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Klin Monbl Augenheilkd 2018; 235(11): 1269-1277
DOI: 10.1055/s-0043-115902
Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Operieren wir die Glaukome zu spät?

Do We Perform Glaucoma Surgery too Late?
Jörg Peter Egon Stürmer
1   Augenklinik, Kantonsspital Winterthur, Schweiz
,
Christoph Faschinger
2   Univ.-Augenklinik, Medizinische Universität Graz, Österreich
› Author Affiliations
Further Information

Publication History

eingereicht 18 April 2017

akzeptiert 28 June 2017

Publication Date:
24 August 2017 (online)

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Zusammenfassung

Aus der Sicht des operativen Glaukomatologen fragt man sich, warum die Patienten erst sehr spät zur Operation zugewiesen werden. Meist besteht schon zur Zeit der Zuweisung zur filtrierenden Operation nach vielen Jahren der konventionellen Therapie ein sowohl funktionell als auch morphologisch fortgeschrittener Glaukomschaden, zusätzlich ist auch oft noch der Augeninnendruck unter einer lokalen Maximaltherapie dekompensiert. Zusätzlich kommt hinzu, dass die Patienten oft ein fortgeschrittenes Alter aufweisen und schon viele Jahre lang mit verschiedenen Kombinationen aus Tropfen therapiert wurden. Sehr spät gestellte Diagnosen stellen eher die Ausnahme dar. Die Gründe für diese späte Zuweisung sind vielfältig. Neben der immer besseren (besser verträglichen und wirksamen) medikamentösen Glaukomtherapie spielen die Abneigung der Patienten gegen den operativen Eingriff (da keine Verbesserung des Sehvermögens zu erwarten ist) und die bis jetzt (noch) nicht verfügbare optimale Glaukomoperation eine entscheidende Rolle. Anhand einer kleinen retrospektiven Studie der letzten 274 zur filtrierenden Glaukomoperation zugewiesenen Patienten sollen die Kriterien für eine rechtzeitige Indikationsstellung erarbeitet und kritisch analysiert werden. In dieser Studie zeigt sich, dass rund ¾ aller Glaukompatienten spät oder zu spät zur Glaukomoperation zugewiesen werden. Für den niedergelassenen Ophthalmologen ohne Spezialisierung im Glaukombereich werden Kriterien formuliert, wann ein Patient zur Glaukomoperation zugewiesen werden sollte. Diese Kriterien sind grundsätzlich für alle Glaukomoperationen anzuwenden. Die Vor- und Nachteile einer filtrierenden Glaukomoperation werden jedoch besonders hervorgehoben, da dieser Eingriff nach wie vor den Goldstandard darstellt. Da aber die Trabekulektomie leider kein optimaler Glaukomeingriff ist, bestehen berechtigte Hoffnungen, dass die moderneren, weniger invasiven und damit auch weniger risikobehafteten Glaukomeingriffe (MIGS) die Indikationen für einen drucksenkenden Eingriff erweitern und damit die Hemmschwelle für die Zuweisung zur Glaukomoperation herabsetzen.

Abstract

As glaucoma specialists, we often ask ourselves why patients are referred so late for surgery. Usually the patient is referred in a far advanced stage of the disease after long-term conventional treatment with topical medications. By that time, substantial morphologic damage is present and the patient is disabled by far advanced visual field defects. In addition, decompensated intraocular pressure, despite maximal tolerated medical treatment, is seen. Delayed surgery due to late diagnosis is rather a rare event. Various reasons may be responsible for this late referral. Improved IOP-lowering medications (i.e., fixed combinations), personal aversion (fear and knowledge of lack of improvement in visual acuity) against surgery, and imperfect glaucoma procedures may play an important role. A retrospective review of the last 274 cases referred for filtering glaucoma surgery is used to describe and analyze criteria for adequate timing of glaucoma surgery. This study reveals that almost ¾ of patients are referred rather late for glaucoma surgery. Criteria for adequate timing of glaucoma surgery are given for non-glaucoma specialists in particular. They apply for all types of glaucoma surgery, and the pros and cons are discussed in detail. Trabeculectomy is still regarded as the gold standard of glaucoma surgery. Because trabeculectomy may not be an ideal glaucoma procedure, there is hope that the modern less-invasive glaucoma procedures (MIGS) will be able to extend indications for glaucoma surgery. This may also lower the hurdle of referral for glaucoma surgery for both patients and non-glaucoma specialist doctors.

Schlüsselwörter

Glaukom - Glaukomoperation - Trabekulektomie - Komplikationen - Indikationsstellung

Key words

glaucoma - glaucoma surgery - trabeculectomy - complications - indications
 

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