Profile of ocriplasmin and its potential in the treatment of vitreomacular adhesion

Abstract

The recent approval by the US Food and Drug Administration of ocriplasmin for the treatment of symptomatic vitreomacular adhesion (VMA), often associated with vitreomacular traction (VMT) and macular hole (MH), has brought new attention to the field of pharmacologic vitreolysis. The need for an enzyme to split the vitreomacular interface, which is formed by a strong adhesive interaction between the posterior vitreous cortex and the internal limiting membrane, historically stems from pediatric eye surgery. This review summarizes the different anatomic classifications of posterior vitreous detachment or anomalous posterior vitreous detachment and puts these in the context of clinical pathologies commonly observed in clinical practice of the vitreoretinal specialist, such as MH, VMT, age-related macular degeneration, and diabetic macular edema. We revisit the outcome of the Phase II studies that indicated ocriplasmin was a safe and effective treatment for selected cases of symptomatic VMA and MH. Release of VMA at day 28 was achieved by 26.5% of patients in the ocriplasmin group versus 10.1% in the placebo group (P<0.001). Interestingly, for MHs, the numbers were more remarkable. Predictive factors for successful ocriplasmin treatment were identified for VMT (VMA diameter smaller than 1,500 μm) and MH (smaller than 250 μm). In comparison with the highly predictable outcome after vitrectomy, the general success rate of ocriplasmin not under clinical trial conditions has not fully met expectations and needs to be proven in real-world clinical settings. The ocriplasmin data will be compared in the future with observational data on spontaneous VMA release, will help retina specialists make more accurate predictions, and will improve outcome rates.

Keywords: macular hole; microplasmin; ocriplasmin; pharmacologic vitreolysis; posterior vitreous detachment; vitreomacular traction.

Figure 1

Images of macular region on spectral domain and swept source optical-coherence tomography (A, B, D: Spectralis OCT, Heidelberg Engeneering, Heidelberg, Germany; C: SS OCT; CArl Zeiss, Oberkochen, Germany). Notes: (A) Attached posterior hyaloid. (B and C) Partial elevation of the nasal posterior vitreous (partial posterior vitreous detachment) can be seen as a thin layer (arrows) anterior of the retinal surface. Vitreous is still attached in foveal region. (D) Complete vitreous detachment, an entire separation between the posterior vitreous cortex (arrows) and the retina surface.

Figure 2

Images of macular region on spectral domain optical coherence tomography (SD-OCT; Spectralis OCT, Heidelberg Engeneering, Heidelberg, Germany). Notes: (A) Vitreomacular traction with focal traction at foveal (arrow) region and intrafoveal pseudocysts. (B) Full-thickness macular hole with vitreomacular traction (yellow and white arrows, respectively).