Ocriplasmin is a truncated plasmin derivative, with vitreolytic enzymatic activity. Following the MIVI-TRUST study, it was approved as a therapeutic option for focal (<1500μm) VMT (Vitreomacular Traction), when accompanied by visual symptoms and/or a macular hole < 400μm. Although few complications have been reported, a few authors report on the unpredictability of the results of this treatment. The authors present 5 illustrative cases, of unconventional and unexpected results following ocriplasmin therapy.

Clinical Cases:

The authors present 5 clinical cases with unconventional results from our study group.

Case 1: 70-year old female patient, with an operculated full-thickness macular hole of 226 µm, considered a candidate for ocriplasmin therapy. 24h after the injection, the patient had complaints of severely reduced vision and blur, along with metamorphopsia, with the OCT examination showing a macular serous detachment, with persistent vitreomacular traction. The condition improved over the following days, with a gradual reduction of the subretinal fluid but no resolution of the traction.

Case 2: 69 year-old female, phakic, with a focal VMT(190 µm), injected with ocriplasmin. The patient presented with photopsia and dyschromatopsia in the first 72hours, with a gradual “pulling” effect on the VMT observed on the OCT in the first month, but with no release. Only after 56 days was the release documented, with VA improving from 4/10 to 9/10. Case 3 is of a 65 year-old femal e with a full-thickness macular hole of 263µm, with a persistent vitreoretinal traction on the temporal border. This patient was also injected with ocriplasmin, successfully releasing the VMT after 9 days. The macular hole, however, remained open for 1 month. The authors opted for a vitrectomy, resulting in a complete closure of the macular hole. VA improved from 4/10 to 9/10. The fourth and fifth cases are of two female patients, with 85 and 82 years of age, with focal VMTs, both phakic. that underwent intravitreal therapy with ocriplasmin, without release after 3 months of follow-up. The solution was a 23G vitrectomy, where a strong vitreo-retinal adhesion was found, with a good final result.

Discussion & Conclusions:

Our study group achieved a better overall success rate when compared with the original MIVI-TRUST study. As many authors have reported, a better selection of patients was crucial for a better outcome, otherwise, a secondary costly procedure will be required. Though complications are rare, a few authors have commented on the unpredictability of results with ocriplasmin. One month of follow-up may not be enough to consider the final result after the injection, as delayed releases of VMT may happen. On the other hand, successful resolution of VMT in macular holes, without resulting in MH closure, has been reported by others. Also, a few ophthalmologists mention case reports in which subretinal fluid accumulates after the injection, temporarily impairing vision, such as our case. Further studies and experience will be necessary to better select patients and predict the effects of this new intravitreal therapy.

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