Further evidence of genetic heterogeneity in familial exudative vitreoretinopathy; exclusion of EVR1, EVR3, and EVR4 in a large autosomal dominant pedigree.

BACKGROUND/AIMS: Familial exudative vitreoretinopathy (FEVR) is an inherited blinding condition characterised by abnormal development of the retinal vasculature. The aim of this study was to perform linkage analysis in a large family affected with FEVR to determine whether the mutation involved was in one of the three known autosomal dominant FEVR loci or in another as yet unidentified gene. METHODS: Genomic DNA samples from family members were polymerase chain reaction (PCR) amplified with fluorescently tagged microsatellite markers spanning the EVR1/EVR4 locus (11q13-14) and the EVR3 locus (11p12-13). The resulting PCR products were resolved using an automated DNA sequencer and the alleles sized. These data were used to construct haplotypes across each locus and linkage analysis was performed to prove or exclude linkage. RESULTS: The clinical evaluation in this family suggested features typical of FEVR, with deficient peripheral retinal vascularisation being the common phenotype in all affected individuals. However, linkage analysis proved that this family has a form of FEVR genetically distinct from the EVR1, EVR3 and EVR4 loci. CONCLUSION: The exclusion of linkage in this family to any of the known FEVR loci proves the existence of a fourth locus for autosomal dominant FEVR and shows that this rare disorder is far more heterogeneous than previously thought.

Mutations in the human forkhead transcription factor FOXE3 associated with anterior segment ocular dysgenesis and cataracts.

Dysgenesis of the anterior segment of the eye delineates a spectrum of human developmental disorders that show wide phenotypic and genetic heterogeneity. It is also frequently associated with cataracts and glaucoma resulting in visual disability in childhood. The recently described forkhead transcription factor gene Foxe3 was shown to be involved in the dysgenetic lens phenotype in mice, which is characterized by small cataractic lens and anterior segment anomalies. Here we report an identification and characterization of the human ortholog of this gene, FOXE3. The gene was found to be expressed in the anterior lens epithelium and to be mutated in patients with ocular disorders. An insertion of G in the coding region of the FOXE3 gene that occurred 15 nucleotides upstream of the stop codon was identified in a family with anterior segment ocular dysgenesis and cataracts. The mutation causes a frameshift that results in an abnormal sequence of five terminal amino acids and an addition of 111 amino acids to the predicted protein. The mutation was present in two affected individuals from this family and was not identified in 180 normal control chromosomes.

Successful amblyopia therapy initiated after age 7 years: compliance cures.

OBJECTIVE: To report successful therapy for anisometropic and strabismic amblyopia initiated after age 7 years. METHODS: A consecutive series of 36 compliant children older than 7 years (range, 7.0 to 10.3 years; mean, 8.2 years) at initiation of amblyopia therapy for anisometropic (19 patients; mean age, 8.3 years), strabismic (9 patients; mean age, 8.0 years), or anisometropic and strabismic (8 patients; mean age, 8.0 years) amblyopia was studied. Initial (worst) visual acuities were between 20/50 and 20/400 (log geometric mean, -0.83 [antilog, 20/134] for all patients; -0.88 [antilog, 20/151] for anisometropic patients; -0.70 [antilog, 20/100] for strabismic patients; and -0.88 [antilog, 20/151] for anisometropic and strabismic patients). Initial (worst) binocularity was absent or reduced in all cases. Therapy consisted of (1) full-time standard occlusion (21 patients; mean age, 8.0 years), (2) total penalization (7 patients; mean age, 7.8 years), or (3) full-time occlusive contact lenses (8 patients; mean age, 8.8 years). RESULTS: Final (best) visual acuities were between 20/20 and 20/30 for all 36 patients. Final (best) binocularity was maintained or improved for 22 (61%) of 36 patients, including 16 anisometropic patients (84%), 2 strabismic patients (22%), and 4 anisometropic and strabismic patients (50%). CONCLUSION: Given compliance, therapy for anisometropic and strabismic amblyopia can be successful even if initiated after age 7 years. Arch Ophthalmol. 2000;118:1535-1541

Isolation and characterization of a novel human paired-like homeodomain-containing transcription factor gene, VSX1, expressed in ocular tissues.

Homeodomain transcription factors control cell fates during the development of all animals. The paired-like subfamily of homeodomain proteins has been particularly implicated in ocular development in different species. In this paper we report the cDNA sequence, genomic structure, localization, and expression data of a novel paired-like homeobox-containing gene, VSX1, isolated from a human embryonic craniofacial cDNA library using the degenerate-PCR approach. The composed VSX1 cDNA sequence of 1433 bp was predicted to encode a protein of 365 amino acid residues. Maximal homology at the protein level was identified with the paired-like homeoproteins of the CVC-domain family: 92-97% identity was seen in the homeodomain region with 55% overall identity to zebrafish and goldfish Vsx1 and 35% overall identity to goldfish Vsx2 and murine Chx10. The gene was found to consist of five exons that are distributed over 6.2 kb of genomic sequence. VSX1 was localized to the 20p11-q11 region, which is homologous with the distal part of mouse chromosome 2. Expression of VSX1 was detected in embryonic craniofacial and adult ocular tissues. Several ocular phenotypes have been mapped to the VSX1 region in both human and mouse genomes, and its candidacy for these disorders is discussed.

Penetrating ocular injury with a fetal scalp monitoring spiral electrode.

PURPOSE: To report a penetrating ocular injury resulting from inadvertent placement of a fetal scalp monitoring spiral electrode into the right eye of a preterm male with a face presentation. METHODS: Case report and review of the literature. RESULTS: A spiral electrode was screwed clockwise into the right eye, tearing the inferior retina and creating two inferior iridotomies. Severe myopic astigmatism resulted from gradual lens dislocation combined with elongation of the eye. Despite persistent occlusive therapy and aggressive optical correction, before and after lensectomy at age 3 years, visual acuity was only 20/200 at age 8 years. CONCLUSIONS: Although complications from spiral monitoring electrodes are uncommon, this case emphasizes that before inserting a spiral monitoring electrode during labor, face presentation must be excluded to prevent inadvertent ocular injury.

Vitreoretinal findings similar to retinopathy of prematurity in infants with compound heterozygous protein S deficiency.

OBJECTIVE: To present previously undescribed vitreoretinal findings similar to severe retinopathy of prematurity (ROP) in two siblings (daughter and son) with a thrombophilic disorder, compound heterozygous protein S (PS) deficiency. DESIGN: Family genotype study and literature review. PARTICIPANTS: Two unrelated heterozygous PS-deficient parents and their two children with compound heterozygous PS deficiency were studied. The gestational age and birth weight of the daughter were 40 weeks and 3200 g, respectively, and those of the son were 34 weeks and 2150 g, respectively. Three other neonates with homozygous or compound heterozygous PS deficiency and ophthalmologic findings were identified in the literature. INTERVENTION: The daughter underwent lensectomy-vitrectomy at 48 weeks adjusted age bilaterally. The son underwent therapy developed for severe ROP: laser therapy of the peripheral avascular retina at 39 weeks adjusted age, and bilateral lensectomy-vitrectomy with membrane peel of intravitreous proliferation from the optic disc at 42 weeks adjusted age. MAIN OUTCOME MEASURES: The main clinical outcome measures were retinal appearance and functional vision. Genotypes of the family members were determined. RESULTS: One of the four eyes retained functional vision. A normal-appearing posterior retina, normal scotopic and photopic flash electroretinograms, and a normal flash visual-evoked response were documented from the left eye of the son at 62 weeks adjusted age. The other three eyes had inoperable retinal detachments and no functional vision. The mother had type I PS deficiency and the father had type II PS deficiency. Compound heterozygous PS deficiency was confirmed in both children. CONCLUSION: In both children, normal vasculogenesis was interrupted. At 39 weeks adjusted age, the retinal examination of the son revealed extraretinal fibrovascular proliferation at the optic disc (reactivation of the hyaloid system) and in the peripheral retina (interruption of inner retinal vascularization). Patients with homozygous or compound heterozygous PS deficiency may present as infants with severe ROP. The authors' experience suggests that appropriately timed surgical procedures, which are efficacious for ROP, can preserve vision in infants with thrombophilic disorders.

A small foveal avascular zone may be an historic mark of prematurity.

OBJECTIVE: To compare in children the area and diameter of the foveal avascular zone (FAZ) of former preterm infants, when no significant retinopathy of prematurity (ROP) developed, to the area and diameter of the FAZ of former term infants. DESIGN: Retrospective observational case series and literature review. PARTICIPANTS: Forty-nine children (39 former preterm infants and 10 former term infants) between the ages of 1 and 17 years had fluorescein angiograms. All of these children had been appropriate weight for gestational age at birth and had no genetic disorders. Neither eye of any of these children had any macular ectopia or vessel traction, had been treated for active ROP, had developed active ROP >stage 3 mild, or had any refractive error > +/- five diopters. Every child had a visual acuity of 20/40 or better in both eyes. METHODS: The area and greatest diameter of the FAZ were measured using digital image analysis of masked fundus fluorescein angiograms. Variables of gender, race, multiple birth, gestational age, birth weight, ROP stage, age, and refraction at the time of fluorescein angiography, and final visual acuity were recorded. RESULTS: Increasing FAZ area and greatest diameter correlated significantly with increasing gestational age and birth weight: FAZ area (microm2) versus gestational age (weeks) (R/F/P = 0.88/166.70/<0.0001); FAZ greatest diameter (microm) versus gestational age (weeks) (R/F/P = 0.87/151.10/<0.0001); FAZ area (micro/m2) versus birth weight (g) (R/F/P = 0.88/167.06/<0.0001); and FAZ greatest diameter (microm) versus birth weight (g) (R/F/P = 0.87/148.74/ <0.0001). A small or absent FAZ was found in all former preterm infants who had been < or = 30 weeks gestational age or had weighed < or = 1100 g at birth. A normal FAZ was present in all children who had been > or = 36 weeks gestational age or had weighed > or = 2650 g at birth. None of the other parameters studied correlated with FAZ area or greatest diameter. CONCLUSION: This study provides evidence that the FAZ in developing humans is initially densely vascularized with a fine meshwork of inner retinal vessels during vasculogenesis. This vascular meshwork undergoes regression by apoptosis in all infants > or = 36 weeks gestational age at birth to form a normal FAZ, but apoptosis almost never occurs in preterm infants < or = 30 weeks gestational age at birth. Although there is no effect on final visual acuity, a small or absent FAZ may be an historic mark of prematurity.

A range of clinical phenotypes associated with mutations in CRX, a photoreceptor transcription-factor gene.

Mutations in the retinal-expressed gene CRX (cone-rod homeobox gene) have been associated with dominant cone-rod dystrophy and with de novo Leber congenital amaurosis. However, CRX is a transcription factor for several retinal genes, including the opsins and the gene for interphotoreceptor retinoid binding protein. Because loss of CRX function could alter the expression of a number of other retinal proteins, we screened for mutations in the CRX gene in probands with a range of degenerative retinal diseases. Of the 294 unrelated individuals screened, we identified four CRX mutations in families with clinical diagnoses of autosomal dominant cone-rod dystrophy, late-onset dominant retinitis pigmentosa, or dominant congenital Leber amaurosis (early-onset retinitis pigmentosa), and we identified four additional benign sequence variants. These findings imply that CRX mutations may be associated with a wide range of clinical phenotypes, including congenital retinal dystrophy (Leber) and progressive diseases such as cone-rod dystrophy or retinitis pigmentosa, with a wide range of onset.

A novel homeobox gene PITX3 is mutated in families with autosomal-dominant cataracts and ASMD.

We report here the identification of a new human homeobox gene, PITX3, and its involvement in anterior segment mesenchymal dysgenesis (ASMD) and congenital cataracts in humans. The PITX3 gene is the human homologue of the mouse Pitx3 gene and is a member of the RIEG/PITX homeobox gene family. The protein encoded by PITX3 shows 99% amino-acid identity to the mouse protein, with 100% identity in the homeodomain and approximately 70% overall identity to other members of this family. We mapped the human PITX3 gene to 10q25 using a radiation-hybrid panel. A collection of 80 DNA samples from individuals with various eye anomalies was screened for mutations in the PITX3 gene. We identified two mutations in independent patients. A 17-bp insertion in the 3'-end of the coding sequence, resulting in a frame shift, occurred in a patient with ASMD and cataracts, and a G-->A substitution, changing a codon for serine into a codon for asparagine, in the 5'-end of the gene occurred in a patient with congenital cataracts. Both mutations cosegregate with the disease phenotype in families, and neither were found in up to 300 control individuals studied. Further expression analysis of Pitx3 in the mouse supports a unique role in early ocular development, with later expression extending to the midbrain, tongue, incisors, sternum, vertebrae and limbs. These data strongly suggest a role for PITX3 in ASMD and cataracts and provide new evidence of the contribution of the RIEG/PITX gene family to the developmental program underpinning normal eye formation.

Long-term form identification vision after early, closed, lensectomy-vitrectomy for stage 5 retinopathy of prematurity.

PURPOSE: Form identification vision after early, closed, lensectomy-vitrectomy for retinopathy of prematurity (ROP) stage 5 open funnel retinal detachment is reported from a database that included 45 eyes of 27 infants. The focus of this report is the verbal responses at a mean age of 7.0 years for nine nonamblyopic (preferred) eyes of nine preterm infants with minimal developmental delay (good central nervous system function). METHODS: All 45 eyes underwent initial cryotherapy for threshold ROP to the avascular retina to decrease the angiogenic stimulus (mean postconceptual age = 34.8 weeks) and subsequently underwent multiple cryotherapy sessions to the avascular retina and shunt with scleral buckling to decrease retinal traction (mean postconceptual age = 38.0 weeks). When tractional retinal detachment occurred with an open funnel, each eye underwent an early, closed, lensectomy-vitrectomy (mean postconceptual age = 45.7 weeks). The 34 eyes with a successful anatomic result were fitted with contact lenses as soon as possible after surgery. RESULTS: The nine nonamblyopic eyes of nine preterm infants with minimal developmental delay had the following visual acuities using Allen figures or Snellen test types: one eye 20/80, one eye 20/200, two eyes 20/400, three eyes 20/800, and two eyes 20/ 1600. CONCLUSION: These nine eyes support the thesis that form identification vision can be obtained by early vitrectomy for ROP stage 5 open funnel retinal detachments.

Peripheral retinopathy in offspring of carriers of Norrie disease gene mutations. Possible transplacental effect of abnormal Norrin.

BACKGROUND: The Norrie disease (ND) gene (Xp11.3) (McKusick 310600) consists of one untranslated exon and two exons partially translated as the Norrie disease protein (Norrin). Norrin has sequence homology and computer-predicted tertiary structure of a growth factor containing a cystine knot motif, which affects endothelial cell migration and proliferation. Norrie disease (congenital retinal detachment), X-linked primary retinal dysplasia (congenital retinal fold), and X-linked exudative vitreoretinopathy (congenital macular ectopia) are allelic disorders. METHODS: Blood was drawn for genetic studies from members of two families to test for ND gene mutations. Sixteen unaffected family members were examined ophthalmologically. If any retinal abnormality were identified, fundus photography and fluorescein angiography was performed. RESULTS: Family A had ND (R109stp), and family B had X-linked exudative vitreoretinopathy (R121L). The retinas of 11 offspring of carrier females were examined: three of seven carrier females, three of three otherwise healthy females, and one of one otherwise healthy male had peripheral inner retinal vascular abnormalities. The retinas of five offspring of affected males were examined: none of three carrier females and none of two otherwise healthy males had this peripheral retinal finding. CONCLUSIONS: Peripheral inner retinal vascular abnormalities similar to regressed retinopathy of prematurity were identified in seven offspring of carriers of ND gene mutations in two families. These ophthalmologic findings, especially in four genetically healthy offspring, strongly support the hypothesis that abnormal Norrin may have an adverse transplacental (environmental) effect on normal inner retinal vasculogenesis.

X-linked exudative vitreoretinopathy caused by an arginine to leucine substitution (R121L) in the Norrie disease protein.

We report the cosegregation of an arginine to leucine substitution at position 121 of the Norrie disease protein in a large kindred where exudative vitreoretinopathy segregates as an X-linked recessive trait. The clinical phenotype and rate of disease progression were extremely variable, with progression to total retinal detachment from less than age 2 years to more than 21 years. To date, all mutations in X-linked vitreoretinopathy have been missense mutations, presumably not affecting the three-dimensional structure of the NDP gene product, and clustered around residues 121-126 of the Norrie protein. This contrasts with the diversity of mutations seen in the more severe, allelic Norrie disease.

Postnatal retinal vascularization in former preterm infants with retinopathy of prematurity.

PURPOSE: To study the postnatally vascularized retina in former preterm infants in whom retinopathy of prematurity (ROP) stages 2 to 4a developed and spontaneously regressed. METHODS: Matched fundus photographs and fluorescein angiograms of the temporal peripheral retinas of 133 eyes (72 patients) were obtained after 2 years of age (mean, 7.7 years; range, 2-16.2 years) and were quantified by two masked observers with respect to the following parameters: (1) macular ectopia (in disc diameters); (2) vessel traction (in 30 degrees sectors); (3) radial length of postnatally vascularized retina (in disc diameters); and (4) capillary scaffolding of postnatally vascularized retina (as a density). These cicatricial outcomes were then compared with their active worst ROP stage. RESULTS: Of the 133 retinal montages, the following active worst ROP stages had been documented: 30 with stage 2, 42 with stage 3 mild, 32 with stage 3 moderate, 20 with stage 3 severe, and 9 with stage 4a. As active worst ROP stage increased, macular ectopia and vessel traction increased, and radial length and capillary scaffolding of postnatal retinal vascularization decreased. Retinal holes were documented frequently in eyes with high myopia. CONCLUSIONS: The peripheral retina in former preterm infants warrants close scrutiny for possible late rhegmatogenous retinal detachments. Prolonged retinal traction (by remnant shunt and extraretinal fibrovascular proliferation) between stable, posterior, prenatally vascularized retina, and unstable, postnatally vascularized retina may lead to the development of retinal holes characteristically located in the fragile, anterior, undifferentiated, nonvascularized retina.

The pattern visual-evoked potential in former preterm infants with retinopathy of prematurity.

PURPOSE: Flash and pattern visual-evoked potentials (VEPs) were recorded in 89 former preterm infants (< or = 1500 g birth weight), in whom retinopathy of prematurity (ROP) developed that spontaneously regressed without macular detachment (stages 2-4a). METHODS: Linear and stepwise regression analyses were performed to determine the correlations between transient pattern-reversal P1 VEP latency (n = 154 eyes) at a mean of 7.2 years (median, 6.9 years) postnatal age using a check size nominally equivalent to 20/100 (30 minutes) and the following nine parameters: three immaturity parameters (gestational age at birth, birth weight, and ROP zone at 1 month postnatal age); one postnatal insults parameter (worst ROP stage); two structural outcome parameters (macular ectopia and vessel traction); one functional outcome parameter (visual acuity); and two methodological parameters (postnatal age at VEP testing and VEP amplitude). RESULTS: Linear regression analyses, with P1 VEP latency as a dependent variable, identified the worst ROP stage (r = +0.42; P < 0.0001), macular ectopia (r = +0.42; P < 0.0001), visual acuity (r = -0.40; P < 0.0001), and vessel traction (r = +0.35; P < 0.0001) as significant correlates. Stepwise regression analysis demonstrated that worst ROP stage and macular ectopia accounted for 18% and 4% of the cumulative variance, respectively. CONCLUSIONS: P1 VEP latency correlates with postnatal insults, structural outcome, and functional outcome parameters in former preterms in whom ROP developed that spontaneously regressed without macular detachment. A permanent arrest in the development of the macula and/or prolonged traction on the incompletely developed macula may alter VEPs.

Criteria to detect minimal expressivity within families with autosomal dominant aniridia.

Autosomal dominant aniridia with complete penetrance without Wilms' tumor in five generations with 27 affected family members has been reassigned from chromosome 2p25 to chromosome 11p13. Clinically, aniridia was obvious in affected individuals with variable expressivity when they had rudimentary iris stumps, typical or atypical iris colobomata, or round, eccentric pupils. However, iris and retinal fluorescein angiography was required to detect abnormal vascular remodeling that resulted in incomplete iris collarettes and decreased retinal foveal avascular zones in 27 family members at risk with round, central pupils. These angiograms distinguished five affected and 22 unaffected individuals, and were the critical criteria required to detect minimal expressivity of aniridia in family members with round, central pupils.

Visual acuity correlates with severity of retinopathy of prematurity in untreated infants weighing 750 g or less at birth.

Visual acuity was assessed in 72 patients who weighed 750 g or less at birth, had intact visual pathways as confirmed with computed tomography or magnetic resonance imaging, and had at least one eye evaluated for cicatricial sequelae after active, untreated retinopathy of prematurity without macular detachment (stage 4a or better). Visual acuities were obtained for 137 untreated, sighted eyes. Severity parameters for retinopathy of prematurity (stage of retinopathy of prematurity, refraction [in spherical equivalents], macular ectopia [in disc diameters], and vessel traction [in 30 degrees sectors]) was were significant predictors of visual acuity (P less than .0001) based on results of linear regression and stepwise regression analyses; however, parameters of retinal immaturity (birth weight, gestational age, and zone of retinopathy of prematurity) were not significant predictors of visual acuity. Visual acuity of the study eyes was good (median, 20/30; geometric mean, 20/33.58), with no statistical differences between eyes evaluated on last examination with linear Allen figures and those evaluated with linear Snellen test types.

Resolution of the two loci for autosomal dominant aniridia, AN1 and AN2, to a single locus on chromosome 11p13.

Two distinct loci have been proposed for aniridia; AN1 for autosomal dominant aniridia on chromosome 2p and AN2 for the aniridia in the WAGR contiguous gene syndrome on chromosome 11p13. In this report, the kindred segregating for autosomal dominant aniridia, which suggested linkage to acid phosphatase-1 (ACP1) and led to the assignment of the AN1 locus on chromosome 2p, has been updated and expanded. Linkage analysis between the aniridia phenotype and ACP1 does not support the original linkage results, excluding linkage up to theta = 0.17 with Z = -2. Tests for linkage to other chromosome 2p markers. APOB, D2S71, D2S5, and D2S1, also excluded linkage to aniridia. Markers that have been isolated from the chromosome 11p13 region were then analyzed in this aniridia family. Two RFLPs at the D11S323 locus give significant evidence for linkage. The PvuII polymorphism detected by probe p5S1.6 detects no recombinants, with a maximum lod score of Z = 6.97 at theta = 0.00. The HaeIII polymorphism detected by the probe p5BE1.2 gives a maximum lod score of Z = 2.57 at theta = 0.00. Locus D11S325 gives a lod score of Z = 1.53 at theta = 0.00. These data suggest that a locus for aniridia (AN1) on chromosome 2p has been misassigned and that this autosomal dominant aniridia family is segregating for an aniridia mutation linked to markers in the 11p13 region.

The pathogenesis of retinopathy of prematurity as it relates to surgical treatment.

Our current surgical treatment for threshold retinopathy of prematurity (ROP) is based upon three concepts which emerged from morphologic and biochemical study of 250 pairs of whole eye donations obtained over a ten year period. 1) Spindle cells normally migrate and canalize to form inner retinal vessels, but when stressed, spindle cells secrete angiogenic factors. The clinical implication is that transretinal cryotherapy to the avascular retina is efficacious because it obliterates spindle cells. The number and timing of cryosessions are determined by the migration and kinetics of spindle cells. 2) Myofibroblasts originate from the shunt, are the major cellular component of extraretinal fibrovascular proliferation (EFP), and contract to produce retinal distortion and detachment. The clinical implication is that a second transretinal cryotherapy session should obliterate the shunt and the EFP, and should eliminate the source of retinal traction. 3) Anterior ocular growth occurs exponentially during the period when ROP develops and is treated. The clinical implication is that a prophylactic scleral buckle supports the fixed surface area of the developing retina while the choroid and sclera enlarge anteriorly. Retinal distortion produces misaligned photoreceptors, and retinal detachment results in rapid retinal death.

The rationale for cryotherapy with a prophylactic scleral buckle for Zone I threshold retinopathy of prematurity.

Our current surgical protocol for Zone I threshold retinopathy of prematurity (ROP) has evolved over 15 years and is rationalized by increasing knowledge of two pathologic processes of ROP: 1) angiogenic stimulation of spindle cells (clinically invisible) near the vitreal surface of the avascular retina; and 2) tractional forces of myofibroblasts [clinically visible as extraretinal fibrovascular proliferation (EFP)] in the vitreous overlying the vascular retina. These two pathologic processes occur concomitantly with normal anterior ocular growth with a constant optic disc-macular distance. Our current surgical protocol for Zone I threshold ROP, involves complex surgeries to achieve success defined as a macula which always remains anatomically attached, but which may be distorted or ectopic. This protocol requires cryotherapy in at least two sessions. The first is to the avascular retina to destroy spindle cells. The second is to the EFP to destroy myofibroblasts and to the shunt to eliminate the site of origin of myofibroblasts. The protocol also requires the concomitant placement of a prophylactic scleral buckle to allow formation of a new complete ora serrata while remnant myofibroblasts contract and while anterior ocular growth continues.