8. st.galler ophtag...st. galler ophtag pharmacologic vitreolysis ∙ ocriplasmin (jetrea), since...
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St. Galler Ophtag
8. St.Galler Ophtag Josef Guber 31.05.2018
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GASINJECTION FOR VITREOMACULAR TRACTION
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Guber/VR
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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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Guber/VR
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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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Guber/VR
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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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