Features
Ocriplasmin is a recombinant truncated form of plasmin approved by the FDA in 2012 for the treatment of symptomatic vitreomacular adhesion. The enzyme has nonspecific proteolytic activity against multiple proteins, including laminin and fibronectin which are constituents of vitreous. Phase 3 randomized clinical trials showed that an intravitreal injection of ocriplasmin resolved vitreomacular adhesion in 26.5% of patients versus 10.1% of controls injected with placebo. The potential advantages of ocriplasmin compared with vitrectomy include the ease of a simple office-based procedure, avoidance of surgical risk, and faster visual and procedure-related recovery. Following more widespread use, it is clear that ocriplasmin may be associated with acute transient panretinal dysfunction in a significant portion of treated eyes. While the retinal alterations are reversible in the majority of eyes, retinal dysfunction and visual compromise persist indefinitely in a small minority of eyes.
Although the intended targets for ocriplasmin are laminin and fibronectin at the vitreoretinal interface, laminin is also found in many other ocular structures, including the zonules and multiple layers of the retina. Because the adverse effects of ocriplasmin correlate well with the distribution of laminin within the eye, enzymatic degradation of laminin is a plausible hypothesis for the primary pathogenic mechanism of ocriplasmin retinopathy. However, ocriplasmin is a nonspecific protease and cleavage of more than one protein may be responsible for its various potential transient adverse effects in the eye.
87.1.1 Common Symptoms
Acute ocriplasmin retinopathy symptoms vary; patients may have atypical photopsias not related to PVD formation (e.g., sparkles, continuous kaleidoscopic lines, white floaters), dyschromatopsias (e.g., black and white or “negative” vision, yellow tint), nyctalopia, acute reduction in visual acuity (rarely to as low as light perception), fragmented or pixilated vision, and/or visual field defect.
87.1.2 Exam Findings
Signs of acute ocriplasmin retinopathy include relative afferent pupillary defect, anisocoria, lens subluxation or phacodonesis, retinal vessel attenuation, macular hole enlargement, macular detachment, and rarely diffuse fundus pigmentary changes (▶ Fig. 87.1, ▶ Fig. 87.2).
Fig. 87.1 Ocriplasmin retinopathy. Horizontal spectral domain optical coherence tomography imaging of the left eye 1 month after ocriplasmin injection. The patient complained bitterly of dyschromatopsia and poor quality vision in the left eye. There is irregular attenuation of the outer retinal signals, including the external limiting membrane, ellipsoid layer, and interdigitation zone. Note also the multifocal microblebs of subretinal fluid, suggesting reduced adhesion between the photoreceptors and retinal pigment epithelium.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
