Antimikrobielles Crosslinking der Hornhaut zur Vermeidung der Keratoplastik à chaud: retrospektive Fallserie

Zusammenfassung

Hintergrund: Das korneale Crosslinking (CXL) mit Riboflavin wird zunehmend zur Behandlung therapieresistenter mikrobieller Keratitiden angewendet, da vermehrt Resistenzen und spezielle Erreger, wie bspw. Akanthamöben bei Kontaktlinsenträgern, diese Therapieoption zur Vermeidung einer Keratoplastik à chaud attraktiv erscheinen lassen.

Patienten und Methoden: In dieser retrospektiven Fallserie mit 11 konsekutiven Patienten (4 Frauen, 7 Männer, Alter 24–82 Jahre), die ein standardisiertes antimikrobielles CXL bei therapieresistenter Keratitis zur Vermeidung einer Keratoplastik à chaud erhielten, waren 4 Fälle mit bakteriellem Keimnachweis, ein Fall mit nachgewiesener Mykose und 6 Fälle ohne Keimnachweis. Ausgewertet wurden auch die ophthalmologische Anamnese, allgemeine Risikofaktoren für eine mikrobielle Keratitis und Therapie vor und nach CXL. Zudem erfolgte die Charakterisierung des Ulkusbefunds einschließlich photometrischer Bestimmung der Infiltratfläche, die im Median 16,2 mm² betrug, wobei 4 Patienten nicht abgrenzbare Befunde präsentierten.

Ergebnisse: Innerhalb der Nachbeobachtungszeit von im Mittel 134 ± Standardabweichung von 82 Tagen konnte bei 6 Patienten (55 %) eine perforierende Keratoplastik à chaud erfolgreich vermieden werden. Nach CXL erhielten 9 Patienten (82 %) zusätzlich eine Amnionmembrantransplantation. Im Mittel wurde nach CXL 27 ± 13 Tage lokal antibiotisch nachbehandelt. Mit Steroiden wurden 91 % der Patienten nachbehandelt. Die Hornhaut klarte bei 9 Patienten (82 %) zumindest partiell auf. Patienten mit neurotropher Keratopathie oder potenziell beeinträchtigtem Immunsystem zeigten keine erhöhte Misserfolgsrate.

Schlussfolgerung: Die Ergebnisse legen nahe, dass bei Patienten mit einem konservativ nicht beherrschbarem Hornhautulkus das antimikrobielle CXL eine sinnvolle Therapie darstellen kann, um eine perforierende Keratoplastik à chaud zu vermeiden. Für eine umfassende wissenschaftliche Bewertung dieser Therapie sind jedoch weitere, idealerweise prospektive randomisierte interventionelle Studien mit großen Fallzahlen notwendig.

Abstract

Background: Corneal cross-linking (CXL) with riboflavin is being used more frequently for the treatment of therapy-resistant microbial keratitis, since increasing drug resistance and specific pathogens, e.g. contact lens-associated Acanthamoeba, make this therapy appear as an attractive option to avoid a keratoplasty à chaud.

Patients and Methods: This retrospective case series of 11 consecutive patients (4 women, 7 men, aged 24–82 years) who received standardised antimicrobial CXL for therapy-resistant keratitis to avoid a keratoplasty à chaud, included 4 cases with detection of bacterial pathogens, one case with proven fungal infection and 6 cases without pathogen detection. Analysed data comprised ophthalmic medical history, general risk factors for microbial keratitis, treatment before and after CXL. The characterisation of the corneal ulcer included photometric measurements of the infiltrates with a median of 16.2 mm² and four unmeasurable cases due to extended, not circumscribed lesions.

Results: Within the follow-up period (mean 134 ± standard deviation 82 days), a penetrating keratoplasty was successfully avoided in 6 patients (55 %). After CXL 9 patients (82 %) received additionally amniotic membrane transplantation. After CXL treatment, topical antibiotic therapy was continued for a mean 27 ± 13 days postoperatively. Steroids were applied in 91 % of the patients. The cornea cleared at least to some extent in 9 patients (82 %). Patients with neurotrophic keratopathy or potentially compromised immune system showed no increased failure rate.

Conclusion: These results suggest that antimicrobial CXL might be a useful option in patients with therapy-resistant corneal ulcer in order to avoid a perforating keratoplasty à chaud. For a comprehensive scientific assessment of this therapy, however, further, ideally prospective randomised interventional studies with large sample sizes are needed.

Schlüsselwörter

Keratitis - Einschmelzung - Crosslinking - CXL - Riboflavin

Key words

keratitis - melting - cross-linking - CXL - riboflavin

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