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Klin Monbl Augenheilkd 2021; 238(02): 193-208
DOI: 10.1055/a-1351-8758
Statement

Stellungnahme von BVA, DOG und RG zur Entwicklung, Diagnostik und Behandlung der epiretinalen Gliose[*]

Stand Oktober 2020 Berufsverband der Augenärzte Deutschlands e. V. (BVA), Deutsche Ophthalmologische Gesellschaft (DOG), Retinologische Gesellschaft e. V. (RG)
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Kernaussagen

  • 1. Neben der idiopathischen Form, bei der altersbedingte Glaskörperveränderungen primär an der Pathogenese beteiligt sind, treten epiretinale Membranen auch sekundär bei anderen Erkrankungen von Retina und Glaskörper auf, z. B. bei:

    • diabetischem Makulaödem,

    • retinalem Venenverschluss,

    • peripherem Netzhautforamen oder Ablatio retinae,

    • Zustand nach Kryo- oder Lasertherapie der Netzhaut,

    • vaskulären, entzündlichen und traumabedingten Netzhauterkrankungen.

    Bei Vorliegen vitreoretinaler Grunderkrankungen sollen diese bei der Therapie berücksichtigt werden.

  • 2. Hauptsymptome der epiretinalen Gliose sind Sehverschlechterung und Metamorphopsie, die sich potenziell auf das beidäugige Sehen störend auswirken. Bei der Beurteilung des subjektiven Leidensdrucks spielt die Funktion des Partnerauges eine wichtige Rolle.

  • 3. Die Diagnostik und Indikationsstellung für eine eventuelle Behandlung einer epiretinalen Membran soll mittels folgender Untersuchungen an beiden Augen erfolgen:

    • bestkorrigierter Visus,

    • Prüfung auf Metamorphopsien (z. B. Amsler-Test),

    • stereoskopische Ophthalmoskopie in Mydriasis,

    • SD-OCT-Untersuchung der Makula.

    Hilfreich zur Verlaufskontrolle vor und nach einer Therapie kann ein Fundusfoto sein. Die Beurteilung im Infrarotbild oder in einer Multicolordarstellung kann zusätzlich hilfreich sein.

  • 4. Die Therapie der Wahl bei symptomatischer epiretinaler Gliose ist die Pars-plana-Vitrektomie mit Entfernen der traktiven Membranen. Bei einer flächigen epiretinalen Gliose soll keine pharmakologische Vitreolyse mittels Ocriplasmin durchgeführt werden.

  • 5. Zur Indikationsstellung einer Operation sollen folgende Parameter berücksichtigt werden:

    • Visusverschlechterung,

    • subjektive Symptomatik (insbesondere Probleme beim binokularen Sehen),

    • Morphologie (z. B. pathologische Veränderung der äußeren Netzhaut in der SD-OCT, Zunahme einer traktionsbedingten Netzhautdicke).

    Bei der Indikationsstellung zur Pars-plana-Vitrektomie soll ein ausführliches Gespräch mit den Patienten hinsichtlich des individuellen Leidensdrucks beim beidäugigen Sehen geführt werden. Hierbei sollen die Aspekte Lesefähigkeit, Berufsfähigkeit und Fahrtauglichkeit Berücksichtigung finden.

  • 6. Beim Aufklärungsgespräch für eine Pars-plana-Vitrektomie soll einerseits auf den häufig benignen Spontanverlauf und die Option des beobachtenden Zuwartens hingewiesen werden, andererseits auch auf die Gefahr einer schlechteren Sehschärfenerholung nach Operation bei Zuwarten und Progression. Über die intra- und postoperativen Komplikationsmöglichkeiten und über eine lange, oft Monate dauernde funktionelle Erholungsphase soll ebenfalls aufgeklärt werden. Bei phaken Patienten soll über das Auftreten oder die Verschlechterung einer Katarakt gesprochen und kann eine simultane Kataraktoperation erwogen werden.

  • 7. Die Prognose für die Sehfunktion nach Vitrektomie ist gut. Eine Stabilisierung der Funktion wird bei ca. 90% durch Pars-plana-Vitrektomie erreicht. Etwa zwei Drittel der Patienten profitieren von einer Operation durch Verringerung der Metamorphopsie oder Besserung des Visus. Bei etwa einem Drittel der Patienten persistieren die Beschwerden, selten tritt ein postoperatives Makulaödem oder eine Verschlechterung durch eine Komplikation, wie z. B. Ablatio retinae, Endophthalmitis oder durch zentrale und parazentrale Skotome auf.

  • 8. Während einer Pars-plana-Vitrektomie kann die Netzhautoberfläche mit einem selektiven Vitalfarbstoff angefärbt werden. Durch das Anfärben ist ein Entfernen der epiretinalen Membran häufig vereinfacht und sicherer.

  • 9. Zur Vermeidung eines Rezidivs einer epiretinalen Membran kann ein Peeling der Membrana limitans interna (engl. „internal limiting membrane“ [ILM]) durchgeführt werden.

  • 10. In der SD-OCT kommt es nur selten wieder zur Ausbildung einer völlig normalen postoperativen Makulakonfiguration nach der Entfernung einer epiretinalen Gliose. Dennoch kann sich die Sehfunktion erholen. Eine solche Verdickung darf nicht mit einem postoperativen zystoiden Makulaödem (welches manchmal auch nach Operation einer ERM auftritt) verwechselt werden und soll keine Indikation für eine IVOM darstellen.

* Diese Leitlinie erscheint auch in der Zeitschrift Der Ophthalmologe, Springer Verlag, Heidelberg.




Publication History

Article published online:
22 February 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
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