Ocriplasmin and Vitreoretinal Interface Disorders
Intravitreal injection of an expansile gas bubble has also been shown to induce a posterior hyaloid face separation. Small case series have documented a resolution of over 80% of VMA-associated macular holes smaller than 200 μm after injection of expansile gas [100% sulfur hexafluoride or 100% perfluoropropane (C3F8)] followed by at least 3 days of prone positioning. This represents a higher success rate of posterior hyaloid face separation than that of ocriplasmin at a fraction of ocriplasmin's cost. However, the safety of this procedure has not yet been evaluated in larger studies; additionally, it requires prone positioning from patients and imposes travel restrictions.
PPV has been the gold standard for treatment of VMA and for repair of macular holes. The use of microincisional (23, 25, 27 G) transconjunctival PPV under local anesthesia results in minimal postoperative discomfort with a short recovery time. The efficacy of PPV in releasing VMA or closing macular holes is thought to be upwards of 90%, significantly higher than the success rate of intravitreal ocriplasmin whose effectiveness is <50%, even in carefully selected patients. An additional benefit of PPV over ocriplasmin is that PPV results in complete removal of vitreous floaters, a common complaint in patients receiving intravitreal ocriplasmin.
Although most surgeons request prone positioning in macular hole patients postoperatively, there is increasing evidence that prone positioning is unnecessary for macular holes <400 μm in diameter. However, a gas bubble is required for surgical macular hole repair, resulting in reduced vision for at least 1 week and travel restriction, which can be bypassed when treating with ocriplasmin. Considering adverse effects and complications of these various approaches, the risk of endophthalmitis may be less with PPV compared with ocriplasmin, whereas the risk of retinal detachment may be similar. Cataract progression is universal after PPV; it is unclear whether this is the case after ocriplasmin injection as follow-up is limited thus far. It is also worth noting that the cost of ocriplasmin is approximately 10% more than the cost of surgery at an ambulatory surgical center including both the facility fee and the surgeon fee (based on author institutional data).
Comparison of Ocriplasmin to Vitrectomy or Pneumatic Induction of Posterior Hyaloid Face Separation
Intravitreal injection of an expansile gas bubble has also been shown to induce a posterior hyaloid face separation. Small case series have documented a resolution of over 80% of VMA-associated macular holes smaller than 200 μm after injection of expansile gas [100% sulfur hexafluoride or 100% perfluoropropane (C3F8)] followed by at least 3 days of prone positioning. This represents a higher success rate of posterior hyaloid face separation than that of ocriplasmin at a fraction of ocriplasmin's cost. However, the safety of this procedure has not yet been evaluated in larger studies; additionally, it requires prone positioning from patients and imposes travel restrictions.
PPV has been the gold standard for treatment of VMA and for repair of macular holes. The use of microincisional (23, 25, 27 G) transconjunctival PPV under local anesthesia results in minimal postoperative discomfort with a short recovery time. The efficacy of PPV in releasing VMA or closing macular holes is thought to be upwards of 90%, significantly higher than the success rate of intravitreal ocriplasmin whose effectiveness is <50%, even in carefully selected patients. An additional benefit of PPV over ocriplasmin is that PPV results in complete removal of vitreous floaters, a common complaint in patients receiving intravitreal ocriplasmin.
Although most surgeons request prone positioning in macular hole patients postoperatively, there is increasing evidence that prone positioning is unnecessary for macular holes <400 μm in diameter. However, a gas bubble is required for surgical macular hole repair, resulting in reduced vision for at least 1 week and travel restriction, which can be bypassed when treating with ocriplasmin. Considering adverse effects and complications of these various approaches, the risk of endophthalmitis may be less with PPV compared with ocriplasmin, whereas the risk of retinal detachment may be similar. Cataract progression is universal after PPV; it is unclear whether this is the case after ocriplasmin injection as follow-up is limited thus far. It is also worth noting that the cost of ocriplasmin is approximately 10% more than the cost of surgery at an ambulatory surgical center including both the facility fee and the surgeon fee (based on author institutional data).