Q: What are your patient selection criteria for ocriplasmim (Jetrea, ThromboGenics)?

Dr. Dugel: I have the same criteria for treatment with ocriplasmin that I have for surgery. Patients must have vitreomacular adhesion (VMA), and it must be symptomatic. Within that group, the patients shown to have the greatest success with ocriplasmin are those with a VMA of 1500 μm or less and those with a macular hole of 400 μm or less. Because there is level 1 evidence to support the use of this drug in these patients, they represent the first tier of candidates for ocriplasmin.

The second group of patients who are candidates for ocriplasmin includes those with epiretinal membrane or VMA greater than 1500 μm. Ocriplasmin was successful in some of these patients, but not to the same extent as in the first group.

The third group of patients who could potentially benefit from ocriplasmin includes those with neovascular age-related macular degeneration, diabetic macular edema, and retinal vein occlusion. The key word here, however, is “potential,” because although there is some preliminary evidence that VMA may have significant influence on these diseases, the scientific data are lacking. If a relationship between VMA and these diseases is confirmed in larger studies, ocriplasmin may have an important role as a combination agent. We look forward to forthcoming scientific evidence.

Q: How do you manage patient expectations for treatment with ocriplasmin?

Dr. Dugel: If patients meet the criteria for ocriplasmin injection, I tell them that they are a candidate for vitrectomy, but that there is a drug with an excellent safety profile that has about a 50% chance of fixing the problem and allowing them to avoid surgery. If the drug doesn't work, they will go on to surgery that they would need anyway, and studies show that the success of surgery will not be compromised. If I were a patient, there would be no reason for me not to accept this line of treatment.

It is also important for surgeons to understand that this drug mirrors surgery very closely. The immediate impressive effects of anti-VEGF injections make it easy to expect a similar “wow” effect with an injection of ocriplasmin. However, that is not the case. Some patients may even have decreased vision before improving. As with vitrectomy, recovery is gradual, not immediate.

Q: Will this drug take away from the surgical procedures that will be performed?

Dr. Dugel: There is a small overlap. Patients with VMA less than 1500 μm and macular hole smaller than 400 μm may no longer need surgery. However, there are also many patients who have symptomatic VMA but who are not candidates for surgery. Although they cannot read or do other near vision tasks, their visual acuity may still be 20/30 or 20/40. They have real symptoms, but the risk-to-benefit ratio of vitrectomy surgery is still too great. We currently watch these patients, which is frustrating to both the patient and the physician. Now we have a medical treatment for this large group of patients who previously had no appropriate treatment, because with a drug the risk-benefit profile is more acceptable than with surgery. This is very exciting.

Pravin U. Dugel, MD, is Managing Partner of Retinal Consultants of Arizona in Phoenix; Clinical Associate Professor of Ophthalmology, Doheny Eye Institute, Keck School of Medicine at the University of Southern California, Los Angeles; and Founding Member of the Spectra Eye Institute in Sun City, AZ. He is a member of the Retina Today Editorial Board. Dr. Dugel states that he is a consultant for Alcon, Abbott Medical Optics, ArcticDx, Ora, Regeneron, and ThromboGenics. He can be reached via email at pdugel@gmail.com.