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Pigmentepithelabhebung bei exsudativer Makuladegeneration

Klinische Charakteristika und therapeutische Optionen

Pigment epithelial detachment in exudative macular degeneration

Clinical characteristics and therapeutic options

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Zusammenfassung

Die vaskularisierte Pigmentepithelabhebungen (PED) ist aufgrund des natürlichen Verlaufs, der besonderen Pathogenese und der Reaktion auf die verschiedenen Behandlungsmethoden als eine spezielle Manifestation der okkulten choroidalen Neovaskularisation (CNV) anzusehen. Dies gilt sowohl für die seröse PED mit okkulter CNV als auch für eine an retinale angiomatöse Proliferationen (RAP) assoziierte PED. Der Einriss des retinalen Pigmentepithels (RPE) stellt eine schwerwiegende Komplikation der vaskularisierten PED dar und geht häufig mit einer akuten Sehminderung einher, die nicht selten mit subretinalen Massenblutungen verbunden ist. Der zugrunde liegende Pathomechanismus, der zum Einriss des RPE führt, ist letztlich noch nicht geklärt. Der Vorstellung eines Platzens der PED aufgrund eines erhöhten Drucks steht die Theorie der narbigen Schrumpfung der CNV mit sekundärem Riss im RPE gegenüber. Die Anti-VEGF-Therapie ist gegenwärtig die Therapie der Wahl. Die anfängliche Stabilisierung der Sehschärfe ist in den Langzeitbeobachtungen nicht nachweisbar, und es kommt nach 2 Jahren zu einer signifikanten Abnahme der Sehschärfe. Auch das optimale Behandlungsschema mit einer Anti-VEGF-Therapie und die Wiederbehandlungskriterien sind weiterhin ungeklärt. Nach gegenwärtigem Stand scheinen Visusverschlechterung sowie sub- und intraretinale Flüssigkeit Indikationen für eine wirkungsvolle Behandlung zu sein. Hierbei werden die weiteren Erkenntnisse durch die hoch auflösende OCT-Bildgebung sicher hilfreich sein.

Abstract

Vascularized pigment epithelial detachment (PE detachment) can be viewed as a special form of occult choriodal neovascularization (CNV) owing to the natural course of the disease, its specific pathogenesis and its response to various forms of treatment. This applies to serous PE detachment associated with both occult CNV and also with retinal angiomatous proliferation (RAP). A tear in the retinal pigment epithelium (RIP) represents a serious complication of vascularized PE detachment and is often associated with acute vision deterioration that not uncommonly also involves massive subretinal hemorrhaging. The pathomechanism underlying the development of RIP has not yet been completely elucidated. The notion that the PED bursts as a result of the increased pressure stands in contrast to the theory that the CNV contracts and causes scarring which in turn causing secondary RIP. Anti-VEGF therapy is currently the preferred treatment. However, the initial stabilization of visual acuity after treatment could not be confirmed in long-term studies and after 2 years visual acuity deteriorated significantly. Furthermore, optimal VEGF treatment regimens have also not been defined and the criteria for repeated treatment have not been established as yet. Presently, visual deterioration and the presence of subretnal and intraretinal exudates seem to indicate that treatment will be effective. Here, high resolution OCT imaging should help to provide further insight into the matter.

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    A. Lommatzsch

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Lommatzsch, A. Pigmentepithelabhebung bei exsudativer Makuladegeneration. Ophthalmologe 107, 1115–1122 (2010). https://doi.org/10.1007/s00347-010-2143-6

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