Neovaskularisationsglaukome – Pathogenese, Diagnose, Therapie und Prophylaxe

Neovaskularisationsglaukome (NVG) gehören zu den im klinischen Alltag am häufigsten anzutreffenden Sekundärglaukomen. Sie stellen ein schwerwiegendes Krankheitsbild dar, das im ungünstigsten Fall bis zu einer Enukleation führen kann. Dieser Beitrag gibt einen Überblick über die Pathogenese, die häufigsten zugrunde liegenden Erkrankungen, die erforderliche Diagnostik und eine stadiengerechte Therapie.

Abstract

Neovascular glaucoma (NVG) is a severe potentially blinding disease, which represents one of the most common types of secondary glaucomas. The majority of cases are caused by ischemic retinal conditions such as diabetic retinopathy, central retinal vein occlusion or ocular ischemic syndrome. If appropriately diagnosed and treated, ideally the development of NVG can be prevented. Since treatment gets increasingly challenging as the disease progresses, early diagnosis is of utmost importance. In this review pathogenesis, diagnosis, treatment and prophylaxis are discussed extensively. A focus is put on the consecutive stages through which the disease progresses and how to diagnose and differentiate them. Ultimately a stage adapted therapy approach is detailed, consisting of the three blocks: 1. treatment of the underlying disease/retinal ischemia, 2. adjunctive medical therapy (anti-VEGF) and 3. therapy of the elevated intraocular pressure.

Kernaussagen

• NVG sind ein schwerwiegendes Krankheitsbild, das zu einer schmerzhaften Erblindung und letztlich einer Enukleation führen kann.

• NVG zählen zu den häufigsten Sekundärglaukomen.

• In den allermeisten Fällen liegt dem NVG eine ischämische Retinopathie (ischämischer ZVV, proliferative DR, OIS etc.) zugrunde.

• Seltene nicht ischämische Ursachen sind chronische Entzündungen, intraokulare Tumoren und chronische Netzhautablösungen.

• Da die Prognose mit zunehmendem Stadium ungünstiger wird, ist eine frühzeitige Diagnose entscheidend.

• Die Gonioskopie nimmt eine Schlüsselstellung in der Früherkennung und Therapieplanung ein.

• Liegt eine RI des Kammerwinkels vor, ist eine zeitnahe Therapieeinleitung essenziell, um eine zunehmende Synechierung des Kammerwinkels zu vermeiden.

• Anti-VEGF-IVOM führen zu einer schnellen Regression der RI, die Wirkung ist aber zeitlich limitiert.

• Für eine langfristige Stabilisierung ist eine pLK bzw. eine Laserbehandlung der ischämischen Netzhaut erforderlich. Auch wiederholte Anti-VEGF-IVOM bieten einen guten Schutz vor einem NVG, sie bedürfen aber eines intensiven Monitorings.

• Ist eine medikamentöse Druckregulierung in fortgeschrittenen Fällen nicht mehr möglich, wird eine operative Therapie erforderlich. Diodenlaser-Zyklophotokoagulation, Trabekulektomie mit Mitomycin C und Glaukom-Drainage-Implantate erzielen vergleichbare Erfolgsraten.

Schlüsselwörter

Neovaskularisationsglaukom - Rubeosis iridis - Pathogenese - Diagnose - Therapie

Key words

Neovascular glaucoma - rubeosis iridis - pathogenesis - diagnosis - treatment

Publication History

Article published online:
17 November 2023

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