Familial exudative vitreoretinopathy and macular hole exhibited in same individual

Successful Management of Familial Exudative Vitreoretinopathy with a Large Macular Hole Using Inverted Internal Limiting Membrane Flap Technique

Introduction

This case report aims to shed light on a rare presentation of familial exudative vitreoretinopathy (FEVR) co-existing with a large full-thickness macular hole (FTMH) in a 16-year-old male and discuss its successful surgical management, thereby adding to the limited existing knowledge on this topic.

Case Presentation

Over an 8-month period, the patient had experienced progressively worsening visual blurring and distortion in his left eye. Following a comprehensive examination, diagnosis confirmed FEVR and an accompanying large FTMH. It was hypothesized that this unusual manifestation resulted from the tractional forces exerted by a thick posterior vitreous membrane and a thin epiretinal membrane - a distinctive attribute of FEVR. The patient underwent surgical intervention, which included pars plana vitrectomy (PPV), internal limiting membrane (ILM) peeling, gas tamponade, and the inverted ILM flap technique. Postoperative outcomes were favorable, with the FTMH successfully closed and substantial improvement observed in the patient's visual acuity at the 3-month follow-up visit.

Conclusion

This case report highlights a rare association of FEVR with FTMH, thereby broadening our understanding of potential complications in patients with FEVR. The successful surgical intervention reinforces the utility of the PPV and the inverted ILM flap technique in managing such complications. It underscores the need for clinicians to maintain vigilance for such atypical manifestations in FEVR patients.

LAMELLAR MACULAR HOLE WITH LAMELLAR HOLE-ASSOCIATED EPIRETINAL PROLIFERATION IN FAMILIAL EXUDATIVE VITREORETINOPATHY

PURPOSE

To present a clinical case of lamellar macular hole with lamellar hole-associated epiretinal proliferation in a pediatric familial exudative vitreoretinopathy patient. Retinal findings are described, and spectral domain optical coherence tomography documentation is provided. The efficacy of surgical intervention is also discussed.

METHODS

A 4-year-old girl presented with poor vision in her right eye, which was discovered during routine physical examination. Clinical examination revealed familial exudative vitreoretinopathy in both eyes and a lamellar macular hole in the right eye. Both of the patient's parents were also examined, which revealed familial exudative vitreoretinopathy in the girl's father. The patient underwent vitrectomy, inner limiting membrane and lamellar hole-associated epiretinal proliferation peeling, and air-fluid exchange.

RESULTS

Images obtained with optical coherence tomography revealed lamellar hole-associated epiretinal proliferation at the lamellar defect edge in the patient's right eye. Postoperative examination showed that the lamellar macular hole had closed.

CONCLUSION

Pediatric familial exudative vitreoretinopathy patients may develop lamellar macular hole with lamellar hole-associated epiretinal proliferation. Vitreoretinal surgery effectively closes this type of macular hole.

Etiologies, Characteristics, and Management of Pediatric Macular Hole

PURPOSE

To report on the etiologies and prognosis of macular hole (MH) in children and to explore the indicators of spontaneous hole closure and poor final visual outcome (vision worse than 20/200).

DESIGN

Consecutive, retrospective case series.

METHODS

A consecutive series of patients aged less than 16 years with a full-thickness macular hole treated from 2013 to 2019 in a singer tertiary center was retrospectively reviewed. Data collected from charts included age, sex, best-corrected visual acuity (BCVA), etiology of MH, size of MH, clinical findings, operations, and anatomic and functional outcomes. Logistic regression models were built to establish the predisposing factors.

RESULTS

Forty eyes of 40 patients were included. Patients were predominantly male with a mean age of 8.3 years. Among the etiologies, trauma prevailed in 29 (72.5%) eyes. Twenty-nine patients underwent surgery, and 18 (62.1%) had traumatic MH. All had achieved hole closure. BCVA improved at the final visit. Spontaneous closure was found in 10 (25%) eyes after an average 2 months after trauma. Regression analysis showed that a relatively smaller macular hole (P = .006) was likely to experience spontaneous closure. Presence of macular lesions (P = .001) was identified as risk factor for poor final vision.

CONCLUSIONS

Most pediatric MH was caused by blunt trauma. BCVA improved after MH closed, regardless of surgery or spontaneous closure. Smaller MH secondary to trauma was more likely to experience spontaneous closure with an average time of 2 months. Presence of macular lesions was a risk factor for final poor vision.

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.

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.

Clinical and next-generation sequencing findings in a Chinese family exhibiting severe familial exudative vitreoretinopathy

Familial exudative vitreoretinopathy (FEVR) is a rare hereditary retinal disorder characterized by the premature arrest of vascularization in the peripheral retina. The aim of the present study was to characterize the clinical presentations of a Chinese family affected by bilateral severe FEVR, and to identify the underlying genetic variations. One family that presented with bilateral FEVR was recruited for this study. Comprehensive ophthalmic examinations, including best‑corrected visual acuity, slit‑lamp examination, fundus photography, fundus fluorescein angiography imaging and electroretinogram were performed. Genomic DNA was extracted from leukocytes of the peripheral blood collected from the affected and unaffected family members, as well as 200 unrelated control subjects from the same population. Next‑generation sequencing of the candidate genes associated with ocular diseases was performed, and the identified mutations were validated by conventional polymerase chain reaction‑based sequencing. The functional effects of the mutations were analyzed by polymorphism phenotyping (PolyPhen) and sorting intolerant from tolerant (SIFT). One heterozygous ATP binding cassette subfamily A member 4 (ABCA4) c.5693G>A (p.R1898H) mutation in exon 40 and one heterozygous LDL receptor related protein 5 (LRP5) c.260T>G (p.I87S) mutation in exon 2 were identified in this family. To the best of our knowledge, the ABCA4 c.5693G>A (p.R1898H) mutation has not been reported in FEVR, and the LRP5 c.260T>G (p.I87S) mutation is a novel mutation. PolyPhen and SIFT predicted that the amino acid substitution R1898H in protein ABCA4 is benign, whereas the amino acid substitution I87S in protein LRP5 is damaging. A single nucleotide polymorphism c.266A>G (p.Q89R, rs41494349) was identified in exon 2 of LRP5. These findings expand the mutation spectrums of ABCA4 and LRP5, and will be valuable for genetic counseling and development of therapeutic interventions for patients with FEVR.

MACULAR HOLE IN A YOUNG PATIENT AFFECTED BY FAMILIAL EXUDATIVE VITREORETINOPATHY

PURPOSE

To report a case of familial exudative vitreoretinopathy in which genetic testing was used to confirm the diagnosis with a new mutation identified in FZD4 gene.

METHODS

A 28-year-old girl was addressed to our clinic for surgical management of a macular hole possibly associated with Coats disease. Multimodal imaging was performed including fundus photography, fundus autofluorescence, optical coherence tomography, fluorescein, and indocyanine green angiography.

RESULTS

On examination, visual acuity was light perception secondary to previous retinal detachment and 20/32, respectively, in her right and left eye. Clinical and imaging evaluations showed findings suggestive for familial exudative vitreoretinopathy. Spectral domain optical coherence tomography study of the macula showed a macular pucker with lamellar macular hole and a conservative approach was preferred. After 18 months of observation, the patient underwent surgery secondary to the onset of a full thickness macular hole. After 24 months, the patient's vision was 20/32. Genetic testing was used to confirm the diagnosis demonstrating 2 new mutations in FZD4 gene.

CONCLUSION

Our case emphasizes the importance of a prompt recognition of familial exudative vitreoretinopathy disease also using gene testing and a close follow-up to prevent and manage possible complications.

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.