Pneumo-Enzymatic Vitreolysis for Resistant Vitreomacular Traction

Aim: Case report describing a patient with resistant vitreomacular traction (VMT) treated with an intravitreal injection of a potentially safer, lower dose of ocriplasmin and with a residual intravitreal gas bubble from pneumatic vitreolysis. Case Report: An 88-year-old man with symptomatic vitreomacular traction (VMT) was observed for 4 weeks without spontaneous release. Pneumatic vitreolysis (PV, intravitreal injection of expansile gas with intermittent face-down positioning [FDP]) was performed. Four weeks later, a 30% bubble was still present in the vitreous, vision remained 20/70, and he had improved but persistent VMT. One-half of the recommended therapeutic dose of ocriplasmin was injected intravitreally and the patient continued FDP. At one-week follow-up, the patient had improved vision of 20/40, associated with complete VMT release. He had no adverse events. Discussion: Resistant VMT can lead to significant foveal distortion and subsequent vision loss. Pneumatic vitreolysis appears to successfully relieve VMT in about 80% of cases, but in the 20% of cases that do not respond, typically invasive, surgical intervention is required. This report shows the efficacy of combining the mechanical forces of PV with the enzymatic fibrinolytic activity available in a potentially safer, lower dose of ocriplasmin to treat resistant VMT cases, non-invasively. Summary: For resistant vitreomacular traction, combining the mechanical force of an intravitreal injection of an expansile gas with a half-dose of ocriplasmin could provide an efficacious treatment option, without the risk of the toxic safety profile often associated with ocriplasmin.