Therapie der vitreomakulären Traktion mit und ohne Makulaforamen

 

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Zusammenfassung

Vitreomakuläre Traktionen (VMT) mit und ohne Makulaforamen, die mit visuellen Symptomen (Visusminderung, Metamorphopsien usw.) assoziiert sind und keine Spontanheilung zeigen, sind i. d. R. behandlungsbedürftig. Zur präzisen Diagnosestellung ist die SD-OCT-Untersuchung ein wichtiges und obligates Hilfsmittel zur genauen Klassifikation und zur Abschätzung des Behandlungserfolgs. Die Indikation für eine pharmakologische Vitreolyse oder eine Vitrektomie ist dann zu stellen, wenn sich der Patient bei persistierender VMT durch Visusminderung oder Metamorphopsien deutlich beeinträchtigt fühlt. Mithilfe einer einmaligen intravitrealen operativen Medikamenteneingabe (IVOM) von Jetrea® besteht die Möglichkeit, bereits zu einem früheren Zeitpunkt einzugreifen. Eine Indikation für die pharmakologische Vitreolyse besteht bei fokaler vitreomakulärer Traktion (≤ 1500 µm, ohne epiretinale Membran, ohne Begleiterkrankung) und bei kleinem Makulaforamen (≤ 250 µm) mit VMT. Für alle anderen Patienten mit behandlungsbedürftiger idiopathischer traktiver Retinopathie sollte eine minimalinvasive transkonjunktivale trokargeführte Pars-plana-Vitrektomie (ppV) durchgeführt werden. Im Rahmen einer Vitrektomie kann eine effektive Entfernung der Traktionen mechanisch erreicht werden. Allerdings wird eine Vitrektomie aufgrund eines gewissen Risikoprofils (Kataraktinduktion bei phaken Patienten, ggf. Netzhautrisse) meist erst bei deutlicher Visusreduktion durchgeführt. Eine ppV ist auch bei Patienten indiziert, bei denen eine pharmakologische Vitreolyse nicht erfolgreich war.

Abstract

Treatment is usually indicated for symptomatic vitreomacular traction (VMT) with or without a full thickness macular hole (FTMH) and without spontaneous resolution. Ultrastructural parameters are evaluated by SD-OCT, in order to classify the vitreoretinal interface and to estimate the success rate of treatment. The resolution rate after therapy with intravitreal Jetrea® (Ocriplasmin) is high (up to 70 %) in patients with symptomatic focal vitreomacular traction (≤ 1500 µm) with or without a macular hole (≤ 250 µm) and with no epiretinal membrane (ERM), but depends on the exact baseline analysis. All other patients with idiopathic traction retinopathy should be treated by minimal invasive pars plana vitrectomy (MIVI). Vitreoretinal surgery effectively removes traction and gives a high closure rate of a full thickness macular hole (FTMH, 90 to 100 %). It is now a very safe procedure with few side effects. Despite a low risk profile (cataract, retinal tear etc.) the indication for surgery needs to take the safety profile into account. Therefore vitrectomy is only indicated in symptomatic patients complaining of blurred vision, VA reduction and metamorphopsia. Vitrectomy is also indicated in patients whose treatment by pharmacologic vitreolysis has failed.

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