OCRIPLASMIN (JETREA) : THE VITREOLYTIC AGENT

OCRIPLASMIN(JETREA) is a recombinant truncated human serine protease plasmin with activity against fibronectin and laminin which are the components of normal vitreo-retinal interface.

• Phase II trials have shown that upto 3 injections of 125 micrograms of Ocriplasmin at monthly interval can lead to resolution of vitreo-macular traction and closure of macular hole (<400 microns) without serious complications.
• Less effective in VMTS + ERM or vitreomacular adhesions >1500 microns.
• Jetrea has not been studied extensively in Macular hole > 400 microns, myopia > 8D, axial length > 28mm, aphakia, history of rhegmatogenous RD, lens-zonule instability, proliferative diabetic retinopathy, ischemic retinopathy, retinal vein occulusions, wet AMD, vitreous hemorrhage. Hence, treatment is not recommended in these patients.
• No clinical data is available on its concurrent use with anti VEGF agents.
• Available as 0.5mg/0.2ml vial ,which is diluted in 0.2ml of 0.9% NaCl to get the final concentration of 125 micrograms/0.1ml.
• Stored at -20+/- 5 degree Clecius.

Adverse effects:

• Transient rise in IOP upto 60 minutes post injection and reduced optic nerve perfusion pressure.
• New macular hole formation or enlargement of pre-existing macular hole in strong adhesions.
• Infection
• Vitreous floaters
• Eye pain
• Photopsia
• Subconjunctival hemorrhage.

MARCUS GUNN PHENOMENON AND ITS VARIANTS

MARCUS GUNN PHENOMENON:

• Elevation of ptotic lid with movement of jaw.
• Due to aberrant connection between 3rd nerve and mandibular division of 5th nerve.
• More common on left side.
• May be associated with superior rectus weakness.
• Grading : 

                          Mild- <2mm elevation of ptotic lid.
                          Moderate- 3-6 mm elevation of ptotic lid.
                          Severe- >= 7 mm elevation of ptotic lid.

INVERSE MARCUS GUNN PHENOMENON:

• Increase in ptosis on jaw movement.
• Due to synkinesis between pterygoids (5th nerve) and orbicularis (7th nerve).
• Also known as ATOIN SYNDROME.

REVERSE MARCUS GUNN PHENOMENON :

• Lateral displacement of jaw on touching cornea.
• Due to synkinesis between ophthalmic division (I) and mandibular division (III) of 5th nerve.
• Seen in supranuclear 5th nerve palsy.

                           

DIAGNOSTIC CRIETERIA FOR IDIOPATHIC INTRACRANIAL HYPERTENSION

1. Signs and symptoms suggestive of raised intracranial tension and papilledema.
2. High opening pressure on lumbar puncture.
3. Normal CSF study.
4. Normal brain MRI. 
5. No systemic cause including medications.

TEN SIGNS OF OPTIC DISC EDEMA

5 MECHANICAL SIGNS :

1. Blurring of the optic disc margins.
2. Full optic disc cup.
3. Elevated optic disc head (1mm elevation induces 3D of hypermetropia).
4. Nerve fiber layer edema.
5. Retinal folds (Paten's striae) or choroidal folds.

5 VASCULAR SIGNS :

1. Venous congestion.
2. Papillary and peripapillary hemorrhages.
3. Cotton wool spots.
4. Hyperemic optic disc.
5. Hard exudates over disc.

PHOTOSTRESS RECOVERY TEST

IMPORTANT POINTS:

• Done in each eye separately.
• Visual acuity must be 20/80 or better for reliable results.
• Eye is exposed to bright light for 10 seconds, source is held 2-3 cms from the eye.
• Ask the patient to read previously read best visual acuity line immediately after withdrawl of light source and the recovery time is noted. 
• Normal recovery time is 45-60 seconds.
• Prolonged recovery time upto 180 seconds or more in patients with maculopathy.
• Normal recovery time in optic neuropathy.