Downloaded from http://bjo.bmj.com/ on August 21, 2017 - Published by group.bmj.com Clinical science Anatomical and functional outcomes following vitrectomy for advanced familial exudative vitreoretinopathy: a single surgeon’s experience Mumin Hocaoglu, Murat Karacorlu, Isil Sayman Muslubas, Mehmet Giray Ersoz, Serra Arf

Istanbul Retina Institute, ABSTRACT areas of avascularity and degeneration in the per- Istanbul, Turkey Purpose To assess the anatomical and functional ipheral retina. An increase in posterior retinal results of vitreoretinal surgery in patients with advanced vessels in mild asymptomatic FEVR has been Correspondence to familial exudative vitreoretinopathy (FEVR). reported recently.7 On the other hand, in moderate Professor Murat Karacorlu, fi FEBO, İstanbul RETINA Methods Retrospective analysis of data for 10 eyes of 9 to severe cases, preretinal brovascular proliferation Enstitüsü, Hakkı Yeten Cad. patients with advanced FEVR who underwent pars plana between the vascular and avascular retina can cause Unimed Center No: 19/7, vitrectomy from March 1997 to May 2015 and had a traction of the macula and retinal vessels, leading Fulya—Şişli, Istanbul 34349, follow-up of at least 12 months. The primary outcomes to radial retinal folds and (RD). Turkey; fi ​mkaracorlu@​superonline.​com were nal visual acuity (VA) and anatomical success. Development of RD (tractional, rhegmatogenous Results The average age at the time of the surgery or serous) is common in FEVR disease and may Received 17 August 2016 was 10.1±6.5 years (range 2 months–18 years). The cause serious . The natural course Revised 5 October 2016 mean follow-up period was 58.4±75.1 months. The of congenital retinal folds in 147 eyes with FEVR Accepted 9 October 2016 male-to-female ratio was 7/2. The mean number of showed progression to tractional RD (TRD) in Published Online First fi 28 October 2016 vitreoretinal operations was 1.5. At the last visit, 7 12.9%, rhegmatogenous RD (RRD) in 8.2%, bro- (70%) eyes had complete or partial retinal attachment. vascular proliferation in 7.5%, and exudative RD Preoperatively, the mean Snellen VA was 20/4000 (n=8), in 1.4%.8 Other, less common, findings include and in the remaining 2 (20%) eyes it was recorded as retinal exudation, neovascularisation, vitreous ‘central, steady and maintained’.Atfinal examination, haemorrhage, secondary epiretinal membrane the mean Snellen VA was 20/330 (n=7), and in the (ERM), peripheral retinoschisis, secondary glau- remaining 3 (30%) eyes it was recorded as light coma, and .2910Taking into consideration perception. At the final visit, 5 eyes (50%) had improved the broad clinical spectrum of the disorder, appro- VA, 2 eyes (20%) showed stabilisation, and 3 eyes priate initiation of treatment may lead to an (30%) with total retinal detachment had a decrease in improved clinical outcome. Over time, the under- VA. No progression to glaucoma was observed and no standing of the disease and its variations has enucleation was necessary. increased. Despite recent advances, the pathophysi- Conclusions Advanced FEVR in young children tends ology is still not completely understood, and man- to be more aggressive, leading to severe complications. agement approaches to this condition remain These cases are challenging and require special uncertain and controversial. Few studies have consideration. Despite surgery, disease-related reported results after surgery for FEVR-associated – complications remain high. However, surgical RD.91117 The surgical approaches in these reports intervention for advanced FEVR might be of benefitin have included pars plana vitrectomy (PPV), scleral helping to preserve vision. buckling, or a combination of both. In this study, we report the experience of a single surgeon in the management FEVR-associated RD using PPV. INTRODUCTION Familial exudative vitreoretinopathy (FEVR) is a PATIENTS AND METHODS rare inherited disorder that was first described by Population Criswick and Schepens in 1969.1 It has been sug- A retrospective chart review of 10 eyes of nine gested that FEVR is a disorder of angiogenesis in patients who underwent vitreoretinal surgery from which the primary vascular plexus develops nor- March 1997 to May 2015 with a diagnosis of mally but the secondary capillary layers in the deep FEVR-associated RD was conducted at the Istanbul and peripheral retina are absent or abnormal.2 Retina Institute, Istanbul. The study protocol was Incomplete vascularisation and poor vascular dif- approved by the Ethics Committee of Sisli ferentiation in these cases leads to an avascular per- Memorial Hospital, Istanbul. The study was per- ipheral retina. in the NDP, FZD4, LRP5, formed in accordance with the tenets of the TSPAN1 and ZNF408 genes have been associated Declaration of Helsinki. – with FEVR disease.3 5 It can be inherited in an The clinical charts were reviewed to collect the autosomal dominant, autosomal recessive, or following data: family and medical history, systemic To cite: Hocaoglu M, X-linked manner, or can affect individuals with no disorders, neonatal characteristics, sex, age, previ- Karacorlu M, Sayman family history. Expressivity may be asymmetric and ous treatment procedures, clinical characteristics of Muslubas I, et al. is highly variable.6 The development of secondary FEVR disease, timing of surgery, intraoperative pro- Br J Ophthalmol complications is associated with the degree of cedures, number of operations, postoperative com- 2017;101:946–950. ischaemia. Mild FEVR cases are characterised by plications, follow-up duration, ,

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slit-lamp biomicroscopy findings, indirect ophthalmoscopy find- then yearly. All the patients were closely followed up at our ings, and visual acuity (VA). Fundus photography (Carl Zeiss, institution, and anisometropia was managed by correction with Inc, Jena, Germany) was performed in cooperative patients. either contact lenses or spectacles. Diagnosis was based on a combination of physical examin- VA measurements were performed by an ophthalmic specialist ation and/or fundus photography, birth and family history. using the Tumbling E or Early Treatment Diabetic Clinical staging of FEVR was determined according to the clas- Study (ETDRS) charts. Following a standardised protocol, the sification scheme previously proposed.11 Before surgery, other ETDRS charts were used with a maximum distance of 4 m, but forms of exudative retinopathy (Norrie disease, persistent fetal the distance was reduced to 1 m or to 0.5 m if needed to permit vasculature, retinopathy of prematurity) had been excluded. letter identification in an eye with poor vision. VA testing was not performed if vision was limited to light perception or Surgery worse, or if the child was unable to cooperate in VA testing (the Indications for PPV surgery were RRD or TRD extending chart-measured vision was ‘fixes and follows’ or towards the posterior pole or circumferentially over two or ‘central-steady-maintained’). more quadrants, for which condition scleral buckling is ineffect- ive. All surgical procedures were planned and performed by the RESULTS same surgeon (MK). All the operations were performed under Baseline characteristics general anaesthesia. The surgical procedures included standard Of the nine patients included, seven were male (78%) and two 3-port, 20- or 23-gauge -sparing vitrectomy (LSV) or len- were female (22%). Overall, the mean±SD gestational age at sectomy and vitrectomy (LV). After the standard conjunctival birth was 38.3±1.7 weeks (range 36–41 weeks), the mean birth opening, incisions were made 1.0–3.5 mm posterior to the weight was 3148±436 g (range 2750–4800 g), the mean age at corneal limbus, the distance depending on the age of the diagnosis was 6.0±4.6 years (range 1 month–14 years), the patient. A lensectomy was performed if the fibrovascular prolif- mean age at the time of surgery was 10.1±6.5 years (range eration was attached extensively to the posterior lens surface, if 2 months–18 years), and the mean follow-up period was 58.4 the lens was found to impede adequate management of periph- ±75.1 months (range 12–216 months). One patient (11%) eral vitreous and fibrovascular structures, or if there was an iat- underwent bilateral surgery. The mean preoperative logMAR VA rogenic injury. A core vitrectomy was performed with a cutting for the eight eyes (80%) with measurable VA was 2.3±0.7 rate of up to 2500/min using the Associate 2500 vitrectomy (Snellen equivalent 20/4000), ranging from 20/100 to 20/ system (DORC, Zuidland, Netherlands). After removal of the 20 000. The remaining two children (two eyes) were unable to anterior and core vitreous, 0.2–0.3 mL (40 mg/mL) triamcino- cooperate in the testing for VA, and the chart-measured vision lone acetonide aqueous suspension (Kenacort, Bristol-Myers was ‘central-steady-maintained’. The baseline characteristics of Squibb, New York, New York, USA) was injected into the mid- the patients are listed in the table 1. vitreous cavity for visualisation of the residual vitreous and pos- The most common referring diagnoses were FEVR (five terior hyaloid membrane, followed by partial or complete patients), RD (three patients), and macular hole (one patient). A removal of the posterior hyaloid. The vitreous was removed family history for FEVR was obtained for two patients (22%). extensively, especially around the fibrovascular proliferation and One patient had a family history of strabismus and decreased posterior vitreous base. Dissection of the fibrovascular tissues, vision of unknown cause. Stage 3 FEVR was identified in four tightly adhered to the retina and/or ciliary body, was minimised (40%) eyes, stage 4 in four (40%) eyes, and stage 5 in two in order to avoid a possible iatrogenic retinal tear or large (20%) eyes (figure 1). One of these eyes had RRD (figure 2), retinal haemorrhage. Laser photocoagulation was performed on and one had retinal dialysis (case 5 OS (left eye)). Three eyes the peripheral avascular areas, away from the fibrovascular pro- (cases 1, 5 OS, and 6) had undergone prophylactic laser photo- liferation in order to prevent contraction. In cases with RRD coagulation 2–24 months before the surgery. The case presenting and retinal dialysis, subretinal fluid was drained by perfluorocar- with retinal dialysis had a history of ocular trauma 2 days earlier. bon liquid. If the peripheral vitreoretinal tractions did not allow None of the other eyes had undergone prophylactic laser, retinal reattachment, then relaxing retinotomy with retinectomy cryotherapy, or intravitreal anti-vascular endothelial growth was performed. Retinotomy was completed using vertical scis- factor (anti-VEGF) injection before the vitreoretinal surgery. sors or a vitreous cutter. To control haemorrhage during retinot- The fellow eyes of each of these 10 had various stages of FEVR. omy, blood vessels were cauterised with endodiathermy, and an Six patients had developed RDs in the fellow eye, which had anterior flap retinectomy was usually completed without any cicatrised and did not satisfy the surgical criteria because a poor bleeding. The retinectomy was extended circumferentially and functional outcome was expected. as much as possible of the peripheral anterior retinal flap was Radial retinal folds were seen in three (30%) eyes, of which removed to minimise ischaemia and its complications. The two (20%) were stage 4 and one (10%) was stage 5. Of the eyes choice of a tamponade agent (silicone oil (1000 cSt or with radial retinal folds, one was superotemporal and two were 5000 cSt), perfluoropropane (C3F8), or no tamponade) was inferotemporal in location. Two eyes (20%) with stage 3 demon- made according to the characteristics of the RD and the patient’s strated circumferential retinal folds. Retinal haemorrhages in age. In all aphakic patients a peripheral iridectomy was per- three eyes (30%) and lipid exudates in five eyes (50%) were formed to prevent pupillary block. Sclerotomies and conjunctiva observed preoperatively or intraoperatively. were closed using 8–0 vicryl suture. None of the patients under- went a scleral buckling procedure. During the postoperative Surgical procedures period the patients were advised to use a topical antibiotic and The initial operation was LSV on six eyes (60%) and combined corticosteroid drops four times a day for 1 month. LVon four eyes (40%). In eight eyes (80%) further vitreoretinal surgery was not performed. The remaining two eyes (20%) Follow-up examination required multiple procedures for redetachment (case 5 OS and All patients were routinely examined on day 1 after the surgery, case 6), including pars plana retinotomy and retinectomy, mem- then at 1 week, then monthly until the disease stabilised, and brane dissection, endolaser photocoagulation, and silicone oil

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Table 1 Demographic data and preoperative and postoperative findings of patients who underwent surgery for advanced familial exudative vitreoretinopathy Additional Final preoperative No. of Initial Final retinal Follow-up Patient Sex Eye Stage findings Age First surgery operations VA VA status (months) Complications

1 M OD 5 Massive subretinal ––– – P− P− –– – exudates OS 3A 150° temporal 18 years LSV PVD, ILM 1 20/100 20/100 Attached, 48 Cataract, band fibrovascular peeling, 90° macular keratopathy ridge, macular retinotomy, hole hole retinectomy, silicone oil 2 F OD 2B –––––FF FF –– – OS 4B Superotemporal 2 months LV PVD, SRF 1 FF P+ Detached 12 Phthisis fold, preretinal drainage, C3F8 haemorrhage gas 3 M OD 1 –––––20/100 20/100 –– – OS 5 360° 5 years LV PVD, 330° 1 HM 20/2000 Attached 12 Temporal circumferential retinotomy, macular contraction, retinectomy, dragging, subretinal fibrotic silicone oil advanced PVR plaque 4 M OD 3B 210° 4 years LSV PVD, Silicone – FF P+ Detached 13 Hypotony inferotemporal oil fibrovascular ridge OS 5 Massive subretinal ––– – P+ P+ –– – exudates 5 M OD 4B İnferotemporal 9 years LV PVD, silicone 1 20/2000 20/200 Attached 16 Band fold, ERM oil keratopathy, ERM OS 4B Retinal dialysis 9 years LSV PVD, 150° 4 20/2000 20/400 Attached 15 Hypotony, retinectomy, cataract, ERM silicone oil 6 M OD 4B Temporal hole 16 years LSV PVD, 120° 3 20/2000 20/2000 Attached 36 Temporal retinotomy, macular retinectomy, dragging, SRF drainage, advanced PVR silicone oil OS 5 HM HM 7FOD5 P− OS 5 Inferotemporal 17 years LV 180° 1 20/2000 P+ Detached 36 Band fold, massive retinotomy, keratopathy subretinal retinectomy, exudates silicone oil 8MOD5 P− OS 3A Vitreous 7 years LSV PVD 1 HM 20/400 Attached 180 Temporal haemorrhage, macular preretinal dragging haemorrhage 9 M OD 5 HM OS 3A Vitreous 16 years LSV PVD 1 20/2000 20/32 Attached 216 Cataract haemorrhage, NVD, preretinal haemorrhage ERM, epiretinal membrane; FF, fixes and follow; HM, hand movement; ILM, internal limiting membrane; LSV, lens-sparing vitrectomy; LV, lensectomy and vitrectomy; OD, right eye; OS, left eye; P, perception of light; NVD, neovascularisation of the disc; PVD, posterior vitreous detachment; PVR, proliferative vitreoretinopathy; SRF, subretinal fluid; VA, visual acuity. injection due to proliferative vitreoretinopathy and TRD. The silicone oil tamponade at the last follow-up (case 6). Intravitreal mean number of vitreoretinal procedures was 1.5 (range 1–4). anti-VEGF (bevacizumab) was injected at the end of the proced- An intraoperative iatrogenic retinal tear occurred in one eye ure in three (30%) eyes (cases 3, 4, and 5 OD (right eye)). (case 2), which was managed with laser photocoagulation and gas tamponade. During follow-up, this eye became phthisical, Anatomical outcomes with total RD. Silicone oil (1000 or 5000 cSt) was used as the At the final visit, stabilisation of the fibrovascular proliferation tamponade agent in seven eyes (70%), perfluoropropane (C3F8) and complete or partial retinal attachment had been achieved in gas in one (10%) (case 2), and fluid in two (20%) (cases 8 and seven eyes (70%). In three eyes (30%) the retina was not reat- 9). The mean silicone oil tamponade duration was 4.0 months tached because of aggressive proliferative vitreoretinopathy for- (range 2–6 months). Removal of the silicone oil was not per- mation and rapid progression to total RD. In five eyes (50%) formed in order to control the disease and its complications and the lens was preserved. In one eye (10%), lensectomy and was not regarded as additional surgery. One eye (10%) still had intraocular lens implantation was performed during the

948 Hocaoglu M, et al. Br J Ophthalmol 2017;101:946–950. doi:10.1136/bjophthalmol-2016-309526 Downloaded from http://bjo.bmj.com/ on August 21, 2017 - Published by group.bmj.com Clinical science

20/330), ranging from 20/32 to 20/2000. The remaining three patients (30%) had light perception. In five eyes (50%), the VA was 20/400 or better and in five eyes (50%) was <20/400. At the final visit, five eyes (50%) had improved VA, two eyes (20%) showed stabilisation, and three eyes (30%) with detached retina had a decrease in VA. Poor visual outcomes were associated with more advanced (stage 4 or 5) disease, younger age, total RD and . Postoperative outcomes of the patients are presented in the table 1.

DISCUSSION FEVR is an important predisposing factor for TRD and RRD development in children. Eyes with RRD usually have juvenile onset and less severe clinical presentation of FEVR. By contrast, cases with TRD generally have a severe degree of FEVR and develop early in childhood. – The surgical management of TRD9111215and RRD12 14 have been discussed in previous reports. Retinal reattachment is difficult to achieve in advanced stages of FEVR, especially with severe complications, unlike in FEVR with mild and moderate retinal folds and posterior fibrovascular proliferation. In the current study, high rates of stabilisation of fibrovascular prolifer- ation and acceptable rates of retinal reattachment were achieved. After the stabilisation of fibrovascular proliferation, 70% of the eyes showed posterior pole attachment and an increase in VA or Figure 1 Preoperative fundus image of case 7, with stage 5 familial stabilisation of VA. exudative vitreoretinopathy, showing severe foveal dragging, The decision for surgical treatment in eyes with advanced inferotemporal folding, and massive subretinal exudates. FEVR is related to the anatomical and functional status of the fellow eye. Six patients had developed total RD in the fellow eye, which had cicatrised and did not satisfy the surgical criteria because a poor functional outcome was expected. In cases with bilateral RD, surgery performed in one or both eyes could be reasonable. On the other hand, if the fellow eye had mild FEVR with good vision, surgical treatment for the eye with total RD could not be recommended. Unfortunately, the ana- tomic success in these cases did not equate to functional improvement. The surgical objectives in these FEVR cases included manage- ment of the peripheral avascular retina and relief of all anter- ior–posterior and tangential tractions. The surgical key points are: core vitrectomy reducing total VEGF concentrations in the vitreous, removal of the posterior hyaloid, and dissection of the posterior cortical vitreous at the junctions of the vascular and avascular retina. Relief of the traction from peripheral fibrovas- cular membranes could be obtained with an additional scleral buckle. If peripheral traction involves two or more quadrants, buckling would not be effective.15 Figure 2 Preoperative fundus image of case 6, with familial exudative LSV prevents amblyopia and promotes normal visual develop- vitreoretinopathy-associated rhegmatogenous retinal detachment, ment in children. However, four eyes (40%) presented with showing inferotemporal macula-off retinal detachment, moderate foveal fibrovascular proliferation at the extreme periphery, and lensect- dragging, and peripheral temporal exudates. omy was unavoidable because the lens was found to impede adequate management of the peripheral vitreous and fibrovascu- lar structures. revisional vitreoretinal surgery (case 6). Surgery and/or Laser photocoagulation was applied intraoperatively to the disease-associated complications included ERM in two eyes entire avascular retina in all cases where it might contribute to (20%), proliferative vitreoretinopathy in two (20%), cataract in stabilisation of the fibrovascular proliferation. This finding con- three (30%), keratopathy in three (30%), hypotony in two firms the importance of laser photocoagulation. Interestingly, (20%), macular hole in one (10%), and phthisis bulbi in one three eyes (30%) had undergone prophylactic laser photo- (10%). No glaucoma occurred postoperatively and no enucle- coagulation before the surgery, and two of these eyes subse- ation was necessary over the follow-up period. quently developed RRD and retinal dialysis. Pendergast and Trese11 performed laser photocoagulation in 15 eyes, and Functional outcomes seven progressed to RD, requiring surgical repair. A prerequis- The mean logMAR VA at the final visit for the seven patients ite for the success of the treatment is the complete ablation of (70%) with measurable VA was 1.22 (±0.7) (Snellen equivalent all exuding vessels. Under-treatment could be a reason for

Hocaoglu M, et al. Br J Ophthalmol 2017;101:946–950. doi:10.1136/bjophthalmol-2016-309526 949 Downloaded from http://bjo.bmj.com/ on August 21, 2017 - Published by group.bmj.com Clinical science

failure. It is very important to destroy the leaking vessels by Most of the published studies are not comparable because of photocoagulation to prevent disease recurrence and secondary small sample size, different clinical presentations, different ages failure. at the time of surgery, surgery performed by multiple surgeons The use of intravitreal anti-VEGF agents to reduce the neovas- using different techniques, and short follow-up. cular and exudative features in FEVR and other paediatric Our study has several limitations, such as the single-centre vitreoretinal diseases has been reviewed.18 Anti-VEGF therapy retrospective design with a single surgeon performing both pre- reduces retinal exudation and stabilises fibrovascular prolifer- operative and postoperative evaluation. The study’s cohort is ation. On the other hand, it can stimulate contraction of fibro- small and the recording of 1 year of follow-up data in two cases vascular proliferation and subsequent RD. Anti-VEGF agents is too short-term for this type of disease and surgery. Large pro- could play a role as an adjunctive therapy in these cases. There spective randomised trials would be helpful to investigate the are still concerns about the negative ocular and systemic effects optimal treatment modality for each stage of FEVR disease. of anti-VEGF agents in children. Taking into consideration the In conclusion, although it is difficult to manage advanced unknown aspects in this area, a single dose of anti-VEGF was FEVR with RD, especially in young patients, surgical interven- given to three (30%) patients in our study at the end of the sur- tion is recommended to improve VA and to prevent complica- gical procedure. The effect of anti-VEGFs is altered in vitrecto- tions like glaucoma and phthisis bulbi. mised eyes. A single dose of anti-VEGF injection at the end of surgery may not be effective enough to completely regress vas- Contributors MH and MK were involved in the conception and design of the study. MH, MK and SA were involved in the analysis, interpretation and critical cular pathology. Anti-VEGF therapy for treating FEVR needs revision of the article. MH was involved in the drafting of the manuscript. MH, MK, further investigation. Destruction of the pathological vascular ISM, MGE and SA were involved in the final approval of the article. MH, ISM and structures by either laser photocoagulation or cryotherapy in MGE were involved in the data collection and literature research. combination with anti-VEGF therapy is crucial for successful Competing interests None declared. treatment. Ethics approval The study protocol was approved by the Ethics Committee of Sisli Eight eyes (80%) of seven patients had surgery combined Memorial Hospital, Istanbul. with tamponade (silicone oil (seven patients), C3F8 gas (one Provenance and peer review Not commissioned; externally peer reviewed. patient)), and five of these eyes achieved reattachment of the retina. The cooperation of infants and young children and main- taining the face-down position after tamponade is essential for REFERENCES surgical success. 1 Criswick VG, Schepens CL. Familial exudative vitreoretinopathy. Am J Ophthalmol 1969;68:578–94. Retinal reattachment rates following surgery for 2 Gilmour DF. Familial exudative vitreoretinopathy and related . FEVR-associated RD of between 50% and 86% have been Eye (Lond) 2015;29:1–14. – reported.91113 17 The surgical procedures in these studies were 3 Collin RW, Nikopoulos K, Dona M, et al. ZNF408 is mutated in familial exudative a mixture of PPV, scleral buckling, or a combination of both, vitreoretinopathy and is crucial for the development of zebrafish retinal vasculature. Proc Natl Acad Sci USA 2013;110:9856–61. and included cases with RRD, TRD, and exudative RD. 15 4 Toomes C, Bottomley HM, Jackson RM, et al. Mutations in LRP5 or FZD4 underlie Recently, Yamane et al evaluated various procedures for the common familial exudative vitreoretinopathy locus on chromosome 11q. treating TRD associated with FEVR in 31 eyes. Twelve eyes Am J Hum Genet 2004;74:721–30. (39%) underwent scleral buckling, one (3%) scleral buckling and 5 Riveiro-Alvarez R, Trujillo-Tiebas MJ, Gimenez-Pardo A, et al. Genotype-phenotype fi vitrectomy, seven (23%) vitrectomy alone, and 11 (36%) LV.The variations in ve Spanish families with Norrie disease or X-linked FEVR. Mol Vis 2005;11:705–12. patients were followed up postoperatively for a mean of 6 Shastry BS, Trese MT. 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Yamane et al concluded that vitrectomy with release of 10 Ranchod TM, Ho LY, Drenser KA, et al. Clinical presentation of familial exudative – posterior traction is essential in younger patients with active vitreoretinopathy. 2011;118:2070 5. fi 11 Pendergast SD, Trese MT. Familial exudative vitreoretinopathy. Results of surgical brovascular proliferation, whereas scleral buckling may be management. Ophthalmology 1998;105:1015–23. important for cases with peripheral traction anterior to the 12 Ikeda T, Fujikado T, Tano Y, et al. Vitrectomy for rhegmatogenous or tractional equator, and laser photocoagulation is applied to all ischaemic retinal detachment with familial exudative vitreoretinopathy. Ophthalmology areas contributing to reduced peripheral neovascularisation. 1999;106:1081–5. et al14 13 Chen SN, Jiunn-Feng H, Te-Cheng Y. Pediatric rhegmatogenous retinal detachment Chen recently reported the clinical characteristics and in Taiwan. 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950 Hocaoglu M, et al. Br J Ophthalmol 2017;101:946–950. doi:10.1136/bjophthalmol-2016-309526 Downloaded from http://bjo.bmj.com/ on August 21, 2017 - Published by group.bmj.com

Anatomical and functional outcomes following vitrectomy for advanced familial exudative vitreoretinopathy: a single surgeon's experience Mumin Hocaoglu, Murat Karacorlu, Isil Sayman Muslubas, Mehmet Giray Ersoz and Serra Arf

Br J Ophthalmol 2017 101: 946-950 originally published online October 28, 2016 doi: 10.1136/bjophthalmol-2016-309526

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