Retinaler Venenverschluss – wann, womit und wie therapieren?

Zusammenfassung

Nach neuesten Erkenntnissen ist ein Makulaödem infolge eines retinalen Venenverschlusses am besten mit einer zeitnahen intravitrealen Anti-VEGF-Therapie (Aflibercept, Bevacizumab [off label], Ranibizumab) sicher und effektiv behandelbar. Nach einem anfänglichen Upload von monatlich 3 Injektionen Anti-VEGF sollte in regelmäßigen Kontrollen vor allem OCT-basiert (bevorzugt gegenüber visusbasiert) über eine erneute Injektion entschieden werden. Nach anfänglichen monatlichen Injektionen haben sich derzeit vor allem das „Pro-re-nata“- (PRN) und das „Treat-and-Extend“-Schema in Bezug auf den weiteren Therapieverlauf durchgesetzt. Unter Beachtung des Nebenwirkungsspektrums (insbesondere Kataraktprogression, Augeninnendruckerhöhung) kann auch eine intravitreale Therapie mit einem Dexamethason-Implantat sinnvoll sein. Die Prognose bez. Visus und Rückgang des Makulaödems hängt von einem frühen Behandlungsbeginn mit konsequenter Therapiefortführung ab. Vor Behandlungsbeginn sowie im Verlauf ist eine Fluoresceinangiografie nötig, um ischämische Netzhautareale zu detektieren. Es gibt Hinweise, dass eine frühe gezielte Laserkoagulation ischämischer Netzhautareale die Frequenz der nötigen Injektionen senkt und zu einem besseren Ansprechen des Ödems auf die Therapie führt. Bei signifikanter retinaler Ischämie, die in der Folge zu Proliferationen, Rubeosis iridis und einem Sekundärglaukom führen kann, ist eine Laserbehandlung unumgänglich.

Abstract

According to the latest findings, macular oedema due to retinal vein occlusion is best treated safely and effectively with near-term intravitreal anti-VEGF therapy (aflibercept, bevacizumab [off label], ranibizumab). After an initial upload of 3 monthly injections of anti-VEGF, the decision on re-injection should be based on OCT (rather than on visual acuity). After initial monthly injections, the “pro-re-nata” (PRN) and the “treat-and-extend” regimens have been predominantly used in the further course of therapy. Taking into account the side effect spectrum (in particular cataract progression, increased intraocular pressure), intravitreal therapy with a dexamethasone implant may be a reasonable alternative. The prognosis for visual acuity and the decline in macular oedema depend on starting treatment early and continuing it consistently. Before starting treatment, as well as during treatment, fluorescein angiography is necessary to detect ischemic retinal areas. There is evidence that early targeted laser coagulation of ischemic retina may reduce the frequency of necessary injections and improve the response of the oedema to therapy. Significant retinal ischemia may lead to proliferations, rubeosis iridis and secondary glaucoma and therefore requires laser treatment.

Schlüsselwörter

retinaler Venenverschluss - Zentralvenenverschluss - Venenastverschluss - Makulaödem - Anti-VEGF

Key words

retinal vein occlusion - CRVO - BRVO - macular edema - anti-VEGF

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