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Transplantation von retinalem Pigmentepithel (RPE) nach CNV-Exzision bei altersabhängiger Makuladegeneration

Techniken, Ergebnisse und Perspektiven

Transplantation of retinal pigment pithelium (RPE) following CNV removal in patients with AMD

Techniques, results, outlook

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Zusammenfassung

Subfoveale choroidale Neovaskularisationen (CNV) sind neben der geographischen Atrophie heute die häufigste Ursache für einen irreversiblen Verlust der zentralen Sehschärfe bei altersabhängiger Makuladegeneration (AMD). Chirurgisch kann eine subfoveale CNV mittels vitreoretinaler Techniken über eine paramakuläre Retinotomie exzidiert werden. Dies ist allerdings in der Regel mit einer gleichzeitigen Entfernung des korrespondierenden retinalen Pigmentepithels (RPE) verbunden. Zur Vermeidung eines konsekutiven Zentralskotoms umfassten bisherige Ansätze zur RPE-Zelltransplantation nach CNV-Exzision die Injektion sowohl heterologer als auch autologer RPE-Zellsuspensionen, die jedoch mit Dedifferenzierung der RPE-Zellen, ausbleibender Bildung einer regulären Adhäsion an die Bruch’sche Membran und eines einschichtigen Zellrasens einhergingen. In jüngster Zeit wurden daher Translokationstechniken mit autologen RPE-Sheets mit intakter Polarität entwickelt, die den Erhalt der fovealen Netzhautfunktion erlaubten. Dabei wird außerhalb der Makula ein RPE/Bruch’Membran/Aderhaut-Komplex gewonnen und intraokular unter die Makula transloziert. Neben den aktuellen pharmakologischen Ansätzen inkl. Anti-VEGF-Präparaten eröffnen sich mit diesen mikrochirurgischen Verfahren neue therapeutische Perspektiven für Patienten mit subfovealer CNV.

Abstract

Neovascular age-related macular degeneration (AMD) has become the leading cause for severe visual loss in all industrialized nations. Surgical excision of choroidal neovascularizations (CNV) is technically feasible but invariably associated with inadvertent removal of corresponding retinal pigment epithelium (RPE) and subsequent atrophy of the choriocapillaris, with the latter two layers being a prerequisite for normal photoreceptor function. To cover the RPE defect both heterologous and homologous RPE cell suspensions have been injected into the subretinal space. The lack of functional improvement has been attributed to various factors including RPE cell dedifferentiation, failure of adherence to Bruch’s membrane as well as development of a regular RPE cell monolayer. Therefore, techniques for translocating intact autologous RPE cell sheets have been sought and preservation of foveal neurosensory functions has recently been successfully demonstrated. Besides translocation of a full-thickness RPE/Bruch’s membrane/choroid patch outside the macular area, superfluous choroidal tissue may be ablated intraocularly using an excimer laser prior to translocation. Besides recent pharmacological approaches including anti-VEGF agents, these surgical developments open new perspectives for patients with neovascular AMD.

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  1. Universitäts-Augenklinik, Bonn

    A. Bindewald, F. Roth & F. G. Holz

  2. Eye Hospital, Rotterdam

    J. van Meurs

  3. Universitäts-Augenklinik, Ernst-Abbe-Straße 2, 53127 , Bonn

    A. Bindewald

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  1. A. Bindewald
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Bindewald, A., Roth, F., van Meurs, J. et al. Transplantation von retinalem Pigmentepithel (RPE) nach CNV-Exzision bei altersabhängiger Makuladegeneration. Ophthalmologe 101, 886–894 (2004). https://doi.org/10.1007/s00347-004-1077-2

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