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Submakuläre Massenblutung und Gerinnungshemmer

Eine unglückliche Kombination?

Massive subretinal hemorrhage and anticoagulants

An unfortunate combination?

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Zusammenfassung

Als häufigste Ursache der subretinalen Massenblutungen gilt die neovaskuläre altersbedingte Makuladegeneration (AMD), die eine Erkrankung des fortgeschritteneren Lebensalters darstellt. Diese Altersgruppe hat jedoch nicht nur ein erhöhtes AMD-Risiko, sondern weist darüber hinaus zahlreiche kardiovaskuläre Begleiterkrankungen auf, die eine vorübergehende oder dauerhafte medikamentöse Gerinnungshemmung erforderlich machen. Jüngere ophthalmologische Studien weisen darauf hin, dass das submakuläre Blutungsrisiko bei exsudativer AMD durch die Einnahme gerinnungswirksamer Medikamente signifikant erhöht ist. Diese Assoziation gilt sowohl für Antikoagulanzien wie Marcumar als auch für Thrombozytenaggregationshemmer. Darüber hinaus zeigte sich in mehreren Studien eindeutig ein signifikant erhöhtes Blutungsrisiko, wenn zusätzlich zur medikamentösen Gerinnungsbeeinflussung ein arterieller Hypertonus vorlag. Da die langfristige Visusprognose bei exsudativer AMD maßgeblich von der Höhe und Ausdehnung der subretinalen Blutung abhängt, kann die Gabe gerinnungswirksamer Medikamente über ein erhöhtes Blutungsrisiko Einfluss auf den langfristigen Krankheitsverlauf haben. Die Beobachtung eines statistisch signifikant erhöhten Blutungsrisikos für schwere subretinale Blutungen bei AMD-Patienten mit gerinnungswirksamen Medikamenten sollte deshalb bei der Frage nach der Initiierung und Dauer einer gerinnungsbeeinflussenden Therapie bei AMD-Patienten – insbesondere bei einem gleichzeitig vorliegenden Hypertonus – mit berücksichtigt werden.

Abstract

Exudative age-related macular degeneration (ARMD) is one of the conditions which has been shown to be associated with a risk of massive subretinal hemorrhage. Patients with thick submacular hemorrhage complicating ARMD typically have a poor visual prognosis. Antiplatelet therapy with aspirin, clopidogrel or ticlopidine has significant benefits in the secondary prevention of fatal and non-fatal coronary and cerebrovascular events. Anticoagulation is frequently used in this elderly age group for a variety of other comorbidities including prosthetic heart valves, atrial fibrillation, ischemic heart disease, cerebrovascular disease and venous thromboembolism. However, it is a well established observation that the longer patients remain on anticoagulant therapy, the higher the cumulative risk of bleeding. Over the past years, there has been a rapidly growing body of literature concerning the risk of hemorrhagic ocular complications with ophthalmic surgery in patients receiving anticoagulant therapy. By contrast, there are still little data on the relationship between anticoagulation or antiplatelet therapy and spontaneous ocular hemorrhages and only few reports have focused on patients with ARMD. Just recently, several authors reported a strong association of anticoagulants and antiplatelet agents with the development of large subretinal hemorrhages in ARMD patients. Moreover, arterial hypertension is a high risk factor for large subretinal hemorrhages in ARMD patients receiving anticoagulants or antiplatelet agents. Physicians should be aware of an increased risk of extensive subretinal hemorrhage in ARMD patients when deciding on the initiation and duration of anticoagulant and antiplatelet therapy.

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Authors and Affiliations

  1. Klinik für Augenheilkunde, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland

    C. Kuhli-Hattenbach

  2. Klinisches Studienzentrum, Klinik für Augenheilkunde, Klinikum Ludwigshafen, Ludwigshafen am Rhein, Deutschland

    C. Kuhli-Hattenbach & L.-O. Hattenbach

  3. Medizinische Klinik III des Zentrums der Inneren Medizin, Abteilung für Hämostaseologie, Johann Wolfgang Goethe-Universität, Frankfurt am Main, Deutschland

    W. Miesbach

  4. III. Medizinische Klinik, Abteilung für Hämostaseologie, Klinikum der Johannes-Gutenberg-Universität, Mainz, Deutschland

    I. Scharrer

  5. Klinik für Augenheilkunde, Klinikum Ludwigshafen, Ludwigshafen am Rhein, Deutschland

    L.-O. Hattenbach

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  1. C. Kuhli-Hattenbach
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  2. W. Miesbach
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  3. I. Scharrer
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  4. L.-O. Hattenbach
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Correspondence to C. Kuhli-Hattenbach.

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Kuhli-Hattenbach, C., Miesbach, W., Scharrer, I. et al. Submakuläre Massenblutung und Gerinnungshemmer. Ophthalmologe 109, 665–669 (2012). https://doi.org/10.1007/s00347-012-2567-2

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  • DOI: https://doi.org/10.1007/s00347-012-2567-2

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