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Vitreoretinale Chirurgie bei altersabhängiger Makuladegeneration

Vitreoretinal surgery in age-related macular degeneration

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Zusammenfassung

Die Glaskörperstruktur, die Interaktion des Glaskörpers mit der Netzhautoberfläche und traktive Veränderungen des vitreoretinalen Interface spielen bei der altersabhängigen Makuladegeneration und ihrer Entwicklung eine kritische Rolle. Aus der Literatur kann man schlussfolgern, dass ein abgehobener bzw. entfernter Glaskörper ein potenzieller Schutzfaktor vor einer feuchten altersabhängigen Makuladegeneration sein kann. Umgekehrt konnte gezeigt werden, dass vitreomakuläre Adhärenzen die Bildung einer neovaskulären altersabhängigen Makuladegeneration fördern und Einfluss auf die Effektivität und Frequenz einer intravitrealen Pharmakotherapie mit VEGF-Hemmern nehmen. Vor diesem Hintergrund kann die Pars-plana-Vitrektomie ggf. mit Chirurgie im Bereich des vitreoretinalen Interface als Therapieergänzung in ausgesuchten Einzelfällen betrachtet werden. Die Präparation epimakulärer Membranen und der inneren Grenzmembran kann einen Beitrag zur Stabilisierung der Sehschärfe leisten und ggf. die Injektionsfrequenz von VEGF-Hemmern in den Glaskörperraum reduzieren. Chirurgische Eingriffe bei altersabhängiger Makuladegeneration kommen heute besonders bei der Behandlung der submakulären Blutung mit fovealer Beteiligung zum Einsatz. Das Vorgehen ist nicht standardisiert und zielt darauf ab, die Blutung durch intravitreal oder subretinal eingegebenes rTPA zu verflüssigen und pneumatisch durch intravitreal appliziertes Gas zu verdrängen, ggf. kombiniert mit einem VEGF-Hemmer. Wichtig ist eine Fortführung der Behandlung durch eine Anti-VEGF-Therapie. Andere submakuläre chirurgische Verfahren wie die subfoveale CNV-Extraktion oder die Verschiebung der Fovea über intaktes RPE durch eine Translokation der Makula sind im Zeitalter der intravitrealen VEGF-Inhibition in den Hintergrund getreten. Submakuläre bzw. subretinale Chirurgie spielte ferner eine wichtige Rolle bei der Transplantation von RPE im Makulabereich, die heute besonderen Ausnahmesituationen vorbehalten bleibt. Letztlich aber waren diese submakulären chirurgischen Therapiekonzepte Wegbereiter für neue Ansätze in der Behandlung der trockenen und neovaskulären AMD wie die submakuläre oder intravitreale Gen- oder Stammzelltherapie.

Abstract

The structure of the vitreous body, its interaction with the retinal surface and tractive alterations of the vitreoretinal interface may play a role in the pathogenesis and the development of age-related macular degeneration (AMD). From clinical trials it can be concluded that posterior vitreous detachment (PVD) or vitreous removal may protect against the development of neovascular AMD. Vitreomacular adhesions may promote neovascular AMD and may have an impact on the efficacy and frequency of intravitreal vascular endothelial growth factor (VEGF) inhibition. Therefore, vitreomacular surgery may be considered as a treatment option in selected cases. Peeling of epimacular membranes and the internal limiting membrane (ILM) may contribute to stabilizing visual acuity and reducing the treatment burden of current intravitreal pharmacotherapy. At present, surgical interventions in AMD are mainly performed in cases of submacular hemorrhage involving the fovea. The treatment is not standardized and consists of liquefaction of the blood using recombinant tissue plasminogen activator (rTPA) and its pneumatic displacement, potentially combined with VEGF inhibition. Other submacular surgical strategies, such as choroidal neovascularization (CNV) extraction, macular translocation or transplantation of retinal pigment epithelium (RPE) are currently limited to selected cases as a salvage treatment; however, the development of these submacular surgical interventions has formed the basis for new approaches in the treatment of dry and neovascular AMD including submacular or intravitreal gene and stem cell therapy.

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Authors and Affiliations

  1. Augenklinik Herzog Carl Theodor, München, Deutschland

    Christos Haritoglou & Maximilian Schultheiss

  2. Klinik für Augenheilkunde, Universitätsklinikum Freiburg, Freiburg, Deutschland

    Stefaniya Boneva

  3. VMR Institute for Vitreous Macula Retina, Huntington Beach, CA, USA

    J. Sebag

  4. Doheny Eye Institute, Pasadena, CA, USA

    J. Sebag

  5. Department of Ophthalmology, Geffen School of Medicine, UCLA, Los Angeles, CA, USA

    J. Sebag

  6. Lehrstuhl für Ophthalmologie, Sigmund Freud Universität, Wien, Österreich

    Susanne Binder

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  1. Christos Haritoglou
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  2. Stefaniya Boneva
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  4. J. Sebag
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Correspondence to Christos Haritoglou.

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Interessenkonflikt

C. Haritoglou erhält Vortragshonorare von Bayer und Novartis. S. Boneva. M. Schultheiss, J. Sebag und S. Binder geben an, dass kein Interessenkonflikt besteht.

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Haritoglou, C., Boneva, S., Schultheiss, M. et al. Vitreoretinale Chirurgie bei altersabhängiger Makuladegeneration. Ophthalmologie 120, 1004–1013 (2023). https://doi.org/10.1007/s00347-023-01933-2

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