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Glaukom und Netzhautchirurgie

Glaucoma and retinal surgery

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Zusammenfassung

In der Therapie komplexer Glaukome werden verschiedene Ausgangssituationen betrachtet: vorbestehendes Glaukom, Glaukominduktion nach vitreoretinaler Chirurgie und antiglaukomatöse Eingriffe. Bei vorbestehendem Glaukom und Zustand nach fistulierender Operation wird zur Erhaltung des Sickerkissens ein vitreoretinaler Zugang mit möglichst bindehautschonender Technik, wie pneumatische Retinopexie und „small-gauge“-Vitrektomie, angewendet. Nach vitreoretinaler Chirurgie steigt häufig der intraokulare Druck (IOD). Sekundärglaukome können nach Buckelchirurgie und Vitrektomien mit oder ohne Gas- bzw. Silikonöltamponade sowie nach Steroidgaben auftreten. Winkelblockglaukome nach Buckelchirurgie entwickeln sich infolge von Stauung und anteriorer Rotation des Ziliarkörpers. Intravitreale Gastamponaden mit expansionsfähigen oder auch gesättigten Gasen können ein Winkelblockglaukom mit oder ohne Pupillarblock verursachen und die okuläre Perfusion kritisch einschränken. Postoperative Kontrollen, sofortiges Handeln und ein Flugverbot verhindern Dauerschäden.

Die meisten Sekundärglaukome können lokal medikamentös und durch adäquate postoperative Lagerung beherrscht werden. Neben passagerer systemischer Gabe von Antiglaukomatosa oder Laserung ist bei massiver Schwellungsreaktion oder Überfüllung eine direkte Intervention wie partielle Gas- oder Silikonölentfernung erforderlich. Eine prophylaktische inferiore periphere Iridektomie verhindert in aphaken Augen bei intraokularer Tamponade einen Pupillarblock. Bei Einsatz von schwerem Silikonöl wird diese superior angelegt. Bei Verschluss derselben ist eine Nd:YAG-Laserung meist tensioregulierend. Die durch Emulsifikation des Silikonöls bedingte Überfrachtung kann durch Trabekelwerkaspiration und Lavage verbessert werden. Bei therapierefraktärem Glaukom haben sich die Zyklophotokoagulation, ggf. repetitiv, und Drainageimplantate zur langfristigen IOD-Regulierung bewährt.

Häufig sind die Ursachen des Sekundärglaukoms multifaktoriell und erfordern eine genaue Beobachtung für eine situative und erfolgreiche Therapie.

Abstract

In the therapeutic approach to complex glaucomas different initial situations were considered: pre-existing glaucoma, induction of glaucoma after vitreoretinal surgery and antiglaucomatous procedures. In pre-existing glaucoma and after filtering surgery maintenance of the filtering bleb requires a vitreoretinal approach for conjunctiva preservation with techniques such as pneumatic retinopexy or small gauge vitrectomy. After vitreoretinal surgery an increase in intraocular pressure (IOP) is common. Secondary glaucoma may occur after scleral buckling and after vitrectomy with or without gas or silicone oil tamponade as well as after application of steroids. Angle closure glaucoma after scleral buckling develops because of congestion and anterior rotation of the ciliary body. Vitreous tamponades with expansive or saturated gases may cause angle-closure glaucoma with or without pupillary blockage and may critically shorten ocular perfusion. Postoperative checks, immediate action and a ban on boarding aircraft over the period of intraocular gas tamponade prevent permanent damage to the eye.

The majority of secondary glaucomas can effectively be controlled by topical medication and adequate postoperative posture of the patient. Besides the temporary use of systemic antiglaucomatous medication or laser therapy, very rarely in cases of massive swelling or overfill, a direct intervention, such as partial gas or silicone oil removal is required. A prophylactic inferior peripheral iridectomy prevents pupillary blockage in aphakic eyes with intraocular tamponade. In cases of heavy silicone oil use, the peripheral iridectomy is placed in the superior position. Nd:YAG laser application will regulate IOP in cases of occlusion. Secondary glaucoma due to silicone oil emulsification overload is treated by trabecular meshwork aspiration and lavage. In refractory glaucoma repetitive cyclophotocoagulation and drainage implants represent an approved method for long-term IOP regulation.

The underlying cause of secondary glaucoma after vitreoretinal surgery is often multifactorial in nature and may benefit from an exact analysis for an adequate and successful treatment regimen.

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Authors and Affiliations

  1. Klinik für Augenheilkunde, Universität zu Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland

    M. Müller

  2. Universitätsaugenklinik, Julius-Maximilians-Universität Würzburg, Würzburg, Deutschland

    G. Geerling & T. Klink

  3. Universitäts-Augenklinik, Department für Augenheilkunde, Eberhard Karls Universität Tübingen, Tübingen, Deutschland

    M. Zierhut

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  1. M. Müller
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  2. G. Geerling
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Correspondence to M. Müller.

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Müller, M., Geerling, G., Zierhut, M. et al. Glaukom und Netzhautchirurgie. Ophthalmologe 107, 419–426 (2010). https://doi.org/10.1007/s00347-009-2064-4

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