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8. St.Galler Ophtag Josef Guber 31.05.2018

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GASINJECTION FOR VITREOMACULAR TRACTION

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Treatment

∙ Symptomatic patients (blurred and distorted vision)

1. Observation 2. Pars plana Vitrectomy 3. Pharmacologic vitreolysis 4. NEW: Pneumatic vitreolysis

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Observation

∙ 189 eyes, follow-up 17.4±12.1 months ∙ Spontanous resolution in 20% (on average at 15months) ∙ 12% developed a macular hole ∙ With persistent VMT, vision and central foveal thickness

remained unchanged

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PPV ± ERM-/ ILM-Peeling

+ 100% Release rate + for all indications (e.g. ERM) - GA, inpatient, costs - surgical risk, cataract formation, postvitrectomy macular hole ~10%,

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Pharmacologic vitreolysis

∙ Ocriplasmin (Jetrea), since 2013:

enzymatic activity at the vitreoretinal interface (fibronectin, laminin, collagen)

∙ MIVI-TRUST Trial: 26.5% VMT resolution, MH<250µm = 58% closure rate

∙ OASIS Trial: 42% VMT resolution

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Pharmacologic vitreolysis

+ simple procedure - low resolution rate - limited indications (absence of ERM, <1500microns) - costs (~3’500CHF) - Side effects: transient vision loss 17%, ellipsoid zone alteration = 50%, FTMH = 9%, RD = 3%, Phacodenesis

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NEW: Pneumatic vitreolysis ∙ Pneumatic retinopexy, rTPA + intravitreal Gas ∙ PVD:

∙ Mechanical by displacement ∙ Destabilization of the vitreous integrity by accentuating liquefaction

(synchysis) during the gas expansion phase and cortical vitreous collapse (syneresis) during the absorption phase of the bubble.

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∙ Paracentesis ∙ Intravitreal injections of

0,3ml C3F8 Gas 100% ∙ Postoperative medication:

Diamox 250 3x/d for 3 days

∙ Follow-up: ∙ 1 day, 1 week, 4 weeks with

OCT ∙ No posture required ∙ Not allowed > 1000 meters ∙ Postoperative Floaters

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Gas Release rate Air 2/14 (14%) SF6 Gas 15/27 (56%) C3F8 Gas 27/32 (84%)

Steinle N, Dhoot D,Pieramici DJ, et al. Comparison of three non-surgical treatments for vitreomacular traction. ARVO 2016

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Exclusion Criteria

∙ History of vitrectomy ∙ Aphakia ∙ PDRP ∙ Uncontrolled Glaucoma ∙ High myopia ∙ History of retinal detachment / breaks / vitreous hemorrhage /

Lattice areas Fundus examination prior treatment

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Study n Release rate

Rodrigues et al 2013

15 6 (40%)

Chan et al 2016

35 31(88%)

Steinle et al 2016

32 27(84%)

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Patients Age Secondary diagnosis Phaco

1 85 No

2 79 ERF No

3 78 ERF No

4 78 Yes

5 81 Yes

6 62 DRP, pALK Yes

7 79 Makulaloch Yes

8 82 Trockenen AMD Yes

9 75 Makulaloch No

10 84 Yes

11 82 Trockene AMD Yes

12 85 ERF No

13 87 Yes

14 77 Yes

15 72 No

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Results Resolution rate ∙ 13/15 (87%) VMT completely or partially resolved

∙ 8/15 (53%) complete ∙ 5/15 (33%) partial / VMA

∙ 2/15 (13%) VMT persistent Complications ∙ 2/15 (13%) Macular hole postoperatively ∙ 0/15 (0%) Retinal tear/detachment, Endophthalmitis, IOP↑

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Patient 4

preop

1/12

0.5

0.6

preop 0.6

Patient 10

1/12 1.0

Patient 15

preop

preop 0.5

1.0

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Patient 5 Patient 8/11 OD Patient 8/11 OS

preop preop preop

1/12 1/12 1/12 0.6

0.3 0.2

0.5 0.9

0.4

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Referent / Bereich

0.5

0.8

0.1

0.5

Patient 7 Patient 9

1/12 1/12

preop preop

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Referent / Bereich

0.7

0.7

0.3

0.4

Patient 2 Patient 3

preop preop

1/12 1/12 1/12 0.2

preop 0.1

Patient 12

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Referent / Bereich

0.4

FZ

0.6

Patient 1 Patient 14

preop preop 0.1

1/12

Post PPV

1/12 0.1

0.1 preop

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Conclusions ∙ Simple procedure, cost-effective ∙ In overall, good VMT resolution rate after C3F8 injection ∙ No intra- or postoperative surgical complications ∙ Presence of epiretinal membrane over the macula,

thickening of posterior vitreous membrane and broad VMT are associated with a higher failure rate

∙ Pronounced foveoschisis can lead to macular hole formation Consider primary PPV

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Thank you

Contact: Josef Guber Augenklinik, Haus 04 Kantonsspital Sankt Gallen josef.guber@kssg.ch

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