RESOLUTION OF SUBRETINAL FLUID AND OUTER RETINAL CHANGES IN PATIENTS TREATED WITH OCRIPLASMIN

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.

COMBINED PNEUMATIC AND ENZYMATIC VITREOLYSIS FOR SEVERE CASES OF VITREOMACULAR TRACTION

PURPOSE

To evaluate the efficacy of combined pneumatic and enzymatic vitreolysis for treatment of severe cases of vitreomacular traction (VMT).

METHODS

We analyzed a retrospective, consecutive series of five patients diagnosed with severe VMT refractory to pneumatic vitreolysis who then received an additional ocriplasmin injection while their gas bubble from pneumatic vitreolysis was still present between February 2015 and February 2019. Vitreomacular traction release was confirmed using spectral-domain optical coherence tomography.

RESULTS

Four of the five patients treated with combined pneumatic and enzymatic vitreolysis achieved VMT release by Day 28, and all cases eventually achieved complete VMT release. In addition to having VMT refractory to pneumatic vitreolysis, patient characteristics included broad adhesion diameter (>1,500 µ m, n = 1), presence of epiretinal membrane (n = 2), age >65 years (n = 4), and pseudophakia (n = 1). The visual acuity improved by three or more lines at 6 months in both of the patients with initial vision worse than 20/50 on an Early Treatment Diabetic Retinopathy Study chart but not in those whose vision was already fairly good (i.e., visual acuity >20/60). None of the patients experienced the following complications after receiving this combined treatment: retinal tears or detachments, vitreous floaters, and ellipsoid zone changes.

CONCLUSION

Sequential, combined pneumatic and enzymatic vitreolysis resulted in VMT release in all 5 cases (4 cases by 28 days) and may be a potentially useful alternative to surgical intervention for refractory VMT cases.

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.

The efficacy and safety of ocriplasmin for patients with vitreous macular traction

PURPOSE

To estimate the efficacy and safety of ocriplasmin for patients with vitreous macular traction (VMT).

METHODS

The PubMed, EMBASE and Ovid were searched up to May 2020 to identify related studies. Statistical analysis was conducted by R software version 3.6.3. Results in proportion with 95% confidence interval (CI) were calculated by means of Freeman-Tukey variant of arcsine square transformation.

RESULTS

The pooling results indicated the overall complete release rate was 50% (95% CI [45%-54%]). For VMT patients younger than 65 years old, with smaller adhesion size of VMT (<1500 μm), phakic eyes, with macular hole (MH) and subretinal fluid (SRF), while without epiretinal membrane (ERM), ocriplasmin could achieve much higher complete release rates than those under opposite conditions. The general nonsurgical closure rate of MH was 34% (95% CI [30%-37%]), and it was positively correlated with the MH size. The visual improvement rate was 45% (95% CI [32%-59%]), and it was higher for patients with VMT resolution (59%, 95% CI [41%-75%]). The secondary pars plana vitrectomy (PPV) rate for patients without MH closure or VMT resolution was about 31% (95% CI [23%-39%]). The incidence of MH progression was 10% (95% CI [4%-18%]), and other severe adverse events such as endophthalmitis, retinal detachment and retinal tear were relatively rare.

CONCLUSION

Ocriplasmin is an effective, reliable and relatively safe intervention for the treatment of VMT. The most suitable candidates were patients younger than 65 years old, with smaller adhesion size (<1500 μm), phakic eyes, with MH and SRF, while without ERM.

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.

Retrospective Study of Ellipsoid Zone Integrity Following Treatment with Intravitreal Ocriplasmin (OZONE Study)

Purpose

To assess generalized (GD) and focal ellipsoid zone disruption (FD) in patients with symptomatic vitreomacular adhesion (sVMA) using spectral domain optical coherence tomography (SD-OCT) following ocriplasmin.

Patients and methods

OZONE was a Phase 4, retrospective study of patients with sVMA treated with a single intravitreal injection of ocriplasmin (0.125 mg). Data from adult patients with at least 6-month follow-up after ocriplasmin were included. SD-OCT was performed at baseline (within 30 days before ocriplasmin), before Day 21 post-injection (early observation, EO), and by last observation (LO) which was maximally 6 months post-injection. The main outcome measure was the development of new and the evolution of existing FD/GD at EO and LO.

Results

The study enrolled 134 eyes/patients from 22 sites in the USA. At baseline, 87 eyes (64.9%) had FD, 21 eyes (15.7%) had GD and 26 eyes (19.4%) had no FD/GD. Among the eyes without FD/GD at baseline, 13 (50%) and 8 (30.8%) developed FD or GD, respectively, by EO. By LO, FD/GD improvement or resolution was seen in >80% of these eyes. Among the eyes with FD/GD at baseline, <40% had improving/resolving EZ integrity at LO. The absence of FD/GD at baseline was associated with less persistent FD/GD at LO (P<0.0005). The presence of FD with MH at baseline was associated with persistent FD at LO (P=0.027).

Conclusion

The fact that a large majority of eyes had FD/GD prior to ocriplasmin was unexpected and demonstrates that EZ disruptions are common in sVMA. This suggests that loss of EZ integrity may be part of the natural history of this disorder. It is hypothesized that the status of the EZ at baseline is a contributing, ocriplasmin independent modulator of subsequent EZ changes after ocriplasmin. Prospective analyses which include a sham control group would be required to test this hypothesis.

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.

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.

EXPERIENCE WITH OCRIPLASMIN IN PATIENTS WITH VITREOMACULAR TRACTION SYNDROME: A RETROSPECTIVE STUDY OF 10 PATIENTS

PURPOSE

To assess the efficacy of ocriplasmin in patients with vitreomacular traction (VMT) syndrome <1,500 μm with or without a full-thickness macular holes of <400 μm.

METHODS

In this study, a retrospective analysis of 10 eyes of 10 patients with VMT who were treated with ocriplasmin between December 2014 and January 2016 was performed. Ocriplasmin 0.125 mg was injected only once in all cases. Outcome measures included the detachment of VMT, best-corrected visual acuity, the evaluation of optical coherence tomography, including the closure of full-thickness macular holes, and the reduction of macular edema (if present) and the decrease of metamorphopsia if present.

RESULTS

Ten patients (7 women and 3 men) with an average age of 75.1 years (range, 63-84 years) were treated with ocriplasmin with a follow-up period of 8 weeks. All patients were treated for VMT syndrome, and 5 patients (50.0%) showed an additional macular hole. An absolute detachment of VMT was seen in 3 patients (30.0%) and partially in 4 patients (40.0%). In three of the five patients, a complete closure of the full-thickness macular holes was seen. The two other patients needed an additional pars plana vitrectomy as a result of the persistent macular hole. An improvement of visual acuity was seen in 6 out of 10 patients (60.0%), a reduction of macular edema in 8 out of 9 patients (88.9%), and a decrease of metamorphopsia in 6 out of 7 patients (85.7%).

CONCLUSION

In this retrospective analysis, the treatment with ocriplasmin showed a resolution of VMT in 7 of 10 patients (70.0%) after a follow-up period of 8 weeks.

Longitudinal ellipsoid zone and subretinal fluid mapping following ocriplasmin injection in the prospective observational ORBIT trial

BACKGROUND

Ocriplasmin is approved for the treatment of symptomatic vitreomacular traction (VMT). However, several retrospective reports have identified ellipsoid zone (EZ) alterations on spectral domain optical coherence tomography (SDOCT) after ocriplasmin injection. This report quantitatively analysed outer retinal changes after intravitreal ocriplasmin.

METHODS

Ocriplasmin Research to Better Inform Treatment is a prospective, observational phase IV clinical study where subjects received a single intravitreal injection of ocriplasmin for symptomatic VMT. Macular cube scans were imported into a semiautomated EZ mapping and fluid feature extraction software for SDOCT analysis. Change in visual acuity, VMT release, macular hole (MH) closure, EZ integrity/volume and subretinal fluid (SRF) volume on SDOCT macular cube scans were recorded and analysed.

RESULTS

This analysis included 55 participants with 6 months of follow-up. Intravitreal ocriplasmin injection caused VMT release in 67% and MH closure in 82% of participants. Visual acuity improved by 4.5 letters (p<0.05) in the whole cohort and by 6.0 letters (p<0.05) in participants with VMT release. EZ volume was reduced by 23.4% at week 1 (p<0.001) and recovered to baseline by between months 3 and 6. EZ volume loss at week 1 did not correlate with ETDRS acuity at final visit.

CONCLUSION

Ocriplasmin treatment resulted in VMT release, MH closure and visual acuity gains in a significant portion of eyes. EZ volume was significantly reduced at week 1, but recovered to baseline levels by final follow-up and was not associated with final visual acuity.

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

PURPOSE

To describe the clinical impact of subfoveal lucency (SFL) seen on OCT before and after treatment of vitreomacular traction (VMT) or symptomatic vitreomacular adhesion (VMA) without macular hole (MH) in the prospective phase 3 trials of ocriplasmin vitreolysis.

DESIGN

Randomized double-blind placebo-controlled multicenter study.

PARTICIPANTS

Four hundred ninety-nine eyes with VMT or VMA without MH.

METHODS

Eyes were randomized to either a single intravitreal injection of ocriplasmin or placebo treatment and were followed up for 6 months.

MAIN OUTCOME MEASURES

Eyes were analyzed for presence, dimensions, and course of SFL on OCT, release of VMT, and their effect on visual acuity (VA).

RESULTS

Among eyes without baseline SFL, new SFL was more frequent after ocriplasmin than placebo at week 1 (23.1% vs. 6.54%; P = 0.0002) and week 2 (19.7% vs. 3.85%; P = 0.0001), but was similar in frequency by week 4 (8.37% vs. 7.69%; P = 0.83). Six-month VA for eyes demonstrating SFL after ocriplasmin during the first 2 weeks was comparable with those without SFL at any point in the study (P = 0.12). In placebo-treated eyes but not ocriplasmin-treated eyes, SFL was associated with worse VA at all visits. The increase in SFL width from baseline to week 2 was significantly greater with ocriplasmin than placebo (P = 0.029). Among ocriplasmin-treated eyes at month 6, those with SFL and VMT release had better VA than those with SFL and persistent adhesion (P = 0.037) and similar VA to those with persistent adhesion without SFL (P = 0.17). In the placebo group, those with baseline SFL showed low rates of spontaneous VMT release at month 6 compared with those without baseline SFL (3/21 eyes vs. 33/99 eyes; P = 0.045).

CONCLUSIONS

Compared with placebo, SFL occurred more frequently only in the initial weeks after treatment with ocriplasmin. When SFL developed after ocriplasmin administration, VA was not impacted at the 6-month visit. Persistent SFL in ocriplasmin-treated eyes at month 6 was associated with poorer vision if VMT had not released. Eyes with SFL at baseline had low rates of spontaneous VMT release and may need treatment.

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.

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.

IMPACT OF VITREORETINAL INTERFACE ARCHITECTURE ON SUCCESSFUL VITREOMACULAR TRACTION RESOLUTION IN EYES SCHEDULED FOR INTRAVITREAL OCRIPLASMIN THERAPY

PURPOSE

To evaluate the impact of the vitreoretinal interface architecture, in specific the angle between the posterior vitreous cortex and the internal limiting membrane, on vitreomacular traction (VMT) resolution in eyes treated with intravitreally injected ocriplasmin (Jetrea).

METHODS

Retrospective, multicenter cohort study and exploratory data analysis. Spectral domain optical coherence tomography assessments were performed before scheduled ocriplasmin injections. General (age and sex) as well as ocular variables (lens status, presence of epiretinal membrane formations, horizontal diameter of VMT, central retinal thickness, and in particular various prespecified angles between the posterior vitreous cortex and internal limiting membrane) were analyzed to evaluate their impact on successful VMT resolution.

RESULTS

Fifty-nine eyes of 59 patients were included. Univariate analysis of age (odds ratio [OR]: 0.881; 95% CI: [0.812-0.955]; P = 0.0022) and lens status (OR: 11.03; 95% CI: [2.23-54.57]; P = 0.0033) had a significant impact on successful VMT resolution, whereas sex (OR: 0.668; 95% CI: [0.126-2.065]; P = 0.4906), epiretinal membrane formation (OR: 0.581; 95% CI: [0.168-2.006]; P = 0.3903), horizontal diameter of VMT (OR: 0.99930; 95% CI: [0.99825-1.00035]; P = 0.1886), and central retinal thickness (OR: 0.9985; 95% CI: [0.9934-1.00436]; P = 0.56) failed. The angle at 500 μm apart from the fovea centralis, irrespective if measured nasally (OR: 1.135; 95% CI: [1.013-1.272]; P = 0.0289) or temporally (OR: 1.099; 95% CI: [1.001-1.208]; P = 0.0485), showed a significant correlation with VMT resolution.

CONCLUSION

The angle between the posterior vitreous cortex and the internal limiting membrane 500 μm apart from the fovea centralis correlates with VMT resolution and may be a clinically useful marker for selection of patients to be treated with ocriplasmin. This observation needs to be proven in a prospective confirmatory investigation.

Calculating the individual probability of successful ocriplasmin treatment in eyes with VMT syndrome: a multivariable prediction model from the EXPORT study

Background/Aims

To evaluate predictive factors for the treatment success of ocriplasmin and to use these factors to generate a multivariate model to calculate the individual probability of successful treatment.

Methods

Data were collected in a retrospective, multicentre cohort study. Patients with vitreomacular traction (VMT) syndrome without a full-thickness macular hole were included if they received an intravitreal injection (IVI) of ocriplasmin. Five factors (age, gender, lens status, presence of epiretinal membrane (ERM) formation and horizontal diameter of VMT) were assessed on their association with VMT resolution. A multivariable logistic regression model was employed to further analyse these factors and calculate the individual probability of successful treatment.

Results

167 eyes of 167 patients were included. Univariate analysis revealed a significant correlation to VMT resolution for all analysed factors: age (years) (OR 0.9208; 95% CI 0.8845 to 0.9586; p<0.0001), gender (male) (OR 0.480; 95% CI 0.241 to 0.957; p=0.0371), lens status (phakic) (OR 2.042; 95% CI 1.054 to 3.958; p=0.0344), ERM formation (present) (OR 0.384; 95% CI 0.179 to 0.821; p=0.0136) and horizontal VMT diameter (µm) (OR 0.99812; 95% CI 0.99684 to 0.99941, p=0.0042). A significant multivariable logistic regression model was established with age and VMT diameter.

Conclusion

Known predictive factors for VMT resolution after ocriplasmin IVI were confirmed in our study. We were able to combine them into a formula, ultimately allowing the calculation of an individual probability of treatment success with ocriplasmin in patients with VMT syndrome without FTHM.

Assessment of intravitreal ocriplasmin treatment for vitreomacular traction in clinical practice

PURPOSE

To assess treatment effects following intravitreal injection of ocriplasmin for vitreomacular traction (VMT), with or without full-thickness macular hole (FTMH), in real-life setting.

METHODS

This is a monocentric, retrospective, consecutive series of 82 eyes from 82 patients who underwent ocriplasmin treatment between July 2013 and December 2016. We included 57 eyes with pure VMT, 17 eyes with small FTMHs, and eight eyes with medium FTMHs. Primary outcome measures were VMT release and MH closure rates. Secondary outcomes were visual acuity (VA), morphological changes, and subjective visual impairment after 1, 3, and 6 months and at last follow-up.

RESULTS

After a median follow-up of 10 months, VMT release was achieved by pharmacologic vitreolysis in 57% of all eyes, whereas the macular hole closure rate was 32%. In those presenting with five or more positive prognostic factors (PPF), eyes with pure VMT showed nonsurgical traction release in 88%, and FTMHs were released in 93%, with a closure rate of 20%. Small FTMHs closed in 41% and medium FTMHs in 13%. The mean change in VA (LogMAR) was -0.07 ± 0.24 (median - 0.10) in all eyes. Subretinal fluid accumulation and ellipsoid zone changes were seen in 31% and 37% of all eyes, respectively. They were more frequent in eyes with traction release, but were self-limited.

CONCLUSIONS

In a real-life setting, release of VMT by ocriplasmin injection can be achieved in the majority of eyes, relying on a strict patient selection. Closure of FTMHs rather correlates with hole diameter than with presence of PPF, and remains a rare finding in medium FTMHs.

The predictability of ocriplasmin treatment effects: is there consensus among retinal experts? Results from the EXPORT study

PURPOSE

To evaluate the agreement and predictability of ocriplasmin treatment effects among retinal experts (raters) by assessment of retinal imaging data of eyes treated for vitreomacular traction in nine different centers in Germany and Austria.

METHODS

Retrospective cohort study. Combined confocal near-infrared scanning laser ophthalmoscopy and spectral-domain optical coherence tomography images (Spectralis® device, Heidelberg Engineering GmbH, Germany) from 136 eyes of 135 subjects were reviewed by 14 raters using an internet-based grading database and a standardized questionnaire. In addition to the images taken within 2 days prior to treatment, age, gender, and lens status were disclosed to the raters. Treatment success was defined as a complete cleavage of the posterior vitreous cortex at day 28±5. Main outcome was the agreement and predictability among raters for assessment of treatment success.

RESULTS

Raters generally accepted starting ocriplasmin treatment (chance for treatment success ≥ 1%) in 22.4 to 69.1% (median 53.2%) of eyes (moderate intra- and interrater agreements with kappa-values of 0.6 and 0.48). The likelihood for a high potential treatment success (equal or higher than 25%) was judged by the raters in 43.4% to 86.0% (median 62.6%) of eyes (moderate intra- and fair interrater agreements with kappa-values of 0.56 and 0.22). Allocating eyes for high potential treatment success overall increased the odds by 3.07, with odds ratios of single raters up to 4.06 to 6.16.

CONCLUSIONS

These results underscore the importance of training health care providers in the evaluation of retinal imaging data and also to define characteristic morphological features better in the presence of vitreoretinal interface diseases. The better results of single raters in the predictability of treatment success by the allocation of eyes in the high-potential group indicates the high relevance of the meticulous analysis of retinal images.

LONGITUDINAL MICROPERIMETRY EVALUATION AFTER INTRAVITREAL OCRIPLASMIN INJECTION FOR VITREOMACULAR TRACTION

PURPOSE

To determine whether improvements in microperimetry testing are associated with anatomic resolution after ocriplasmin treatment in patients with symptomatic vitreomacular adhesion (VMA)/vitreomacular traction and relatively preserved baseline best-corrected visual acuity (BCVA).

METHODS

Patients with vitreomacular traction received a single 125-μg intravitreal ocriplasmin injection and were followed longitudinally for 6 months with optical coherence tomography, BCVA testing, and microperimetry. Visual function changes were compared between eyes with and without VMA resolution on optical coherence tomography.

RESULTS

Eleven of 16 eyes (68.8%) achieved VMA resolution after treatment. Mean baseline BCVA was relatively good (79 ± 3 Early Treatment Diabetic Retinopathy Study letters; 20/52); no patients had a ≥2-line improvement in BCVA over the 6-month follow-up period. In the group with VMA resolution, mean retinal sensitivity significantly increased in the central 4° (15.2 ± 1.9 dB vs. 18.9 ± 0.7 dB, P < 0.001) when comparing baseline and final follow-up microperimetry testing. No change in mean retinal sensitivity was found in the group without VMA resolution.

CONCLUSION

Microperimetry demonstrates a significant gain in retinal sensitivity, particularly in the central 4° area, in eyes with anatomic resolution after treatment of vitreomacular traction with intravitreal ocriplasmin injection, even when no significant gain in BCVA is seen.

ELLIPSOID ZONE MAPPING AND OUTER RETINAL CHARACTERIZATION AFTER INTRAVITREAL OCRIPLASMIN

PURPOSE

To assess outer retinal architectural alterations after intravitreal ocriplasmin with a novel automated ellipsoid zone (EZ) mapping algorithm.

METHODS

A single-center, retrospective, consecutive case series of image analysis was performed. Quantitative assessment of EZ status imaged with spectral-domain optical coherence tomography was performed before and after single intravitreal injection of 0.125 mg of ocriplasmin (Jetrea, Thrombogenics). A novel EZ mapping algorithm was used to assess the EZ retinal pigment epithelium (RPE) central area, EZ-RPE macular volume, and en face EZ integrity based on the percentage of sampling areas with 20 μm or greater EZ-RPE thickness. Longitudinal assessment of these changes with custom optical coherence tomography reading software was completed. Clinical characteristics and outcomes were compared with these retinal changes.

RESULTS

Nineteen eyes were included in this study. The retinal volume between EZ and RPE was significantly reduced at 1 week after ocriplasmin (P = 0.0036). Seven of 19 patients (36.8%) complained of color abnormalities or brightness reduction after injection. All of these seven patients had increased subretinal fluid after ocriplasmin and EZ attenuation. The EZ-RPE volume was reduced at 1 week (P = 0.0036), 1 month (P = 0.015) after ocriplasmin, and restored by 3 months. The area with EZ-RPE thickness below 20 μm was increased at 1 week (P = 0.046) after ocriplasmin and recovered with time.

CONCLUSION

Mapping of EZ is feasible to assess EZ-RPE volume and overall EZ integrity with en face thickness mapping. Alterations in EZ occur in a significant proportion of eyes after ocriplasmin therapy. The EZ-RPE volume and the EZ-RPE central foveal area typically recover to baseline by 3 months. This effect appears to be panretinal and associated with subjective symptoms.

Ocriplasmin for Treatment of Vitreomacular Traction: An Update

Pharmacologic vitreolysis with ocriplasmin, a 27 kilodalton serine protease, is an effective nonsurgical treatment option for vitreomacular traction (VMT). Data from phase III clinical studies, including the Microplasmin for Intravitreal Injection-Traction Release without Surgical Treatment (MIVI-TRUST) and Ocriplasmin for Treatment for Symptomatic Vitreomacular Adhesion Including Macular Hole (OASIS) studies, have demonstrated the treatment efficacy of ocriplasmin for VMT and full-thickness macular hole (FTMH). Subgroup analysis of these clinical trials as well as post-marketing clinical series have aided in patient selection by identifying features associated with successful pharmacologic release of VMT with ocriplasmin, including adhesion diameter ≤1500 μm, absence of epiretinal membrane, phakic status, and age younger than 65. As a first-in-class therapeutic, ocriplasmin and its side effects have been carefully monitored by the vitreoretinal community. The following categories of related or possibly related adverse events have been identified: acute reduction in visual acuity, ERG changes, dyschromatopsia, retinal tear or detachment, lens subluxation or phacodonesis, abnormal pupillary reflex, retinal vascular changes, and OCT ellipsoid zone alterations. Adverse events have almost all been transient with restoration of visual acuity; however, in select patients, alterations may persist.

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.

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?"