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Neue Behandlungsmöglichkeiten des diffusen diabetischen Makulaödems

New treatment options for diffuse diabetic macular edema

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Summary

WHO reports let assume that 180 million people suffer from diabetes worldwide. Diabetic macular edema is the most common cause of visual deterioration in these patients. Factors for the development of a diabetic macular edema are the duration of the disease, age at onset and general factors, which give evidence for the heaviness of the disease. Focal macular edema responds well to focal laser treatment whereas diffuse edema often persists despite modified grid laser treatment. For these eyes several new treatment options were evaluated during the last years. Since OCT investigations became more and more popular the role of the vitreous was of main interest. A thickened posterior hyloid was recognized as a diffusion barrier and cause of possible traction on the central retina. Numerous studies showed a visual increase and a decrease of the retinal thickness after vitrectomy in these patients. Intravitreal injections of triamcinolone acetonide seemed to displace surgical interventions. Several authors report of distinct improvements after intravitreal application of 4 mg. However, major problems are secondary glaucoma up to 68 %, secondary cataract development and the need for repeated injections due to a 3-months clearance of the substance in non-vitrectomized eyes. To avoid these complications long term sustain released systems with steroids which are implanted via the pars plana were described recently. New options are intravitreal anti-VEGF therapies. Promising reports with 3 different products (bevacizumab, ranibizumab and pegabtanib) show a good effectiveness for patients with diabetic macular edema. These studies are still running. Last but not least there are new systemic options (PKC ß inhibitors, somatostatin) under investigation. These substances are taken orally and could influence the progression of diabetic changes but not cure a diabetic edema so far.

Zusammenfassung

WHO Berichten zufolge leiden weltweit 180 Millionen Menschen an Diabetes mellitus. Das diabetische Makulaödem ist die häufigste Ursache für eine Visusverschlechterung bei diesen Patienten. Faktoren, die die Entwicklung fördern sind die Dauer der Erkrankung, das Alter bei Diagnosestellung und allgemeine Faktoren, die über die Schwere der Erkrankung aussagen. Fokale Makulaödeme sprechen gut auf Laserbehandlungen an während diffuse Ödeme oft trotz modifizierter Grid Laserbehandlung persistieren. Für diese Augen wurden während der letzten Jahre neue Behandlungsmethoden evaluiert. Seit die OCT Untersuchung an Popularität zunimmt, wurde die Bedeutung von Glaskörperveränderungen beim diabetischen Ödem klarer. Eine verdickte hintere Glaskörpergrenzschicht wurde als Diffusionsbarriere, aber auch als Ursache für mögliche Traktionen an der zentralen Netzhaut erkannt. Zahlreiche Studien weisen auf Sehverbesserungen und Abnahme der Netzhautdichte nach Vitrektomie und Membrane peeling in diesen Augen hin. Intravitreale Injektionen von Triamcinolonacetonid schienen chirurgische Eingriffe abzulösen. Viele Autoren berichten von deutlichen Verbesserungen nach einer intravitrealen Applikation von 4 mg. Es wurden jedoch Komplikationen, wie zum Beispiel sekundäre Drucksteigerungen, in bis zu 68 % der Fälle beschrieben, Die Wirkung des Medikaments lässt im nicht-vitrektomierten Auge nach ca. 3 Monaten nach, sodass wiederholte Injektionen erforderlich werden. Um dies zu vermeiden, wurden zuletzt Release Systeme mit Steroiden beschrieben, die über die Pars plana implantiert werden. Eine neue Option sind intravitreale Anti-VEGF Therapien. Vielversprechende Berichte mit 3 unterschiedlichen Produkten (Bevacizumab, Ranibizumab und Pegabtanib) zeigen eine gute Wirksamkeit bei Patienten mit diabetischem Makulaödem. Die Studien laufen derzeit noch. Nicht zuletzt sind neue systemische Optionen (PKC ß Inhibitoren, Somatostatin) geprüft worden. Diese Substanzen werden oral eingenommen und konnten bis jetzt die Progression von diabetischen Augenveränderungen aber nicht ein Makulaödem beeinflussen.

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  1. Augenabteilung KA Rudolfstiftung, L. Boltzmann Institut für Retinologie und biomikroskopische Laserchirurgie, Lehrkrankenhaus der Gemeinde Wien, Wien, Austria

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Stolba, U., Binder, S. Neue Behandlungsmöglichkeiten des diffusen diabetischen Makulaödems. Spektrum Augenheilkd. 21, 297–304 (2007). https://doi.org/10.1007/s00717-007-0231-z

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