Managing vitreomacular adhesion

Since the invention of ocular coherence tomography (OCT), we have learned more about the eye and treatment of retinal disease. Reese first described vitreomacular traction (VMT) in 1970,¹ when he was able to confirm his diagnosis by histology. but now we can see the changes within the eye using OCT. But now we can see the changes in the eye using OCT, and, because we cannot measure the traction histologically, the diagnosis is properly coined vitreomacular adhesion (VMA). This adhesion is associated with cystoid macular Edema (CME), epiretinal membrane formation (EMR,) and macular hole formation (MH).² Aside from diabetic retinopathy (DR) and age-related macular degeneration (AMD or ARMD), VMA is very prominent in my practice.

VMT is VMA with any abnormal macular retinal architecture. Symptomatic VMT can be treated with vitrectomy. And while this procedure is successful, just as with every surgery, there are also risks. Vitrectomy is invasive, costly, labor-intensive, and has a long healing time.³ In some cases, I may decide to insert a gas bubble into the eye. If so, the patient has to maintain facedown positioning until the gas bubble inserted into their vitreous dissolved. This typically takes days to weeks. In October 2012, the FDA allowed us a new treatment option-the first medical treatment for symptomatic VMA-a pharmaceutical agent called Jetrea (ocriplasmin, ThromboGenics).⁴

Using ocriplasmin

Jetrea comes to us frozen and packed in dry ice. We obtained a freezer from the manufacturer to store the medication before use. My assistants carefully remove the Jetrea from the container, avoiding direct contact with the dry ice. They immediately store it in our Jetrea freezer. It is thawed for a few minutes before being injected.

The advantage of using Jetrea is that it is administered by in-office intravitreal injection. Because we use Avastin (bevacizumab, Genentech), Lucentis (ranibizumab, Genentech), and Eylea (aflibercept, Regeneron) on a regular basis, my assistants are very comfortable with this procedure. There is no involved hospital admission process. There is no inconvenience to the patient of having to be face-down for prolonged periods. We perform a benefits investigation to make sure the patient’s medical insurance will cover the treatment, then we initiate applying for copay assistance if the patient qualifies. This reduces the patient’s burden, depending on annual income, of approximately $800 per treatment to something more manageable.

I have found that patient selection for Jetrea is critical to the success of the treatment. Patients with small focal adhesions and/or small macular holes have done well in my experience. 

The risks of Jetrea therapy are relatively few compared to vitrectomy. According to the FDA, the most common side effects reported in patients treated with Jetrea include:⁴

• Eye floaters

• Bleeding of the conjunctiva

• Eye pain

• Flashes of light (photopsia)

• Blurred vision

• Unclear vision

• Vision loss

• Retinal edema (swelling)

• Macular edema

I see my Jetrea patients one week after injection. I have seen release of VMA after this short amount of time. If I do not see residual macular edema, then we schedule the patient to return in one month. If macular edema is present, then I treat it and ask the patient to return in approximately 2 weeks. Of course, I treat and follow any other possible side effects, if present.

We have been offering this treatment option for less than one year, but have had excellent results. I carefully select the optimum candidates and hope for the best. So far, I have found that symptomatic patients treated with Jetrea have experienced release of the adhesion. This release appears to result in macular edema and subretinal fluid at their one-week injection visit. I treat the macular edema with topical medications. With time, the swelling subsides, and visual acuity improves. Patients with VMA and small MHs have resulted in closure of the hole. The resounding reaction from my patients has been positive. They are pleased to have complete resolution of their VMA and restored vision. At the 1-month visit, we must consider other treatment options if the adhesion is not dissolved and the patient is still symptomatic.

Moving to vitrectomy

Unfortunately, there is the possibility of failure. Before we treat, I always explain that there is a risk that Jetrea will not work. If it does not work and the patient is bothered by his or her VMA, then I perform a vitrectomy and membrane peel as an outpatient procedure at a local hospital. I have found that Jetrea helps to loosen the adhesion between the macula and vitreous, so surgery is fairly straightforward.

We see patients the day after their vitrectomy. We ask the patients to keep their patch and protective shield over their operated eye. Once the patient arrives to our office, one of my assistants carefully removes the patch and shield and gently cleans the area. The assistant then measures visual acuity without and then with pinhole. As long as the eye appears as I would expect, we see the patient again in 1 week and again in 1 month. Of course, if there is inflammation or increased intraocular pressure, I treat it and see the patient more often.

VMA is an OCT finding. Once the adhesion progresses to abnormalities in the retina and becomes symptomatic, some patients become candidates for Jetrea treatment. Careful selection of symptomatic patients with focal areas of adhesion and/or small holes have produced the best post-injection results. I look forward to offering Jetrea treatment to more of my patients.

References

1. Reese AB, Jones IS, Cooper WC. Vitreomacular traction syndrome confirmed histologically. Am J Ophthalmol. 1970 June;69(6):975–7.

2. Bottós J, Elizalde J, Arevalo JF, Rodrigues EB, Maia M. Vitreomacular traction syndrome. J Ophthalmic Vis Res. 2012 Apr;7(2):148-61.

3. Sebag J. Treatment of VMA. Retina Today. 2012 April:56.

4. FDA news release. FDA approves Jetrea for symptomatic vitreomacular adhesion in the eyes.

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm324369.htm. Accessed November 7, 2013.