The authors of this retrospective study report their experience with intravitreal ocriplasmin in a large retinal private practice, showing that treatment outcomes are superior to the clinical trial resolution rate and comparable to smaller published case series at academic institutions. It also underscores the necessity of SD-OCT monitoring, as transient toxicity to the outer retina occurs frequently.
This was the largest clinical series of ocriplasmin following FDA approval and it included patients with macular comorbidities. Of the 35 consecutive patients included, 31 percent (11 subjects) had macular comorbidities. Average adhesion diameter was 571 μm, with a mean symptom duration of about 8 months. Nine subjects (26%) had epiretinal membrane and six (17%) had a macular hole (mean diameter, 186 μm).
The vitreomacular adhesion release rate was comparable to previous studies, with 42.9% achieving complete resolution; however, they reported a lower closure rate for full-thickness macular holes, at 16.7%, perhaps due to having a much larger associated vitreomacular adhesion (658 μm).
Vitreomacular adhesion resolution occurred earlier than previous reports suggest, at mean 10 days after injection, with 73% of cases releasing during the first week.
Additionally, they found that those with comorbidities had a much lower adhesion resolution rate of 9% (1/11) compared to those with isolated vitreomacular adhesion, who achieved a release rate of 58% (14/24).
Similar to clinical trial results, younger age (<65 years), presence of full-thickness macular hole, phakic status, adhesion diameter (≤1500 μm), and absence of epiretinal membrane were predictive of adhesion release. They also found that shorter adhesion duration was associated with adhesion release, which provides a likely explanation for why the presence of mature epiretinal membrane has been associated with reduced efficacy of ocriplasmin.
Ten subjects (28.6%) had outer retinal disruption and associated ellipsoid zone loss on OCT, first detected at a mean 6.3 days after injection, and resolved in all cases. All cases of outer retinal attenuation occurred in eyes where the broadest diameter of the vitreomacular adhesion was located within 200 μm of the foveal center; moreover, the ellipsoid zone changes always extended broadly, present not only in the foveal region but extending out into the parafovea and, rarely, the perifovea. One subject developed a retinal detachment.
Finally, the finding of ellipsoid zone changes on SD-OCT in a significant subset of patients suggests that patients who receive ocriplasmin should be carefully selected, informed, and monitored.