New Drug Induces Posterior Vitreous Detachment (PVD)

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New Drug Induces Posterior Vitreous Detachment (PVD)

A Posterior Vitreous Detachment May Cause a Retinal Tear

Posterior Vitreous Detachment "Separates" from the Retinal Surface

A new drug, Ocriplasmin, is seeking FDA approval for treatment of some retinal disorders.  Ocriplasmin (also known as microplasmin) may help patients with vitreomacular traction syndrome (VMT) and macular hole by chemically inducing a PVD.

The drug may gain Priority Review status by FDA later this year.  Priority Review is a special designation for drugs that show either a significant improvement over existing therapies, or where there is not current therapy.

VMT and macular hole are two similar conditions where vitreous remains adherent to the macula causing pulling and stretching of the macular area.  This physically disrupts the macula causing decreased vision and /or  distortion.

Current therapy includes surgery to separate the vitreous from the underlying retinal tissue.  Ocriplasmin may achieve the same goal by chemically separating this interface.

The drug has been given by intravitreal injection.

Posterior Vitreous Detachment (PVD)

The excitement in the retinal field stems from the fact that so many retinal diseases are caused by the vitreous.  Many macular disorders are probably caused by interaction between the macula (retina) and the adherent vitreous.

Currently, the vitreous separates from the retina either naturally as we get older or it is induced surgically.

As we age, the vitreous proteins degenerate as does the “glue” keeping the vitreous adherent to the retina.  At some point in everyone’s life a posterior vitreous detachment naturally occurs. At the time of a PVD, there is a naturally increased risk of sustaining a retinal tear.  Retinal tears may develop into retinal detachments.

During surgery for many retinal diseases, surgical induction of a PVD is often helpful to achieve the surgical goal.  There are, however, potential complications from pulling the vitreous away from the retina.  There is a greater chance of surgically causing retinal tears!

What Does This Mean?

Chemical induction of a PVD would be a great alternative to surgery.  In theory, the chance of retinal tear is greatly reduced by avoiding surgery.  Hence, it is an attractive and potentially safer alternative compared to surgery because the complications may be fewer.

Just as important, however, is whether the new treatment is as effective as the current treatment.  In other words, will simply injecting the new drug improve patient results as compared to surgical techniques.

If the drug gets approved by the FDA, it will be “approved” for VMT/macular holes.  Once on the market, however, it will be likely be adopted for use in many other retinal conditions.

Used as an adjunct to surgery, the complication rate of retinal tears might be decreased making “surgery” much safer.

 

 

 

Comments
  • Al February 24, 2012 at 7:29 am

    Dear Doctor Wong,
    do you think, that this new drug can also be helpful for floater vitrectomy ??
    Is it useful here and can it reduce some risks here ?
    Thanks,
    br Al

    • Randall V. Wong, M.D. February 24, 2012 at 9:58 pm

      Dear Al,

      Tough question. I struggled with adding a bit about that toward the end of the article. Not sure there is really a place for the new drug. One thing that is not clear is how long the PVD will take to occur. It may take at least 3-4 weeks and only in some of the patients…not sure that I’d consider this a “slam-dunk” yet.

      On the other hand, if you have VMT/macular hole….that’s a different story…not dealing with a normal eye and in eyes with reduced vision.

      This is why we must also question how effective the drug may be.

      Good question.

      Randy

  • Lee February 26, 2012 at 6:15 pm

    Dear Dr. Randall,

    I keep reading about how inducing a PVD would help patients with floaters. Can you tell me why?

    Thanks,
    Lee

    • Randall V. Wong, M.D. February 28, 2012 at 5:24 pm

      Dear Lee,

      There is a fear that if a PVD is NOT induced at the time of surgery then when a PVD naturally occurs later in life, the floaters will return.

      Not sure if this is really true. Consider everyone gets a PVD as we age. It is a natural event. Very few people have issues with floaters.

      Also, no telling when a PVD will occur. If you are young and have issues with floaters, it may be decades before a PVD occurs naturally.

      Hope this was somewhat helpful.

      Randy

  • harm March 31, 2012 at 4:25 pm

    Dear dr Wong,

    Many young people have floaters that are located very close to the retina that can hardly be seen by doctors because theya re too small, but appear big to the patients. Do you know if inducing a PVD or a natually occuring PVD may get rid of those floaters when the distance to the retina gets bigger?

    Harm

    • Randall V. Wong, M.D. April 4, 2012 at 6:41 am

      Dear Harm,

      Inducing a PVD would indeed remove any floaters close to the retina. I don’t think that’s the problem. Most, if not all, floaters/vitreous can be safely removed by getting close enough to the retina and NOT inducing a PVD.

      Remember, too, doctors/examiners can NOT see all the floaters visible to a patient, or rather, we (docs) can NOT always determine which floaters are problematic – your vitreous is supposed to be transparent to you, yet completely visible to me.

      Hope this was more helpful than confusing.

      Randy

  • Josh April 10, 2012 at 9:19 pm

    How about inducing PVD to reduce risk of PDR? Remove the “scaffolding” for neovasculation and add oxygen all at once?

    Thoughts?

  • Pete April 11, 2012 at 3:51 pm

    Hi dr Wong,

    Do you think this drug could already help floater patients without performing a FOV? or would FOV still be needed after inducing PVD?

    Pete

    • Randall V. Wong, M.D. April 20, 2012 at 11:39 am

      Dear Pete,

      That was my point in writing about this. There is the potential that this drug may obviate the need to surgically “induce” a PVD, but I don’t think it will obviate the need for surgery. It may simply chemically cause a PVD versus physically separating the vitreous from the retina.

      Randy

  • Ken E April 22, 2012 at 1:28 pm

    Thanks Dr. Wong. I’ve been following this developing story and feel good that you are too. I had a vitrectomy in one of my eyes several months ago following PVD that caused a tear. My doc repaired the tear and then several months later performed the vitrectomy to remove all the floaters and debris caused by PVD. I now have tons of floaters in my other eye but I don’t think that I have had PVD yet as the floaters are different than my other eye, however, the sheer volume is exponential. Reading your comment above, are you implying that a vitrectomy to remove floaters can be done successfully on a patient who has not yet had PVD and without inducing PVD? I’ll add that I’m not “young” being just over 50. I don’t like what I hear about how the induced PVD process involves if I understand it correctly as it sounds like there is a potential for both short- and long-term risks. Thanks for all the valuable info you put onyour sires and for participating in these comments.

    • Randall V. Wong, M.D. April 23, 2012 at 6:38 pm

      Dear Ken,

      Yes, I feel strongly that a vitrectomy can be done to successfully remove the floaters that are bothering you without inducing a PVD.

      I do not induce a PVD in this situation and do not feel it is necessary.

      Randy

  • Ken E May 2, 2012 at 8:03 pm

    Do you have any additional info about non-PVD induced vitrectomies? I went in for my follow up and my doc wasn’t interested in discussing a PVD induced or a non-PVD induced vitrectomy. He said just wait but who knows, I could wait 5-10 years for my PVD. Thanks Dr. Wong.

    • Randall V. Wong, M.D. May 3, 2012 at 12:08 pm

      Dear Ken,

      I don’t feel that non-PVD vitrectomies are bad. I think removing most of the vitreous, but not specifically inducing a PVD probably;

      1. Decreases the likelihood of dense floaters when the PVD eventually, and naturally, occurs.
      2. Prolongs onset of the PVD, that is, it may occur later in life as there is less inertia from the central “core” vitreous to naturally induce the PVD.

      Randy

  • Ken E May 4, 2012 at 3:54 pm

    Ok, one more and I’ll leave you alone on this subject. What about frill? My doc (appropriately) left vitreous against and near the lens, however, I guess there is no way to determine what the patient may see. I have a somewhat bothersome area from frill. In doing a core FOV, would the patient be subject to frill around the entire eye? Did I ask that correctly? It would be fantastic to be rid of my floaters but not as a trade off to frill. Thanks a million.

    • Randall V. Wong, M.D. May 13, 2012 at 1:25 pm

      Dear Ken,

      Believe it or not, I’ve never heard of “frill.” Is it the interface between “cut” vitreous and fluid?

      Usually it doesn’t impact or create much change in the vision.

      Wouldn’t be terribly concerned.

      r

  • Ken E May 15, 2012 at 2:37 pm

    The frill I’m referring to is the edge of the vitreous left after a vitrectomy to preserve the lense. I see a type of flapping in the very upper right part of my periphery. If vitreous is left around the entire circumference of the eye during a core vitrectomy, does the vitreous left behind become visible? thanks Dr. Wong

    • Randall V. Wong, M.D. May 22, 2012 at 1:32 pm

      Dear Ken E,

      No I doubt it would be visible. It is possible that there was/is some opacity/large floater left in the remaining “frill’ and that’s what you are seeing and not the “edge.”

      r

  • David Lee May 26, 2012 at 3:35 pm

    Hello there….. I to had a induced PVD……

    Had a follow up with my surgeon, he said he cant see this frill/ wavy dark line I see to the far right of my fov’ed eye…..

    he did say it wasent anything serious like a retinal tear ect so it must either be a strand of lose vitreous or where the surgeons stopped cutting….

    I just wonderd could a core fov help this?

    thanks

    David

    • Randall V. Wong, M.D. June 4, 2012 at 3:19 pm

      Dear David,

      FOV is the same as core vitrectomy….or at least in the world according to Wong!

      The vitrectomy operation is the same as a “core” vitrectomy. When performed to remove floaters, it is called FOV.

      Any help?

      r

  • Subir June 16, 2012 at 5:48 pm

    thanks for the article. Like many males in their 20s, I have a floater very close to my retina in the “bursa premacularis” area, and I think chemically inducing PVD may make the shadow on my retina much smaller by just moving the floater a few millimeters further away without having to go through the additional problem of FOV.

    Do you think my suspicion could be right, Dr. Wong?

    -Subir

    • Randall V. Wong, M.D. June 18, 2012 at 10:39 am

      Dear Subir,

      Yes. Possible, but also many not be helpful as there is no way to predict if there will be a change in the location of the floater upon PVD.

      There are risks of the injection vs. risks of an operation.

      Randy

  • Jochem October 22, 2012 at 9:26 am

    For those interested: FDA approves ocriplasmin: November 18

    http://thrombogenics.com/news-events/latest-press-releases/

    I hope it will be of any use in the treatment of floaters by inducing PVD so that the floaters move away from the retina or just to make vitrectomy easier.

    • Randall V. Wong, M.D. October 24, 2012 at 7:25 am

      Dear Jochem,

      This indeed may be helpful. Remember, when a PVD “naturally” occurs, there is a chance of a retinal tear. Who knows if this is true with a chemically induced PVD?

      Also, I would like to find out the risk of infection of the actual injection vs. risks of vitrectomy.

      Stay tuned!

      r

  • ND October 26, 2012 at 2:24 pm

    Hi Dr Wong
    I am just 29 and have been diagnosed today with a PVD in my Right eye where i had a retinal tear 10 years back. Could you point out complications of PVD at such a young age and how the new drug might help.

    • Randall V. Wong, M.D. October 30, 2012 at 12:10 pm

      Dear ND,

      29 years is pretty young for a PVD. In a way, however, it is a good thing. The vitreous only causes problems in the eye…such as a retinal tear. I don’t know any long term complications that might occur from a long-standing pvd.

      The new drug, in my opinion, won’t help. It is only good a creating a PVD…which you already have.

      Randy

  • ND October 26, 2012 at 2:52 pm

    Sorry for asking one more question…just taking time to collect my thoughts…wouldnt this drug could help prevent ‘epiretinal membrane’…since the seperation of vitreous from retina would be induced and (probably) controlled !

    • Randall V. Wong, M.D. October 30, 2012 at 12:11 pm

      Good thought, but in my experience, PVD is the start or instigating factor leading to the development of ERM.

      In most of patients with ERM, a PVD is already present.

      Good thought!

      r

  • Freddie Maxwell September 2, 2013 at 11:52 am

    Hello Dr, Wong

    I have what my eye Doc calls Weiss ring floaters, I have them in both eyes and it’s been over a year and a half since the onset. They have dropped a little bit, but now they are right in my field of vision, My retinologist seems to think they might still settle to the bottom with time, but I have my doubts at this point. Do you think I may have a full PVD or maybe a partial one that is still keeping the virus from fully separating from the retina? I’m experiencing flashes in my left eye which my ophthalmologist believes virus gel is still tugging on the retina. These rings have what appears to be a tail at the end, is this tail whats attached to the retina and keeping the natural gravity from letting them drop…Or am I just making an untrained guess…My question is, will this drug help in allowing these Weiss rings drop out of my field of vision and eventually drop to the bottom?, or is a FOV the only option (which my retinologist refuses to preform because of the risks involved) This condition is very debilitating and my quality of life has diminished to the point that I almost had a successful suicide attempt last fall where I ended up in the ICU for 15 days. Very bad situation, but that’s another story. I am willing to try anything no matter the risks to make them go away. Thanks for taking the time to read this…Freddie

    • Randall V. Wong, M.D. October 8, 2013 at 2:41 pm

      Freddie,

      Apologize for the long delay.

      You undoubtedly have a PVD. No real such thing as partial.

      Jetrea may do nothing at all as it is designed to chemically induce a PVD. But you already have one (or two).

      Vitrectomy (25 gauge) is safer than cataract surgery with regards to infection and/or retinal detachment. Your retinologist may not understand this nor perform using 25 gauge.

      If you had one choice to definitively remove the floaters…vitrectomy (FOV).

      Hope this was helpful and, again, sorry for the long delay in responding.
      Randy
      Randall V. Wong, M.D.
      Retina Specialist
      Fairfax, VA 22030

      http://www.TotalRetina.com

  • cathy seeman gajdos January 7, 2014 at 9:18 am

    hi I having been dealing with a Weiss ring for 5 years I was 21 with a retinal detachment then 30 years later a retinal tear I am 58 years old I have gone to several retina specialist all they say is there is nothing they can do but just recently I went to a retina doctor in Pittsburgh dr verstada he said to come back in 6 months he was talking about this drug. I also have cataracts, astigmatisms, the light are unbearable I have to follow up in February to my optholmoligists to see if the cataract which has the Weiss ring is ready. my question like the gentleman up above will the surgery help with this Weiss ring or the retina doctor who said to come back? thank you cathy gajdos

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  • Ocriplasmin Approved for VMT and Macular Hole October 31, 2012 at 11:37 am

    […] Ocriplasmin, or Jetrea,  has been FDA approved.  The drug is approved only for a retinal condition called vitreomacular traction (VMT) or vitreomacular adhesion (VMA).  The VMT may or may not be associated with a macular hole. […]