Best Treatment for Epiretinal Membrane and Macular Hole: New Drug for Macular Hole Treatment–Jetrea or Ocriplasmin

Best Treatment for Epiretinal Membrane and Macular Hole

A patient from London asked:
If a ophthalmologist says you have an epiretinal member and a new macular hole that’s developed what does it mean?

New treatment for Macular holes.
A friend’s son was hit in the eye with a baseball during a game recently at the young age of 17 at high speed. He immediately lost vision and the eye. When he was seen by an eyeMD a full thickness macular hole. I went through the treatment options for him and noted that there was a new drug that, though it would likely not close the whole completely, it might help. I sent him to Johns Hopkins for many reasons and they treated him with initially with Jetrea (Ocriplasmin). In the end, though, he needed a Pars Plana Vitrectomy and face down position for 10 days. He is now doing much better and has regained sight in that eye and is enjoying his freshman year at Princeton. 

Macular holes can be devastating no matter the cause.  It is good to know about your options. Of course the best treatment is prevention: prevention of trauma, prevention of EPIRETINAL MEMBRANES, which are due to:
1. Sun exposure
2. Poor diet
3. Genetics
4. Aging
Thus it is always important to wear sun protection, eye protection, eat a green leafy veggie diet daily, and pray you have good genes and the aging process goes gentle on you.

Here is more info.
Recent approval of Jetrea (Ocriplasmin) to treat symptomatic VMA (Vitreo Macular Adhesion) has opened up a new era in non surgical management of macular holes. Previously only a hospital based surgery was able to reverse the process of macular hole development but now a new drug can be injected into the eye painlessly in the office and within a few weeks the process reverses back to more normal vision levels. The key to high success rates for this process is catching the problem early. If the holes are small and have not been present for long then there is a 50% rate of closure but as the hole enlarges and becomes bigger, the success rate of the drug drops to >25%. Finding the earliest hole or “pre” hole where the vitreous gel in the middle of the eye is just starting to pull on the macula (center of the vision) and causing symptoms is the best use of the new technology. Some of the symptoms can be increasing blur of the vision especially while reading and trying to see small objects. Distortion of the amsler grid around the central point or straight lines looking bent or crooked is also an indicator. Do not wait for pain to develop as this process is usually painless. Obviously any change in the vision needs an eye exam and the faster the symptoms are coming, the faster you need to be seen. If the hole is too large or the drug does not work, then surgical repair still enjoys a high success rate. The cost of any new drug is obviously very high however most if not all insurances cover this with the usual deductibles. For those with poor insurance or without insurance, the company that makes the drug (Thrombogenics, Inc) has a very generous financial assistance program that can pay for the drug.
Alternatives & risks:
The alternative to the drug is surgery called Vitrectomy that is usually done in the hospital or out patient surgery suite. It usually involves removing the vitreous get from the center of the eye and replacing it with a gas bubble (and needing about 2 weeks of face down positioning) or a silicone oil bubble (does not need positioning as much but needs a second surgery to remove the oil later). There are no other drugs or lasers that can be done for symptomatic VMA or macular hole.
The risks of injection is very small on the order of one in a thousand or less but can be devastating. Most patents get a red eye and some temporary vision symptoms that resolve in a few weeks. More serious problems that may need further treatment or surgery and can recover but there is always a small chance of loss of vision or loss of the eye. These risks are still smaller than surgical risks in my opinion.
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