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In cases of symptomatic vitreomacular adhesion without full-thickness macular hole, do you tend to observe for spontaneous resolution or treat with Jetrea (ocriplasmin, ThromboGenics)?
Perspective
Paul E. Tornambe
At the moment, I approach VMT as follows: If there is OCT evidence of VMT and the patient has no symptoms, no treatment is advised. (It is difficult to make a patient better who has no complaints.) If there are symptoms, but the adhesion is small (less than 500 µm), and if the fellow eye has had no problems, such as a macular hole, I manage these eyes conservatively, for I have found that many of these remain stable or release without treatment. If the fellow eye had VMT that spontaneously resolved without problems, I manage the fellow eye conservatively. If the fellow eye developed a macular hole, and if the adhesion is less than 1,500 µm, I will suggest Jetrea. If the adhesion is greater than1,500 µm, I will advise vitrectomy.
Paul E. Tornambe, MD, FACS
Disclosure: Tornambe has no relevant financial disclosures.
Perspective
Michael Singer
I tend to treat symptomatic vitreomacular adhesion with ocriplasmin, depending on symptoms, area of adhesion and patient motivation. When a patient comes into my office, I assess their motivation. If they are symptomatic, I start the consideration of ocriplasmin. I look at the OCT and make sure that it is a very small area of vitreomacular adhesion and that the adhesion is causing traction. I counsel the patient on different options including risks and benefits. If they decide to do ocriplasmin, I explain that there is a chance that this may be successful, but there is also a chance that this may not be successful. If it is not successful, they can still go to surgery. Depending on the patient, I usually get one of three responses: They want surgery, they are willing to try ocriplasmin, or it is not so bad after all and they want to wait. In terms of observation, I usually see them back in 2 to 3 months.
Michael Singer, MD
Disclosure: Singer is a consultant for ThromboGenics and Bausch + Lomb.
Perspective
Timothy W. Olsen
In my opinion, one should observe symptomatic vitreomacular adhesion and watch the OCT for signs of progression (ie, release of traction). Data suggest that most early-stage macular holes (stage 1) will spontaneously involute. Most patients with this condition are modestly symptomatic and are able to report progression. Also, a macular hole is not an urgent condition, and management can be carefully discussed and planned, should the adhesion evolve into a full-thickness hole. Therefore, cautious observation seems to be the best initial choice and is supported by the literature. If the lesion progresses, remains symptomatic or progresses to a full-thickness macular hole, then either pars plana vitrectomy with membrane peeling or consideration of ocriplasmin could be discussed, including the cost-benefit ratio as well as clinical experience with each.
Timothy W. Olsen, MD
Disclosure: Olsen has no relevant financial disclosures.
Perspective
Nikolas London
For me this depends quite a bit on the situation. I ask my patients a lot of questions before I discuss the options with them, and I always present all of the options. Some questions I might ask: How much does it bother the patient, and are the symptoms evolving for the better or for worse? Not everyone is bothered by a 20/40 adhesion and every patient has a different threshold for considering treatment. How long has the VMA has been present? Adhesions present for many months or longer are less likely to resolve spontaneously, and may be less likely to respond to ocriplasmin. Is there similar disease in the other eye (eg, VMA that progressed to a hole, or VMA that responded good or bad to a particular treatment)? I also consider all of the clinical factors that impact the potential success of ocriplasmin, including age, phakic status, presence of an ERM, and size of the VMA. Following consideration of all of these factors I discuss the options with my patients and give them my opinion. In general, to answer the question, I prefer observation in any situation where I think the patient may improve on their own, ocriplasmin if I am worried that they will not, and surgery for patients with a low chance of success with ocriplasmin.
Nikolas London, MD
Disclosure: London has no relevant financial disclosures.