Surgical Outcomes for Persistent Macular Hole After Ocriplasmin

Long-Term Results of Vitrectomy for Macular Holes after Failure of Vitreolysis

PURPOSE

Ocriplasmin injection may close some small-to-medium macular holes associated with vitreoretinal traction. If the treatment fails, does vitrectomy and gas injection yield the same results as primary surgery?

MATERIAL AND METHODS

We report a retrospective case series study of 3 eyes of 3 consecutive patients operated on a few months after initial intravitreal injection of ocriplasmin and enlargement of the macular hole. The minimal follow-up period after surgery was 18 months.

RESULTS

Surgery was uneventful in all cases. Vitrectomy, internal limiting membrane peeling, and gas injection allowed closing of the 3 macular holes with a progressive improvement in visual acuity over time. Before ocriplasmin injection, visual acuity ranged from 20/60 to 20/32, after failed ocriplasmin injection from 20/80 to 20/40, and at the final follow-up after 18 months from 20/32 to 20/25.

CONCLUSION

Vitrectomy with internal limiting membrane peeling leads to closure of macular holes even in cases of prior failure to close them by ocriplasmin injection.

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.

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?"