Ocriplasmin for VMA: Lessons learned

Royal Oak, MI-Findings from a single-center, retrospective review of patients treated for vitreomacular adhesion (VMA) with ocriplasmin (Jetrea, ThromboGenics) add to accumulating evidence demonstrating that appropriate patient selection increases success and also showing that subretinal fluid and ellipsoid zone changes are common, but temporary post-treatment findings.

“Our data are consistent with a number of other reports showing that the efficacy of ocriplasmin treatment can be high when carefully selecting cases based on optical coherence tomography (OCT) findings shown to be associated with success in the subgroup analyses for MIVI-TRUST,” said Jeremy D. Wolfe, MD, MS, Associated Retinal Consultants, Royal Oak, MI.

“We found the rate of separation was higher in patients with smaller adhesions without an epiretinal membrane, and eyes with VMA and small macular holes appeared to be a particular ‘sweet spot’ for ocriplasmin treatment,” Dr. Wolfe said.

Observations also corroborate findings from after-market reports on early anatomical changes occurring post-treatment, he noted.

“We hope that all of this information should be helpful to clinicians in terms of knowing what to expect when using ocriplasmin and how to counsel patients,” Dr. Wolfe said.

The outcomes presented were for all patients treated by Dr. Wolfe and Eric Nudleman, MD, PhD, between February and September 2013. The series included 36 eyes, of which 9 had a stage 2-3 macular hole. Baseline logMAR visual acuity was 0.49 (~20/40).

“As more and more centers are reporting outcomes with ocriplasmin, we were motivated to look at own experience,” Dr. Wolfe said.

VMA release at 1 month was analyzed as the primary endpoint, and it was achieved in 15 eyes (42%), including 8 (89%) of the 9 eyes with a macular hole. Macular hole closure was achieved in 7 eyes (78%).

Analyses performed with eyes categorized according to whether separation was achieved showed eyes that separated had a significantly smaller mean adhesion (311 versus 654 µm), and a significantly lower incidence of epiretinal membrane (13% versus 48%).

Follow-up with post-treatment spectral domain-OCT (SD-OCT) at 1 week showed a higher incidence of subretinal fluid among eyes that separated compared with those that did not (73.3% versus 19%).

Ellipsoid zone changes-characterized by attenuation of the ellipsoid zone band-were also more common in the group achieving separation (66.7% versus 52.3%), although the difference between groups did not achieve statistical significance.

Findings from serial SD-OCT imaging showed that by 1 month, subretinal fluid had resolved in some patients and mean subretinal fluid height and diameter were each reduced by about half. At 6 months, most changes had resolved. Subretinal fluid persisted at 6 months in 3 patients and improved thereafter in all, but was still present in 2 patients at 1 year.

The ellipsoid zone changes, when present, were also improved at 1 month, and normal anatomy was present in nearly all eyes seen at 6 months, and in all eyes at 1 year.

Visual acuity also continued to improve during follow-up among eyes achieving VMA release. Whereas mean visual acuity was not significantly different between the responders and non-responders to ocriplasmin at 1 month, there was improvement over time in the responder group. At 1 year, eyes that responded to ocriplasmin had a mean gain of 17 letters from baseline best-corrected visual acuity compared with no change in the non-responders, Dr. Wolfe noted.

Safety of ocriplasmin treatment was favorable. There was a single retinal detachment and no cases of severe or persistent vision loss or endophthalmitis.

Jeremy D. Wolfe, MD, MS

E: jeremydwolfe@gmail.com

This article was adapted from the 2014 meeting of the American Society of Retina Specialists. Dr. Wolfe receives research support from ThromboGenics. Dr. Nudleman has no financial interest to disclose.