Vitreomacular Traction: What s the Role of the Vitreoretinal Interface in this Disease?

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1 Vitreomacular Traction: What s the Role of the Vitreoretinal Interface in this Disease? Robert A. Stoltz, M.D., Ph.D. Georgia Retina, P.C. Retinal Pearls 2013

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3 Anatomy of the Vitreous Gel Physical Properties Clear gel about 4 ml in volume Allows the transmission of about 90% of light wavelengths between 300 and 1400 nm Mechanically stabilizes the volume of the globe Pathway for nutrients to reach the lens and retina 98% water by volume solution of salts, soluble proteins, and hyaluronic acid contained within a meshwork of insoluble protein fibers (fine collagen fibrils, Type II)

4 Vitreous Gel Composition

5 Vitreous Attachments Vitreous Base Peripheral margin of the Optic Nerve Head Posterior pole margin of the fovea retinal veins in the mid-periphery may account for avulsed retinal vessels and HSTs with bridging vessels after acute PVD Abnormal areas Lattice degeneration Cystic retinal tufts Chorioretinal scars

6 Aging Changes Young Eyes--macroscopic structure is uniform dense portions of gel have greater resistance to mechanical stress (peripheral central in 1st yr. of life) Adults--differentiation and degeneration of the vitreous gel results Liquefaction/syneresis 25% by yr of age 50% in more than 70% of eyes by age >70 earlier in myopic eyes accelerated by trauma, surgery, inflammation

7 Aging Changes Posterior Vitreous Detachment (PVD) most important age-related pathologic change <10% of pts. under age 50 27% of pts. age % of pts. age >70

8 Vitreomacular Adhesion (VMA) Occurs when the vitreous remains attached to the macula during vitreous separation

9 Vitreomacular Adhesion (VMA)

10 Symptomatic Vitreomacular Adhesion (VMA)

11 Symptomatic Vitreomacular Adhesion (VMA)

12 Symptomatic Vitreomacular Adhesion (VMA)

13 Treatment Paradigm Release the vitreo-macular adhesion to thereby allow the retina to relax and restore the normal central retinal architecture Observation Surgery Pharmacologic vitreolysis

14 Surgery for Symptomatic VMA Pros Very successful in most cases Short OR time Quick recovery (unless patient has an accompanying MH)

15 Surgery for Symptomatic VMA Clinical Vignette L.W. is an 82 y.o. pseudophakic female who presented with decreased vision in the right eye of 20/100 and symptoms of distorted vision and difficulty reading. Observed for 2 months with no resolution Opted for surgery

16 Surgery for Symptomatic VMA Show Video

17 Surgery for Symptomatic VMA Post-op Face down for 3 days Final Vision: 20/60 OCT Improved central retinal architecture

18 Surgery for Symptomatic VMA Cons Large economic impact on the individual patient, his or her family, and the health system Patient has to take time off from work Patient has to enlist help from family or friends for care and transportation perioperatively Multiple post-operative visits Ocular drops Face down positioning paraphernalia Lost work time associated with surgery and recuperation OR costs

19 Surgery for Symptomatic VMA Cons Anesthesia risks Surgical risks Infection, retinal tears ± retinal detachment, cataract progression Some patients are poor surgical candidates Comorbid conditions Obesity Lack of support network for post-operative care

20 A New Treatment Option for VMA Pharmacologic Vitreolysis Promising prospect for manipulation of the vitreous and retina Vitreous has characteristics that make it ideal for enzymatic manipulation Predominantly water Mostly acellular Allows rapid diffusion of drugs The vitreoretinal interface has molecular adhesions that occur via linkages among heparin sulfates, proteoglycans, collagen and opticin.

21 Ocriplasmin (Jetrea, Thrombogenics) FDA-approved on October 17, 2012 for symptomatic VMA

22 Ocriplasmin (Jetrea, Thrombogenics) Purported Mechanism of Action Ocriplasmin, sometimes referred to as microplasmin, is a recombinant truncated form of human plasmin obtained by recombinant DNA technology Ocriplasmin is purported to exert proteolytic effects on fibrinogen, fibronectin and, to a lesser extent, laminin and collagen, each of which is a component of vitreomacular adhesion (VMA).

23 Individual Studies/Clinical Trials Safety and efficacy of ocriplasmin for the treatment of VMA was evaluated in two phase 3 trials (MIVI-006 and MIVI-007). Both multicenter, randomized, placebocontrolled, double-masked, 6 month studies. Identical in design (except for allocation ratio of 2:1 in TG-MV-006 and 3:1 in TG- MV-007) and conduct (except for geography: -006 conducted in the US and conducted in the EU and the US.

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35 Summary Ocriplasmin treatment demonstrated efficacy in VMA resolution in a phase 3 clinical trial program Pharmacologic VMA resolution occurred at day 28 in a significantly larger proportion of patient in the ocriplasmin group versus placebo Greater than 70% of the ocriplasmin responders had VMA resolution by 7 days post-injection FTMH closure occurred in a larger proportion of patients in the ocriplasmin group vs. placebo at day 28 Most suspected adverse drug reactions were non-serious, transient and mild in severity Ocriplasmin was well-tolerated and is the first pharmacologic treatment for patients with symptomatic VMA Possible role in pediatric retina, diabetic retinopathy, and other vitreoretinal diseases.

36 Conclusions VMA is a disease process affecting older patients disproportionately With improvements in OCT, VMA more widely recognized The old treatment paradigm of Watch and wait for less symptomatic patients with vision >20/40, or surgery for symptomatic patients with lesser vision is changing Pharmacologic vitreolysis with Ocriplasmin has the potential to have a large positive economic impact on the individual patient, his/her family, and the health care system.

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