Das pseudophakiebedingte zystoide Makulaödem

 

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Zusammenfassung

Das pseudophakiebedingte zystoide Makulaödem bleibt trotz der enormen Fortschritte in der modernen Kataraktchirurgie aufgrund der hohen Anzahl an jährlichen Operationen weiterhin ein Krankheitsbild mit immenser klinischer Relevanz, da auch nach unkomplikativer Operation eine bedeutsame und permanente Visusreduktion auftreten kann. Pathophysiologisch spielen in der Entstehung 4 intraokuläre Vorgänge eine entscheidende Rolle: 1. die operationsbedingte intraokuläre Freisetzung verschiedener Entzündungsmediatoren in die vordere Augenkammer; 2. die Entfernung der linsenbedingten Barriere mit einer konsekutiven Erhöhung der Diffusion zwischen vorderem und hinterem Augenabschnitt; 3. die Entstehung eines zystoiden Makulaödems durch die lokale Wirkung der Entzündungsmediatoren auf die Makula und 4. die vitreoretinale Traktion durch den nach anterior ziehenden Glaskörper. Zur Prävention werden die optimale präoperative Einstellung von systemischen und okulären Grunderkrankungen sowie die Risikobewertung des einzelnen Patienten empfohlen. Eine möglichst atraumatische Operationstechnik kann zusätzlich das Risiko des Auftretens eines postoperativen Makulaödems deutlich reduzieren. Zur Diagnostik des pseudophakiebedingten zystoiden Makulaödems stehen neben der subjektiven Beschwerdesymptomatik des Patienten die Durchführung von Funduskopie, Fluoreszenzangiografie und optischer Kohärenztomografie zur Verfügung. Präventive und therapeutische medikamentöse Leitlinien der Fachgesellschaften gibt es aktuell noch nicht. In einer Zusammenschau der Literatur wird für die Therapie ein Stufenschema, welches verschiedene Kombinationen aus medikamentösen und chirurgischen Therapieoptionen vorschlägt, empfohlen. Hier spielen die topische Gabe von nicht steroidalen Antiphlogistika, Kortikosteroiden und Karboanhydrasemmern sowie chirurgische Interventionsmöglichkeiten im Rahmen einer Vitrektomie eine wichtige Rolle.

Abstract

Pseudophakic cystoid macular oedema is still a relevant clinical disease entity although major progress in modern cataract surgery has been made within the last decades. The relevance is attributed to the large number of cases that are performed each year. Even after uneventful surgery, a pseudophakic cystoid macular oedema can develop and may lead to severe and lasting visual impairments. In respect to the pathophysiology, four consecutive steps have to be considered: (i) surgical procedure-related induction and release of various inflammation mediators into the anterior chamber; (ii) removal of the physiological lens barrier between the anterior and posterior segments of the eye, leading consecutively to an increase in diffusion rate in either direction; (iii) local action of the inflammation mediators towards the macular area; and (iv) increased vitreoretinal traction due to the anteriorly oriented drive of the vitreous. To prevent the development of a pseudophakic cystoid macular oedema, systemic and ocular pathologies should be treated consequently prior to surgery. Furthermore, an individual risk profile of each patient needs to be evaluated to define the best pre- and postsurgical medical treatment. A less traumatic surgical approach can help to prevent macular oedema development additionally. The diagnosis is made by performing biomicroscopy, fluorescence angiography and optical coherence tomography as well as by evaluating the patients' major complaints. Standard operation procedures or recommended guidelines by the specialised eye associations to prevent and treat pseudophakic cystoid macular oedema are not available up to date. A synopsis of recommendations in the literature suggests a step-wise treatment regimen, including topical medical treatment on the one hand and a surgical approach on the other hand as well as a combination of both, if needed. Topical medical treatment options include the use of non-steroidal, corticosteroid and/or carbonic anhydrase inhibitor eye drops. Surgical interventions include pars plana vitrectomy.

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