Efficacy of intravitreal ocriplasmin for treatment of vitreomacular adhesion: subgroup analyses from two randomized trials

[Macular hole: Differential diagnosis, treatment options and new guideline recommendations]

Full-thickness macular holes (FTMH) usually result in a pronounced reduction of visual acuity and represent one of the most frequent indications for retinal surgery. If diagnosed and treatment is initiated at an early stage, surgery has a high success rate with respect to both hole closure and improvement of visual acuity. Optical coherence tomography (OCT)-based staging and sizing enables an estimation of the surgical outcome. The differential diagnostic distinction from clinically similar disorders, such as lamellar macular holes, macular pseudoholes, and foveoschisis is clinically relevant as the pathogenesis, prognosis and treatment are significantly different. While vitrectomy with peeling of the inner limiting membrane (ILM) and gas tamponade is established as the standard treatment for FTMH, some aspects of treatment are handled differently between surgeons, such as the timing of surgery, the choice of endotamponade and the type and duration of postoperative positioning. For FTMH associated with vitreomacular traction, alternative treatment options in addition to vitrectomy include intravitreal ocriplasmin injection and pneumatic vitreolysis. The current clinical guidelines of the German ophthalmological societies summarize the evidence-based recommendations for diagnosis and treatment of FTMH.

Ocular Pharmacology

Treatment of ocular diseases presents unique challenges and opportunities for the clinician and for the clinical pharmacologist. Ophthalmic pharmaceuticals, typically given as liquids, require consideration of solubility, physiological pH, and osmolarity, as well as sterility and stability, which in turn requires optimal pharmaceutics. Ocular tissue levels are challenging to obtain in humans, and the clinical pharmacokinetics is typically blood levels, which are primarily related to safety, rather than efficacy. The eye is a closed compartment with multiple physiological barriers with esterases and transporters, but relatively little cytochrome oxidases. Delivery routes include topical, intravitreal, and systemic. Patient dosing involves not only adherence issues common to all chronic diseases, but also performance requirements on eye drop instillation. Therapeutically, ocular diseases and their pharmacological treatments include both those analogous to systemic diseases (e.g., inflammation, infection, and neuronal degeneration) and those unique to the eye (e.g., cataract and myopia).

The time course of spontaneous closure of idiopathic full-thickness macular holes

PURPOSE

Spontaneous closure of idiopathic full-thickness macular holes (iFTMH) has been reported regularly. However, little is known about its probability and timeline.

METHODS

In this retrospective study all consecutive patients who presented between August 2008 and August 2019 were screened for the presence of a macular hole and only iFTMHs were included. The primary outcome measure was the spontaneous closure of the iFTMH.

RESULTS

Of 1256 eyes with macular holes, 338 fulfilled the inclusion criteria. Spontaneous closure of the iFTMH was detected in 31 eyes (9.2%) with a median time of 44 days after diagnosis. Eyes exhibiting spontaneous closure demonstrated a higher baseline best-corrected visual-acuity (BCVA) and smaller iFTMH diameter (p < 0.0001 and p < 0.0001, respectively). The mean BCVA improved from 0.4 logMAR (SD ± 0.21) to 0.29 logMAR (SD ± 0.20) after spontaneous closure (p = 0.031). The iFTMH diameter was positively correlated with the time to spontaneous closure (Pearson-r = 0.37, p = 0.0377). Spontaneously closed iFTMHs reopened in 16% (n = 5) of cases, with a median of 136 days after closure. A logistic regression model showed the hole diameter was associated with spontaneous closure (odds-Ratio 0.97, 95%CI [0.96, 0.98]). The Kaplan-Meier-Curve revealed that approximately 25% of small-iFTMH (n = 124) and 55% of iFTMH with a diameter < 150µm (n = 48) closed spontaneously within two months.

CONCLUSION

The established gold-standard for the treatment of iFTMHs is macular surgery. However, the potential for spontaneous closure of small iFTMHs must be acknowledged. Therefore, if surgical treatment is delayed in individual cases, close observation is recommended.

Pneumatic vitreolysis versus vitrectomy for the treatment of vitreomacular traction syndrome and macular holes: complication analysis and systematic review with meta-analysis of functional outcomes

BACKGROUND

We conducted a systematic review to compare  the effects of pneumatic vitreolysis (PV), enzymatic vitreolysis (EVL) with ocriplasmin, and pars plana vitrectomy (PPV) on vitreomacular traction (VMT) syndrome and macular holes (MHs) to assess their efficacy as treatment options.

METHODS

Databases, including PubMed, ClinicalTrials.gov ( www.

CLINICALTRIALS

gov ), the Cochrane Central Register of Controlled Trials (CENTRAL)-including the Cochrane Eyes and Vision Group Trials Register (The Cochrane Library 2013, Issue 2)-, Ovid MEDLINE, and EMBASE (January 2000-October 2022), were searched to identify studies comparing the outcomes of PV versus PPV, PPV versus ocriplasmin and ocriplasmin versus PV. RevMan 5.1 was used for the meta-analysis of the studies.

RESULTS

Among the 89 studies, 79 were considered eligible for qualitative analysis, and 10 quantitative studies were subjected to meta-analysis. PPV resulted in better postoperative visual acuity improvement than ocriplasmin (standardized mean deviation (SMD) = 0.38, 95% CI 0.03-0.73, p = 0.0003). PV resulted in no significant difference in visual improvement compared  with  PPV (SMD = - 0.15, 95% CI - 0.47 to 0.16, p = 0.35). PPV was significantly more effective in terms of the VMT release rate (risk ratio = 0.48, 95% CI 0.38-0.62, p = 0.00001) and MH closure rate (risk ratio = 0.49, 95% CI 0.30-0.81, p = 0.006) than ocriplasmin. PV was more effective than ocriplasmin in terms of the VMT release rate (risk ratio = 0.49, 95% CI 0.35-0.70, p = 0.0001). Qualitative analysis showed MH closure rates of 46%, 47.8%, and 95% and VMT releases rates of 46%, 68% and 100% after ocriplasmin, PV, and PPV treatments, respectively.  Adverse events and postoperative complications occurring after treatment have also been documented in these studies.

CONCLUSION

PPV appears to be the most promising option for MH closure and VMT release, with fewer serious complications than EVL  or PV. However, given the limited number of studies comparing these treatments, further research is needed to establish the superiority of PPV over the other options.

Quantification of Retinal Vein and Artery Trajectories Using Second-Order Polynomial Equation in Eyes with Vitreomacular Traction

BACKGROUNDS

To measure the degree of curvature of the retinal artery trajectory (RAT) and retinal vein trajectory (RVT) in the eyes of patients with vitreomacular traction (VMT) and compare them with their healthy fellow eyes.

METHODS

This was a retrospective, cross-sectional, case-control study of 58 eyes of 29 patients with unilateral VMT. The participants were divided into two groups. Group 1 VMT was defined as having only morphological changes, while group 2 VMT was defined as morphological changes accompanied by the presence of a cyst or hole to quantify the severity of the disease. The RATs and RVTs were assessed from the color fundus photographs using the ImageJ program. The fundus photographs were rotated 90 degrees. The course of the retinal arteries and veins were marked on a color fundus photograph and fitted to a second-degree polynomial curve (ax[x]/100+bx+c). The coefficient ''a'' was the width and steepness of the trajectories. The comparison between the RAT and RVT of vitreomacular traction and healthy fellow eyes was investigated and the association between the RAT and RVT and the severity of disease were determined using the Image J program.

RESULTS

Eleven subjects were male, and 18 subjects were female. The mean ± SD age was 70.6 ± 7.6 years. Eighteen of the eyes had VMT in the right and 11 of the eyes had VMT in the left eye. Eleven eyes were in group 1 and 18 eyes were in group 2. Axial length (AL) was similar between the two groups (22.63 ± 1.20 mm vs 22.45 ± 1.45 mm p=0.83). (Table 1) The mean RAT was 0.60±0.18 in eyes with VMT and 0.51±0.17in healthy eyes (p=0.063). The mean RVT was 0.74±0.24 in eyes with VMT and 0.62±0.25 in healthy eyes for the whole group (p=0.02). In group 1, the mean RVT of the eyes with VMT was statistically significantly higher than the healthy eyes (p=0.014). There was not any statistically significant difference for the other parameters evaluated between eyes with VMT and healthy eyes according to the groups and the whole group. (Table 2-3-4) CONCLUSION: Unlike other vitreoretinal interface diseases such as epiretinal membrane and macular hole, VMT may be characterized by a narrower RVT, which is characterized by a larger "a" value.

Spontaneous Closure of an Idiopathic Full-Thickness Macular Hole: A Literature Review

Purpose:

This work reviews the literature regarding spontaneous closure of idiopathic full-thickness macular holes (FTMHs).

Methods:

Literature on patients with spontaneous idiopathic FTMH closure was reviewed via Ovid MEDLINE, EMBASE, and PubMed through July 16, 2020. A total of 27 of 66 identified articles were included.

Results:

A total of 68 eyes had spontaneous closure. Of the patients, 62.7% were women and the average age was 67.5 years. Visual acuity improved from Snellen 20/78 to 20/33 post closure. The average hole diameter was 176.8 μm; the largest was 350 μm. Most were stage 2 according to Gass and of small size according to International Vitreomacular Traction Study Group (IVTS) staging. The predominant classification system in recent literature is IVTS staging. The average optical coherence tomography–observed closure time was 4.5 months.

Conclusions:

On review, reported spontaneous closure rates of all idiopathic FTMH range from 3% to 15%, and no demographic subgroups are more likely to have closure. Holes ≤250 µm have higher closure rates (22.2%) than those in the range of >250 to 400 µm (13.3%) and ≥400 µm (0%). Closure is associated with favorable visual outcomes, and retinal bridging via glial cells is likely critical to closure. These determinations were based on limited numbers; prospective studies are needed to further ascertain rate, mechanism, and characteristics. IVTS staging provides reliable reporting and insight into whether FTMH can be observed before surgery.

Internal limiting membrane peeling in macular hole surgery

Since the era when macular hole was considered untreatable, macular hole surgery has come a long way to being one of the most successful surgeries. Internal limiting membrane (ILM) peeling has been an essential step of macular hole surgery since the establishment of the role of ILM in the aetiopathogenesis and progression of macular hole. However, the novel technique was not all virtuous. It had some vices which were not evident immediately. With the advent of spectral domain optical coherence tomography, short- and long-term effects of ILM peeling on macular structures were known; and with microperimetry, its effect on the function of macula could be evaluated. The technique has evolved with time from total peeling to inverted flap to just temporal peeling and temporal flap in an attempt to mitigate its adverse effects and to improve its surgical outcome. ILM abrasion technique and Ocriplasmin may eliminate the need of ILM peeling in selected cases, but they have their own limitations. We here discuss the role of ILM in the pathogenesis of macular hole, the benefits and adverse effects of ILM peeling, and the various modifications of the procedure, to then explore the alternatives.

Predictive factors of spontaneous release of vitreomacular traction: a systematic review and meta-analysis

PURPOSE

To review predictive factors of spontaneous vitreomacular traction (VMT) release.

METHODS

A systematic literature search was performed on Ovid MEDLINE, Embase, and Cochrane Library. Studies comparing spontaneously released VMT to persistent VMT were included. A meta-analysis was performed using a random effects model, and weighted mean difference (WMD), risk ratio (RR) and 95% confidence intervals (95%CI) were reported as appropriate.

RESULTS

Out of a search of 258 studies, twelve studies were included, from which 272 out of 934 eyes (29%) underwent spontaneous release. Mean age was 70.0 years, 37.2% of patients were male, and mean follow-up was 22.0 months. Significant predictive factors for spontaneous release were smaller VMT diameter (n=177;WMD=-212.48μm,95%CI=[-417.36,-7.60],P=0.04), epiretinal membrane (ERM) absence (n=162;RR=2.17,95%CI=[1.18,3.97],P=0.01), and right eye involvement(n=76;RR=2.10,95%CI=[1.14,3.88],P=0.02). Non-significant factors were age, initial best corrected visual acuity (BCVA), sex, ocular comorbidity, fellow-eye posterior vitreous detachment, previous intravitreal injection, and VMT classification with focal defined as ≤400μm. Mean release time was 15.3 months (n=212). Mean BCVA improved from 0.34±0.21 (Snellen 20/44) to 0.20±0.58 logMAR (Snellen 20/32) post-release (n=121).

CONCLUSION

Smaller VMT diameter, ERM absence, and right eye involvement may support spontaneous VMT release. If patients have tolerable symptoms, clinicians may consider observation in patients with these predictive factors.

Effect of pneumatic vitreolysis in management of patients with symptomatic focal vitreomacular traction

PURPOSE

To evaluate the efficacy of single intravitreal injection of an expansile concentration of sulphur hexafluoride gas (SF6) in treating patients with symptomatic focal vitreomacular traction (VMT) documented by spectral domain optical coherence tomography (SD-OCT) preoperatively.

METHODS

This is a prospective interventional case series including 30 eyes of 29 patients with symptomatic focal VMT evident on SD-OCT. Pre-operatively, mean best corrected visual acuity (BCVA) was 20/125 (range 20/400-20/40). Mean central foveal thickness (CFT) was 382 μm (range 149-576 μm; SD ± 91.88). All eyes received single intravitreal injection of 0.3 mL of 100% SF6 gas. Postoperatively, we performed SD-OCT at one week, one month, and three months for all eyes. Primary outcome measure was release of VMT. Secondary outcome measures were changes in postoperative BCVA andCFT.

RESULTS

Overall, VMT release occurred in 24 of 30 eyes by the final follow-up visit (80% final release rate); furthermore, 76.9% of eyes with diabetic maculopathy and 25% of eyes with concurrent epiretinal membrane (ERM) had successful VMT release. VMT release was documented on SD-OCT at an average of 3 weeks (range, 1-12 weeks). The rate of release in phakic eyes was 90% (18 of 20 eyes) versus 60% in pseudophakic eyes (6 of 10 eyes). One patient developed a retinal break at upper nasal retina after two weeks of injection.

CONCLUSION

Pneumatic vitreolysis (PVL) with limited face-down position is a viable option for treating focal VMT with few adverse events. Further studies are needed to evaluate its indications, benefits, and risks.

Anatomical and functional outcomes of pneumatic vitreolysis for treatment of vitreomacular traction with and without macular holes

PURPOSE

To evaluate the outcome of pneumatic vitreolysis (PVL) for vitreomacular traction (VMT) with or without full thickness macular hole (MH) < 400 µm.

METHODS

Forty-seven eyes of 47 patients were included who had undergone PVL for VMT with or without MH. Main outcome measures were release of VMT, MH closure, best-corrected visual acuity (BCVA) and adverse events.

RESULTS

Thirty-three patients had isolated VMT and 14 patients VMT with a MH. Four weeks after PVL, the overall VMT release rate was 35/47 (74.5%): 25/37 (67.6%) in phakic and 10/10 (100%) in pseudophakic eyes (p = 0.03). Four of 14 MH (28.6%) were closed. Twenty-two of 47 (46.8%) eyes required a subsequent PPV: 12/33 (36.4%) in the VMT only group and 10/14 (71.4%) in the VMT with MH group. Mean BCVA improved from 0.48 (± 0.24) to 0.34 (± 0.23) logMAR at 6 months in patients with VMT alone (p < 0.001), and from 0.57 (± 0.27) to 0.41 (± 0.28) logMAR in patients with VMT and MH (p = 0.008). Adverse events included new formation of a large MH in 4/33 (12.1%) eyes, failure of MH closure in 10/14 (71.4%) eyes, progression of mean minimum linear diameter (MLD) MH size from baseline 139 (± 67) to 396 (± 130) µm (p < 0.001) and development of a retinal detachment in 4/47 (8.5%) eyes.

CONCLUSION

While PVL leads to a high VMT release rate particularly in pseudophakic eyes, it is associated with a relatively high incidence of MH formation, MH size progression and retinal detachment.

Predicting the individual probability of macular hole closure following intravitreal ocriplasmin injections for vitreomacular traction release using baseline characteristics

The primary objective was to create and establish a new formula that predicts the individual probability of macular hole closure for eyes with full thickness macular holes (FTMH) accompanied by vitreomacular traction (VMT) which received enzymatic vitreolysis using intravitreally administered ocriplasmin. The secondary objective was to evaluate the forecast reliability of a previously published formula for VMT resolution in VMT-only eyes (Odds_IVO-Success = e^Intercept× OR^years× OR^ln(µm); Probability_IVO-Success = Odds_IVO-Success/(Odds_IVO-Success + 1)) on VMT resolution using the current dataset of eyes with FTMH accompanied by VMT. Retrospective analysis of the OASIS, ORBIT, and INJECT-studies. Patients with FTMH and VMT with complete information (n = 213) were included. The effect of gender, age, FTMH diameter, lens status and the presence of epiretinal membranes (ERM) on FTMH closure was assessed using separate univariate logistic regression analyses. With regard to VMT release separate univariate regression analyses were carried out and results were compared with formerly published data of VMT resolution in eyes with VMT only. Overall, 126 eyes (63%) experienced VMT resolution within 28 days. Younger age (p < 0.0001) and VMT diameter (p = 0.041) had a significant impact on VMT release. Overall, 81 eyes (38%) treated with ocriplasmin showed FTMH closure within 28 days. Univariate analysis of the different predictors analyzed revealed that FTMH diameter < 250 µm had a significant impact on treatment success (p = 0.0495). It was not possible to calculate and establish a new multivariate formula that can predict the individual FTMH closure probability for eyes with FTMHs and VMT. However, the results of VMT release prediction in eyes with FTMHs accompanied by VMT matched the prediction of VMT release in eyes with VMT only when using the previously published formula. All in all, predictors for calculating the individual probability of VMT resolution on the one hand and FTMH closure on the other hand are different suggesting diverse pathophysiological mechanisms.

The Effect of Intravitreal Ocriplasmin on Hue Discrimination

SIGNIFICANCE

We report 13 patients who received ocriplasmin for symptomatic vitreomacular adhesion. Farnsworth-Munsell 100 (FM 100) hue test total error score (TES) increased from baseline to month 1, before recovering at year 1. Ocriplasmin may alter hue discrimination.

PURPOSE

This study aimed to determine whether intravitreal ocriplasmin affects hue discrimination.

METHODS

Thirteen patients with symptomatic vitreomacular adhesion received intravitreal ocriplasmin 125 μg. Patients underwent full ocular examination, optical coherence tomography, and FM 100 hue test at baseline, 1 week, 1 month, and 1 year.

RESULTS

Mean age was 74.8 years. The median baseline FM 100 TES was similar in the injected and fellow eyes (272 vs. 252, respectively). Median TES in the injected eye increased from 272 to 348 at 1 week (median difference compared with baseline, +52.0; 98.8% confidence interval of difference, -64.0 to 184.0; P = .29), decreased to 324 at 1 month (median difference compared with baseline, -4.0; 98.8% confidence interval of difference, -44.0 to 256.0; P = .40), and decreased to 268 at 1 year (median difference compared with baseline, -108.0; 93.8% confidence interval of difference, -200.0 to 52.0; P = .19). Two patients (15.4%) had anatomic release of vitreomacular adhesion, occurring within 1 month of injection.

CONCLUSIONS

Ocriplasmin may alter hue discrimination, but larger studies are required to provide sufficient power to detect or exclude a statistically significant effect. Longer follow-up is needed to determine the duration of any effect.

REVISED PREDICTIVE BIOMARKER FOR OCRIPLASMIN THERAPY IN VITREOMACULAR TRACTION DISORDERS

PURPOSE

To determine a statistically optimal limit of adhesion size in vitreomacular traction (VMT) syndrome for ocriplasmin treatment.

METHODS

In this retrospective, consecutive, interventional study, we included 106 patients treated with ocriplasmin injection because of VMT between July 2013 and January 2018. A univariate and multivariate risk analysis was performed with grouped factors and continuous factors. We used a receiver operating characteristic curve to measure the prognostic relevance of each continuous factor for therapy success and determined the statistically optimal cutoff value at which specificity and sensitivity are simultaneously maximized.

RESULTS

Among the grouped factors, only a phakic lens status showed a highly significant positive influence on the resolution of the VMT. For the continuous factors, only the adhesion diameter before injection was a good predictor of anatomical success. The statistically optimal threshold value for the adhesion size was calculated to be 480 µm. Eyes below this limit had a 6.84-fold better chance of VMT resolution compared with eyes with a larger adhesion diameter.

CONCLUSION

The threshold value of the VMT diameter for ocriplasmin therapy could be statistically defined as 480 µm and may thus be a new quantitative biomarker to predict treatment success.

Ocriplasmin for treatment of vitreomacular traction and macular hole: A systematic literature review and individual participant data meta-analysis of randomized, controlled, double-masked trials

Ocriplasmin is used to treat vitreomacular traction (VMT), with or without full-thickness macular hole (MH). We systematically reviewed the evidence on ocriplasmin's effect on vitreomacular adhesion resolution (VMAR), MH closure, vitrectomy, and best-corrected visual acuity (BCVA) and investigated the effect of baseline covariates on outcome. We applied individual participant data meta-analyses to the entire population and to subgroups defined by MH or epiretinal membrane (ERM) presence. Safety data were pooled and tabulated. Five randomized controlled trials (1,067 participants) were included. Six months after treatment, ocriplasmin achieved higher rates of VMAR and MH closure versus control, lowered vitrectomy odds, and increased the likelihood of a ≥10-letter BCVA increase. VMAR rates were lower when ERM, broad VMA (> 1500 µm), diabetic retinopathy, or pseudophakia were present and higher in younger participants, women, and eyes with MHs. Ocriplasmin-treated participants experienced more short-term visual impairment that was not predictive of final BCVA, as well as vitreous floaters, photopsia, photophobia, eye pain, blurred vision, and dyschromatopsia. The most common serious adverse events for ocriplasmin and control, respectively, were MH progression (22.5%, 17.3%), new MH (1.5%, 3.4%) and retinal detachment (0.8%, 1.2%). Ocriplasmin promotes VMAR and MH closure. Transient visual phenomena are not uncommon.

Effectiveness of ocriplasmin in real-world settings: A systematic literature review, meta-analysis, and comparison with randomized trials

Purpose

Effectiveness of ocriplasmin for vitreomacular traction (VMT) varies depending on the presence of common ocular conditions and patient selection criteria. We carried out a systematic literature review and meta‐analysis of ocriplasmin studies conducted in real‐world settings (RWS) and compared outcomes with those from randomized controlled trials (RCTs).

Methods

We included prospective and retrospective studies from RWS documenting effectiveness of ocriplasmin in patients with VMT with or without MH, and RCTs of ocriplasmin versus control. Key end‐points were vitreomacular adhesion resolution (VMAR), nonsurgical MH closure, need for vitrectomy and safety. We conducted meta‐regression on pooled results to evaluate effects of baseline covariates and study design on outcomes.

Results

Thirty RWS (2402 patients) and 5 RCTs (737 patients) were included epiretinal membrane (ERM) and broad VMA were more prevalent in RCTs. Primary VMAR, vitrectomy and MH closure rates were comparable between RWS and RCTs. Rates of nsVMAR were significantly higher in RWS than RCTs (odds ratio 1.66; 95% confidence interval [CI]: 1.18–2.34). nsVMAR rates were inversely associated with ERM prevalence (odds ratio 0.20; 95% CI: 0.08–0.51). Compared with the recent OASIS trial, RWS reported a higher incidence of new/worsening subretinal fluid cases and less photophobia, photopsia, vitreous floaters, electroretinogram abnormalities and MH progression.

Conclusions

Ocriplasmin was significantly more effective in achieving nsVMAR in RWS than in RCTs. Lower ERM prevalence in RWS was the single significant explanatory variable for this difference. Conclusions on ocriplasmin safety in RWS are limited due to inconsistent reporting.

Inverted Internal Limiting Membrane Flap Technique: Is It the Best Option for Macular Holes?

Surgical treatment is generally necessary to repair full-thickness macular holes (FTMH). Although vitrectomy with or without internal limiting membrane (ILM) peeling remains the standard surgical technique, the inverted ILM flap procedure has increasingly assumed a role in the primary surgical repair of FTMHs. Some vitreoretinal surgeons reserve this technique to treat large or myopic holes, whereas others use it routinely in all cases. This paper is a comprehensive review of the current scientific evidence on the anatomical and functional outcomes of the inverted ILM flap technique in the repair of macular holes, following the International Vitreomacular Traction Study (IVTS) group classification.

Use of Exogenous Enzymes in Human Therapy: Approved Drugs and Potential Applications

The development of safe and efficacious enzyme-based human therapies has increased greatly in the last decades, thanks to remarkable advances in the understanding of the molecular mechanisms responsible for different diseases, and the characterization of the catalytic activity of relevant exogenous enzymes that may play a remedial effect in the treatment of such pathologies. Several enzyme-based biotherapeutics have been approved by FDA (the U.S. Food and Drug Administration) and EMA (the European Medicines Agency) and many are undergoing clinical trials. Apart from enzyme replacement therapy in human genetic diseases, which is not discussed in this review, approved enzymes for human therapy find applications in several fields, from cancer therapy to thrombolysis and the treatment, e.g., of clotting disorders, cystic fibrosis, lactose intolerance and collagen-based disorders. The majority of therapeutic enzymes are of microbial origin, the most convenient source due to fast, simple and cost-effective production and manipulation. The use of microbial recombinant enzymes has broadened prospects for human therapy but some hurdles such as high immunogenicity, protein instability, short half-life and low substrate affinity, still need to be tackled. Alternative sources of enzymes, with reduced side effects and improved activity, as well as genetic modification of the enzymes and novel delivery systems are constantly searched. Chemical modification strategies, targeted- and/or nanocarrier-mediated delivery, directed evolution and site-specific mutagenesis, fusion proteins generated by genetic manipulation are the most explored tools to reduce toxicity and improve bioavailability and cellular targeting. This review provides a description of exogenous enzymes that are presently employed for the therapeutic management of human diseases with their current FDA/EMA-approved status, along with those already experimented at the clinical level and potential promising candidates.

Intravitreal injection associated rhegmatogenous retinal detachment: outcomes of a European analysis

Purpose

As the number of intravitreal injections (IVI) increases annually, this study aimed to assess the anatomical and functional outcomes following rhegmatogenous retinal detachment (RRD) surgery for IVI-associated RRD (IVARD).

Methods

All non-vitrectomized eyes developing IVARD since 2007 in two European vitreoretinal centers (Department of Ophthalmology, LMU Munich, Germany, and Eye Clinic Luigi Sacco, University of Milan, Milan, Italy) were included. Main outcomes were primary and secondary retinal attachment rate after surgery, rate of proliferative vitreoretinopathy (PVR), and final functional result. Ten years of incidence rates per injection were calculated for one center.

Results

Fifty-two eyes of 52 patients comprised the study. Primary anatomic success rate was 83% (n = 43) and secondary 96% (n = 50). PVR was observed in all uveitic eyes (n = 3), in eyes with postoperative cystoid macular edema (n = 2), and in 8 of 9 eyes that received the dexamethasone implant (DEX). Age, number of prior injections, duration of symptoms, or time between last IVI and RRD did not show any statistically significant differences with regard to presence of PVR or not. Mean BCVA improved in 28 cases, remained stable in 16 cases, and worsened in 8 cases. The RRD incidence rate was statistically significant higher for DEX and ocriplasmin compared with that for anti-VEGF agents.

Conclusion

The anatomical result after one surgical intervention seems acceptable, but the final visual outcome remains rather poor, because of the underlying macular disease. In our population, injection with DEX is associated with higher IVARD rate, presence and development of PVR, and recurrent RRD in comparison with anti-VEGF agents.

Prognostic Factors Associated with Ocriplasmin Efficacy for the Treatment of Symptomatic Vitreomacular Adhesion and Full-thickness Macular Hole: Analysis from Four Studies

Purpose

To assess the effect of patient baseline characteristics on the efficacy of ocriplasmin treatment for symptomatic vitreomacular adhesion (VMA) with full-thickness macular hole (FTMH) from phase 3/4 studies.

Methods

Patients with symptomatic VMA and FTMH at baseline and receiving ocriplasmin treatment 125 μg were pooled from the MIVI-TRUST, OASIS, and ORBIT studies. Multivariable logistic regression analysis was used to evaluate whether patient baseline characteristics were predictors of having VMA resolution by Day 28 and FTMH closure by Month 6.

Results

Two hundred and seventy-four patients receiving ocriplasmin treatment were assessed. Overall, 22.6% (62/274) of the patients experienced both VMA resolution by Day 28 and non-surgical FTMH closure by Month 6. Patients with FTMH ≤250 µm at baseline had a significantly higher success rate compared to those with FTMH >400 µm (29.9% [41/137] vs 2.2% [1/48]; P = 0.009). In patients with VMA resolution by Day 28, both small FTMH size (P = 0.001) and FTMH width at RPE (P = 0.012) were significantly associated with a higher FTMH closure rate. Patients with VMA resolution had higher rates of FTMH closure. Previously identified baseline predictive factors, including age, lens status, or presence of epiretinal membrane (ERM) were not found to be predictive of both VMA release and FTMH closure.

Conclusion

The analysis revealed that FMTH ≤250 µm was the only factor predictive for achieving both pharmacological VMA resolution by Day 28 and nonsurgical FTMH closure by Month 6; neither lens status or presence of ERM, previously identified baseline characteristics favoring VMA resolution, showed statistically significant predictive power for both outcomes.

OCRIPLASMIN FOR VITREOMACULAR TRACTION IN CLINICAL PRACTICE: The INJECT Study

PURPOSE

Randomized clinical trials have demonstrated the safety and efficacy of ocriplasmin in patients with vitreomacular traction (VMT), including those with macular hole (MH). The INJECT study prospectively evaluated ocriplasmin in the setting of clinical practice.

METHODS

INJECT was a Phase 4, multicenter, prospective observational study. Patients were followed up for 12 months. Assessments included nonsurgical VMT resolution, nonsurgical MH closure, best-corrected visual acuity, occurrence of vitrectomy, and adverse events.

RESULTS

The efficacy population (N = 395) received an ocriplasmin injection and had optical coherence tomography-confirmed VMT at baseline. At Day 28, the rate of nonsurgical VMT resolution was 40.7% in the overall group, and the rate of nonsurgical MH closure was 36.0% in the VMT with MH group. At Month 12, the rate of ≥2-line best-corrected visual acuity gain (irrespective of vitrectomy) was 36.8% in the overall group and 59.6% in the VMT with MH group. The percentage of patients who underwent vitrectomy in the study eye was 29.1% in the overall group and 55.6% in the VMT with MH group. Photopsia (9.8%) and vitreous floaters (6.8%) were the most frequent adverse events.

CONCLUSION

The INJECT study showed that ocriplasmin is effective in a clinical setting in patients with VMT, with or without MH. No new safety signals were identified from this large and surgeon-selected patient group, although the significant limitations of the study design without an image reading center and scheduled study visit timings should be noted.

THE EFFECT OF ELECTIVE CATARACT EXTRACTION BY PHACOEMULSIFICATION IN EYES WITH VITREOMACULAR TRACTION SYNDROME

PURPOSE

To evaluate the effect of cataract extraction (CE) by phacoemulsification on the vitreomacular interface (VMI) of eyes with preexisting vitreomacular traction (VMT).

METHODS

Retrospective, observational case series. Patients with VMT who elected to proceed with CE, before any vitreoretinal intervention, were studied. Eyes with at least a 12-month follow-up period were included. The status of the vitreomacular adhesion at different time points was assessed using spectral-domain optical coherence tomography. The best-corrected visual acuity was recorded at different time points. Other macular and systemic comorbidities were documented.

RESULTS

Fifteen eyes from 15 phakic patients with symptomatic VMT were included. Six of them were male subjects. Seven patients had diabetes mellitus and two of them also had nonproliferative diabetic retinopathy. The preoperative macular comorbidities included macular hole in six eyes (Stage 1 in 3 eyes and Stage 2 or 3 in another 3 eyes), epiretinal membrane in five eyes, and cystoid macular edema in four eyes. After uncomplicated CE, the VMT was released in 5 eyes, whereas in 10 eyes, CE did not significantly change the status of the vitreomacular adhesion. Three of 3 eyes with preexisting full-thickness macular hole (Stage 2 or 3 macular hole) were found to have Stage 4 macular hole shortly after CE. In seven of seven patients with diabetes mellitus, the status of the vitreomacular interface did not change after CE. Eventually, 7 of 15 patients underwent additional pars plana vitrectomy. Compared with the baseline vision, and vision before other interventions, the visual acuity after CE improved in 5 patients, remained unchanged in 7 patients, and decreased in the 3 patients with Stage 2 or 3 macular hole. The mean preoperative and early postoperative visual acuity was 20/59 and 20/68, respectively (P > 0.05).

CONCLUSION

The effect of CE in phakic eyes with known VMT varies significantly. In the current case series, every eye with VMT and Stage 2 or 3 macular hole ended up with Stage 4 macular hole, although the VMT did not change significantly in the eyes of diabetic patients. Studies with larger sample size are needed to further elucidate the impact of elective CE on VMT.

Pneumatic Vitreolysis With Intravitreal Air for Focal Vitreomacular Traction

Purpose:

To determine whether pneumatic vitreolysis with intravitreal air is effective for focal vitreomacular traction (VMT).

Methods:

We conducted a retrospective consecutive case series of 20 eyes from 19 individuals with focal VMT who underwent pneumatic vitreolysis with intravitreal air (January 2017 to November 2018). We analyzed patients via spectral-domain optical coherence tomography before intravitreal air injection and at 1 month. The primary outcome measure was release of VMT.

Results:

We observed release of VMT in 55% of individuals. An analysis limited to phakic eyes demonstrated release of VMT in 69%, and 65% developed improved best-corrected visual acuity. Individuals with persistent VMT and visual improvement had a significant reduction in angle of vitreoretinal insertion ( P < .01), area under VMT ( P < .05), and subfoveal cyst area ( P < .05).

Conclusions:

Intravitreal air is an effective treatment for focal VMT. In individuals with persistent VMT, visual-acuity improvement was associated with a reduction in overall VMT.

Recurrent Vitreomacular Traction in a Patient Treated with Ocriplasmin: A Case Report

INTRODUCTION

To describe a case of recurrent vitreomacular traction and macular edema that appeared both before and after the intravitreal injection of ocriplasmin.

CASE REPORT

An 82-year-old monocular man presented with metamorphopsia and reduced vision of 1-week duration. The patient's general medical history was unremarkable. His ophthalmic history was significant for severe ocular trauma in the right eye in childhood that caused phthisis. The left eye had undergone uncomplicated phacoemulsification 3 months earlier and the 1-month postoperative best corrected visual acuity (BCVA) was logarithmic mean angle of resolution (logMAR) 0.0. There was no history of other ocular conditions. At presentation, BCVA was logMAR 0.2 and optical coherence tomography (OCT) revealed the presence of cystoid macular edema caused by vitreomacular traction (VMT). The patient was scheduled for intravitreal ocriplasmin injection. Prior to treatment, the vision improved spontaneously to logMAR 0.1, and no VMT could be detected with spectral domain (SD)-OCT. The ocriplasmin injection was deferred but 3 weeks later the patient presented again with metamorphopsia, while VMT was again evident on SD-OCT. Ocriplasmin was injected and 1 month later the BCVA reached logMAR 0.1 without VMT. However, at 2 months post injection the VMT reappeared and a conservative approach with observation and topical nepafenac administration was decided. At the 3-month post-injection visit there was no VMT. More than 3 years after the ocriplasmin injection there is still no evidence of VMT, the patient is free of metamorphopsia, and his BCVA is logMAR 0.0.

CONCLUSION

Separation of consecutive layers of the vitreous cortex (vitreoschisis) may account for recurrent VMT.

Vitreomacular traction quantitative cutoffs for the assessment of resolution after ocriplasmin intravitreal treatment

This study aimed to assess optical coherence tomography (OCT) parameters associated with vitreomacular traction (VMT) resolution after ocriplasmin intravitreal injection and also associated with the development of vitreomacular complications. Study designed was a retrospective case series. Structural OCT images were acquired at baseline and over the follow-up after treatment. We developed a mathematical model to provide quantitative parameters associated with VMT resolution. Moreover, we adopted the same model to assess the quantitative parameters associated with development of further vitreomacular complications or with the worsening of the coexisting condition. Main outcome measures were BCVA, central macular thickness (CMT), VMT reflectivity, VMT size, VMT resolution, epiretinal membrane (ERM), macular holes. 73 eyes of 73 VMT patients (mean age 73 ± 9 years) were recruited. The mean follow-up duration was 2.6 ± 1.1 years. Mean baseline BCVA was 0.38 ± 0.18 LogMAR, improving to 0.26 ± 0.20 at the end of the follow-up (p < 0.01). Baseline CMT was 431 ± 118 µm, improving to 393 ± 122 µm at the end of the follow-up (p < 0.01). 38/73 eyes (52%) showed only VMT, whereas 35/73 eyes (48%) also showed coexisting alterations at baseline. VMT resolved in 40/73 eyes (55% of cases). Our model disclosed VMT reflectivity as the most involved parameter in VMT resolution. VMT size showed less influence on the success of ocriplasmin treatment. ERM was negatively associated with VMT resolution. Moreover, VMT reflectivity values and ERM represented the most important parameters for the onset of vitreomacular complications.

ASSESSMENT OF ANATOMICAL AND FUNCTIONAL OUTCOMES WITH OCRIPLASMIN TREATMENT IN PATIENTS WITH VITREOMACULAR TRACTION WITH OR WITHOUT MACULAR HOLES: Results of OVIID-1 Trial

Enzymatic vitreolysis with ocriplasmin is more effective in patients with focal vitreomacular adhesion without epiretinal membrane and macular hole ≤400 µm (if present) at baseline. This study shows that the treatment outcomes are related to patient selection.

Purpose:

To evaluate the anatomical and functional outcomes with ocriplasmin in patients with vitreomacular traction (VMT) with or without macular hole (MH).

Methods:

In a Phase 4, multicenter, single-arm, open-label study, eligible patients (VMT with focal adhesion, without epiretinal membrane, and with MH ≤400 µm [if present]) received a single intravitreal injection of ocriplasmin. Nonsurgical resolution of VMT (Day 28 [primary endpoint]), best-corrected visual acuity, MH closure, vitrectomy rate, and safety were assessed through Day 180.

Results:

Overall, 466 patients were included in the full analysis set, of whom 47.4% had VMT resolution by Day 28; resolution rates in patients with VMT without MH, VMT with MH ≤250 µm, and VMT with MH >250 to ≤400 µm were 43.4%, 68.6%, and 62.7%, respectively. Macular hole closure was higher in eyes with VMT and MH ≤250 µm (57.1%) than in eyes with VMT and MH >250 to ≤400 µm (27.5%) at Day 28. Overall, 30.8% of patients with VMT resolution gained ≥10 letters in best-corrected visual acuity at Day 180. Adverse events were consistent with the known safety profile of ocriplasmin.

Conclusion:

Ocriplasmin is effective for resolution of VMT without or with MH (≤400 μm); treatment outcomes can be optimized with patient selection.

The effectiveness of ocriplasmin versus surgery for the treatment of macular holes: A systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review looking at the effects of ocriplasmin compared to pars plana vitrectomy on macular holes to assess the effectiveness of the treatment options.

METHODS

Literature was searched through MEDLINE, EMBASE, CINAHL, Clinical Trials.gov, and ProQuest Dissertations and Theses until June 12, 2018. Conferences held through Association for Research in Vision and Ophthalmology, Canadian Society of Ophthalmology, and American Academy of Ophthalmology were searched until June 18, 2018. A total of 208 records were screened leaving 26. One author independently reviewed them for quality and extracted data. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines were followed. The adverse events, MH closure rate, change in MH size, and the extent to which the patients' visual acuity is restored by each treatment option; ocriplasmin and vitrectomy.

RESULTS

Twenty-six articles were included for qualitative and quantitative analysis. Meta-analysis results showed a 34% closure of macular holes after ocriplasmin treatment compared to 92% after vitrectomy. A significant improvement in visual acuity was seen after vitrectomy (SMD = -1.42; CI: [-1.98, -0.86]) as well as the ocriplasmin treatment (SMD = -0.73; CI: [-0.98, -0.48]).

CONCLUSIONS

Results suggested 92% macular hole closure after vitrectomy compared to 34% after ocriplasmin. A significant improvement in visual acuity of patients was seen after both treatments. More good quality randomized controlled trials are required to make strong conclusions.

THE OASIS MP-1 SUBSTUDY: Characterization of the Effect of Ocriplasmin on Microperimetry Parameters

The MP-1 substudy of the OASIS trial evaluated the effects of ocriplasmin and symptomatic VMA resolution on visual fixation and macular sensitivity using microperimetry, identifying parameters that were distinct between patients with and without VMA resolution.

Purpose:

To evaluate the effects of ocriplasmin and symptomatic vitreomacular adhesion resolution on visual fixation and macular sensitivity using microperimetry.

Methods:

MP-1 parameters were analyzed from 3 OASIS sites after the use of standardized instruments and testing procedures over 24 months.

Results:

A total of 27 patients (19 ocriplasmin, 8 sham) were evaluated. Mean distance of the preferred fixation locus to the anatomical center was farther in the sham group at baseline and farther in the sham versus ocriplasmin group throughout the study. Retinal sensitivity values were consistently higher in the ocriplasmin versus sham group after Month 3. Fewer patients in the ocriplasmin group had predominantly eccentric fixation at study end compared with the sham group, which also had an increased number of patients with unstable fixation. Patients with vitreomacular adhesion resolution had lower bivariate contour area, fewer relative scotomas, and higher retinal sensitivity parameters at baseline than those with unresolved vitreomacular adhesion.

Conclusion:

Substudy results suggest that fixation and sensitivity parameters tended to be better in the ocriplasmin group than in the sham group over time. The substudy identified parameters that were distinct between patients with and without vitreomacular adhesion resolution, suggesting that microperimetry warrants further study as a relevant biomarker for visual function.

Cost-effectiveness analysis of ocriplasmin versus watchful waiting for treatment of symptomatic vitreomacular adhesion in the US

Aim: Evaluate the cost-effectiveness of ocriplasmin in symptomatic vitreomacular adhesion (VMA) with or without full-thickness macular hole ≤400 μm versus standard of care. Methods: A state-transition model simulated a cohort through disease health states; assignment of utilities to health states reflected the distribution of visual acuity. Efficacy of ocriplasmin was derived from logistic regression models using Ocriplasmin for Treatment for Symptomatic Vitreomacular Adhesion Including Macular Hole trial data. Model inputs were extracted from Phase III trials and published literature. The analysis was conducted from a US Medicare perspective. Results: Lifetime incremental cost-effectiveness ratio was US$4887 per quality-adjusted life year gained in the total population, US$4255 and US$10,167 in VMA subgroups without and with full-thickness macular hole, respectively. Conclusion: Ocriplasmin was cost effective compared with standard of care in symptomatic VMA.

Morphological Reconstitution and Persistent Changes After Intravitreal Ocriplasmin for Vitreomacular Traction and Macular Hole

Purpose: To assess the long-term anatomical and functional findings in patients with symptomatic vitreomacular traction (VMT), with or without full thickness macular hole (FTMH), after eye treatment with intravitreal ocriplasmin injection (IOI). Methods: This longitudinal case series includes 51 eyes from 51 symptomatic patients with VMT (<800 μm) who received a single IOI (Jetrea^® 0.125 mg); 21 cases with an FTMH (<400 μm) were included. Best-corrected visual acuity (BCVA) and optical coherence tomography findings were recorded before IOI, and 1 day to 24 months thereafter. Data are presented as mean ± standard deviation. Results: Mean adhesion size before injection was 345 ± 146 μm. In 34 eyes (67%), complete release of VMT was observed; whereas VMT persisted in 17 eyes (33%). The latter included 15 of the 21 eyes (71%) with FTMH, 15 of which underwent pars plana vitrectomy and inner limiting membrane peeling. BCVA improved from (logarithm of the minimal angle of resolution [logMAR]) 0.41 ± 0.03 before injection to 0.32 ± 0.03 after 1 month and 0.23 ± 0.05 after 6 months and remained stable thereafter (0.24 ± 0.06 after 24 months of follow-up). Forty-five percent of the eyes presented submacular deposits soon after IOI that were not functionally relevant; 61% completely resolved by 12 months. Except floaters that disappeared within 48 h, no other adverse events were reported during follow-up. Conclusions: Treatment with ocriplasmin in a real-life setting showed an overall efficacy of 67% in patients with symptomatic VMT, with better results evident in the absence of an FTMH (70% vs. 62% VMT release) and a visual gain for over 2 years.

COMPARING INTRAVITREAL AIR AND GAS FOR THE TREATMENT OF VITREOMACULAR TRACTION

PURPOSE

To compare the effect of intravitreal injections of air with gas on vitreomacular traction (VMT) release and attempt to analyze predictive factors for success.

METHODS

The medical records of patients with symptomatic VMT undergoing intravitreal injections (0.3 mL) of either octafluoropropane (C3F8) or air were retrospectively reviewed. The VMT release (primary end point) and the best-corrected visual acuity (secondary end point) were noted 1 month after injection. At baseline and 1 month after the injection, a macular optical coherence tomography was performed.

RESULTS

Twenty-four eyes of 22 patients were included. Vitreomacular traction was released in 10 cases, 7 among 11 C3F8-injected eyes (63%) and 3 among 13 air-injected eyes (23%) (P = 0.045). In eyes with released VMT, ETDRS improved from 61 ± 35 (0-100) to 65 ± 37 (0-100) 1 month after the injection (P = 0.03). All patients with VMT release had a horizontal vitreomacular adhesion of less than 600 µm. Five eyes (23%) underwent vitrectomy after the injection of gas or air.

CONCLUSION

Posterior vitreous detachment in VMT can be observed with both air and gas injection with a low complication rate. The occurrence of VMT release observed with air seemed to be less frequent than that observed with gas.

Short-term changes in posterior vitreous cortex following intravitreal ocriplasmin for symptomatic vitreomacular traction syndrome: a prospective study

PURPOSE

To describe and analyze short-term posterior vitreous abnormalities following intravitreal ocriplasmin in eyes with symptomatic vitreomacular traction syndrome (VMT).

METHODS

In this institutional, prospective and interventional study enrolled patients with symptomatic focal VMT syndrome treated with intravitreal ocriplasmin. In all cases, spectral-domain optical coherence tomography scans were quantitatively and qualitatively analyzed preoperatively and at 1 and 4 weeks postoperatively.

RESULTS

Twenty-three patients, of which 5 were males and 18 females, with a mean age of 69.5 ± 8.2 years were included in this study. Postoperatively, VMT resolved in 11 of 23 eyes (47.8%). In 9 out of 11 cases (81.8%), VMT resolved by postoperative week 1, whether in the remaining 2 (18.2%) anatomical restoration, was diagnosed at postoperative week 4. At postoperative week 1, a foveolar detachment was detected in 9 out of 23 eyes (39.1%). The foveolar detachment resolved all but one eye by the end of postoperative week 4. At the end of the follow-up period, the presence of subretinal fluid was detected in 7 out of 9 eyes (77.8%), and it was significantly associated with a shrinkage of the posterior vitreous cortex (p < 0.006). At the end of the follow-up period, visual acuity was significantly higher in those eyes with VMT resolution (p < 0.001).

CONCLUSION

Intravitreal ocriplasmin is effective for the treatment of patients with VMT. The postoperative presence of posterior hyaloid shrinkage may be associated with higher traction over the foveal area and the appearance of foveolar detachment.

Vitreomacular interface alterations following peripheral laser retinopexy: Interface changes after laser

AIM

To demonstrate the morphological outcomes of macular hole following prophylactic peripheral laser retinopexy (PPLR).

METHODS

Our retrospective case-control analysis included 92 eyes, 55 in the laser group and 37 in the non-laser group. Fifty-five patients were subjected to prophylactic peripheral laser retinopexy in preparation for pars plana vitrectomy for macular hole, with and without vitreomacular adhesion (laser group). Before and after prophylactic peripheral laser retinopexy, we evaluated any changes in vitreomacular anatomy by optical coherence tomography. Optical coherence tomography changes were also analyzed in the visits preceding pars plana vitrectomy in 37 macular hole eyes not subjected to prophylactic peripheral laser retinopexy (non-laser group).

RESULTS

In the laser group, 7 out of 55 eyes (12.7%) showed macular hole closure (6 out of 18 macular hole eyes with vitreomacular adhesion (33.3%) and 1 out of 37 eyes without vitreomacular adhesion (2.7%)), while no patients showed macular hole closure in the non-laser group (p < 0.05). The mean width of the seven closed macular hole was 191.4 µm (range: 59-282 µm). In all except one of the six macular hole eyes with vitreomacular adhesion, the macular hole closed without vitreomacular adhesion release. In our analysis of the patient subgroup with vitreomacular adhesion, we observed a release of vitreomacular adhesion in 3 out of 18 eyes (16.6%) in the laser group and in 1 out of 13 eyes (7.6%) in the non-laser group (p > 0.05).

CONCLUSION

These findings support a possible beneficial role for prophylactic peripheral laser retinopexy in selected individuals with macular hole.

Enzymatic vitreolysis for the treatment of tractional diabetic macular edema

Background:

A new approach to address focal vitreomacular adhesion in patients with diabetic macular edema may control and stabilize diabetic macular edema with fewer anti-vascular endothelial growth factor injections.

Objectives:

The aim of this study was to demonstrate that diabetic macular edema can be improved by inducing the release of a vitreomacular adhesion, with less than 2500 μm, with enzymatic vitreolysis.

Methods:

From a retrospective analysis of clinical records from patients with diabetic retinopathy, patients with diabetic macular edema and vitreomacular adhesion <2500 μm were selected for a single-arm prospective study. The primary endpoint was to control diabetic macular edema with fewer anti-vascular endothelial growth factor injections after an observed vitreomacular adhesion release. A statistical subanalysis was performed for the following two groups: the group with vitreomacular adhesion release (group 1) and the group without vitreomacular adhesion release (group 2).

Results:

A total of 23 eyes from 19 patients were included. A reduction of the median number of injections was achieved in group 1 (p = 0.006). Adverse events were mild and transitory.

Conclusion:

Release of vitreomacular adhesion <2500 μm through enzymatic vitreolysis contributed to the control and stabilization of diabetic macular edema with fewer anti-vascular endothelial growth factor injections, reducing the burden and the risks related to these invasive and frequently chronic treatments.

Pneumatic Vitreolysis for the Treatment of Vitreomacular Traction Syndrome

Objectives:

To evaluate the posterior vitreous release rates after a single injection of expansile gas in patients with vitreomacular traction (VMT) syndrome with or without associated full-thickness macular hole (FTMH).

Materials and Methods:

Thirteen eyes of 12 consecutive patients with VMT (11 eyes) or VMT+FTMH (2 eyes) were reviewed retrospectively. Intravitreal injection of 0.3 mL of pure sulfur hexafluoride (SF6) (9 eyes) or perfluoropropane (C3F8) (4 eyes) was performed. Bobbing the head forward and backward similar to ‘drinking bird’ head movements was instructed until VMT release. Full ophthalmic examination and optical coherence tomography was performed at each visit.

Results:

VMT was released in all patients (100%) and mean release time was 5.2 days (1-19 days). Macular hole closure was not achieved in either of the two eyes with FTMH. Mean central subfield thickness decreased significantly from 361 μm to 263 μm (p=0.007). The mean pretreatment visual acuity was 0.44 LogMAR, which significantly improved to 0.25 LogMAR at the last visit (p=0.003). One of 13 eyes had retinal tear after the procedure which was successfully treated with laser retinopexy. Gas migration to the anterior chamber occurred in one patient. No other complications were observed.

Conclusion:

Pneumatic vitreolysis with C3F8 and SF6 gases is a relatively safe, low-cost, and minimally invasive treatment modality for VMT. However, FTMH closure could not be achieved with pneumatic vitreolysis.

BASELINE CHARACTERISTICS OF VITREOMACULAR TRACTION PROGRESSING TO FULL-THICKNESS MACULAR OR LAMELLAR HOLES IN THE PHASE III TRIALS OF ENZYMATIC VITREOLYSIS

PURPOSE

To identify characteristics associated with progression from vitreomacular traction (VMT) to a full-thickness macular hole (FTMH) or lamellar hole (LH).

METHODS

Post-hoc analysis of the Phase III clinical trial comparing ocriplasmin with placebo for treatment of vitreomacular adhesion (MIVI-TRUST). Exact logistic regression analyses were used to identify baseline characteristics significantly associated with progression from vitreomacular traction to FTMH or LH over the 6-month study period.

RESULTS

Twenty eyes (4.5%) developed an FTMH and 38 (9.7%) developed an LH during the study period. The rate of progression to FTMH or LH did not differ significantly between ocriplasmin- and saline-treated eyes (P = 0.090 for FTMH, P = 0.369 for LH). On univariate analysis, the presence of subretinal fluid (adjusted odds ratio 5.64, 95% confidence interval 2.02-17.17, P < 0.001) and mean subretinal fluid thickness (adjusted odds ratio 1.10, 95% confidence interval 1.04-1.16, P = 0.003) were associated with FTMH development. Both remained significantly associated with FTMH development on multivariate testing. On univariate analysis, the presence of macular schisis (adjusted odds ratio 2.26, 95% confidence interval 1.30-3.82, P = 0.004) and mean retinal thickness (adjusted odds ratio 1.06, 95% confidence interval 1.01-1.10, P = 0.010) were associated with LH development. Schisis remained a significant predictor of LH formation on multivariate testing.

CONCLUSION

Vitreomacular traction is more likely to progress to FTMH when associated with subretinal fluid, but when associated with intraretinal changes (such as schisis), vitreomacular traction appears more likely to progress to a LH after a single intravitreal injection of ocriplasmin or saline.

Absence of Posterior Vitreous Detachment Is a Risk Factor of Severe Bleb-Related Endophthalmitis

Purpose

Bleb-related endophthalmitis (BRE) after glaucoma surgery is an infection caused by bacteria in the avascular bleb gaining access into the eye. We report the clinical features and outcome of 10 consecutive eyes with severe BRE treated at our hospital.

Methods

Ten patients (10 eyes) with stage IIIb BRE after trabeculectomy diagnosed and treated at the Department of Ophthalmology, Tokyo Medical University, between April 2013 and May 2015, were studied. Patient background, type of glaucoma, interval from the first trabeculectomy, pretreatment bleb findings, causative microorganisms, surgical methods, status of posterior vitreous detachment (PVD), and postoperative visual acuity were examined.

Results

The 10 patients comprised 8 males and 2 females, with mean age of 70.6 years at BRE onset. The types of glaucoma were open-angle glaucoma in 7 patients, neovascular glaucoma in 2, and secondary glaucoma in 1. All eyes underwent trabeculectomy combined with mitomycin C prior to the development of BRE. The interval from the first glaucoma surgery to onset of endophthalmitis was 8.5 ± 4.1 years. Examination of the bleb revealed leakage of aqueous humor from the avascular bleb in all eyes. Bacteria were isolated from intraocular samples of 8 eyes; namely, Viridans streptococci in 5 eyes, Staphylococcus epidermidis in 1, Branhamella catarrhalis in 1, and coagulase-negative Staphylococci in 1. BRE was treated by vitrectomy in 9 eyes and enucleation in 1 eye. PVD was produced intentionally during vitrectomy in 6 eyes. Histopathological examination of the enucleated eye showed no PVD. Visual acuity improved by 3 lines or more in 6 patients, while decimal visual acuity remained lower than 0.1 in 4 patients.

Conclusion

BRE developed frequently in eyes with no PVD. The absence of PVD may be a risk factor of severe BRE.

Pharmacotherapy for Choroidal Neovascularization Due to Uncommon Causes

BACKGROUND

Choroidal neovascularization (CNV) in adults is most commonly associated with neovascular age-related macular degeneration (AMD) and pathologic myopia. Though less common, CNV can also develop from other conditions such as uveitis, central serous chorioretinopathy, angioid streaks, intraocular tumors, hereditary chorioretinal dystrophies, or can be idiopathic in origin. If left untreated, CNV may cause visual loss because of exudation of intraretinal or subretinal fluid, retinal or subretinal hemorrhage, or fibrosis involving the macula. It is well known that one of the main drivers of angiogenesis in CNV development is vascular endothelial growth factor (VEGF) and therefore inhibitors of VEGF might be an effective treatment for CNV.

METHODS

The goal of this review is to provide an overview and summary in the use of pharmacotherapy especially anti-VEGF therapy, in the treatment of CNV due to uncommon causes.

RESULTS

Results from uncontrolled case series and controlled clinical trials have reported good efficacy and safety in using anti-VEGF agents including bevacizumab, ranibizumab, aflibercept and ziv-aflibercept in the treatment of CNV due to uncommon causes. Anti-VEGF has also been used in combination with verteporfin PDT and anti-inflammatory agents for treating CNV of various causes.

CONCLUSION

Pharmacotherapy with anti-VEGF agents is an effective treatment option for CNV due to uncommon etiologies.

Pharmacological Adjuncts to Vitrectomy Surgery

Pharmacological adjuncts to vitrectomy surgery are useful tools to better deal with surgery. Their introduction has enriched the therapeutic choice before, during and after operations. Although several classifications could be made to frame adjuncts to vitrectomy, we preferred to divide the pharmacological adjuncts to vitrectomy surgery for therapeutic use in the pre-operatory procedure (neo-adjuvant), for intraoperative use and for post-operatory practice (adjuvant). This type of classification allowed us to explore all the adjuncts based on the timing of their use. The actual interest in vitrectomy surgery is giving rise to considerable interest in new molecules with and without the pharmacological effect that will soon be available for the aid of vitreoretinal surgery.

Diabetic retinopathy: a complex pathophysiology requiring novel therapeutic strategies

INTRODUCTION

Diabetic retinopathy (DR) is the leading cause of vision loss in the working age population of the developed world. DR encompasses a complex pathology, and one that is reflected in the variety of currently available treatments, which include laser photocoagulation, glucocorticoids, vitrectomy and agents which neutralize vascular endothelial growth factor (VEGF). Whilst these options demonstrate modest clinical benefits, none is yet to fully attenuate clinical progression or reverse damage to the retina. This has led to an interest in developing novel therapies for the condition, such as mediators of angiopoietin signaling axes, immunosuppressants, nonsteroidal anti-inflammatory drugs (NSAIDs), oxidative stress inhibitors and vitriol viscosity inhibitors. Further, preclinical research suggests that gene therapy treatment for DR could provide significant benefits over existing treatments options.

AREAS COVERED

Here we review the pathophysiology of DR and provide an overview of currently available treatments. We then outline recent advances made towards improved patient outcomes and highlight the potential of the gene therapy paradigm to revolutionize DR management.

EXPERT OPINION

Whilst significant progress has been made towards our understanding of DR, further research is required to enable the development of a detailed spatiotemporal model of the disease. In addition, we hope that improvements in our knowledge of the condition facilitate therapeutic innovations that continue to address unmet medical need and improve patient outcomes, with a focus on the development of targeted medicines.

The Manchester Large Macular Hole Study: Is it Time to Reclassify Large Macular Holes?

PURPOSE

To evaluate anatomic and functional outcomes of full-thickness macular holes (FTMH) larger than 400 μm following vitrectomy, internal limiting membrane peel, gas tamponade, and face-down posturing.

DESIGN

A retrospective interventional case series.

METHODS

A total of 258 consecutive eyes with FTMH larger than 400 μm were enrolled at the Manchester Royal Eye Hospital study over a 5-year period from 2012 to 2017. All eyes underwent pars plana vitrectomy, ILM peel, and gas tamponade. Anatomic success rates were measured. A correlation between macular hole size and closure was evaluated.

RESULTS

A total of 258 eyes were analyzed. The anatomic closure rate was 89.92%. When divided into quartiles, the closure rate of FTMH was 98% (64/65) in the 400-477 μm quartile, 91% (59/65) in the 478-558 μm quartile, 94% (60/64) in the 559-649 μm quartile, and 76% (49/64) in the 650-1416 μm quartile. Using receiver operating characteristic and area under the curve analysis, the maximum sensitivity and specificity was obtained with a cutoff ≤ 630 μm (sensitivity 76.7%, specificity 69.2%) giving a Youden index (J) of 0.46. One hundred and forty-six eyes (56.6%) improved by 0.3 logMAR units from their preoperative best-corrected visual acuity at 3 months following surgery.

CONCLUSION

This study shows that standard FTMH surgical repair has very high success rate up to 650 μm. It may suggest that there is a need for a reclassification of large FTMH, and new surgical techniques such as internal limiting membrane flaps should be reserved for macular holes larger than 650 μm.

Intravitreal gas for symptomatic vitreomacular adhesion: a synthesis of the literature

Symptomatic vitreomacular adhesion (sVMA) is defined as visual loss secondary to foveal damage from vitreomacular traction (VMT) and includes isolated VMT, impending macular hole (MH), and full-thickness MH with persisting vitreous attachment. Management options include pars plana vitrectomy (PPV), intravitreal ocriplasmin, intravitreal gas injection or observation. This synthesis of the literature aimed to assess the safety and efficacy of intravitreal gas for sVMA. Articles describing patients with VMT or MH treated with intravitreal expansile gas were selected by systematic literature review using MEDLINE, EMBASE, and the Cochrane Database of Controlled Trials (CENTRAL) up to September 2016. The main outcomes at 1 month and final review were logarithm of the minimum angle of resolution (logMAR) visual acuity (VA), anatomical success (absence of both VMT and MH, without PPV) and adverse events (AEs). The intended comparator was observation. Nine of 106 identified articles were eligible, and none were randomized controlled trials. The mean VA of 91 eyes improved from 0.55 (Snellen equivalent 6/21) to 0.48 (6/18) logMAR at 1 month and to 0.35 (6/13) logMAR at final review. The mean VA at final review, prior to a vitrectomy, was 0.42 (6/16). Anatomic success was 48% at 1 month and 57% at final review. The reported AEs comprised retinal detachment in two highly myopic eyes. Intravitreal gas injection can relieve sVMA. Larger controlled studies are needed to determine safety and efficacy relative to observation, ocriplasmin, or vitrectomy.

Italian real-life experience on the use of ocriplasmin

Objective

To evaluate the success of an intravitreal injection of ocriplasmin to release symptomatic vitreomacular traction (VMT) and close a full-thickness macular hole.

Methods and analysis

An observational retrospective multicentre study conducted in Italy. Patients with symptomatic distortion and loss of vision secondary to VMT were included in the study. The patients received a single injection of ocriplasmin and were followed up for 1, 3 and 6 months. Best-corrected visual acuity (BCVA) and spectral domani OCT (SD-OCT) were performed for patient assessment, and adverse events were recorded and analysed.

Results

74 patients (74 eyes) were included in the study. 44 of 74 eyes (59.5%) experienced complete release of the VMT. Macular hole closure was obtained in eight eyes (40%). BCVA improved about three lines after 3 months of follow-up in the patients with VMT resolution in comparison with the patients who did not have VMT resolution (p<0.0001). In 55/74 eyes of 55 patients (74.3%), no adverse events were reported, and most of them were transitory (17/19; 89.5%). The mean time to resolve VMT was 27.4±21.9 days. No cases of retinal tear, retinal detachment or lens destabilisation were observed.

Conclusion

Ocriplasmin is a potential alternative treatment for patients with symptomatic VMT and has a good safety profile. A more careful selection of patients, in clinical practice, may increase the success rate.

Ocriplasmin Treatment Leads to Symptomatic Vitreomacular Adhesion/Vitreomacular Traction Resolution in the Real-World Setting: The Phase IV ORBIT Study

PURPOSE

To evaluate clinical outcomes and safety up to 12 months after ocriplasmin injection for the treatment of patients with symptomatic vitreomacular adhesion (VMA)/vitreomacular traction (VMT) in a real-world setting.

DESIGN

The Phase IV Ocriplasmin Research to Better Inform Treatment (ORBIT) trial (NCT02079883) was a Phase IV multicenter, prospective, observational study.

PARTICIPANTS

Patients aged ≥18 years with symptomatic VMA/VMT treated with ocriplasmin.

METHODS

Patients received a single 0.125 mg intravitreal injection of ocriplasmin. All assessments and treatment decisions were at the discretion of the treating physician. Spectral-domain OCT (SD-OCT) images were analyzed by an independent central reading center (CRC). All enrolled patients were included in demographic, baseline characteristics, and safety analyses. Patients with symptomatic VMA/VMT at baseline determined by CRC were included in baseline ocular characteristics and efficacy analyses.

MAIN OUTCOME MEASURES

Clinical outcomes were measured up to 12 months and included resolution of symptomatic VMA, closure of full-thickness macular hole (FTMH), mean change from baseline in best-corrected visual acuity (BCVA), incidence of vitrectomy, and time to first vitrectomy. Safety outcomes included the incidence and timing of onset of adverse drug reactions (ADRs).

RESULTS

Of the 539 patients enrolled, 480 were determined to have symptomatic VMA/VMT at baseline post-CRC assessment. After treatment with ocriplasmin, the rate of VMA/VMT resolution was 45.8% (95% confidence interval [CI], 41.3-50.4) at month 1 and 59% (95% CI, 54.4-63.4) at months 10 to 12. The rate of FTMH closure was 30.5% (95% CI, 22.4-39.7) at month 1 and 32.2% (95% CI, 23.9-41.4) at months 10 to 12. Mean (standard deviation) change from baseline in BCVA was 1.5 (11.19) letters at month 1 and 5.2 (13.60) letters at months 10 to 12. Vitrectomy was performed in 28.5% of patients, with a median time to vitrectomy of 63 days. Adverse drug reactions were reported by 30.6% of patients; 5.2% experienced a serious ADR.

CONCLUSIONS

Results from the ORBIT study demonstrate that treatment with ocriplasmin is effective and well tolerated in patients with symptomatic VMA/VMT in a real-world setting. The percentage of patients with VMA/VMT resolution at month 1 was higher than previously reported in well-controlled clinical trials. No new safety signals were identified.