1. Pre-Laser Fundus images Post-Laser Fundus images
Horizontal Caliper
Vertical Caliper
Pre-Laser OCT frames
Post-Laser OCT frames *
Figure 1: OCT guided localization and photocoagulation of invisible tumor. Horizontal Caliper identified the lateral extent of the tumor. Vertical Caliper identified point localization of the tumor. Point and lateral locations were identified in each of the pre-laser OCT frames that showed the tumor. Rectangular area (blue star) were plotted over pre-laser fundus images putting in consideration nearby vascular bifurcations (yellow stars) and upper and lower limits (green lines) corresponding to one frame below and above last ones (yellow box) with detected tumor. Post-laser fundus images can show retinal whitening in response to treatment. Post-laser OCT frames ensured complete tumor treatment. *
Pre-Laser Fundus images
Post-Laser Fundus images

2. Pre-Laser treatment Post-Laser treatment Final follow up*
45 days earlier
Figure 2: OCT detection of subclinical tumors and scar recurrence. Upper row (yellow box): a small rounded invisible tumor (*) was missed in initial OCT scanning and diagnosed 45 days later when it attained a larger size. Laser was applied using the described technique and verified by post-laser OCT that showed tumor swelling, hyper-reflectiveness and shadowing. A flat scar can be seen within 2 months verified by OCT. Lower row (green box): a small tumor scar (*) within 2 disc diameters of the foveal center (yellow arrowhead) showed initial stability after treatment with the described laser technique followed by subclinical subtle recurrence 84 days later detected on OCT. It was treated with a single laser session verified by post-laser OCT. the scar is flat with pigmentary changes 1 year post laser.
Pre-Laser treatment
Post-Laser treatment
Final follow up * *

3. Prenatal RB1 mutation detection
Positive
100 % risk
Negative
0 % risk
Planned late preterm or early term delivery (36/37 weeks)
No Screening required
Figure 3: Flow chart showing proposed secondary prevention protocol for familial retinoblastoma.
Clinical tumors at birth
20 % probability
No clinical tumors at birth
80 % probability
Manage per standard practice according to staging
OCT-guided posterior pole screening
No tumor detected
Invisible tumor detected
Clinical tumors detected
OCT-guided localization and photocoagulation
OCT guided tight follow up
Every 2weeks for 3 months
Every 3 weeks for 3 months
Every 4 weeks for 6 months
Invisible tumor/recurrence detected