IMPROVED EFFICACY OF OCRIPLASMIN FOR VITREOMACULAR TRACTION RELEASE AND TRANSIENT CHANGES IN OPTIC DISK MORPHOLOGY

Scoping review of nonsurgical treatment options for macular holes

Macular holes (MH) are full-thickness retinal defects affecting central vision. While vitrectomy with inner limiting membrane (ILM) peel is the conventional MH treatment, non-surgical alternatives are gaining interest to mitigate surgical risks. This study conducted a comprehensive literature review and analysis of nonsurgical MH management. A systematic literature search was conducted on PubMed, Embase, Scopus, and the Cochrane Library from January 1, 1973, to September 13, 2023. Treatments included laser therapy, carbonic anhydrase inhibitors (CAIs), nonsteroidal antiinflammatory drugs (NSAIDs), steroids (topical, subtenons, peribulbar, intravitreal), intravitreal gas, anti-vascular endothelial growth factors and ocriplasmin injections. Data extraction covered study details, patient characteristics, MH features, treatment outcomes, and recurrence rates. The initial search yielded 3352 articles, refined to 83 articles that met inclusion criteria following screening. Overall reported anatomical closure rates were 36% with laser photocoagulation, 37% with intravitreal ocriplasmin, 55% with intravitreal gas. Closures were more frequently observed with topical NSAIDs (79%), steroids (84%) and CAIs (73%). Closures were more often observed in patients with smaller MH and in the presence of cystic macular oedema. Although non-surgical MH management approaches show potential for conservative therapy, evidence is limited to support routine use. Stage 1 and traumatic MH may benefit from a short period of observation, but the gold standard approach for full-thickness MH remains to be vitrectomy with ILM peel.

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.

EPIDEMIOLOGY OF VITREOMACULAR INTERFACE ABNORMALITIES USING MACULAR SPECTRAL-DOMAIN OPTICAL COHERENCE TOMOGRAPHY IN AN ELDERLY POPULATION (THE MONTRACHET STUDY)

PURPOSE

The aim of this study was to investigate the prevalence of vitreomacular interface abnormalities (VMIAs) and to identify associated factors in an elderly population in Europe.

METHODS

The MONTRACHET (Maculopathy Optic Nerve nuTRition neurovAsCular and HEarT diseases) Study is a population-based study, conducted in subjects older than 75 years. Vitreomacular adhesions, vitreomacular tractions, macular holes, epiretinal membranes, and macular cysts were assessed on spectral-domain optical coherence tomography examinations. The prevalence of VMIAs was estimated. We studied the association of demographic and clinical factors with VMIAs.

RESULTS

The mean age of the participants was 82.3 (SD, 3.8) years, and 37.3% were men. The prevalence rates of VMIAs were vitreomacular adhesions (17.7%), vitreomacular tractions (1.4%), lamellar macular holes (1.0%), full-thickness macular holes (0.2%), macular pseudoholes (0.4%), epiretinal membranes (38.9%), and macular cysts (5.8%). In multivariate analysis, vitreomacular adhesions were positively associated with male sex (P < 0.001) and negatively associated with older age (P < 0.001) and cataract extraction (P < 0.001). Epiretinal membranes were positively associated with older age (P < 0.001) and cataract extraction (P < 0.001).

CONCLUSION

The prevalence of VMIAs based on spectral-domain optical coherence tomography analysis was high in subjects older than 75 years.

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.

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.

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.

Intravitreal ocriplasmin for the treatment of vitreomacular traction and macular hole- A study of efficacy and safety based on NICE guidance

Purpose

To evaluate the real world clinical outcomes of intravitreal ocriplasmin in patients with vitreomacular traction (VMT) with and without full thickness macular holes (FTMH) treated according to NICE guidance.

Methods

Retrospective observational case series of 25 patients treated with a single intravitreal ocriplasmin injection between December 2013 and December 2015. Best corrected visual acuity and optical coherence tomography exams were performed to determine visual outcomes and anatomical VMT release and FTMH closure over time. Two patient groups were identified: ocular macular co-morbidity (OCM) and no OCM (nOCM), with follow-up at 4, 12, and 24 weeks.

Results

Twenty-five patients were identified that included 19 patients with VMT, and 6 patients with VMT plus FTMH. In the nOCM group of 22 patients, the release rate of VMT was 44%, 63%, and 69% at 4, 12 and 24 weeks respectively. In the “real-world” OCM group of 25 patients, the VMT release rate was 37%, 53%, and 58% at the same time-points. In both groups, the FTMH closure rate was 33%, 50%, and 67% at 4, 12, and 24 weeks. At mean follow-up of 30 weeks in the VMT group with nOCM, the mean LogMAR VA improved significantly from 0.44 to 0.28 (p = 0.0068, paired t-test). Three were no serious adverse events.

Conclusions

This study reports improved efficacy of intravitreal ocriplasmin for both VMT and FTMH, and is more favourable in patients with no ocular co-morbidity. We highlight the importance of careful patient selection and structured standard of care pathways to identify patients who will benefit from the positive visual and anatomical effects of intravitreal ocriplasmin.

Multimodal imaging of macular subretinal deposits following intravitreal ocriplasmin injection

Purpose

Ocriplasmin is effective in closing macular holes due to vitreomacular traction. We present a case of macular subretinal material deposition observed with spectral-domain optical coherence tomography (SD-OCT) and multimodal imaging, following successful closure of a macular hole following intravitreal ocriplasmin injection.

Observations

An 81-year-old male presented with decreased vision in the left eye due to a full-thickness macular hole secondary to vitreomacular traction. Ocriplasmin (Jetrea) was injected into the vitreous and hole closure was observed after one week. Macular subretinal material deposition developed along the outer surface of the resultant serous detachment on OCT one week post-injection. Fluorescein angiography demonstrated no expanding hyperfluorescence due to retinal or choroidal leak, or staining of the lesion. The material was mildly autofluorescent. The macular subretinal material complex spontaneously decreased with no significant effect on vision over 60 weeks.

Conclusions and importance

Macular subretinal material deposition has not previously been reported following intravitreal ocriplasmin injection. This material is likely composed of photoreceptor outer segments. It is important to recognize that macular subretinal deposits can occur following intravitreal ocriplasmin injection as it may cause diagnostic confusion and potentially influence the visual and anatomical outcomes following successful hole closure.

Assessment of Ocriplasmin Effects on the Vitreoretinal Compartment in Porcine and Human Model Systems

Ocriplasmin (Jetrea®) is a recombinant protease used to treat vitreomacular traction. To gain insight into vitreoretinal observations reported after ocriplasmin treatment, we have developed an in vivo porcine ocriplasmin-induced posterior vitreous detachment (PVD) model in which we investigated vitreoretinal tissues by optical coherence tomography, histology, and cytokine profiling. Eight weeks postinjection, ocriplasmin yielded PVD in 82% of eyes. Subretinal fluid (85%) and vitreous hyperreflective spots (45%) were resolved by week 3. Histological analysis of extracellular matrix (ECM) proteins such as laminin, fibronectin, and collagen IV indicated no retinal ocriplasmin-induced ECM distribution changes. Retinal morphology was unaffected in all eyes. Cytokine profiles of ocriplasmin-treated eyes were not different from vehicle. In cell-based electrical resistance assays, blood-retinal barrier permeability was altered by ocriplasmin concentrations of 6 μg/mL and higher, with all effects being nontoxic, cell-type specific, and reversible. Ocriplasmin was actively taken up by RPE and Müller cells, and our data suggest both lysosomal and transcellular clearance routes for ocriplasmin. In conclusion, transient hyperreflective spots and fluid in a porcine ocriplasmin-induced PVD model did not correlate with retinal ECM rearrangement nor inflammation. Reversible in vitro effects on blood-retinal barrier permeability provide grounds for a hypothesis on the mechanisms behind transient subretinal fluid observed in ocriplasmin-treated patients.

VITRECTOMY FOR PERSISTENT MACULAR HOLES FOLLOWING OCRIPLASMIN INJECTION: A Comparative Multicenter Study

PURPOSE

To determine functional and anatomical outcomes of pars plana vitrectomy for persistent full-thickness macular hole (MH) after intravitreal injection of ocriplasmin.

METHODS

This is a multicenter retrospective interventional study of 37 eyes of 37 patients who underwent pars plana vitrectomy with internal limiting membrane peeling for persistent MH after ocriplasmin treatment between December 2013 and December 2015 and comparison with 35 eyes of 35 patients who were offered ocriplasmin injection but underwent pars plana vitrectomy alone without pharmacologic vitreolysis before surgery. In addition, 24 matched pairs (MH diameter at baseline ±5 µm) were analyzed. Clinical data such as visual acuity, intraoperative characteristics, and spectral domain optical coherence tomography images were reviewed. Main outcome measures were visual acuity and MH closure rate.

RESULTS

After a mean follow-up period of 9 months, postoperative mean visual acuity showed no significant differences between ocriplasmin-treated eyes (logarithm of minimum angle of resolution 0.37 ± 0.26, Snellen 20/47) and eyes without ocriplasmin treatment (logarithm of minimum angle of resolution 0.39 ± 0.25; Snellen 20/49) (P > 0.9). After ocriplasmin injection, mean MH diameter enlarged from 217 ± 102 µm to 384 ± 239 µm (P < 0.001). Matched-pair analysis revealed no difference in gain of visual acuity between the first visit and the last follow-up (P = 0.29). Macular hole closure was observed in similar proportion in ocriplasmin-treated eyes (97%) and vitrectomy-only eyes (94%) (P > 0.5).

CONLCUSION

Eyes with persistent MH after ocriplasmin injection showed significant visual improvement after pars plana vitrectomy. Matched-pair analysis revealed no statistical differences in functional and anatomical postoperative results comparing with eyes of similar MH diameter that proceeded directly to surgery without ocriplasmin pretreatment.

Results of the 2-Year Ocriplasmin for Treatment for Symptomatic Vitreomacular Adhesion Including Macular Hole (OASIS) Randomized Trial

PURPOSE

The Ocriplasmin for Treatment for Symptomatic Vitreomacular Adhesion Including Macular Hole (OASIS) trial was designed to evaluate the long-term efficacy and safety profile of ocriplasmin for the treatment of symptomatic vitreomacular adhesion (VMA)/vitreomacular traction, including full-thickness macular hole (FTMH).

DESIGN

Phase 3b, randomized, sham-controlled, double-masked, multicenter clinical trial.

PARTICIPANTS

Sample size was 220 subjects (146 ocriplasmin, 74 sham) randomized in a 2:1 ratio to receive intravitreal ocriplasmin 0.125 mg or sham injection.

METHODS

The trial involved 12 visits over 24-months. Inclusion criteria included presence of VMA and best-corrected visual acuity (BCVA) of 20/32 or worse in the study eye. Exclusion criteria included FTMH >400 μm, presence of epiretinal membrane (ERM), and aphakia in the study eye.

MAIN OUTCOME MEASURES

The primary efficacy end point was the proportion of subjects with pharmacologic VMA resolution at day 28. Secondary efficacy end points were assessed at month 24 and included proportion of subjects with BCVA gain from baseline, nonsurgical FTMH closure, vitrectomy, and Visual Function Questionnaire 25 (VFQ-25) outcomes.

RESULTS

The OASIS trial met its primary end point with pharmacologic VMA resolution at day 28 being significantly higher in the ocriplasmin group (41.7%) compared with the sham group (6.2%). The treatment effect was maintained until study end. In the ocriplasmin group, pharmacologic VMA resolution at day 28 was higher in subgroups with the following baseline characteristics compared with the complementary subgroups without them: presence of focal VMA, presence of FTMH, absence of ERM, and phakic lens status. In the ocriplasmin group, 50.5% of subjects had a ≥2-line improvement in BCVA from baseline compared with 39.1% of subjects in the sham group. The nonsurgical FTMH closure rate was 30.0% for the ocriplasmin group compared with 15.4% for the sham group. All other secondary end points also favored ocriplasmin over sham. Regarding safety, most adverse events were mild to moderate, had a short onset time, and were transient, with no new safety signals identified.

CONCLUSIONS

The OASIS trial demonstrates the long-term efficacy and safety of ocriplasmin, providing improved resolution of symptomatic VMA compared with previous phase 3 trials with no additional safety signals identified.

Treatment of vitreomacular traction with intravitreal ocriplasmin preceded by anterior chamber paracentesis: case reports

PURPOSE

To evaluate the efficacy of an intravitreal ocriplasmin injection using anterior chamber paracentesis to release symptomatic vitreomacular traction (VMT).

METHODS

Five patients with symptomatic VMT were enrolled. All patients underwent a complete ophthalmologic examination including acquisition of spectral-domain optical coherence tomography. Before intravitreal injection of ocriplasmin, anterior chamber paracentesis was performed in the study eye to induce mild ocular hypotonia. Control visits were performed the day after the injection, at 1 week, and after 1, 2, and 3 months.

RESULTS

In 4 patients, we had complete release of VMT and visual improvement after the intravitreal ocriplasmin injection preceded by anterior chamber paracentesis. No adverse events were observed.

CONCLUSIONS

In our small case series, anterior chamber paracentesis performed before intravitreal ocriplasmin seemed to increase the efficacy of the drug in the resolution of symptomatic VMT. Our success estimate is imprecise due to small sample size (95% confidence interval 0.28 to 0.99) and no definitive conclusion can be reached. Further research is worth being conducted to assess the potential usefulness of paracentesis before ocriplasmin injection to increase vitreoretinal traction release rate.

The Portuguese Experience with Ocriplasmin in Clinical Practice

AIM

Evaluate the real-life experience with ocriplasmin on vitreomacular traction (VMT) release and full-thickness macular hole (FTMH) closure in Portugal.

METHODS

Multicentric, retrospective study of 83 eyes of 78 patients who were treated with intravitreal ocriplasmin for VMT with and without FTMH. Primary outcomes were VMT release and FTMH closure. Secondary outcomes included visual acuity changes and structural features on spectral-domain ocular coherence tomography.

RESULTS

VMT resolved in 47 of the 83 eyes (56.6%) and 6 of the 12 FTMH were closed (50.0%). Mean best-corrected visual acuity (BCVA) improved from 65.1 at baseline to 70.8 ETDRS letters at the end of follow-up (p < 0.0001) with a mean follow-up of 138.8 days. Improvement in BCVA was significantly better in eyes with VMT release (p = 0.021). Approximately 73% of patients had normal ellipsoid zone integrity at the end of follow-up, 87% had no neurosensorial detachment and 40% had no intra- or subretinal fluid.

CONCLUSION

VMT release and FTMH closure were achieved in more than half of the treated eyes and were correlated with significant BCVA improvements and favorable baseline characteristics. In fact, if a careful patient selection is carried out, VMT resolution with ocriplasmin can be optimized, tailoring the best approach to each patient.

From the analysis of pharmacologic vitreolysis to the comprehension of ocriplasmin safety

INTRODUCTION

Pharmacologic vitreolysis is a strategy used to treat anomalous posterior vitreous detachment, by weakening vitreoretinal adhesion with an intravitreal drug. Pharmacologic vitreolysis facilitates surgery, and abnormalities of the vitreoretinal interface including vitreomacular traction (VMT) and early stage macular hole (MH) could be resolved. Ocriplasmin is a recombinant protease, active against fibronectin and laminin, which are important components of the vitreoretinal interface. Ocriplasmin has been approved for symptomatic treatment of VMT and MH with visible traction, and it functions by dissolving the proteins that link the vitreous to the macula, thereby creating a complete posterior vitreous detachment (PVD).

AREAS COVERED

This paper reviews the current knowledge and status of investigations regarding the use of ocriplasmin for pharmacologic vitreolysis and its safety.

EXPERT OPINION

Ocriplasmin is a non-specific enzyme; therefore, it dissolves vitreal proteins as well as possibly proteins associated with visual function in the retina, choroid, and lens. Ocular adverse events (OAEs) of ocriplasmin include transient visual loss, intraocular inflammation, vitreous floaters, lens opacification, zonular instability of the lens, and intraocular hemorrhage. The prevalence of the OAEs is very low; however, on rare occasions, they can result in widespread retinal dysfunction. Research into the acute and long-term safety of ocriplasmin is required.

Prevalence of Vitreoretinal Interface Abnormalities as Detected by Spectral-Domain Optical Coherence Tomography

Purpose: The primary objective of this study was to determine the prevalence of vitreomacular interface (VMI) changes on optical coherence tomography (OCT) in the general population. Second, other OCT changes were described. Methods: Abnormalities in the VMI were diagnosed by OCT scan and graded according to the International Vitreomacular Traction Study (IVTS) Group classification and subdivided into 3 grades according to John et al. [Retina 2014;34:442-446]. Results: The estimated prevalence of vitreomacular abnormalities within a Belgian population aged ≥50 years was 1.17% [confidence interval (CI 0.38-3.62)] for focal vitreomacular traction (VMT) grade 1; 0.39% (CI 0.05-2.76) for focal VMT grade 2; 8.17% (CI 5.33-12.53) for focal vitreomacular adhesion, and 17.9% (CI 13.41-23.9) for broad vitreomacular adhesion. Conclusion: The prevalence of vitreomacular abnormalities within a Belgian study cohort was reported. These results closely match previously reported data on the prevalence of VMT. Correct knowledge of the epidemiology of VMI disorders and early diagnosis will enable adequate intervention.

Rhegmatogenous retinal detachment following intravitreal ocriplasmin

Purpose

To describe the characteristics and outcomes of patients presenting with rhegmatogenous retinal detachment (RRD) after ocriplasmin (OCP) injection.

Methods

Retrospective, multi-centre, observational case series with case note review.

Results

Eight patients with symptomatic vitreomacular traction (six with concomitant macular hole) were diagnosed with RRD after a median of 16 days (range 3–131 days) post-OCP injection. Presentation was within 3 weeks of the OCP injection in six of the cases. Five patients presented with symptoms post-OCP, and three were diagnosed asymptomatically on planned visits. Seven cases were phakic, one had high myopia (>8 dioptres), and two cases had lattice degeneration. Following RRD surgery, hole closure was achieved in 5/6 MH cases. The final median BCVA at 7 months was 20/80 (range 20/40–20/1200) similar to the baseline BCVA 20/80, with four patients gaining ≥1 line of vision compared to baseline but three losing ≥3 lines.

Conclusions

RRD is a non-negligible risk associated with intravitreal OCP, and it should be used with caution in eyes with high myopia and peripheral retinal pathology predisposing to RRD. Detailed peripheral retinal examination is recommended pre- and postoperatively at all visits. Patients should be advised to seek attention if symptoms recur after initial presentation.

Ocriplasmin: who is the best candidate?

Enzymatic vitreolysis is currently the focus of attention around the world for treating vitreomacular traction and full-thickness macular hole. Induction of posterior vitreous detachment is an active area of developmental clinical and basic research. Despite exerting an incompletely elucidated physiological effect, ocriplasmin (also known as microplasmin) has been recognized to serve as a well-tolerated intravitreal injection for the treatment of vitreomacular traction and full-thickness macular hole. There are several unexplored areas of intervention where enzymatic vitreolysis could potentially be used (ie, diabetic macular edema). Recent promising studies have included combinations of enzymatic approaches and new synthetic molecules that induce complete posterior vitreous detachment as well as antiangiogenesis. Although no guidelines have been proposed for the use of ocriplasmin, this review attempts to aid physicians in answering the most important question, "Who is the best candidate?"

Optimal management of idiopathic macular holes

This review evaluates the current surgical options for the management of idiopathic macular holes (IMHs), including vitrectomy, ocriplasmin (OCP), and expansile gas use, and discusses key background information to inform the choice of treatment. An evidence-based approach to selecting the best treatment option for the individual patient based on IMH characteristics and patient-specific factors is suggested. For holes without vitreomacular attachment (VMA), vitrectomy is the only option with three key surgical variables: whether to peel the inner limiting membrane (ILM), the type of tamponade agent to be used, and the requirement for postoperative face-down posturing. There is a general consensus that ILM peeling improves primary anatomical hole closure rate; however, in small holes (<250 µm), it is uncertain whether peeling is always required. It has been increasingly recognized that long-acting gas and face-down positioning are not always necessary in patients with small- and medium-sized holes, but large (>400 µm) and chronic holes (>1-year history) are usually treated with long-acting gas and posturing. Several studies on posturing and gas choice were carried out in combination with ILM peeling, which may also influence the gas and posturing requirement. Combined phacovitrectomy appears to offer more rapid visual recovery without affecting the long-term outcomes of vitrectomy for IMH. OCP is licensed for use in patients with small- or medium-sized holes and VMA. A greater success rate in using OCP has been reported in smaller holes, but further predictive factors for its success are needed to refine its use. It is important to counsel patients realistically regarding the rates of success with intravitreal OCP and its potential complications. Expansile gas can be considered as a further option in small holes with VMA; however, larger studies are required to provide guidance on its use.