First Author: E.Pedemonte-Sarrias SPAIN
Co Author(s): X. Valldeperas
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To report the use of intravitreal perfluoropropane (C3F8) injection in the management of a diabetic vitreomacular traction (VMT) previously unresponsive to ocriplasmin.
Ophthalmology Department. Hospital Universitari Germans Trias i Pujol, Badalona (Spain). Universitat Autònoma de Barcelona.
An 80 year-old pseudophakic diabetic female patient with a mild non-proliferative diabetic retinopathy was studied in our department. Best-corrected visual acuity (BCVA) was 20/63 in the right eye and 20/100 in the left eye. She had bilateral VMT that required pars plana vitrectomy and posterior vitreous detachment (PVD) in the left eye, one year before. The right macula showed a focal vitreomacular adhesion (568µm) and underlying cystoid changes on SD-OCT examination. The patient was treated with three monthly ranibizumab (Lucentis®) injections in order to reduce macular edema.
After anti-VEGF treatment, BCVA improved to 20/40 but VMT and macular cystoid degeneration remained unchanged. Seven months later, the patient received an intravitreal Ocriplasmin (Jetrea®) injection (0,125mg) suspecting a tractional cause of the cystoid macular edema more than a hyperpermeability aetiology. Nevertheless, 6 months later no changes on BCVA or cystoid edema were observed, and posterior vitreous was still attached to the fovea. The patient was then proposed for another treatment to release the posterior vitreous and was injected with 0.4mL pure C3F8 under sterile conditions. After the intravitreal treatment, the patient was instructed to perform “drinking bird” head movements, by bobbing the head forward and backward two times every hour for the first five days after the injection. One month later, posterior vitreous had successfully detached but, unfortunately, BCVA and cystoid changes remained unmodified. This chronic situation of the macular persisted six months later even after a dexamethasone implant (Ozurdex®) was placed in the vitreous cavity of the patient, with similar BCVA.
Enzymatic vitreolysis with intravitreal Ocriplasmin has shown a moderate efficacy inducing a PVD in several studies. PVD induction rate may be increased by adequate patient selection, especially in younger female phakic patients with focal vitreomacular adhesion. Similarly, intravitreal anti-VEGF injections have been reported to induce PVD, also in diabetic patients. The patient we present did not respond to Ocriplasmin injection although she presented a focal vitreomacular adhesion. This might be to a poor selection of the treatment option in this specific case, as the patient had diabetic retinopathy, was old and pseudophakic. We report a successful induction of a PVD in a focal VMT after the injection of expansile C3F8 and specific head movements the days after the procedure, in a diabetic macular edema case unresponsive to previous Ocriplasmin injection. The rationale behind this treatment is the potential vitreous mobilization with the expansion of the gas agent and sudden head movements, inducing a more controlled, slow and “physiological” PVD.