Outcomes and Complications 5 Years After Surgery for Pediatric Cataract Associated With Persistent Fetal Vasculature

PURPOSE

To report 5-year outcomes after surgery for cataract associated with persistent fetal vasculature (PFV).

DESIGN

Clinical cohort study using pediatric cataract registry data collected annually from medical records.

METHODS

This study included 64 children <13 years of age who were undergoing surgery for unilateral, nontraumatic cataract associated with PFV. Proportions with age-normal visual acuity (VA) and VA better than 20/200 at 5 years' follow-up were estimated. Cumulative incidences of complications and additional surgeries by 5 years were calculated. Outcomes were compared between eyes with unilateral PFV and eyes with unilateral non-PFV cataract from our registry.

RESULTS

Forty-eight of 64 eyes were aphakic postoperatively (median age at surgery 2 months [range 1-13 months]) and 16 were pseudophakic (29 months [range 2-92 months]). Overall, 4 of 42 eyes (10% [95% confidence interval {CI} 3%-23%]) achieved age-normal VA. VA better than 20/200 was achieved in 17 (59% [95% CI 39%-76%]) unilateral aphakic PFV eyes and 44 (43% [95% CI 32%-54%]) unilateral non-PFV aphakic eyes (age-adjusted odds ratio = 1.90 [95% CI 0.81-4.50]; P = .14). The most common complication in aphakic PFV eyes was glaucoma-related adverse events (cumulative incidence 24% [95% CI 9%-37%]). There was no significant difference in glaucoma-related adverse events between PFV and non-PFV eyes in aphakic participants ≤1 year of age at lensectomy (age-adjusted hazard ratio = 1.20 [95% CI 0.54-2.64], P = .66).

CONCLUSIONS

A wide range of visual outcomes for PFV cataract were observed with a 10% probability of achieving age-normal VA. There was an ongoing risk for the development of glaucoma-related adverse events in PFV eyes.

Severe anterior persistent fetal vasculature: the role of anterior retinal elongation on prognosis

PURPOSE

This study aims to investigate surgical outcomes of eyes with severe anterior persistent fetal vasculature (PFV) and the role of associated anatomical anomalies on prognosis.

METHODS

This is a retrospective, comparative case series of 32 eyes of 31 patients who underwent vitreoretinal surgery for severe anterior PFV, defined as fibrovascular tissue totally covering the back of cataractous lens. Based on the degree of anterior retinal elongations, cases were classified as follows: group 1, eyes with well-developed pars plana and minor/no abnormalities (n = 11, 34%); group 2, eyes with partially developed pars plana and broad-based elongations (n = 9, 28%); and group 3, eyes with no visible pars plana and fibrovascular membrane having 360° continuity with peripheral retina (n = 12, 38%). Complications and functional and anatomical outcomes were investigated.

RESULTS

The median surgical age was 2 (1-12) months. The median follow-up was 26 (6-120) months. Seventy-three percent in group 1 achieved finger counting or better vision with a single surgery and without any pupillary/retinal complication. Groups 2 and 3 required 2.1 ± 0.9 and 2.6 ± 1.2 surgeries on average. Pupillary obliteration and RD occurred in 33% and 22% in group 2 and 58% and 67% in group 3. Retina remained attached after silicone oil removal in 89% of group 2 and 25% of group 3. Phthisis developed in 50% in group 3.

CONCLUSION

Peripheral retinal anomalies are common in severe anterior PFV and have a major impact on prognosis. Prognosis is favorable in cases with mild-to-moderate anomalies with appropriate management of possible retinal tears. In eyes with 360° retinal elongations, severe fibrous proliferation and eventual eye loss are common.

Surgical outcomes of posterior persistent fetal vasculature syndrome: cases with tent-shaped and closed funnel-shaped retinal detachment

BACKGROUND/OBJECTIVES

To determine the role of vitreoretinal surgery (VRS) for two different forms of posterior persistent fetal vasculature syndrome (PFVS); with tent-shaped tractional retinal detachment (TRD) and closed funnel-shaped TRD.

SUBJECTS/METHODS

Retrospective, single surgeon, consecutive case series of 52 eyes of 44 patients with posterior PFVS who underwent VRS. Cases were divided into "tent-shaped TRD" and "funnel-shaped TRD" groups based on the preoperative TRD configuration. Associated anomalies, functional and anatomical outcomes were evaluated. The cosmetic appearance was defined as poor if there was phthisis bulbi, gross buphthalmos, or corneal opacification; acceptable if there was apparent leukocoria; and excellent if none were noted at the last follow-up.

RESULTS

Thirty eyes of 29 patients presented with tent-shaped TRD; 70% of which obtained counting fingers or better vision and 90% showed significant reversal of tenting achieving retinal reattachment. The cosmetic appearance was excellent in 87%. Two eyes (7%) became phthisic. Twenty-two eyes of 15 patients presented with funnel-shaped TRD and leukocoria; 45% achieved LP vision and 70% of patients with bilateral pathology had LP in at least one eye. The cosmetic appearance was acceptable to excellent in 73%. Three eyes (14%) became phthisic, one (5%) of which required enucleation. The median follow-up time was 16 (6-71) months.

CONCLUSIONS

VRS often provides functional vision and anatomy in posterior PFVS with tent-shaped TRD morphology. In the funnel-shaped TRD morphology, where no treatment has historically been recommended, surgery may be considered with an aim of restoring light perception and globe preservation, particularly in bilateral cases.

Anterior elongation of the retina in persistent fetal vasculature: emphasis on retinal complications

PURPOSE

To identify the characteristics of peripheral retinal anomalies associated with persistent fetal vasculature (PFV) and evaluate the complications and outcomes.

METHODS

Retrospective, noncomparative case series of patients with PFV who underwent surgery. Type of PFV, presence of peripheral retinal anomalies, extent of the retrolental membrane, complications, and functional and anatomical results were evaluated.

RESULTS

Twenty-nine eyes of 28 patients were enrolled in the study: 14 eyes (48.3%) with anterior PFV, 10 eyes (34.5%) with posterior PFV, and 5 eyes (17.2%) with combined PFV. The retina was found to elongate anteriorly as finger-like projections beyond the ora serrata, incorporating into retrolental fibrovascular tissue in 81.8% of the anterior PFV cases. Cases with more extensive retrolental tissue had a higher risk of retinal complications (p = 0.009) and anterior segment complications (p = 0.026) than those with localized disease. Leaving the peripheral part of the fibrovascular tissue in place led to complications by later contraction. A total of 35.7% of the anterior PFV cases had 20/200 or better vision at the final follow-up versus 6.7% of the cases with posterior involvement. Retinal attachment was achieved in 12 eyes (80%) with posterior involvement. Four eyes (13.7%) resulted in total retinal detachment at final follow-up.

CONCLUSIONS

The high incidence of peripheral retinal anomalies that are found in anterior PFV patients and their relation to retinal complications warrant careful examination of the ora serrata-ciliary body area. Limbal approach may be preferred as a safer method in cases with an extensive fibrovascular membrane obscuring the view. Leaving the peripheral part of the fibrovascular tissue may result in severe postoperative complications, which should be avoided.

Persistent Fetal Vasculature

During development, the fetal vasculature nourishes the developing lens and retina, and it subsequently regresses after the formation of the retinal vessels. Persistent fetal vasculature (PFV) occurs as a result of a failure of fetal ocular vasculature to undergo normal programmed involution, which leads to blindness or serious loss of vision. Persistent fetal vasculature is responsible for as much as 5% of childhood blindness in western countries. The regulatory mechanisms responsible for fetal vascular regress remain obscure, as do the underlying causes of the failure of regression. Because of recent advancements in microinvasive surgical techniques, the early treatment of PFV has become safer and more effective, thus paving the way for the development of a future new treatment strategy. In this review, clinical and imaging manifestations of PFV and the progress in the treatment of PFV are highlighted.

PERSISTENT HYALOID ARTERY - PERFORM A SURGERY OR NOT?

The review points to the issues of persistent hyaloid artery, more precisely to possible clinical features, the influence on visual functions and potential complications during intraocular surgeries. In professional journals we can find just few reviews regarding this rare deviation of the eye development, therefore we want to present our experience. The persistent hyaloid artery causes chronical local changes of eye background at both of our patients, retinal detachment and retinoschisis. The findings werent accompanied by significant decrease of visual functions or subjective patients complaints. Considering the potential complications published in journals such as hemoftalmus or retinal vessel occlusion we decided to be more conservative. Thats why we just checked-up the condition of the eye background and we were prepared to perform a surgery if necessary. Key words: persistent hyaloid artery, tractional retinal detachment, retinoschisis.

Three Cases of Associated Persistent Fetal Vasculature and Ocular Coloboma: Posterior Segment Dysgenesis

The authors discuss the association of persistent fetal vasculature and ocular coloboma in three children. They explore the possibility of a cause-effect relationship between these disorders, and link them together as a broader posterior dysgenesis. [J Pediatr Ophthalmol Strabismus. 2017;54:e77-e80.].

[Apply of RetCam Ⅱ and color Doppler imaging in persistent hyperplastic primary vitreous]

OBJECTIVE

To observe the manifestations of RetCam Ⅱ and color Doppler imaging (CDI) in a retrospective case series of persistent hyperplastic primary vitreous (PHPV).

METHODS

Retrospective study. The medical records of 9 eyes/9 patients with PHPV went through RetCamⅡ and CDI from 2009 to 2014.

RESULTS

There were 6 young boys and 3 young girl in this study, age from 2 months to 5 years. All the patients were born at full term. 9 eyes had complication (cataract). The manifestations of RetCam Ⅱ: There were pale in optic disc. There were white fibre rod connected with optic disc, then prolonged to vitreous cavity, connected with posterior lens capsule. CDI showed arterial blood stream signal in band-shaped echogenic structure within vitreous cavity, prolonged to lens from the optic disc, or showed funnel-shaped echogenic mass at the posterior surface of lens and anterior of vitreous body, adhered to ciliary body, lens and the optic disc.

CONCLUSIONS

PHPV is congenital ocular anomalies because of a failure of primary vitreous and the hyaloids vascular system to regress. It manifests as unilateral and boys. We diagnosis PHPV by RetCamⅡ and CDI.

Potential blindness in children of patients with hereditary bone disease

Mono- and bi-allelic mutations in the low-density lipoprotein receptor related protein 5 (LRP5) may cause osteopetrosis, autosomal dominant and recessive exudative vitreoretinopathy, juvenile osteoporosis, or persistent hyperplastic primary vitreous (PHPV). We report on a child affected with PHPV and carrying compound mutations. The father carried the splice mutation and suffered from severe bone fragility since childhood. The mother carried the missense mutation without any clinical manifestations. The genetic diagnosis of their child allowed for appropriate treatment in the father and for the detection of osteopenia in the mother. Mono- and bi-allelic mutations in LRP5 may cause osteopetrosis, autosomal dominant and recessive exudative vitreoretinopathy, juvenile osteoporosis, or PHPV. PHPV is a component of persistent fetal vasculature of the eye, characterized by highly variable expressivity and resulting in a wide spectrum of anterior and/or posterior congenital developmental defects, which may lead to blindness. We evaluated a family diagnosed with PHPV in their only child. The child presented photophobia during the first 3 weeks of life, followed by leukocoria at 2 months of age. Molecular resequencing of NDP, FZD4, and LRP5 was performed in the child and segregation of the observed mutations in the parents. At presentation, fundus examination of the child showed a retrolental mass in the right eye. Ultrasonography revealed retinal detachment in both eyes. Thorough familial analysis revealed that the father suffered from many fractures since childhood without specific fragility bone diagnosis, treatment, or management. The mother was asymptomatic. Molecular analysis in the proband identified two mutations: a c.[2091+2T>C] splice mutation and c.[1682C>T] missense mutation. We report the case of a child affected with PHPV and carrying compound heterozygous LRP5 mutations. This genetic diagnosis allowed the clinical diagnosis of the bone problem to be made in the father, resulting in better management of the family. It also enabled preventive treatment to be prescribed for the mother and accurate genetic counseling to be provided.

Subretinal peripapillary neovascularization associated with persistent fetal vasculature

PURPOSE

The purpose of this study was to report a unique case of persistent fetal vasculature presenting as peripapillary choroidal neovascularization.

METHODS

Ophthalmologic examination, examination under anesthesia, fluorescein angiogram, chart review, review of relevant literature. A 2-year 4-month-old white girl was referred for decreased vision and suspicious retinal findings.

RESULTS

Fundus examination of the right eye demonstrated a peripapillary macular scar with old subretinal hemorrhage, subretinal fluid consistent with peripapillary neovascular net, a persistent fetal vascular stalk, and a central posterior lenticular opacity. Fluorescein angiogram of the right eye showed normal arterial filling in the early phase, normal arteriovenous transit, and late staining with mild leakage.

CONCLUSION

This is a unique case of persistent fetal vasculature presenting with the findings of subretinal exudates and choroidal neovascularization that has not been described before. Although the etiology of the choroidal neovascularization is unclear, we postulate it may be a result of the traction from the persistent fetal vasculature stalk in the peripapillary region. These findings may also be secondary to an optic disk anomaly that was not detected on examination.

[Pars plana vitrectomy due to the intravitreal hemorrhage caused by persistent hyaloid artery in three children]

PURPOSE

To report pars plana vitrectomy (PPV) of a vitreous hemorrhage (VH) as a complication of a persistent hyaloid artery (PHA) in three children. A persistent hyaloid artery is result of incomplete regression of embryonic hyaloid vascular system, and is mostly seen as the fibrotic remnants of the artery at the disc. Severity of a pathology varying from an asymptomatic course during a life to complications as an ambylopia, strabismus, cataract, nystagmus or intraocular bleeding, usually a vitreous hemorrhage. Changed vitreopapillary interface can troubled posterior vitreous detachment.

METHODS

Three case reports analyzed data of three children, 6-years-old and 10-years-old boys and 6-years-old girl, with VH and PHA treated by PPV with diathermy of partially regressed PHA in period from 2006 to 2011. There was unilateral, right side pathology in all children, all left eyes were normal. A traumatic origin, a blunt trauma and a bike accident respectively, was found in both boys. In a girl, she was the only patient, who was treated before VH for amblyopia, was no history of trauma.

RESULTS

Preoperative best corrected visual acuity (BCVA) varied between light perception to 6/9 and improved postoperatively to 6/9 - 6/6. We waited for spontaneous resolving of VH for four month in older boy, but it was complicated by other trauma (falling down at home) and recurrent bleeding. Progression of traumatic cataract in older boy 22 month postoperatively worsened BCVA to 6/60. Cataract surgery with implantation of an artificial posterior chamber lens and Nd: YAG laser capsulotomy improved BCVA to 6/6. An occlusion therapy was used in both 6-years-old children postoperatively. Postoperative average follow-up period is 54 month. There were no recurrent intraocular bleeding postoperatively.

CONCLUSION

Pars plana vitrectomy removed VH not only as an optical barrier, but eliminated the vitreopapillary traction too. Timing of early vitrectomy eliminated risk of recurrent VH and the other complications.

Differentials and approach to leukocoria

Leukocoria is an important clinical examination finding as it can be a sign of significant intraocular pathology, with the most common being retinoblastoma and congenital cataracts. The Brückner test is a quick, easy, and inexpensive way to assess the red reflex. When leukocoria is suspected, prompt referral to an ophthalmologist is necessary for further evaluation.

[Complex ultrasound examination children with persisting hyperplastic primary vitreous]

Complex ultrasound examination was performed in 108 children with unilateral congenital cataract (UCC) and persisting hyperplastic primary vitreous syndrome (PHPVS) to reveal indications and contraindications for surgery. The presence of functioning vessels with linear blood flow velocity (LBFV) measurement was performed in fibrovascular band and retrolenticular membrane (RLM) in different stages of PHPVS using color Doppler and energetic mapping. The echographic density of fibrovascular band and RLM was estimated using echodensitometry. The results of the study showed correlation of PHPVS severity and fibrovascular band diameter, LBFV in the vessels of the band and echographic density of the band, RLM and their thickness as well.

Submicroscopic deletion in 7q31 encompassing CADPS2 and TSPAN12 in a child with autism spectrum disorder and PHPV

We performed array comparative genomic hybridization utilizing a whole genome oligonucleotide microarray in a patient with the autism spectrum disorders (ASDs) and persistent hyperplastic primary vitreous (PHPV). Submicroscopic deletions in 7q31 encompassing CADPS2 (Ca(2+) -dependent activator protein for secretion 2) and TSPAN12 (one of the members of the tetraspanin superfamily) were confirmed. The CADPS2 plays important roles in the release of neurotrophin-3 and brain-derived neurotrophic factor. Mutations in TSPAN12 are a relatively frequent cause of familial exudative vitreoretinopathy. We speculate that haploinsufficiency of CADPS2 and TSPAN12 contributes to ASDs and PHPV, respectively.