Intravitreal Injection of Expansile Perfluoropropane (C3F8) for the Treatment of Vitreomacular Traction

doi:10.1016/j.ajo.2012.08.018

American Journal of Ophthalmology

Volume 155, Issue 2, February 2013, Pages 270-276.e2

https://doi.org/10.1016/j.ajo.2012.08.018 Get rights and content

Purpose

To study the efficacy of a single intravitreal injection of expansile gas in releasing vitreomacular traction.

Design

Retrospective, interventional case series.

Methods

Fifteen eyes of 14 consecutive patients with symptomatic and persistent vitreomacular traction (>3 months’ duration) on spectral-domain optical coherence tomography (SD OCT) received a single intravitreal injection of 0.3 mL 100% perfluoropropane (C₃F₈) as an alternative to pars plana vitrectomy (PPV). Primary outcome was the number of eyes with complete vitreomacular traction release on OCT 1 month following treatment. Secondary outcomes included changes in visual acuity (VA), foveal contour, central foveal thickness, and maximal foveal thickness 1 month following treatment, and final VA.

Results

Mean age (± SD) was 72.1 ± 12.6 years. Mean follow-up was 398.7 ± 174.4 days. Vitreomacular traction was idiopathic in 7 eyes and associated with diabetes in 6. One month following treatment, vitreomacular traction was released in 6 eyes (40%). Three further eyes (20%) had resolution of vitreomacular traction within 6 months, 4 (27%) underwent PPV, and 2 (13%) subsequently declined surgery. Foveal contour was restored in 7 eyes (47%). VA and central foveal thickness were similar 1 month following treatment, but maximal foveal thickness decreased by 65.8 μm (P = .041). Mean final VA decreased 0.03 logMAR units from baseline (P = .536). Eyes with vitreomacular traction release within 1 month had less extensive vitreomacular traction (P = .037), low vitreous face reflectivity, and maximal foveal thickness <500 μm (P = .004) pretreatment. There were no associated adverse events.

Conclusions

Intravitreal C₃F₈ injection could offer a minimally invasive alternative to PPV in patients with symptomatic and persistent vitreomacular traction. It appears particularly effective in eyes with less extensive vitreomacular traction and low vitreous face reflectivity on SD OCT. Further studies are warranted.

Section snippets

Methods

This study reports a retrospective consecutive series of patients who elected to undergo an intravitreal gas injection for the treatment of vitreomacular traction, between September 2009 and May 2011, in a tertiary retinal unit in a large London teaching hospital. All patients underwent assessment of Snellen VA, tonometry, anterior and posterior segment biomicroscopy, and SD OCT (Spectralis HRA+OCT, Heidelberg Engineering, Heidelberg, Germany; or Cirrus, Carl Zeiss Meditec, Dublin, California,

Patient Demographics

Fifteen eyes of 14 patients with persistent and symptomatic vitreomacular traction were treated. Eight patients were male. Nine were white, 3 were Afro-Caribbean, and 2 were Asian. Mean age (± SD) at presentation was 72.1 ± 12.6 years (range: 36-89). Vitreomacular traction was documented on SD OCT for a mean of 328.1 ± 250.9 days prior to treatment (range: 70-860). Mean follow-up after treatment was 353.75 ± 159.62 days (range: 91-658). In 7 eyes vitreomacular traction was labeled as idiopathic

Discussion

This study describes the use of single intravitreal injection of expansile gas to relieve vitreomacular traction as an alternative to PPV, in a range of conditions, observed using SD OCT. We found it to be successful in 40% of patients within 1 month of the intervention, and in 60% within 6 months. Although there was no significant change in VA, there was restoration of normal foveal contour in 77% of eyes following successful vitreomacular traction release. Only 33% of these cases, all of

Ian Rodrigues is a Specialty Registrar in the London Ophthalmology post-graduate training program. He undertook his undergraduate medical training at Guy’s, King’s & St Thomas’ Medical School, University of London and completed an intercalated BSc in diabetes and endocrinology. He continues to have a wide area of interest in clinical ophthalmology.

References (37)

A.B. Reese et al.
Vitreomacular traction syndrome confirmed histologically
Am J Ophthalmol
(1970)
R.G. Mirza et al.
Optical coherence tomography use in evaluation of the vitreoretinal interface: a review
Surv Ophthalmol
(2007)
A.R. Simpson et al.
Vitreomacular adhesion and neovascular age-related macular degeneration
Surv Ophthalmol
(2012)
T. Hikichi et al.
Course of vitreomacular traction syndrome
Am J Ophthalmol
(1995)
C.K. Chan et al.
Treatment of idiopathic macular holes by induced posterior vitreous detachment
Ophthalmology
(1995)
R. Jorge et al.
Optical coherence tomography evaluation of idiopathic macular hole treatment by gas-assisted posterior vitreous detachment
Am J Ophthalmol
(2006)
K. Mori et al.
Treatment of stage 2 macular hole by intravitreous injection of expansile gas and induction of posterior vitreous detachment
Ophthalmology
(2007)
F.L. Ferris et al.
New visual acuity charts for clinical research
Am J Ophthalmol
(1982)
M.S. Benz et al.
A placebo-controlled trial of microplasmin intravitreous injection to facilitate posterior vitreous detachment before vitrectomy
Ophthalmology
(2010)
G.F. Hilton et al.
Pneumatic retinopexy. A two-step outpatient operation without conjunctival incision
Ophthalmology
(1986)

C.K. Chan et al.

Pneumatic retinopexy for the repair of retinal detachments: a comprehensive review (1986-2007)

Surv Ophthalmol

(2008)

J. Sebag

Anatomy and pathology of the vitreo-retinal interface

Eye (Lond)

(1992)

F. Best

Der Glaskorper bei Augenbewegungen

Klin Monbl Augenheilkd

(1904)

J. Sebag

Anomalous posterior vitreous detachment: a unifying concept in vitreo-retinal disease

Graefes Arch Clin Exp Ophthalmol

(2004)

V.J. Srinivasan et al.

High-definition and 3-dimensional imaging of macular pathologies with high-speed ultrahigh-resolution optical coherence tomography

Ophthalmology

(2006)

M.W. Johnson

Posterior vitreous detachment. Evolution and complications of its early stages

Am J Ophthalmol

(2010)

M.W. Johnson

Tractional cystoid macular edema: a subtle variant of the vitreomacular traction syndrome

Am J Ophthalmol

(2005)

N.S. Melberg et al.

Vitrectomy for vitreomacular traction syndrome with macular detachment

Retina

(1995)

Cited by (60)

Pneumatic Vitreolysis with Perfluoropropane for Vitreomacular Traction with and without Macular Hole: DRCR Retina Network Protocols AG and AH
2021, Ophthalmology
To evaluate pneumatic vitreolysis (PVL) in eyes with vitreomacular traction (VMT) with and without full-thickness macular hole (FTMH).
Two multicenter (28 sites) studies: a randomized clinical trial comparing PVL with observation (sham injection) for VMT without FTMH (Protocol AG) and a single-arm study assessing PVL for FTMH (Protocol AH).
Participants were adults with central VMT (vitreomacular adhesion was ≤3000 μm). In Protocol AG, visual acuity (VA) was 20/32 to 20/400. In Protocol AH, eyes had a FTMH (≤250 μm at the narrowest point) and VA of 20/25 to 20/400.
Pneumatic vitreolysis using perfluoropropane (C₃F₈) gas.
Central VMT release at 24 weeks (Protocol AG) and FTMH closure at 8 weeks (Protocol AH).
From October 2018 through February 2020, 46 participants were enrolled in Protocol AG, and 35 were enrolled in Protocol AH. Higher than expected rates of retinal detachment and tear resulted in early termination of both protocols. Combining studies, 7 of 59 eyes (12% [95% CI, 6%–23%]; 2 eyes in Protocol AG, 5 eyes in Protocol AH) that received PVL developed rhegmatogenous retinal detachment (n = 6) or retinal tear (n = 1). At 24 weeks in Protocol AG, 18 of 23 eyes in the PVL group (78%) versus 2 of 22 eyes in the sham group (9%) achieved central VMT release without rescue vitrectomy (adjusted risk difference, 66% [95% CI, 44%–88%]; P< 0.001). The mean change in VA from baseline at 24 weeks was 6.7 letters in the PVL group and 6.1 letters in the sham group (adjusted difference, –0.8 [95% CI, –6.1 to 4.5]; P = 0.77). In Protocol AH, 10 of 35 eyes (29% [95% CI, 16%–45%]) achieved FTMH closure without rescue vitrectomy at 8 weeks. The mean change in VA from baseline at 8 weeks was –1.5 letters (95% CI, –10.3 to 7.3 letters).
In most eyes with VMT, PVL induced hyaloid release. In eyes with FTMH, PVL resulted in hole closure in approximately one third of eyes. These studies were terminated early because of safety concerns related to retinal detachments and retinal tears.
Time dependent degradation of vitreous gel under enzymatic reaction: Polymeric network role in fluid properties
2020, Journal of Biomechanics
Citation Excerpt :
Recently an enzymatic intravitreal injection, Jetrea (Ocriplasmin, Thrombogenics, Inc), has been found to induce pharmacologic vitreolysis by means of proteolysis of the vitreoretinal connections (Haller et al., 2015). In addition, studies introduced intravitreal injection of certain gases to exert mechanical forces and remove the adhesion of the vitreous gel to the retina (McDonald et al., 1994; Rodrigues et al., 2013). Further investigations are essential to fully characterize and improve the effects of the mentioned treatments on the vitreous gel.
The viscoelastic behavior of vitreous gel is due to the presence of biopolymers in its structure. Fluid properties of the vitreous is mainly the result of interactions between the characteristics of collagen type II and Hyaluronic Acid networks. Having a better understanding of the structure of each component and their changes during aging and various diseases such as diabetes can lead to better monitoring and treatment options. We study the effects of collagenase type II on 44 samples of porcine vitreous using an in situ rheological experiment in comparison with 18 eyes in a control group injected with Phosphate Buffered Saline Solution. We analyze the behavior of each component over time in both groups. We focus on the changes of viscosity and elasticity of the collagen network within the vitreous. The results of the analysis in this study show that the changes in the fluid properties of the vitreous after collagenase injection is driven by the structural alterations of the collagen network. Creep compliance values of the collagen network are significantly higher in the first group compared to the control group one hour and twenty-four hours after the injection. In contrast, creep compliance of the HA network shows no statistically significant change one hour after the injection in both groups. The results of the reported analysis of individual components in this study support the previous findings on the alterations within the vitreous structure in its entirety.
Intravitreal gas injection for the treatment of full-thickness macular holes
2020, Canadian Journal of Ophthalmology
A Study of the Natural History of Vitreomacular Traction Syndrome by OCT
2018, Ophthalmology
To examine the natural history of vitreomacular traction syndrome (VMTS) in the absence of other ocular comorbidities.
Retrospective clinical case series.
A total of 183 eyes of 159 patients diagnosed with VMTS with no other ocular comorbidity.
Patients with VMTS were identified from an OCT database at Moorfields Eye Hospital, London. Sequential OCT scans and patient notes were reviewed over a minimum period of 6 months. Data collected included patient demographics, best-corrected visual acuity, and OCT features of vitreomacular adhesion. Contingency tests and binary logistic modeling were used to identify baseline predictors of stability and progression.
The rates of spontaneous resolution (defined by release of traction), progression to full-thickness macular hole, and surgical intervention were analyzed.
Presenting visual acuity was 0.3±0.3 logMAR units. The mean length of follow-up was 17.4±12.1 months. During this period, VMTS persisted in 60% and resolved in 20% (occurring on average at 15 months). Of the remainder, 12% developed a macular hole and 8% elected to proceed with surgery for symptoms. Focal adhesion <1500 μm was present in 87%. A premacular membrane with macular pucker (PMM) was present in 20%. With persistent VMTS, vision and central foveal thickness remained unchanged. The relative risk of resolution increased in those cases with better presenting visual acuities, lesser foveal thicknesses, and no associated PMMs; vision significantly improved in those cases with resolution.
VMTS persists in the majority of patients but despite this, visual acuities did not deteriorate significantly over the study period unless patients developed a full-thickness macular hole or required surgical intervention for symptoms. Resolution spontaneously occurred in 20%, with an improvement in vision.
Evaluating the effect of Perfluoropropane assisted pneumatic vitreolysis in cases of symptomatic focal vitreomacular traction
2023, Delta Journal of Ophthalmology
Role of Small-Gauge Proportionate Reflux-Assisted Hydrodissection in Elevated Symptomatic Vitreofoveal Traction
2023, Retina

View all citing articles on Scopus

Tim Jackson is a senior clinical lecturer at King’s College London, and Honorary Consultant Vitreoretinal Surgeon at King’s College Hospital. He undertook his medical training in New Zealand, and his Ophthalmology Residency and Vitreoretinal Fellowships at Moorfields Eye Hospital, London. He completed a PhD within the University of London and maintains an active clinical and laboratory-based research portfolio.

: See Accompanying Editorial on page 203.

View full text

Original articleIntravitreal Injection of Expansile Perfluoropropane (C3F8) for the Treatment of Vitreomacular Traction

Purpose

Design

Methods

Results

Conclusions

Section snippets

Methods

Patient Demographics

Discussion

Am J Ophthalmol

Surv Ophthalmol

Surv Ophthalmol

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Ophthalmology

Ophthalmology

Surv Ophthalmol

Anatomy and pathology of the vitreo-retinal interface

Eye (Lond)

Der Glaskorper bei Augenbewegungen

Klin Monbl Augenheilkd

Anomalous posterior vitreous detachment: a unifying concept in vitreo-retinal disease

Graefes Arch Clin Exp Ophthalmol

High-definition and 3-dimensional imaging of macular pathologies with high-speed ultrahigh-resolution optical coherence tomography

Ophthalmology

Posterior vitreous detachment. Evolution and complications of its early stages

Am J Ophthalmol

Tractional cystoid macular edema: a subtle variant of the vitreomacular traction syndrome

Am J Ophthalmol

Vitrectomy for vitreomacular traction syndrome with macular detachment

Retina

Original article
Intravitreal Injection of Expansile Perfluoropropane (C₃F₈) for the Treatment of Vitreomacular Traction