Limited coverage criteria – ocriplasmin

For the treatment of symptomatic vitreomacular adhesion (VMA) confirmed through optical coherence tomography

AND

Administered by a retinal specialist

Excluded:

Coverage cannot be considered if patient has any of the following:

• Large diameter macular holes (> 400 micrometre)
• High myopia (> 8 dioptre spherical correction or axial length > 28 millimetre)
• Aphakia
• History of retinal detachment
• Lens zonule instability
• Recent ocular surgery or intraocular injection (including laser therapy)
• Proliferative diabetic retinopathy
• Ischemic retinopathies
• Retinal vein occlusions
• Exudative age-related macular degeneration
• Vitreous hemorrhage

One injection per eye (lifetime maximum)