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Tripepi D, Jalil A, Ally N, Buzzi M, Moussa G, Rothschild PR, Rossi T, Ferrara M, Romano MR. The Role of Subretinal Injection in Ophthalmic Surgery: Therapeutic Agent Delivery and Other Indications. Int J Mol Sci 2023; 24:10535. [PMID: 37445711 DOI: 10.3390/ijms241310535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Subretinal injection is performed in vitreoretinal surgery with two main aims, namely, the subretinal delivery of therapeutic agents and subretinal injection of fluid to induce a controlled and localized macular detachment. The growing interest in this technique is mainly related to its suitability to deliver gene therapy in direct contact with target tissues. However, subretinal injection has been also used for the surgical management of submacular hemorrhage through the subretinal delivery of tissue plasminogen activator, and for the repair of full-thickness macular holes, in particular refractory ones. In the light of the increasing importance of this maneuver in vitreoretinal surgery as well as of the lack of a standardized surgical approach, we conducted a comprehensive overview on the current indications for subretinal injection, surgical technique with the available variations, and the potential complications.
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Affiliation(s)
- Domenico Tripepi
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Italy
| | - Assad Jalil
- Manchester Royal Eye Hospital, Oxford Road, Manchester M13 9WL, UK
| | - Naseer Ally
- Manchester Royal Eye Hospital, Oxford Road, Manchester M13 9WL, UK
| | - Matilde Buzzi
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Italy
| | - George Moussa
- Manchester Royal Eye Hospital, Oxford Road, Manchester M13 9WL, UK
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston PR2 9HT, UK
| | - Pierre-Raphaël Rothschild
- Department of Ophthalmology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
- Centre de Recherche des Cordeliers, INSERM, UMR_1138, Université Paris Cité, 75270 Paris, France
| | | | - Mariantonia Ferrara
- Manchester Royal Eye Hospital, Oxford Road, Manchester M13 9WL, UK
- Faculty of Medicine, University of Malaga, 29016 Malaga, Spain
| | - Mario R Romano
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele, Italy
- Eye Center, Humanitas Gavazzeni-Castelli, 24128 Bergamo, Italy
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Rezende FA, Ferreira BG, Rampakakis E, Steel DH, Koss MJ, Nawrocka ZA, Bacherini D, Rodrigues EB, Meyer CH, Caporossi T, Mahmoud TH, Rizzo S, Johnson MW, Duker JS. Surgical classification for large macular hole: based on different surgical techniques results: the CLOSE study group. Int J Retina Vitreous 2023; 9:4. [PMID: 36717928 PMCID: PMC9885593 DOI: 10.1186/s40942-022-00439-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/29/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The CLOSE study group proposes an updated surgical classification for large macular holes based on a systematic review of new treatments. Recently, many new techniques have been introduced to treat large full-thickness macular holes (FTMH); although the indications are not clear. An updated surgical classification is needed to help surgical decision-making. METHODS We gathered published series by the CLOSE Study Group members and from literature search until June 2021. Techniques included: internal limiting membrane peeling (ILM peeling), ILM flaps, macular hydrodissection (macular hydro), human amniotic membrane graft (hAM), and autologous retinal transplantation (ART). Within each technique, chi-square test assessed association between the minimal linear diameter (MLD) (in µm) and closure rate; the postoperative best-corrected visual acuity (BCVA) gains were compared among groups. RESULTS Data extraction included 31 published articles: total of 1135 eyes. Eyes were divided into the following groups: ILM peel (n: 683), ILM Flap (n: 233), macular hydrodissection (n: 64), hAM (n: 59), and ART (n: 96). The initial BCVA and size were heterogenous between the groups. ILM peel showed the best results in large FTMH ≤ 535 µm (closure rate 96.8%); adjusted mean BCVA: 0.49 (LogMAR) with a statistical difference among groups. Large FTMH between 535 and 799 µm: ILM flap technique showed better results (closure rate 99.0%); adjusted mean BCVA: 0.67(LogMAR); also with a statistical difference. For large FTMH ≥ 800 µm more invasive techniques are required. Use of hAM, macular hydrodissection and ART showed higher closure rates for this category (100%, 83.3% and 90.5% respectively), and adjusted mean BCVA varied from 0.76 to 0.89. Although there was no statistical difference between those techniques for this group due to the smaller number of cases. CONCLUSIONS The CLOSE study group demonstrated the potential usefulness of a new surgical classification for large FTMHs and propose OCT biomarkers for use in clinical practice and future research. This new classification demonstrated that Large (400-550 µm) and X-Large (550-800 µm) holes can be treated highly successfully with ILM peel and ILM flap techniques, respectively. Further studies are necessary for the larger FTMHs (XX-Large and Giant), using the CLOSE classification, in order to determine which technique is better suited for each hole size and characteristics.
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Affiliation(s)
- Flavio A. Rezende
- grid.14848.310000 0001 2292 3357Department of Ophthalmology, Maisonneuve-Rosemont Hospital, CIUSSS de l’est d’ile de Montréal, University of Montreal, 801 Rue de la Commune est, ap 501, Montreal, QC H2V0A3 Canada
| | - Bruna G. Ferreira
- grid.14848.310000 0001 2292 3357Department of Ophthalmology, Maisonneuve-Rosemont Hospital, CIUSSS de l’est d’ile de Montréal, University of Montreal, 801 Rue de la Commune est, ap 501, Montreal, QC H2V0A3 Canada
| | - Emmanouil Rampakakis
- grid.14709.3b0000 0004 1936 8649Faculty of Medicine and Health Sciences, McGill University, Montreal, QC Canada
| | - David H. Steel
- grid.1006.70000 0001 0462 7212Sunderland Eye Infirmary, Sunderland, and Newcastle University, Newcastle-Upon-Tyne, UK
| | - Michael J. Koss
- Augenzentrum Nymphenburger Höfe/Augenklinik Herzog Carl Theodor, Munich, Germany
| | | | - Daniela Bacherini
- grid.8404.80000 0004 1757 2304Department of Neurosciences, Psychology, Drug Research and Child Health, Eye Clinic, University of Florence, Florence, Italy
| | - Eduardo B. Rodrigues
- grid.262962.b0000 0004 1936 9342Department of Ophthalmology, St. Louis University, St. Louis, MO USA
| | | | - Tomaso Caporossi
- grid.8142.f0000 0001 0941 3192Fondazione Policlínico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy ,grid.418879.b0000 0004 1758 9800Instituto di Neuroscienze - CNR, Pisa, Italy
| | - Tamer H. Mahmoud
- grid.261277.70000 0001 2219 916XAssociated Retinal Consultants, Beaumont Neuroscience Center, Oakland University William Beaumont School of Medicine, Royal Oak, MI USA
| | - Stanislao Rizzo
- grid.8142.f0000 0001 0941 3192Fondazione Policlínico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy ,grid.418879.b0000 0004 1758 9800Instituto di Neuroscienze - CNR, Pisa, Italy
| | - Mark W. Johnson
- grid.214458.e0000000086837370Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI USA
| | - Jay S. Duker
- grid.67033.310000 0000 8934 4045New England Eye Center, Tufts Medical Center, Boston, MA USA ,grid.67033.310000 0000 8934 4045Department of Ophthalmology, Tufts Medical Center, Boston, MA USA
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Romano MR, Rossi T, Borgia A, Catania F, Sorrentino T, Ferrara M. Management of refractory and recurrent macular holes: A comprehensive review. Surv Ophthalmol 2022; 67:908-931. [DOI: 10.1016/j.survophthal.2022.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 01/22/2022] [Accepted: 01/24/2022] [Indexed: 10/19/2022]
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Refractory full thickness macular hole: current surgical management. Eye (Lond) 2021; 36:1344-1354. [PMID: 33479488 PMCID: PMC9232562 DOI: 10.1038/s41433-020-01330-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/08/2020] [Accepted: 11/13/2020] [Indexed: 11/09/2022] Open
Abstract
This review aims to collect the proposed surgical techniques for treating full thickness macular hole (FTMH) refractory to pars plana vitrectomy and internal limiting membrane (ILM) peeling and to analyse and compare anatomical and functional outcomes in order to evaluate their efficacy. The articles were grouped according to the surgical techniques used. Refractory FTMH closure rate and best-corrected visual acuity (BCVA) gain were the two analysed parameters. Thirty-six articles were selected. Ten surgical technique subgroups were defined: autologous platelet concentrate (APC); lens capsular flap transplantation (LCFT); autologous free ILM flap transplantation (free ILM flap); enlargement of ILM peeling, macular hole hydrodissection (MHH), autologous retinal graft (ARG), silicon oil (SO), human amniotic membrane (hAM), perifoveal relaxing retinotomy, arcuate temporal retinotomy. Refractory FTMH closure rate was similar among subgroups, not significant heterogeneity emerged (p = 0.176). BCVA gain showed a significant dependence on surgical technique (p < 0.0001), significant heterogeneity among subgroups emerged (p < 0.0001). Three sets of surgical technique subgroups with a homogeneous BCVA gain were defined: high BCVA gain (hAM); intermediate BCVA gain (APC, ARG, LCFT, MHH, SO); low BCVA gain (free ILM flap, enlargement of peeling, arcuate temporal retinotomy). In terms of visual recovery, the most efficient technique for treating refractory FTMH is hAM, lens capsular flap and APC that allow to obtain better functional outcomes than free ILM flap. MHH, ARG, perifoveal relaxing and arcuate temporal retinotomy require complex and unjustified surgical manoeuvres in view of the surgical alternatives with overlapping anatomical and functional results.
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Lachance A, You E, Garneau J, Bourgault S, Caissie M, Tourville É, Dirani A. Revision Surgery for Idiopathic Macular Hole after Failed Primary Vitrectomy. J Ophthalmol 2021; 2021:8832538. [PMID: 33520301 PMCID: PMC7817234 DOI: 10.1155/2021/8832538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/30/2020] [Accepted: 12/03/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To investigate the anatomical and functional outcomes of revision surgery after failed primary surgery for idiopathic macular hole (MH). METHODS All consecutive patients with MH were identified from a cohort of patients operated between 2014 and 2018 at the CHU de Québec-Université Laval (Québec). The clinical and anatomical features of patients with unclosed MH after primary surgery were retrospectively collected. Our primary outcome was MH nonclosure rate after revision surgery. Our secondary outcomes were best-corrected visual acuity (BCVA) with ETDRS scale and MH size of eyes with revision surgery preoperatively and at 3 and 12 months after revision surgery. RESULTS In our cohort of 1085 eyes, 926 eyes met inclusion criteria and were analyzed in the study. We identified 22 eyes with failed primary surgery (2.4%), of which 20 underwent revision surgery. We had no bilateral MH in these 22 eyes. The nonclosure rate of MH after revision surgery was 15%. The mean final BCVA for closed MH after revision surgery was 55 ± 19 letters. Compared to the initial presentation, the mean change in visual acuity (VA) for closed MH was +4 ± 31 letters and +16 ± 17 letters at 3 and 12 months after the revision surgery, respectively. At initial presentation, patients with failed primary surgery had a baseline MH size of 665 ± 226 μm. The mean MH size after failed primary surgery was 607 ± 162 μm and 546 ± 156 μm for the three unclosed MHs one month after revision surgery. CONCLUSION The success rate of revision surgery in eyes with unclosed MH is 85%. After successful revision surgery, eyes demonstrated an improvement in VA and closure of the MH.
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Affiliation(s)
- Alexandre Lachance
- Faculté de Médecine, Université Laval, Québec City, Québec, Canada
- Département d'Ophtalmologie et d'Oto-Rhino-Laryngologie–Chirurgie Cervico-Faciale, Centre Universitaire d'Ophtalmologie, Hôpital du Saint-Sacrement, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Eunice You
- Faculté de Médecine, Université Laval, Québec City, Québec, Canada
- Département d'Ophtalmologie et d'Oto-Rhino-Laryngologie–Chirurgie Cervico-Faciale, Centre Universitaire d'Ophtalmologie, Hôpital du Saint-Sacrement, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Jérôme Garneau
- Faculté de Médecine, Université Laval, Québec City, Québec, Canada
| | - Serge Bourgault
- Faculté de Médecine, Université Laval, Québec City, Québec, Canada
- Département d'Ophtalmologie et d'Oto-Rhino-Laryngologie–Chirurgie Cervico-Faciale, Centre Universitaire d'Ophtalmologie, Hôpital du Saint-Sacrement, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Mathieu Caissie
- Faculté de Médecine, Université Laval, Québec City, Québec, Canada
- Département d'Ophtalmologie et d'Oto-Rhino-Laryngologie–Chirurgie Cervico-Faciale, Centre Universitaire d'Ophtalmologie, Hôpital du Saint-Sacrement, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Éric Tourville
- Faculté de Médecine, Université Laval, Québec City, Québec, Canada
- Département d'Ophtalmologie et d'Oto-Rhino-Laryngologie–Chirurgie Cervico-Faciale, Centre Universitaire d'Ophtalmologie, Hôpital du Saint-Sacrement, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Ali Dirani
- Faculté de Médecine, Université Laval, Québec City, Québec, Canada
- Département d'Ophtalmologie et d'Oto-Rhino-Laryngologie–Chirurgie Cervico-Faciale, Centre Universitaire d'Ophtalmologie, Hôpital du Saint-Sacrement, CHU de Québec-Université Laval, Québec City, Québec, Canada
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Li JQ, Brinken R, Holz FG, Krohne TU. Silicone oil tamponade for persistent macular holes. Eye (Lond) 2020; 35:2206-2212. [PMID: 33087884 DOI: 10.1038/s41433-020-01228-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/07/2020] [Accepted: 10/08/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND A variety of treatment strategies have been proposed for macular holes that persist or recur after surgery, and the debate about the best re-treatment approach is ongoing. To allow for a comparison with alternative surgical therapies, we assessed the anatomical and functional outcome of a temporary tamponade with conventional silicone oil in persistent or recurrent full-thickness macular holes. METHODS We retrospectively investigated consecutive patients with full-thickness macular holes that persisted or recurred following vitrectomy with internal limiting membrane peeling and gas tamponade. All patients received re-treatment by temporary tamponade of silicone oil and were allowed free postoperative positioning. Anatomical closure rate was assessed by optical coherence tomography, and change of best-corrected visual acuity (BCVA) was analyzed. RESULTS A total of 33 eyes of 33 consecutive patients were included. Macular hole closure following silicone oil tamponade was achieved in 30 of 33 eyes (90.9%). Median BCVA improved from 1.00 logMAR (interquartile range, 0.60-1.00) to 0.65 logMAR (0.49-1.00; p = 0.010) after silicone oil removal. In patients with macular hole closure, 61.3% exhibited functional improvement with median BCVA changing from 1.00 logMAR (0.70-1.00) to 0.60 logMAR (0.49-1.00; p = 0.0005). Mean minimal linear diameter of macular holes before primary surgery was 391.0 µm (±137.8; range 133-630), and 48.5% of macular holes were >400 µm in diameter. CONCLUSIONS Treatment of persistent or recurrent full-thickness macular holes by temporary conventional silicone oil tamponade without postoperative positioning results in a high closure rate and a significant mean improvement of visual acuity.
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Affiliation(s)
- Jeany Q Li
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, D-53127, Bonn, Germany
| | - Ralf Brinken
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, D-53127, Bonn, Germany
| | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, D-53127, Bonn, Germany
| | - Tim U Krohne
- Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, D-53127, Bonn, Germany.
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Application of subretinal fluid to close refractory full thickness macular holes: treatment strategies and primary outcome: APOSTEL study. Graefes Arch Clin Exp Ophthalmol 2020. [DOI: 10.1007/s00417-020-04735-3 10.1007/s00417-020-04735-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Application of subretinal fluid to close refractory full thickness macular holes: treatment strategies and primary outcome: APOSTEL study. Graefes Arch Clin Exp Ophthalmol 2020; 258:2151-2161. [PMID: 32583283 DOI: 10.1007/s00417-020-04735-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/14/2020] [Accepted: 05/06/2020] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Persisting macular holes (PMH) after surgical release of any epiretinal traction of the vitreous and adjacent membrane may rely on secondary firm adhesions between the retracted retina and adjacent retinal pigment epithelium. Secondary application of subretinal (SR)-fluid may release these adhesions followed by an anatomical closure. METHODS Twelve surgeons applied in a consecutive case series SR-fluid in 41 eyes with PMH and reported retrospectively their initial surgical, anatomical and functional experience with this approach. RESULTS The mean duration of the MH prior to SR-fluid application was 17 months (6-96 months). The mean age of the patients at the time of surgery was 72 years (54-88). The mean preoperative aperture diameter of the opening was 1212 μm (239-4344 μm), base diameter 649 μm (SD 320 μm). The mean preoperative BCVA prior to surgery was 0.1 (0.01-0.3). All patients (41/41) complained about reduced BCVA and a significant central scotoma (negative scotoma) in their central field of vision. The secondary closure rate for our PMH was 85.36% (35 out of 41 eyes) at 6 weeks after surgery. The postoperative BCVA improved to 0.22 (0.02-0.5). The application of SR-fluid was not associated with major intraoperative adverse effects. CONCLUSION Remaining SR-adhesions may inhibit PMH closure. Their release by application of SR-fluid will lead to a fast and immediate anatomical closure in many cases without serious adverse events.
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Meyer CH, Adamcova M, Rodrigues EB, Stanzel B, Koss MJ. [Closure of Persisting Full Thickness Macular Holes by Subretinal Fluid Application: Technical Approach and Surgical Considerations]. Klin Monbl Augenheilkd 2020; 238:173-178. [PMID: 32289849 DOI: 10.1055/a-1120-8673] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Firm adhesions between the retina and adjacent retinal pigment epithelium (RPE) may prevent the closure of macular holes (MH) after chromovitrectomy. Controlled application of subretinal (SR) fluid with BSS may release these adhesions leading to closure of the retracted retina in large and or refractory macular holes. METHODS For a standardized procedure, it is recommended to exclude residues of epiretinal membranes on the retinal surface preoperatively at OCT or intraoperatively by means of vital dyes. Intraoperatively, a perfluorocarbon (PFO) bubble is placed above the MH and lowers the infusion bottle of 20 mmHg. Subsequently, SR-fluid blebs are applied in the upper, temporal and inferior quadrants with a subretinal 41-gauge cannula. After removing decalin bubble, the SR-detachment is enlarged toward the foveal center. This is essential to achieve a complete detachment of the outer macular edges from the RPE. The MH can be closed by a temporary gas endotamponade. RESULTS With a standardized procedure, the operation can be carried out safely and with minimal effort. Additional measures, such as care for bubble-free SR-fluid sands or machine assistance, were added. In a pilot study, experienced VR surgeons performed the SR-fluid application safely and without complications. The preoperative diameter of the MH was 1150 µm (651 - 2350 µm). The secondary closure rate for our PMH was 80.9%. CONCLUSION SR-adhesions seem to have a previously unnoticed component in persistent macular holes. An SR-fluid application can be carried out quickly, safely and with minimal material effort. The initial results show a high secondary closure rate.
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Affiliation(s)
- Carsten H Meyer
- Augenärzte Graubünden, Davos, Schweiz.,Department of Ophthalmology, Faculty of Medicine, Federal University of São Paulo, Brasilien
| | | | - Eduardo B Rodrigues
- Department of Ophthalmology, Faculty of Medicine, Federal University of São Paulo, Brasilien.,Department of Ophthalmology, University of St. Louis, St. Louis, USA
| | - Boris Stanzel
- Augenklinik, Knappschaftsklinikum Saar GmbH, Krankenhaus Sulzbach
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