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Klin Monbl Augenheilkd 2000; 216(1): 33-39
DOI: 10.1055/s-2000-10513
KLINISCHE STUDIE

Georg Thieme Verlag Stuttgart · New York

Klinische Ergebnisse über die intravitreale Gabe von Gewebe-Plasminogen-Aktivator (tPA) und Gas zur Verdrängung von subretinalen Blutungen bei altersabhängiger Makuladegeneration[*]

Clinical results about intravitreal tissue plasminogen activator (tPA) assisted gas displacement of subretinal hemorrhage in age related macular degenerationCarsten Framme1 , Hesham El Toukhy2 , Helmut  G. Sachs1 , Detlef Spiegel1 , Johann Roider1 , Veit-P. Gabel1 , Chris  P. Lohmann1
  • 1 Universitäts-Augenklinik Regensburg, Franz-Josef-Strauss-Allee 11, 93042 Regensburg(Direktor: Prof. Dr. med. V.-P. Gabel)
  • 2 Ophthalmology Department, Tanta University, Tanta, Ägypten (Direktor: Prof. Dr. med. B. Bondok)
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Publication History

Publication Date:
31 December 2000 (online)

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Zusammenfassung

Hintergrund Subretinale Blutungen bei altersabhängiger Makuladegeneration (AMD) verursachen gewöhnlich einen akuten Sehverlust mit einer reduzierten Prognose. Um einen stärkeren Netzhautschaden durch das Blut zu verhindern und um die zugrundeliegende choroidale Neovaskularisation (CNV) gegebenenfalls einer Laserbehandlung zugänglich zu machen, muss die subretinale Blutung aus dem Bereich der choroidalen Neovaskularisation entfernt werden. Dieses kann durch die intravitreale Injektion von Gewebe-Plasminogen-Aktivator (tPA) und Gas erreicht werden.

Patienten und Methode Gewebe-Plasminogen-Aktivator (tPA; 40 μg in 400 μl BSS) und SF6-Gas (0,75ml) wurde bei acht konsekutiven Patienten in den Glaskörperraum injiziert, um die subretinale Blutung zu verflüssigen und aus dem Makulabereich zu verdrängen. Die Patienten beschrieben Sehprobleme zwischen einem und 16 Tage (im Mittel neun Tage).

Ergbnisse Bei allen Patienten konnten postoperativ eine Verflüssigung und eine Verlagerung der Blutung aus dem Makulabereich erreicht werden. Während der ersten Woche nach Operation zeigte sich ein signifikanter Visusanstieg im Gesamtkollektiv, ophthalmoskopisch zeigte sich allerdings nur eine geringe Reduktion der Blutung. Bei einem Patienten konnte anschließend eine Laserkoagulation der zugrundeliegenden CNV durchgeführt werden. Bei den anderen Patienten wurde keine Laserkoagulation aufgrund der subfovealen Lage der okkulten Membran oder wegen einer bereits bestehenden disziformen Narbe durchgeführt. Bei einem Patienten kam es nach der Operation zu einer persistierenden Glaskörperblutung. Als ernste Komplikation trat bei einem Patienten eine Endophthalmitis auf.

Zusammenfassung Die intravitreale Gabe von tPA und Gas bei subretinaler Blutung im Rahmen einer altersabhängigen Makuladegeneration kann innerhalb der ersten Woche zu einem signifikanten Visusanstieg führen. Eine weitgehende Verlagerung der Blutung aus dem Funduszentrum konnte zwar erreicht werden, doch ist eine Abgrenzung zum Spontanverlauf schwierig. Hier müsste eine kontrollierte Studie weitere Aufschlüsse liefern. Eine anschließende Laserkoagulation konnte erfahrungsgemäß aufgrund von Ausschlusskriterien bei AMD nur selten durchgeführt werden.

Background Subretinal hemorrhage in age related macular degeneration (AMD) usually causes acute visual loss and is associated with poor visual prognosis. In order to prevent retinal damage and to perform laser treatment of the underlying choroidal neovascularization (CNV) the subretinal hemorrhage has to be removed from the macular region. This could be achieved by intravitreal injection of tissue plasminogen activator (tPA) and gas.

Patients and methods In 8 consecutive patients, suffering from a massive macular hemorrhage (duration of visual problems: mean 9 days), tissue plasminogen activator (tPA) (40 μg in 400 μl BSS) and SF6-gas (0.75 ml) was transsclerally injected into the vitreous cavity to achieve liquification and displacement of the hemorrhage.

Results In all patients liquification and displacement of the hemorrhage out of the macular region was achieved during follow up. During the first week after operation a significant increase of visual acuity was noticed in all patients, however ophthalmoscopically there was just little reduction of the hemorrhage in the foveolar area. After successful removal of the blood the choroidal neovascularization was treated successfully by laser coagulation in one patient. No laser treatment was performed in the other patients because of the subfoveal location of the neovascularisation or because of disciform scar. Visual acuity increased 4 lines after surgery. In one case the procedure was complicated by a persistent vitreous hemorrhage and vitrectomy had to be performed in another patient due to an endophthalmitis.

Conclusion Intravitreal injection of tPA assisted gas displacement of subretinal hemorrhage due to AMD leads to a significant increase of visual acuity during the first week after operation. Although a nearly complete removal of the hemorrhage out of the macular area could be achieved, it was difficult to differentiate this from the spontaneous course. Laser photocoagulation could be performed in only few cases.

Schlüsselwörter

Makuladegeneration - choroidale Neovaskularisation - subretinale Hämorrhagie - tPA

Key words

macular degeneration - choroidal neovascularization - subretinal hemorrhage - tPA

1 Manuskript eingereicht am 17. 9. 99 und in der vorliegenden Form angenommen am 23. 11. 99.

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1 Manuskript eingereicht am 17. 9. 99 und in der vorliegenden Form angenommen am 23. 11. 99.

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