Infektionen nach Linsenchirurgie: Implikationen für die refraktive Chirurgie

Zusammenfassung

Neben der klassischen Indikationsstellung der Kataraktoperation bei Vorliegen einer visusmindernden Trübung in der kristallinen Linse gewinnt die Extraktion der noch nicht getrübten Linse auch als primär refraktiver Eingriff zunehmend an Bedeutung. Die vorliegende Literaturübersicht soll unter Berücksichtigung der gültigen Empfehlungen verschiedener Fachgesellschaften und neuerer Studien helfen, die Inzidenz einer postoperativen Endophthalmitis einzuschätzen und evidenzbasierte Empfehlungen zur Prophylaxe, Diagnose und Therapie geben.

Die nach Kataraktextraktion berichtete Inzidenz beträgt in den meisten umfangreichen Studien zwischen 0,04 % und 0,3 %. Die beiderseitige Kataraktoperation am selben Tag findet international zunehmend Verbreitung. Ob dabei das Endophthalmitisrisiko verändert ist, bleibt derzeit schwierig abzuschätzen. Von einer postoperativen Endophthalmitis ist das Toxic Anterior Segment Syndrome (TASS) abzugrenzen. Dabei handelt es sich um eine akut auftretende sterile Entzündung nach Kataraktoperation. Reste von Reinigungs- und Sterilisationsmitteln am chirurgischen Instrumentarium werden als Hauptauslöser vermutet. Zudem gilt die unsachgemäße Präparation von intrakameralen Spüllösungen und Antibiotika als ein bedeutsamer Grund. Ein TASS wurde auch nach Implantation einer irisgestützten Vorderkammerlinse in ein phakes Auge berichtet. Das in der ESCRS-Studie zur Endophthalmitisprophylaxe verwendete und für die kataraktchirurgische Routine anempfohlene Cefuroxim ist in Deutschland nicht als fertige Lösung für die intraoperative Applikation kommerziell erhältlich. Zur Prophylaxe der postoperativen Endophthalmitis werden in verschiedenen Ländern unterschiedliche Maßnahmen praktiziert, deren Wert nicht exakt quantifizierbar ist. Die Povidon-Iod-Antisepsis gilt immer noch als am besten abgesicherte Komponente zur Endophthalmitisprophylaxe. Zur Therapie der akuten postoperativen Endophthalmitis wird ergänzend zur intravitrealen Instillation von Antibiotika deren systemische Gabe empfohlen. Wenige Kasuistiken wurden publiziert, in denen eine Infektion nach Implantation von refraktiven Linsen in ein phakes Auge beschrieben wurde, jedoch konnten wir keine aussagekräftige Angabe zur Inzidenz der Endophthalmitis nach Implantation von refraktiven Intraokularlinsen finden. Aufgrund der Tatsache, dass die Introkularlinse nicht in den Kapselsack implantiert wird, sondern vor die Augenlinse bzw. in die Vorderkammer, und der insgesamt vermutlich besseren antimikrobiellen Abwehrlage in dieser überwiegend jüngeren Population im Vergleich zu Kataraktpatienten kann vermutet werden, dass die Infektionsrate niedriger ist als nach der Kataraktoperation. Dennoch erscheint ein prospektives Register zur Dokumentation möglichst aller Endophthalmitispatienten wünschenswert.

Abstract

Apart from the classical indication of removing an opaque lens that is compromising vision, extraction of the crystalline lens is gaining increasing importance as a refractive procedure. This literature review which considers the present guidelines of various ophthalmological societies and recently published studies is intended to give an estimate of the incidence of postoperative endophthalmitis and evidence-based recommendations for its prophylaxis, diagnosis, and therapy. The incidence of endophthalmitis after cataract extraction is reported to be 0.04 % to 0.3 % in most sizeable studies. Immediate sequential bilateral cataract surgery is internationally gaining popularity. It remains difficult to estimate whether or not the risk of endophthalmitis is affected with this approach. A toxic anterior segment syndrome (TASS) needs to be differentiated from postoperative endophthalmitis. TASS is an acute sterile inflammation after cataract surgery. Remnants of detergents and antiseptics on the surgical instruments are supposed to be main triggers. Additionally, the inappropriate preparation of solutions and antibiotics for intracameral use is considered to be a major cause. A case of TASS was also reported after implantation of an iris-fixated anterior chamber lens in a phakic eye. The cefuroxime solution that was prophylactically used in the ESCRS study and that is recommended for routine cataract surgery is not commercially available in Germany as a ready preparation for intraoperative application. Different measures are undertaken in different countries to prevent postoperative endophthalmitis, whose values are not exactly quantifiable. Antisepsis with povidone-iodine is still considered to be the component with the best evidence. For management of acute postoperative endophthalmitis, the systemic application of antibiotics is recommended in addition to their intravitreal injection. Few case reports have been published describing an infection after the implantation of refractive intraocular lenses (IOLs) in a phakic eye. However, we could not find meaningful information regarding the incidence of endophthalmitis after implantation of refractive IOLs. Based on the fact that these IOLs are not implanted into the capsular bag but in front of the crystalline lens or into the anterior chamber, and the presumably better anti-microbial immunity of this younger population compared to cataract patients, one may assume that the infection rate is lower than after cataract surgery. Nevertheless, a prospective register to document all endophthalmitis cases is desirable.

Schlüsselwörter

postoperative Endophthalmitis - Inzidenz - refraktive Linsenimplantation - phake IOL - Kataraktoperation

Key words

postoperative endophthalmitis - incidence - refractive intraocular lens implantation - phakic IOL - cataract surgery

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