INTRAVITREAL RANIBIZUMAB TREATMENT FOR ADVANCED FAMILIAL EXUDATIVE VITREORETINOPATHY WITH HIGH VASCULAR ACTIVITY

Angiographic features of pediatric stage 4 familial exudative vitreoretinopathy with radial retinal folds

PURPOSE

To describe vascular anomalies and nonperfusion areas (NPAs) of stage 4 familial exudative vitreoretinopathy (FEVR) with radial retinal folds (RFs) and analyze their potential clinical significance.

METHODS

Retinal detachment (RD) could exceed the RFs due to exudative, rhegmatogenous, or tractional factors, which we could call secondary RD. Fluorescein fundus angiography (FFA) and risk factors for progression to secondary RD of pediatric stage 4 FEVR patients with radial RFs were respectively explored.

RESULTS

Fifty-eight eyes with RFs from 49 stage 4 pediatric FEVR patients were studied. Various angiographic changes were noted, including peripheral NPAs (93.1%), thinning retinal arteries (48.3%), straightened retinal vessels (34.5%), supernumerary vascular branching (32.8%), arteriovenous shunt (20.7%), aberrant circumferential vessels (13.8%), bulbous vascular endings (10.3%) and peripheral vascular dilation (6.9%). Nineteen (35.2%), 21(38.2%), and 14 (25.9%) of 58 eyes showed severe, moderate, and mild peripheral NPAs, respectively. The rate of secondary RDwas higher in eyes with severe peripheral NPAs (p = 0.004). The severity of the nonperfusion area (p = 0.040) was higher in eyes with exudation. Eight eyes (42.1%) with exudation and 12 eyes (30.8%) without exudation on color fundus pictures exhibited fluorescein leakage (p = 0.394). The rate of secondary RD was 26.3% in eyes with exudation, and 2.6% in eyes without exudation (p = 0.012).

CONCLUSIONS

The majority of stage 4 FEVR eyes with RFs have severe peripheral NPAs. Exudation is related to more severe peripheral NPAs. Exudation and NPAs are predictive factors for secondary RD.

KEY MESSAGES

What is known • Radial retinal folds are a typical clinical sign of FEVR, observed in 50.9% of FEVR patients, but little is known about the angiographic characteristics of these individuals. What is new • The severity of the nonperfusion area was graded into 3 levels. The severity of the nonperfusion area and hard exudation are risk factors for progression to total retinal detachment.

Intra-Anterior Chamber Injection of Ranibizumab in Advanced Pediatric Vitreoretinal Diseases

Importance

Anti-vascular endothelial growth factor (VEGF) treatment through intravitreal or subretinal administrations has been proven effective for VEGF-driven pediatric vitreoretinal diseases but are not feasible for advanced cases, such as shallow traction retinal detachments or peripheral circumferential retinal detachments which adhere to the lens. Intra-anterior chamber injection (IAcI) of anti-VEGF may be a viable alternative in such cases but needs evaluation.

Objective

To investigate the effects and safety of IAcI of anti-VEGF to treat VEGF-driven pediatric vitreoretinal diseases.

Design, Setting, and Participants

This was a retrospective observational case series study conducted at Xinhua Hospital, affiliated with Shanghai Jiao Tong University School of Medicine in China. The study included 14 eyes of 13 children diagnosed with vitreoretinal disease exhibiting elevated vascular activity between January and August 2023.

Intervention

IAcI with ranibizumab.

Main Outcomes and Measures

Retinal vascular abnormalities, vitreous hemorrhage resolution, and complications 1 month and 3 months after injection.

Results

Of 13 patients included in this study, 12 were male. The mean age was 4.6 years (range, 1 month to 9 years). Six patients were diagnosed with familial exudative vitreoretinopathy, 4 with morning glory syndrome, 1 with retinopathy of prematurity, and 2 with chronic retinal detachments of unknown causes. At 1-month postoperative follow-up, vascular activity had decreased in 14 of 14 eyes. At 3-month follow-up, vascular activity had resolved in 7 of 14 eyes, persisted in 6 of 14 eyes, and reactivated in 1 of 14 eyes. On final observation, no complications were reported.

Conclusions and Relevance

These findings support the possibility of treatment using IAcI with ranibizumab to decrease retinal vascular abnormalities in familial exudative vitreoretinopathy or retinopathy of prematurity or related conditions, but further studies are needed to understand more precise benefits and risks. This approach might be considered in cases where intravitreal or subretinal injection are not feasible, recognizing the limitations of these findings and that longer-term outcomes still need to be monitored.

Extraretinal Fibrovascular Proliferation in a Neonate Possibly Associated with an ESAM Gene Variant

A female infant born with a gestational age of 35 weeks and birth weight of 2500 g was referred for ophthalmic examination on the second postnatal day. Bilateral venous dilatation and arterial tortuosity, severe extraretinal fibrovascular proliferation, and peripheral ischemia were detected. Fluorescein angiography showed profoundly delayed arteriovenous transit and peripheral avascularity. Both eyes were treated with diode laser photocoagulation and bevacizumab injection. Cranial magnetic resonance imaging (MRI) revealed hydrocephalus, ventricular dilatation, and cerebral atrophy. Her family history revealed that the patient’s brother presented to the ophthalmology outpatient clinic at postnatal 3 months with inoperable total retinal detachment and similar cranial MRI findings. No systemic or ocular findings were detected in the parents. A recent study showed that in 13 cases, including our patients, bi-allelic variants in the ESAM gene lead to a new neurodevelopmental disease whose main clinical features include impaired speech and language development, seizures, varying degrees of spasticity, ventriculomegaly, intracranial hemorrhage, and developmental delay/mental disability. Newborn siblings of children with serious pathological retinal findings should undergo a detailed ophthalmic examination as soon as possible after birth to prevent total retinal detachment, even without a diagnosis of specific inherited retinal vascular diseases. Further investigations performed in collaboration with an international network may reveal more candidate gene variants possibly related to retinopathy of prematurity-like ophthalmological findings such as extraretinal fibrovascular proliferation.