Subfoveal Lucency after Treatment of Vitreomacular Traction without Macular Hole in the Phase 3 Trials of Ocriplasmin Vitreolysis

Resolution of outer retinal abnormalities in eyes with vitreomacular traction without macular hole in the OASIS trial

BACKGROUND/AIMS

To describe the clinical impact of external limiting membrane (ELM) disruption, ellipsoid zone (EZ) disruption and subretinal fluid (SRF) seen on optical coherence tomography (OCT) in eyes with vitreomacular traction (VMT) without macular hole (MH) in the Ocriplasmin for Treatment for Symptomatic Vitreomacular Adhesion Including Macular Hole study.

METHODS

Phase 3b randomised double-blind sham-controlled multicentre study including 144 eyes with VMT without MH. Eyes were randomised to receive a single intravitreal injection of ocriplasmin or sham injection and were followed for 24 months. Eyes were analysed for presence, course and clinical impact of ELM disruption, EZ disruption and SRF on OCT.

RESULTS

ELM disruption, EZ disruption and SRF were present in 32.6%, 52.2% and 45.8% of ocriplasmin-treated eyes and 39.6%, 42.6% and 37.5% of sham-treated eyes at baseline. VMT resolution was associated with resolution of ELM and EZ disruption and SRF. A small number of eyes had persistent ELM disruption, EZ disruption and/or SRF at the seventh visit or later (17 months or later) following medical or surgical VMT resolution. Resolution of ELM disruption, EZ disruption and/or SRF was associated with an improvement of visual acuity from baseline. Following VMT resolution, ELM recovery usually preceded EZ recovery and SRF resolution.

CONCLUSIONS

ELM disruption, EZ disruption and/or SRF are present in a significant percentage of eyes with VMT without MH. Release of VMT is usually associated with outer retinal recovery and an associated improvement in visual acuity. ELM recovery typically precedes EZ recovery and SRF resolution following VMT release.

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.

Myopic macular hole detachment associated with intravitreal ocriplasmin

Purpose

To describe a case of macular hole retinal detachment in a high myope following intravitreal ocriplasmin injection.

Observations

A 71-year-old highly myopic (−18.63 Dioptres) female received 125 μg of intravitreal ocriplasmin (Jetrea, Oxurion, Leuven, Belgium) to treat a right, full-thickness macular hole (FTMH) with vitreomacular adhesion. Presenting best-corrected visual acuity (BCVA) letter score was 45, using the Early Treatment Diabetic Retinopathy Study chart. Past ocular history in the affected, pseudophakic eye included anisometropic amblyopia, but with a documented pre-morbid BCVA of 75 letters. One week post-injection the vitreomacular adhesion persisted. One month post-injection, a large posterior macular hole retinal detachment developed with BCVA of 45 letters. Over the course of one year she underwent three pars plana vitrectomies aiming to treat the retinal detachment and close the FTMH. The detachment was treated successfully but the FTMH persisted, albeit with a reduced diameter. Final BCVA was 55 letters.

Conclusions

The pathogenesis of this macular hole detachment may be related to the combination of a FTMH and high myopia. Ocriplasmin functions in a twofold manner; inducing a posterior vitreous detachment and as a proteolytic enzyme digesting the fibronectin and laminin at the pathological vitreoretinal interface. With access through a FTMH, ocriplasmin may exert an enzymatic effect on the interphotoreceptor matrix and the photoreceptor-retinal pigment epithelium interface that normally helps maintain neuroretinal adhesion to the retinal pigment epithelium. The reported increase in basal diameter of FTMHs following ocriplasmin supports this hypothesis. High myopia was another likely contributing factor. Highly myopic patients were excluded from the initial ocriplasmin registration studies, mainly due to the risk of retinal detachment, but were eligible for subsequent large trials.

Importance

Clinicians should be aware of a potential association between ocriplasmin and macular hole detachments in eyes with high myopia.