0.1185). The most frequent stage at which the more severe eye conditions was present was at stage 4 in both groups (40.7% vs. 34.7%). However, the advanced stages of 3 to 5 in the more severe eye were found more frequently in probands with variants than in those without variants (83.3% vs. 58.4%, P < 0.0001). Patients with rhegmatogenous retinal detachments progressed from stage 1 or 2 were found less frequently in the variant-positive probands (8.3% vs. 17.3%, P = 0.0346). Nine probands with NDP variants had features different from probands with typical Norrin/β-catenin gene variants including the sporadic, symmetrical, and systemic characteristics consistent with Norrie disease.

Conclusions

The results showed that the clinical characteristics of FEVR of patients with variants in the Norrin/β-catenin genes are different from those with other etiologies. We recommend that clinicians who diagnose a child with FEVR perform genetic testing so that the parents can be informed on the prognosis of the vision and general health in the child.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Pars Plana Vitrectomy in Inherited Retinal Diseases: A Comprehensive Review of the Literature

Inherited retinal diseases (IRDs) are a group of clinically and genetically heterogeneous disorders that may be complicated by several vitreoretinal conditions requiring a surgical approach. Pars plana vitrectomy (PPV) stands as a valuable treatment option in these cases, but its application in eyes with such severely impaired chorioretinal architectures remains controversial. Furthermore, the spreading of gene therapy and the increasing use of retinal prostheses will end up in a marked increase in demand for PPV surgery for IRD patients. The retinal degeneration that typically affects patients with hereditary retinal disorders may influence the execution of the surgery and the expected results. Considering the importance of PPV application in IRD-related complications, it is fundamental to try to understand from the literature what is adequate and safe in posterior eye segment surgery. Use of dyes, light toxicity, and risk of wounding scar development have always been themes that discourage the execution of vitreoretinal surgery in already impaired eyes. Therefore, this review aims to comprehensively summarize all PPV applications in different IRDs, highlighting the favorable results as well as the potential precautions to consider when performing vitreoretinal surgery in these eyes.

Reaching a FEVR Pitch: A Case Series of Familial Exudative Vitreoretinopathy in Northern Ireland

PURPOSE

To evaluate the heterogeneity of both the clinical features and genetics of familial exudative vitreoretinopathy (FEVR) in a Northern Irish population.

METHODS

A retrospective trawl of a secure pediatric database was completed, as well as communication with all Northern Ireland ophthalmologists to identify adult cases. Cases were cross-referenced with a regional genetics database. Data on patient demographics, clinical findings, genetic testing, and patient treatment were collected.

RESULTS

Sixteen patients were identified. Average age at presentation was 11.8 years (range: 4 months to 38 years). Earlier age at presentation was associated with more advanced disease and those presenting later had more subtle signs such as retinal tear or vitreous hemorrhage. Four types of gene mutations were identified in 7 patients (NDP, TSPAN12, FZD4, and KIF11). Thirteen patients had complications associated with FEVR and associated systemic conditions were found in 5 patients. Twelve eyes received active treatment to control disease.

CONCLUSIONS

FEVR is a sight-threatening disease affecting prenatal retinal angiogenesis with a spectrum of disease and diverse genetic basis. Clinicians should look for signs of systemic and other ophthalmic sequelae in patients with FEVR because this could point to a genetic cause. Vigilance should also be exercised in older patients with unexplained vitreous hemorrhage or retinal tear with consideration of widefield angiography if FEVR is suspected. [J Pediatr Ophthalmol Strabismus. 2022;59(2):102-109.].

Analysis of Predisposing Clinical Features for Worsening Traction After Treatment of Familial Exudative Vitreoretinopathy in Children

PURPOSE

To determine the incidence of worsening vitreoretinal traction after laser treatment for familial exudative vitreoretinopathy (FEVR) and to determine whether any baseline clinical features are associated with worsening.

DESIGN

Retrospective cohort comparison study in a university tertiary referral center.

METHODS

All patients 0-21 years of age treated with laser from January 1, 2001, to June 1, 2018, were studied. Worsening traction after treatment was defined as the occurrence within 6 months of worsening or development of tractional retinal detachment, folds, dragging, breaks, rhegmatogenous detachment, or worsening tractional membranes. Comparisons of baseline features between groups with and without worsening were performed to determine features associated with higher risk.

RESULTS

A total of 46 eyes from 28 patients met inclusion criteria. Of the 46 eyes, 6 (13%) had worsening after treatment. There were no significant differences in age or other baseline demographics between the cohorts with and those without worsening traction. The presence of proliferative tissue in contact with the lens was found in 2 of 6 patients with worsening compared to 1 of 40 (3%) without worsening (P = .04). Mean follow-up was 57.8 months (range, 6.6-134 months). At the 6-month follow-up, median logMAR visual acuity in the cohorts with and without worsening was 1.7 (Snellen 20/1002; n = 5) and 0.24 (Snellen 20/35; n = 16), respectively.

CONCLUSIONS

Laser treatment resulted in worsening traction in a substantial proportion of eyes with FEVR. Children with proliferative tissue in contact with the lens may be at higher risk of worsening after laser. Potential measures to reduce risk will require further study to establish efficacy.

Outcome and risk factors of vitreoretinal surgery in pediatric patients with familial exudative vitreoretinopathy

PURPOSE

To evaluate the outcome for vitreoretinal surgery in children with familial exudative vitreoretinopathy (FEVR) and to evaluate the risk factors associated with failure.

METHODS

This is a retrospective interventional case series of 43 consecutive eyes (34 patients) with vitreoretinal surgery for FEVR. Ocular status prior to intervention and at last follow-up and all surgical steps were recorded. Follow-up time was at least 6 months. Main outcome measure was surgical failure (defined as one of the following: (1) deterioration of visual acuity and stage, (2) persistence or development of total retinal detachment, (3) phthisis).

RESULTS

After a mean follow-up of 3.3 ± 3.4 years (median 2.3; 0.5-15.7 years), surgery was successful in 30 eyes (70%) and failed in 13 eyes (30%). Twenty-one eyes (49%) improved, 13 (30%) remained stable, and 9 (21%) deteriorated. Postoperatively, stages and VA improved significantly (p = 0.001; p = 0.04, respectively). Surgical failure was only observed on patients with stages 4 and 5. Mean macular thickness decreased significantly in eyes (stages 2 and 3) with tractional epiretinal membrane.

CONCLUSION

Eyes with tractional epiretinal membrane in stages 2 and 3 seem to benefit from vitrectomy and membrane peeling with a positive risk-benefit profile. Advanced stages have a low success rate and limited functional improvement, but in selected cases, surgery seems beneficial.

LONGITUDINAL CHANGES IN THE OPTIC NERVE HEAD AND RETINA OVER TIME IN VERY YOUNG CHILDREN WITH FAMILIAL EXUDATIVE VITREORETINOPATHY

PURPOSE

To explore vitreoretinal pathologies and their longitudinal changes visible on handheld optical coherence tomography (OCT) of young children with familial exudative vitreoretinopathy.

METHODS

The authors retrospectively analyzed handheld OCT images for vitreoretinal interface and retinal abnormalities and optic nerve head (ONH) elevation.

RESULTS

From 26 eyes of 16 children (mean age 32 months) with familial exudative vitreoretinopathy, 10 had ONH dragging on photographs, and in these, handheld OCT revealed temporal and anterior retinal displacement, prominent vitreopapillary adhesion or traction, and retinal nerve fiber layer thickening at ONH margins with adjacent retinal elevation. Despite a nearly normal photographic appearance, handheld OCT revealed ONH elevation with vitreopapillary traction (6/16 eyes), ONH edema (1/16 eye), and retinal vascular protrusion (5/16 eyes). Handheld OCT-visualized vitreous abnormalities (18/26 eyes) were more prevalent at higher stages of disease. Handheld OCT-visualized elevation of ONH and the retina worsened over time in nine eyes and improved in 5/6 eyes after vitrectomy.

CONCLUSION

Handheld OCT can detect early ONH, retinal, and vitreous changes in eyes with familial exudative vitreoretinopathy. Contraction of strongly adherent vitreous in young patients with familial exudative vitreoretinopathy appears to cause characteristic ONH dragging and tractional complications without partial posterior vitreous detachment. Vitreopapillary dragging may be visible only on OCT and may progress in the absence of obvious retinal change on conventional examination.

Clinical Features of Vitreomacular Traction Syndrome with Peripheral Vitreoretinal Adhesion

Purpose

To retrospectively review and analyze the clinical and imaging data of patients with vitreomacular traction syndrome (VMTS) with strong peripheral vitreoretinal adhesion.

Subjects and Methods

This retrospective case-series study involved 4 eyes of 4 VMTS patients with vitreoretinal adhesion in both the macular region and the periphery who underwent vitreous surgery. In all 4 cases, preoperative refraction, fundoscopic findings, optical coherence tomography (OCT) findings, and intraoperative findings were evaluated.

Results

The preoperative fundoscopy and OCT findings revealed fibrous membranes around the optic nerve head in 3 eyes. Thickened posterior vitreous membranes extending from the posterior pole to the periphery were observed in all eyes. Apparent VMTS or epimacular membrane was also found in the fellow eyes of 2 patients. The preoperative refractive errors ranged from +0.5 diopters (D) to +2.75 D (mean, +1.13 D). Intraoperatively, a thickened posterior vitreous membrane was found strongly adhered to the retina in the macula regions, optic nerve head, and periphery. In 2 eyes, when artificial posterior vitreous detachment (PVD) was created, an iatrogenic tear developed in the periphery.

Conclusion

The features of VMTS that cause strong peripheral vitreoretinal adhesion include the preoperative presence of a thickened posterior vitreous membrane over a wide area, hypermetropia, and a short axial length.

Outcomes of surgery in eyes with familial exudative vitreoretinopathyassociated retinal detachment

OBJECTIVE

The aim of this study was to evaluate various techniques of surgical treatment of retinal detachment associated with familial exudative vitreoretinopathy (FEVR) and the factors affecting the anatomical and visual outcome.

DESIGN

Retrospective case series.

PARTICIPANTS

Patients diagnosed with FEVR associated retinal detachment and operated for the same between January 2004 and September 2017.

METHODS

A retrospective chart review was conducted of all patients diagnosed with FEVR between January 2004 and September 2017. Patients with rhegmatogenous retinal detachment (RRD) and tractional retinal detachment (TRD) were included for analysis. Statistical analysis was performed using the t test for mean visual acuities, Fisher's exact test for categorical data, and the one-way analysis of variance for visual outcomes among surgical management options.

RESULTS

A total of 44 eyes of 38 patients diagnosed with FEVR-associated retinal detachment and operated for the same were evaluated. At the time of initial presentation, the mean age of the 38 patients was 14.6 ± 10.9 years and 57.8% were males. Out of 44 eyes that underwent surgical intervention, 79.5% cases were of RRD (n = 35), and TRD was seen in 20.5% cases (n = 9). Primary management in the form of scleral buckle was done in 14 (31.8%) eyes, with 11 eyes (78.6%) having an attached retina after a single surgery and 85.7% after multiple surgeries. Primary pars plana vitrectomy (PPV) was done in 30 (68.2%) eyes, of which 73.3% had attached retina after single surgery and 83.8% after multiple surgeries. Poor pre-operative best-corrected visual acuity, presence of TRD, and presence of falciform folds were associated with poor anatomical outcome.

CONCLUSIONS

Favourable outcomes can be achieved, though multiple surgical interventions may, however, be necessary for the ultimate success in some cases.

Diagnosis of complicated FEVR preoperatively and intra-/post-operatively: characteristics and risk factors for diagnostic timing

Background

To delineate the characteristics of complicated familial exudative vitreoretinopathy (FEVR) patients diagnosed before surgery or intra−/post-operatively and to analyze the risk factors for the diagnostic timing.

Methods

Forty-eight patients who underwent surgery and were diagnosed as FEVR in our department were retrospectively reviewed. Data were collected including the demographic and clinical characteristics of these patients. FEVR patients were divided into 2 groups according to the diagnostic timing: FEVR diagnosed pre-operatively (23 patients), FEVR diagnosed intra−/post-operatively (25 patients). Multivariable analysis was applied for analyzing the risk factors for diagnostic timing.

Results

The clinical characteristics of the FEVR patients were of great variability, including retinal detachment (RD), disappear of anterior chamber, retrolental membrane, epiretinal membrane (ERM), vitreous hemorrhage (VH), myopic foveoschisis (MF), lamellar macular hole (LMH), high myopia (HM). And the referral diagnosis or pre-operative diagnosis were always non-specific. The majority of the referral or preoperative diagnosis were unilateral RD (52.1%), bilateral RD (8.3%), unilateral persistent fetal vasculature (PFV) (8.3%), bilateral PFV (4.2%). There are two risk factors for the complicated FEVR cases diagnosed as FEVR preoperatively: pre-operative ocular manifestations with RD only (OR, 0.104; p-value, 0.022), positive parent’s fluorescein angiography (FA) (OR, 0.105; p-value, 0.035).

Conclusions

The phenotypes of FEVR were greatly variable, they can mimic many non-specific vitreoretinal disorders. The most non-specific referral diagnosis/pre-operative diagnosis was unilateral RD, bilateral RD, unilateral PFV, bilateral PFV. A positive family history or a simple ocular presentation with RD only could contribute to diagnose FEVR preoperatively.

Characteristics of Retinal Breaks and Surgical Outcomes in Rhegmatogenous Retinal Detachment in Familial Exudative Vitreoretinopathy

PURPOSE

To determine the characteristics of retinal breaks and surgical outcomes in eyes with a rhegmatogenous retinal detachment (RRD) with familial exudative vitreoretinopathy (FEVR).

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Thirty-seven patients (46 eyes) with a RRD in FEVR.

METHODS

The medical records were reviewed and the types, directions, and positions of the retinal breaks and surgical outcomes were analyzed.

MAIN OUTCOME MEASURES

Fundus examinations, including ophthalmoscopy, fluorescein angiography, and RetCam imaging (Natus Medical Incorporated, Pleasanton, CA).

RESULTS

The retinal breaks were identified as tears in 12 eyes, atrophic holes in 24 eyes, tears and atrophic holes in 2 eyes, dialysis-related in 1 eye, a retinal break in the ora serrata in 1 eye, and unidentified in 6 eyes. Most retinal breaks (86.1%) were identified only in the temporal retina. Most tears (85.7%) were observed on the demarcation line, whereas atrophic holes were identified both on the demarcation line (53.8%) and the avascular retina (42.3%). The representative tears were almond-shaped, which differs from the typical horseshoe-shaped tears. Scleral buckling was performed as the initial surgery in 37 eyes and resulted in reattachment in 35 eyes (94.6%). Vitrectomy with or without scleral buckle was performed for eyes with more complex RRD in FEVR and resulted in reattachment in 5 of 9 eyes (55.6%). In total, reattachment was achieved in 40 of 46 eyes (87.0%). There was a history of stage 1A or 2A FEVR in 45 eyes and a history of stage 2B FEVR in 1 eye.

CONCLUSIONS

Our data clarified the types, directions, and positions of the retinal breaks and the effectiveness of scleral buckling as the first surgical choice for treating RRDs in FEVR.

Clinical observations of vitreoretinal surgery for four different phenotypes of X-linked congenital retinoschisis

AIM

To evaluate the outcomes of vitreoretinal surgery for four different phenotypes of X-linked retinoschisis (XLRS).

METHODS

This study included thirty-one eyes of 25 patients who developed XLRS with severe complications. Among the 31 eyes, there were 7 eyes with vitreous hemorrhage, 8 eyes with retinal detachment and vitreous hemorrhage, and 16 eyes with rhegmatogenous retinal detachment. All of the patients underwent standard three-port pars plana vitrectomy. All of the eyes were divided into 4 groups before surgery according to a modified classification scheme, with the first three groups as follows: group A, with foveal cystic schisis; group B with macular lamellar schisis; and group C with foveolamellar changes. Peripheral schisis was not present in these 3 groups; however, group D was a complex group with both macular and peripheral changes. One year after surgery, we analyzed the best corrected visual acuity and postoperative anatomical and functional outcomes of these 4 groups.

RESULTS

There were 7 eyes in group A (22.6%), 1 eye in group B (3.2%), 15 eyes in group C (48.4%) and 8 eyes in group D (25.8%). Postoperative anatomical and functional outcomes were satisfactory at the last visit, while the mean visual acuity was increased to 0.27±0.11, with a significant difference (t=-1.049, P=0.000) compared with the results before surgery (0.1±0.08). Visual acuity was improved in 23 eyes (74.2%). Complications were found in three eyes: two eyes with proliferative vitreoretinopathy and traction retinal detachment 10 and 12mo after surgery, respectively; and one eye with vitreous hemorrhage 15mo after surgery. These eyes were in groups C and D. The retinas remained attached in these 3 eyes after reoperation.

CONCLUSION

We should pay greater attention to XLRS with foveolamellar changes because it is the most changeable phenotype. Once complications occur, vitreoretinal surgery can significantly improve visual acuity and restore the anatomic structure of the retina.

Familial exudative vitreoretinopathy complicated with full thickness macular hole: A case report

RATIONALE

To report a case of familial exudative vitreoretinopathy (FEVR) complicated with full-thickness macular hole (FTMH).

PATIENT CONCERNS

A 39-year-old male presented after becoming aware of metamorphopsia in his left eye.

DIAGNOSES

Fundus examination showed a retinal avascular area, retinal vascular abnormality, and yellow exudation at the peripheral retina in both eyes. Optical coherence tomography findings revealed impending MH (IMH) due to posterior vitreous detachment (PVD) in his left eye. Despite of the occurrence of spontaneous complete PVD, an FTMH developed at 4 months after the onset of IMH.

INTERVENTIONS

To treat the FTMH, vitreous surgery was performed. Intraoperative findings revealed that the thick posterior vitreous membrane (PVM) had no adhesions with the edge of the FTMH. However, a thin epiretinal membrane (ERM) was observed around the MH.

OUTCOMES

Postoperatively, the FTMH was closed, and the patient's corrected visual acuity improved from (0.4) to (0.8).

LESSONS

In this present case, an IMH developed via traction by a thick PVM, characteristic of FEVR, with FTMH then developing via traction by a thin ERM. Our findings reveal that it is vital to fully understand these anatomical features before performing vitreous surgery for FTMH complicated with FEVR.

Familial Exudative Vitreoretinopathy: Pathophysiology, Diagnosis, and Management

Familial exudative vitreoretinopathy (FEVR) is a heritable vitreoretinopathy characterized by anomalous retinal vascular development. The principal feature of the disease is an avascular peripheral retina. This in turn can cause further pathological changes including neovascularization, exudation, hemorrhage, and retinal detachment. The biological basis of the disease is thought to be from defects in the Wnt signaling pathway. Many gene mutations have been implicated, and these can be inherited in an autosomal dominant (most common), autosomal recessive, and X-linked recessive fashion. Examination with wide-field fluorescein angiography is essential and can identify the disease in its earlier stages, enabling timely treatment, in addition to helping identify asymptomatic family members. The current treatment paradigm involves laser photocoagulation of the avascular peripheral retina for neovascular sequelae and vitreoretinal surgery for progressive retinal detachment. Further studies are underway to better characterize this complex vitreoretinopathy.

Surgical treatments for fibrous tissue extending to the posterior retina in eyes with familial exudative vitreoretinopathy

PURPOSE

To describe the clinical features and surgical outcomes of macular dragging or tractional retinal detachment that occurred as a result of fibrovascular tissue (FT) progression toward the posterior retina in eyes with familial exudative vitreoretinopathy (FEVR).

METHODS

The medical records of 4 patients (2 girls, 2 boys) with FEVR were reviewed retrospectively.

RESULTS

All 4 patients had retinal dragging or radial retinal folds with FT in the peripheral retina in at least 1 eye at the initial visit. During the follow-up period, all the patients had FT that progressed toward the posterior pole and developed from the peripheral FT, resulting in macular dragging or posterior tractional retinal detachment. Vitrectomy with or without scleral buckling and laser photocoagulation were performed in all 4 cases, with removal of the FT in the posterior pole and segmentation of the FT between the posterior and peripheral FT. The traction resolved postoperatively and the retina extended in all 4 cases.

CONCLUSIONS

In 4 cases with FEVR, the FT developed from the peripheral FT, progressed toward the posterior retina, and generated traction. Vitrectomy with focal removal and segmentation of the FT in the posterior pole might be a good surgical option in such eyes.

CLINICAL FEATURES OF AFFECTED AND UNDETACHED FELLOW EYES IN PATIENTS WITH FEVR-ASSOCIATED RHEGMATOGENOUS RETINAL DETACHMENT

PURPOSE

To report the clinical characteristics of the affected and fellow eyes in patients with familial exudative vitreoretinopathy-associated rhegmatogenous retinal detachment (FEVR-RRD).

METHODS

This was a retrospective observational case series. The affected and fellow eyes were given complete examinations. The age, sex, clinical features of the affected eyes, and varied abnormalities of the fellow eyes were analyzed.

RESULTS

Forty-three patients with FEVR-RRD were included. The average age was 21.8 ± 10.9 years, and the males (19.9 ± 9.6) were younger than the females (28.1 ± 1.2). Retinal round holes were noted in 32 (71.1%) eyes. In addition, horseshoe retinal tears and giant retinal tears were present in 10 (22.2%) eyes and 3 (6.7%) eyes. Subretinal fibrosis was seen in 20 (44.4%) eyes, and choroidal detachment was shown in 6 (13.3%) of the eyes. A high prevalence of abnormalities was noted in the undetached fellow eyes in the peripheral retina, including vascular leakage in fundus fluorescein angiography (75.6%), lattice degeneration (53.7%), and vitreous traction (51.2%).

CONCLUSION

Male patients with FEVR-RRD experience an earlier onset than females in our series. Retinal tears, even giant tears, could be responsible for FEVR-RRD. The fellow eyes of FEVR-RRD patients were characterized by predetachment changes, which need both lifelong monitoring and timely vision-saving intervention.

Anatomical and functional outcomes following vitrectomy for advanced familial exudative vitreoretinopathy: a single surgeon's experience

PURPOSE

To assess the anatomical and functional results of vitreoretinal surgery in patients with advanced familial exudative vitreoretinopathy (FEVR).

METHODS

Retrospective analysis of data for 10 eyes of 9 patients with advanced FEVR who underwent pars plana vitrectomy from March 1997 to May 2015 and had a follow-up of at least 12 months. The primary outcomes were final visual acuity (VA) and anatomical success.

RESULTS

The average age at the time of the surgery was 10.1±6.5 years (range 2 months-18 years). The mean follow-up period was 58.4±75.1 months. The male-to-female ratio was 7/2. The mean number of vitreoretinal operations was 1.5. At the last visit, 7 (70%) eyes had complete or partial retinal attachment. Preoperatively, the mean Snellen VA was 20/4000 (n=8), and in the remaining 2 (20%) eyes it was recorded as 'central, steady and maintained'. At final examination, the mean Snellen VA was 20/330 (n=7), and in the remaining 3 (30%) eyes it was recorded as light perception. At the final visit, 5 eyes (50%) had improved VA, 2 eyes (20%) showed stabilisation, and 3 eyes (30%) with total retinal detachment had a decrease in VA. No progression to glaucoma was observed and no enucleation was necessary.

CONCLUSIONS

Advanced FEVR in young children tends to be more aggressive, leading to severe complications. These cases are challenging and require special consideration. Despite surgery, disease-related complications remain high. However, surgical intervention for advanced FEVR might be of benefit in helping to preserve vision.

Familial Exudative Vitreoretinopathy

Familial exudative vitreoretinopathy (FEVR) is a hereditary disease associated with visual loss, particularly in the pediatric group. Mutations in the NDP, FZD4, LRP5, and TSPAN12 genes have been shown to contribute to FEVR. FEVR has been reported to have X-linked recessive, autosomal dominant, and autosomal recessive inheritances. However, both the genotypic and phenotypic features are variable. Novel mutations contributing to the disease have been reported. The earliest and the most prominent finding of the disease is avascularity in the peripheral retina. As the disease progresses, retinal neovascularization, subretinal exudation, partial and total retinal detachment may occur, which may be associated with certain mutations. With early diagnosis and prompt management visual loss can be prevented with laser photocoagulation and anti-VEGF injections. In case of retinal detachment, pars plana vitrectomy alone or combined with scleral buckling should be considered. Identifying asymptomatic family members with various degrees of insidious findings is of certain importance. Wide-field imaging with fluorescein angiography is crucial in the management of this disease. The differential diagnosis includes other pediatric vitreoretinopathies such as Norrie disease, retinopathy of prematurity, and Coats’ disease.

Surgical outcomes of progressive tractional retinal detachment associated with familial exudative vitreoretinopathy

PURPOSE

To evaluate various surgeries for treating retinal detachment (RD) associated with familial exudative vitreoretinopathy (FEVR).

DESIGN

Retrospective, interventional case series.

METHODS

The charts of 22 patients who underwent surgery were reviewed. A complete ophthalmic examination was performed including wide-field fundus images with fluorescein angiography. The primary and secondary outcomes were fundus features (vascular activity of the fibrovascular proliferation and extent of tractional RD) and visual acuity (VA), respectively.

RESULTS

Thirty-one eyes were included (12 eyes underwent scleral buckling, 1 scleral buckling and vitrectomy, 7 vitrectomy alone, and 11 lensectomy and vitrectomy). Twenty-six eyes were reattached during 1 surgery. Scleral buckling resulted in cessation of fibrovascular proliferation and retinal reattachment; only 1 of these eyes required vitrectomy. Lens-sparing vitrectomy resulted in stabilized fibrovascular proliferation and retinal reattachment. Vitrectomy with lensectomy did not achieve retinal reattachment in 4 eyes. Fibrovascular proliferation has a rich vascular component in patients younger than 3 years, and collagen fibers were present mainly with more advanced age. The postoperative VA improved in 5 of 8 eyes examined, was unchanged in 1 eye, and decreased in 2 eyes with macular involvement.

CONCLUSIONS

FEVR-induced RDs are highly variable and require careful preoperative evaluation to determine the best surgical procedure. Vitrectomy with release of posterior traction is essential in younger patients with vascularly active fibrovascular proliferation, whereas scleral buckling may be important for cases with peripheral traction anterior to the equator. In all cases, peripheral thermal treatment applied to all ischemic areas contributed to reduced peripheral neovascularization.

Familial exudative vitreoretinopathy and related retinopathies

Familial exudative vitreoretinopathy (FEVR) is a rare inherited disorder of retinal angiogenesis. Cases can be autosomal dominant, autosomal recessive, or X-linked. FEVR patients have an avascular peripheral retina which, depending on the degree of ischaemia, causes the secondary complications of the disease. Expressivity may be asymmetric and is highly variable. Five genes have been identified that when mutated, cause FEVR; NDP (X-linked), FZD4 (autosomal dominant and recessive), LRP5 (autosomal dominant and recessive), TSPAN12 (autosomal dominant and recessive), and ZNF408 (autosomal dominant). Four of these genes have been shown to have a central role in Norrin/Frizzled4 signalling, suggesting a critical role for this pathway in retinal angiogenesis. In addition to the ocular features, LRP5 mutations can cause osteopenia and osteoporosis. All FEVR patients in whom molecular testing is not easily accessible should have dual energy X-ray absorptiometry (DEXA) scans to assess bone mineral density, as treatment can be initiated to reduce the risk of bone fractures.

Major challenges in vitreoretinal surgery

Since the first vitrectomy surgery was used for treatment of vitreoretinal diseases, surgical techniques and instrumentation have been rapidly improved in the past decades. However, there are complicated vitreoretinal diseases that cannot be successfully treated, even with state-of-the-art surgeries. The outcomes of some complicated cases are still poor due to different reasons and debates still remain in some areas regarding what are the best treatments. There is still a lack of full understanding on many complicated vitreoretinal diseases, such as the molecular basis of proliferative vitreoretinopathy (PVR), the role of scleral buckling (SB) in the management of rhegmatogenous retinal detachment (RRD), the optimal surgical consideration for pediatric RD, and the possibility of surgical management for various retinal degenerations and congenital retinal anomalies. This review discusses the current understandings of some complicated vitreoretinal diseases.

Traction retinal detachment under silicone oil treated with two-port, 25-gauge pars plana vitrectomy and scissor segmentation in a child with familial exudative vitreoretinopathy

PURPOSE

To describe a method of 25-gauge pars plana vitrectomy (PPV) with posterior hyaloid scissor segmentation in a child with recurrent retinal detachment caused by vitreous traction under silicone oil.

METHODS

A two-port, 25-gauge PPV was performed under previously instilled silicone oil with retinotomy and internal drainage of subretinal fluid.

RESULTS

A 5-year-old monocular girl with familial exudative vitreoretinopathy presented with decreased vision and a recurrent retinal detachment 3 weeks after PPV and air-silicone exchange for rhegmatogenous retinal detachment. Ophthalmoscopy, fundus photography, and optical coherence tomography revealed persistent posterior hyaloid adherent to multiple retinal foci inducing a tractional detachment. The patient underwent two-port PPV revision with scissor segmentation of vitreous traction. Follow-up examination at 3 months revealed the absence of vitreous traction, an attached retina, and markedly improved vision.

CONCLUSION

Posterior vitreous sequestered under silicone oil inducing consecutive retinal detachment may be successfully managed with two-port interface PPV and scissor segmentation of vitreous traction.

Familial exudative vitreoretinopathy presenting with unilateral rhegmatogenous retinal detachment in a Malay teenager

To describe a case of familial exudative vitreoretinopathy presenting with unilateral rhegmatogenous retinal detachment in a Malay teenager.

Vitreomacular interface in patients with familial exudative vitreoretinopathy

Familial exudative vitreoretinopathy (FEVR) is a rare hereditary vitreoretinal disease that occurs in young patients and results in an avascular peripheral retina, retinal neovascularization, and tractinal retinal detachment. Patients occasionally have concurrent macular diseases. However, the vitreomacular relationship in FEVR remains unclear. We report two cases, a 22-year-old woman (case 1) and a 14-year-old boy (case 2) with FEVR who have the characteristic findings of the disease in the vitreomacular interface and the macular morphology, observed using spectral-domain optical coherence tomography (SD-OCT). In case 1, the best-corrected visual acuity (BCVA) was 20/20 bilaterally. SD-OCT showed a perifoveal posterior vitreous detachment (PVD) with vitreofoveal adhesion in the left eye. In case 2, SD-OCT showed a perifoveal PVD in the right eye (BCVA, 20/30) with numerous small deposits that appeared as rod-shaped attachments perpendicular to the parafoveal face without intraretinal and subretinal materials beneath the posterior hyaloid face that corresponded to white material on the fundus examination. Fluorescein angiography showed a circumferential peripheral avascular area and peripheral neovascularization in both cases. These SD-OCT findings suggested that a perifoveal PVD and small deposits, which appeared as rod-shaped attachments perpendicular to the parafoveal face in patients with FEVR, may carry the risk of macular disease and decreased visual acuity.

Characteristics and surgical outcomes of pediatric rhegmatogenous retinal detachment

Purpose

To describe the characteristics and surgical outcomes of pediatric rhegmatogenous retinal detachment.

Methods

A retrospective study of pediatric patients (15 years old or younger) who had undergone primary surgery for rhegmatogenous retinal detachment was conducted. Patients were divided into five groups according to the predisposing factors: trauma (group 1), myopia (group 2), atopic dermatitis (group 3), congenital or developmental anomalies (group 4), and others (group 5).

Results

A total of 48 eyes of 44 patients were included in this study. There were 18 eyes (37.5%) in group 1, twelve eyes (25.0%) in group 2, six eyes (12.5%) in group 3, five eyes (10.4%) in group 4, and seven eyes (14.6%) in group 5. The initial retinal reattachment rate was 89% in group 1, 100% in group 2, 83% in group 3, 20% in group 4, and 86% in group 5 (P = 0.002). The final retinal reattachment rate was 100% in group 1, 100% in group 2, 100% in group 3, 80% in group 4, and 86% in group 5 (P = 0.16). The frequency of visual acuity of 0.1 or better after surgery was 100% in group 1, 92% in group 2, 83% in group 3, 40% in group 4, and 71% in group 5 (P = 0.01).

Conclusion

The overall surgical outcome was successful, but the patients in group 4 had the lowest initial reattachment rate and the worst visual prognosis.