Zusammenfassung
Die intravitreale Injektion als minimalinvasiver Eingriff stellt bei zahlreichen vitreoretinalen Krankheitsbildern eine wertvolle Behandlungsform dar. Nicht standardisiertes Durchführen der Injektion kann jedoch zu schwerwiegenden Komplikationen führen. Die hier diskutierten Empfehlungen zur Durchführung der intravitrealen Injektion sollen daher zur Minimierung des Komplikationsrisikos beitragen. Bedeutsam ist insbesondere eine intensive präoperative Antisepsis mit Povidon Jod, ein steriles Arbeiten mit sterilem Lidspekulum, Abdecktuch und Handschuhen, Anwenden einer adäquaten Injektionstechnik sowie der Ausschluss einer postoperativen retinalen Perfusionsstörung.
Abstract
The intravitreal injection as a minimally invasive intervention has proved to be an effective therapy in the management of numerous vitreoretinal diseases. However, non-standardized performance of the procedure might cause severe complications. The recommendations for intravitreal injections discussed here are intended to contribute to a minimization of the risk for complications. Of particular importance are a meticulous preoperative antisepsis with povidon iodine, a sterile environment using a sterile lid speculum, drape and gloves, the use of an adequate injection technique and the exclusion of postoperative retinal non-perfusion.
Schlüsselwörter
Intravitreale Injektion - Injektionsstandard - Durchführung - Komplikationen - Risikofaktoren - Triamcinolon - Macugen
Key words
Intravitreal Injection - standards for injection - complications - risk factors - triamcinolone - Macugen
Literatur
1
Abe T, Nakajima A, Nakamura H. et al .
Intraocular pressure during pneumatic retinopexy.
Ophthalmic Surg Lasers.
1998;
29
391-193
2
Aiello L P, Brucker A J, Chang S. et al .
Evolving guidelines for intravitreous injections.
Retina.
2004;
24
S3-S19
3
Apt L, Isenberg S, Yoshimori R. et al .
Chemical preparation of the eye in ophthalmic surgery. III. Effect of povidone-iodine on the conjunctiva.
Arch Ophthalmol.
1984;
102
728-729
4
Bakri S J, Shah A, Falk N S. et al .
Intravitreal preservative-free triamcinolone acetonide for the treatment of macular edema.
Epup Eye Aug.
2004;
27
5
Buzard K, Liapis S.
Prevention of endophthalmitis.
J Cataract Refract Surg.
2004;
30
1953-1959
6
Ciardella A P, Klancnik J, Schiff W. et al .
Intravitreal triamcinolone for the treatment of refractory diabetic macular oedema with hard exudates: an optical coherence tomography study.
Br J Ophthalmol.
2004;
88
1131-1136
7
Ciulla T A, Walker J D, Fong D S. et al .
Corticosteroids in posterior segment disease: an update on new delivery systems and new indications.
Curr Opin Ophthalmol.
2004;
15
211-220
8
Coden D J, Freeman W R, Weinreb R N.
Intraocular pressure response after pneumatic retinopexie.
Ophthalmic surgery.
1988;
19
667-669
9
Danis R P, Ciulla T A, Pratt L M. et al .
Intravitreal triamcinolone acetonide in exudative age-related macular degeneration.
Retina.
2000;
20
244-250
10 De Kaspar H M, Chang R, Egbert P. Greater elimination of conjunctiva bacteria after preoperative irrigation with 10 cc of 5 % povidone-iodine. Presented at: Annual Meeting of the American Academy of Ophthalmology. Anaheim, Florida; November 15 - 18, 2003
11
De Kaspar H M, Shriver E M, Nguyen E V. et al .
Risk factors for antibiotic-resistant conjunctival bacterial flora in patients undergoing intraocular surgery.
Graefe’s Arch Clin Exp Ophthalmol.
2003;
241
730-733
12
Eckardt C.
Staphylococcus epidermidis endophthalmitis after pneumatic retinopexy.
Am J Ophthalmol.
1987;
103
720-721
13
Ferguson A W, Scott J A, McGavigan J. et al .
Comparison of 5 % Povidone-Iodine solution against 1 % Povidone-Iodine solution in preoperative cataract surgery antisepsis: a prospective randomised double blind study.
Br J Ophthalmol.
2003;
87
163-167
14
Flynn H W, Scott I U.
Introduction. Intravitreal injections: The route of retinal pharmacotherapies.
Retina.
2004;
24
S1
15
Gillies M C, Simpson J M, Luo W. et al .
A randomized clinical trail of a single dose of intravitreal triamcinolone acetonide for neovascular age-related macular degeneration. One-year results.
Arch Ophthalmol.
2003;
121
667-673
16
Goldstein M H, Kowalski R P, Gordon Y J.
Emerging fluoroquinolone resistance in bacterial keratitis. A 5-year review.
Ophthalmology.
1999;
106
1313-1318, discussion 1318
17
Gupta M S, McKee H DR, Stewart O G.
Perioperative prophylaxis for cataract surgery: Survey of ophthalmologists in the north of England.
J Cataract Refract Surg.
2004;
30
2021-2022
18
Handwerger B A, Blodi B A, Chandra S R. et al .
Treatment of submacular hemorrhage with low-dose intravitreal tissue plasminogen activator injection and pneumatic displacement.
Arch Ophthalmol.
2001;
119
28-32
19
Hanscom T A.
Postoperative endophthalmitis.
Clin Infect Dis.
2004;
38
542-546
20
Hilton G F, Grizzard W S.
A two-step outpatient operation without conjunctival incision.
Ophthalmology.
1986;
93
626-641
21
Hilton G F, Kelly N E, Salzano T C. et al .
Pneumatic retinopexie. A collaborative report of the first 100 cases.
Ophthalmology.
1987;
94
307-314
22
Hilton G F, Tornambe P E.
The retinal detachment study group. Pneumatic retinopexy. An analysis of intraoperative and postoperative complications.
Retina.
1991;
11
285-294
23
Isenberg S J, Apt L, Yoshimori R. et al .
Chemical preparation of the eye in ophthalmic surgery. IV. Comparison of Povidone-Iodine on the conjunctiva with a prophylactic antibiotic.
Arch Ophthalmol.
1985;
103
1340-1342
24
Jager R D, Aiello L P, Patel S C. et al .
Risks of intravitreous injection: a comprehensive review.
Retina.
2004;
24
676-698
25
Jonas J B, Kreissig I, Degenring R.
Intraocular pressure after intravitreal injection of triamcinolone acetonide.
Br J Ophthalmol.
2003;
87
24-27
26
Jonas J B, Kreissig I, Degenring R F.
Endophthalmitis after intravitreal injection of triamcinolone acetonide.
Arch Ophthalmol.
2003;
121
1663-1664
27
Jonas J B, Kreissig I, Degenring R F.
Retinal complications of intravitreal injections of triamcinolone acetonide.
Graefe’s Arch Clin Exp Ophthalmol.
2004;
242
184-185
28
Keverline M R, Kowalski R P, Dhaliwal D K.
In vitro comparison of Ciprofloxacin, Ofloxacin, and Povidone-Iodine for surgical propyhlaxis.
J Cataract Refract Surg.
2002;
28
915-916
29
Kirsch L S, Arevalo J F, De Clercq E. et al .
Phase I/II study if intravitreal Cidofovir for the treatment of cytomegalovirus retinitis in patients with the acquired immunodeficiency syndrome.
Am J Ophthalmol.
1995;
119
466-476
30
Krepler K, Kruger A, Tittl M. et al .
Intravitreal injection of tissue plasminogen activator and gas in subretinal hemorrhage caused by age-related macular degeneration.
Retina.
2000;
20
251-256
31
Leitlinien von BVA und DOG. augeninfo.de/leit/index.htm.
32
Leong J K, Shah R, McCluskey P J. et al .
Bacterial contamination of the anterior chamber during phakoemulsification cataract surgery.
J Cataract Refract Surg.
2002;
28
826-833
33
Magugen, FDA.com.
34
Mamalis N, Kearsley L, Brinton E.
Postoperative endophthalmitis.
Curr Opin Ophthalmol.
2002;
13
14-18
35
Mather R, Karenchak L M, Romanowski E G. et al .
Fourth generation fluoroquinolones: New weapons in the arsenal of ophthalmic antibiotics.
Am J Ophthalmol.
2002;
133
463-466
36
Moshfeghi D M, Kaiser P K, Scott I U. et al .
Acute Endophthalmitis following intravitreal triamcinolone acetonide injection.
Am J Ophthalmol.
2003;
136
791-796
37
Nelson M L, Tennant M TS, Sivalingam A. et al .
Infectious and presumed noninfectious endophthalmitis after intravitreal triamcinolone acetonide injection.
Retina.
2003;
23
686-691
38
Parke D W.
Intravitreal triamcinolone and endophthalmitis.
Am J Ophthalmol.
2003;
136
918-919
39
Penfold P L, Gyory J F, Hunyor A B. et al .
Exudative macular degeneration and intravitreal triamcinolone. A pilot study.
Aust N Z J Ophthalmol.
1995;
23
293-298
40
Perry L D, Skaggs C.
Preoperative topical antibiotics and lash trimming in cataract surgery.
Ophthalmic Surg.
1977;
8
44-48
41
Roth D B, Chieh J, Spirn M J. et al .
Noninfectious endophthalmitis associated with intravitreal triamcinolone injection.
Arch Ophthalmol.
2003;
121
1279-1282
42
Sakamoto T, Enaida H, Kubota T. et al .
Incidence of acute endophthalmitis after triamcinolone-assisted pars plana vitrectomy.
Am J Ophthalmol.
2004;
138
137-138
43
Schmitz S, Dick H B, Krummenauer F. et al .
Endophthalmitis in cataract surgery. Results of a German survey.
Ophthalmology.
1999;
64
1084-1087
44
Snyder-Perlmutter L, Katz H R, Melia M.
Effect of topical ciprofloxacin 0.3 % and ofloxacin 0.3 % on the reduction of bacterial flora on the human conjunctiva.
J Cataract Refract Surg.
2000;
26
1620-1625
45
Speaker M G, Menikoff J A.
Prophylaxis of endophthalmitis with topical povidone-iodine.
Ophthalmology.
1991;
98
1769-1775
46
Speaker M G, Milch F A, Shah M K. et al .
Role of external bacterial flora in the pathogenesis of acute postoperative endophthalmitis.
Ophthalmology.
1991;
98
639-649, discussion 650
47
Starr M B, Lally J M.
Antimicrobial prophylaxis for ophthalmic surgery.
Surv Ophthalmol.
1995;
39
485-501
48
Sutter F KP, Gillies M C.
Interim (3 months) analysis of the safety of intravitreal triamcinolone for diabetic macular oedema that persists after laser treatment. Results from a randomized clinical trial: TDMO.
Invest Ophthalmol Vis Sci.
2003;
44: ARVO E-Abstract 454
49
Sutter F KP, Gillies M C.
Pseudo-endophthalmitis after intravitreal injection of triamcinolone.
Br J Ophthalmol.
2003;
87
972-974
50
Ta C N.
Minimizing the risk of endophthalmitis following intravitreous injections.
Retina.
2004;
24
699-705
51
Ta C N, Egbert P R, Singh K. et al .
Prospective randomized comparison of 3-day versus 1-hour preoperative ofloxacin prophylaxis for cataract surgery.
Ophthalmology.
2002;
109
2036-2040, discussion 2040 - 2041
52
Tornambe P E, Hilton G F.
The retinal detachment study group. Pneumatic retinopexy. A multicenter randomized controlled clinical trial comparing pneumatic retinopexy with scleral buckling.
Ophthalmology.
1988;
96
772-784
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