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Grundzüge der medikamentösen Therapie und chirurgische Optionen bei Uveitis

Pharmacological treatment strategies and surgical options for uveitis

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Zusammenfassung

Hintergrund

Eine moderne Uveitistherapie zielt auf die Kontrolle der Uveitisaktivität, Erhaltung der Sehfunktion und die Verhinderung sekundärer Organschäden durch die entzündliche Grunderkrankung und deren Therapie.

Ziel dieser Arbeit

Ziel ist ein Update zu den Grundzügen der medikamentösen und chirurgischen Therapie der Uveitis.

Material und Methoden

Anhand einer Literaturrecherche in PubMed zu den Stichworten <„uveitis“ AND „therapy“> sowie <„uveitis“ AND „surgery“ OR „surgical treatment“> wurden alle prospektiven Studien, Fallserien mit mehr als 20 Fällen sowie Übersichtsartikel der letzten 5 Jahre identifiziert und mit den darin zitierten Querverweisen ausgewertet.

Ergebnisse

Nach Ausschluss einer infektiösen Ätiologie bilden lokale und systemische Steroide die Grundlage der Therapie. Sollte die Uveitisaktivität nicht innerhalb 6 Wochen kontrolliert oder die tägliche Steroiddosis inakzeptabel hoch sein, kommen nichtbiologische Medikamente zum Einsatz. In einer dritten Phase werden diese bei weiterhin vorhandener Restaktivität frühzeitig ergänzt durch antikörperbasierte Therapien oder Zytokine, sog. Biologika, mit dem Ziel einer vollständigen langfristigen Reizfreiheit ohne lokale oder systemische Steroide. Dieses Ziel wird in 65–80 % erreicht und stellt die langfristige funktionelle Stabilität und anatomische Integrität sicher. Eine frühzeitige Therapieeskalation bei persistierender Aktivität und Rezidiven verhindert in der Regel neue sekundäre Organschäden. Chirurgische Verfahren werden diagnostisch, zur Applikation intravitrealer Medikamente und zur Behandlung von Sekundärkomplikationen genutzt.

Diskussion

Die Uveitis ist wie die meisten immunologischen Erkrankungen eine chronische Erkrankung, die einer Dauertherapie bedarf, nur in weniger als 20 % wird eine Remission (Reizfreiheit ohne Therapie) erreicht. Chirurgische Verfahren werden, wenn Papille und Makula nicht betroffen sind, mit guter Prognose eingesetzt und haben eine erheblich geringere Komplikationsrate, wenn präoperativ über mindestens 3 Monate Reizfreiheit besteht.

Abstract

Background

Modern treatment of uveitis aims at a complete control of inflammatory activity, preservation of visual function and the prevention of secondary organ damage as a consequence of the underlying inflammatory disease and its treatment.

Objective

This article gives an update about the strategies of pharmacological and surgical options for uveitis.

Material and methods

The outcomes reported here are based on a PubMed search using the terms <“uveitis” AND “therapy”> and <“uveitis” AND “surgery” OR “surgical treatment”>. All prospective studies and case series with more than 20 cases as well as review articles from the last 5 years along with cited cross-references were evaluated.

Results

Local and systemic corticosteroids form the foundation of treatment after exclusion of an infectious etiology. If uveitis activity is not controlled within 6 weeks or if the daily corticosteroid dosage is unacceptably high, a treatment escalation using immunomodulatory drugs is required. If a complete control of inflammatory activity is not achieved, in a third phase treatment is supplemented by antibody-based treatment or cytokines, so-called biologics, with the aim of complete long-term freedom from disease without local or systemic steroid treatment. This target is achieved in 65–80% and guarantees long-term functional stability and anatomical integrity. Early treatment escalation in cases of persisting or recurrent activity as a rule prevents new secondary organ damage. Surgical options are utilized for diagnostic purposes, the administration of intravitreal drugs and for treatment of secondary complications.

Conclusion

Just like the majority of immunological diseases, uveitis is a chronic disease requiring long-term and possibly lifelong treatment and remission (absence of inflammation without treatment) is achieved in only <20%. Surgical interventions can be performed with a good prognosis, if the optic nerve head and macula are not involved. They have a substantially lower complication rate when freedom from symptoms exists preoperatively for at least 3 months.

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  1. Berner Augenklinik am Lindenhofspital, Affiliation: Klinik und Poliklinik für Augenheilkunde, Inselspital, Universität Bern, Bremgartenstr 119, 3012, Bern, Schweiz

    Justus G. Garweg

  2. Swiss Eye Institute, Rotkreuz, Schweiz

    Justus G. Garweg

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Dieses Manuskript entspricht einem Vortrag auf dem Tübinger Ophthalmo-Immunologischen Seminar (TOIS) 2018.

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Garweg, J.G. Grundzüge der medikamentösen Therapie und chirurgische Optionen bei Uveitis. Ophthalmologe 116, 942–950 (2019). https://doi.org/10.1007/s00347-019-0870-x

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