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Keratoplastik: Lamellieren oder perforieren?

Teil 2: Lamelläre Keratoplastik

Keratoplasty: laminate or penetrate?

Part 2: Lamellar keratoplasty

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Zusammenfassung

Zahlreiche Hornhauterkrankungen führen früher oder später zu der Entscheidung, ob eine Hornhauttransplantation notwendig wird. Im Gegensatz zum bisherigen Goldstandard, der perforierenden Keratoplastik (PKP), lagen die Nachteile ursprünglicher lamellärer Transplantationstechniken in schlechten visuellen Ergebnissen durch Interfaceprobleme. Zahlreiche technische Neuerungen haben in jüngster Vergangenheit zu einer Wiederentdeckung verschiedener lamellärer Operationsverfahren geführt. Bei der Deep Anterior Lamellar Keratoplasty (DALK) wird die Gefahr endothelialer Abstoßungsreaktionen vermieden. Bei unvollständiger Deszemetfreilegung sind die visuellen Ergebnisse jedoch mit denen nach einer PKP nicht vergleichbar. Bei einer Variante der posterioren lamellären Keratoplastik, der sog. Descemet Stripping (Automated) Endothelial Keratoplasty [DS(A)EK], wird am Empfänger ausschließlich das erkrankte Endothel mit Descemet-Membran (Descemetorhexis) entfernt. Anschließend kann das lamelläre, endotheltragende Transplantat über einen korneoskleralen/kornealen Tunnel implantiert werden, wobei kaum Astigmatismus induziert wird. Der Hauptvorteil der DS(A)EK im Vergleich zur PKP liegt in einer rascheren visuellen Rehabilitation bei nahezu unveränderter Refraktion, wobei die Visuswerte häufig etwas schlechter ausfallen. Für diese neu entwickelten Operationstechniken fehlen jedoch noch valide Studienergebnisse, die einen nachhaltigen Vergleich der neuen Verfahren gegen die konventionelle perforierende Keratoplastik erlauben.

Abstract

A number of corneal disorders sooner or later call for a decision as to whether corneal grafting is necessary. In contrast to the current gold standard, penetrating keratoplasty (PKP), former lamellar techniques had the disadvantage of worse visual outcomes due to interface problems. A number of recent new technical developments have led to a ‘renaissance’ of various lamellar keratoplasty methods. Deep anterior lamellar keratoplasty (DALK) avoids the risk of endothelial immune reactions. However, visual ourcomes are comparable to PKP only is complete baring of Descemet’s membrane is achieved. In Descemet stripping (automated) endothelial keratoplasty [DS(A)EK], a variation of posterior lamellar keratoplasty, only the diseased endothelium is removed with the Descetmet membrame (descemetorhexis). The lamellar, endothelium-bearing graft can subsequently be implanted via a corneoscleral/corneal tunnel, whereby little astigmatisum is induced. The main advantage of DS(A)EK compared to PKP is faster visual recovery with almost unaltered refraction, although visual acuity is often slightly lower. However, valid study results are still lacking for this new surgical technique to allow a long-term comparison of the new techniques with conventional penetrating keratoplasty.

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    P. Maier & T. Reinhard

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Maier, P., Reinhard, T. Keratoplastik: Lamellieren oder perforieren?. Ophthalmologe 106, 649–663 (2009). https://doi.org/10.1007/s00347-009-1943-z

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