Konsenspapier der Retinologischen Gesellschaft, der Deutschen Ophthalmologischen Gesellschaft und des Berufsverbandes der Augenärzte - Stellungnahme zur aktuellen Therapie der neovaskulären AMD

Zusammenfassung

Hintergrund: Bis vor kurzem waren lediglich zwei therapeutische Optionen zur Behandlung der neovaskulären altersabhängigen Makuladegeneration (AMD) verfügbar: die thermische Laserkoagulation und die photodynamische Therapie (PDT) mit Verteporfin. Dieses therapeutische Spektrum hat sich in den letzten Monaten durch die Publikation von Studienergebnissen neuer Therapieansätze erweitert. Im vorliegenden Konsenspapier soll deshalb eine Abwägung der derzeitig publizierten Studienergebnisse für die verschiedenen Subtypen der chorioidalen Neovaskularisationen (CNV) bei der AMD vorgenommen werden. Als neue therapeutische Optionen bei der Behandlung der neovaskulären AMD stehen Triamcinolon eventuell auch in Kombination mit einer PDT, Anecortave Acetat, Pegaptanib und Ranibizumab zur Verfügung. Die sich aus diesen neuen Therapieansätzen ergebenden neuen Therapieoptionen sollen in diesem Konsenspapier dargestellt werden. Empfehlung: Für extrafoevolare rein klassische CNVs ist eine thermische Laserkoagulation zu empfehlen. Für subfoveale Läsionen (juxta- und subfoveolar) einer vorwiegend klassischen CNV oder kleinen (≤ 4 MPS-Papillenflächen) okkulten CNV bei eindeutiger Progression ist die PDT mit Verteporfin die beste therapeutische Option. Für subfoveale Läsionen einer minimal klassischen CNV kann die Behandlung mit PDT oder Pegaptanib durchgeführt werden, auch wenn bei beiden Verfahren gewisse Unsicherheiten bei der statistischen Auswertung der Studien bestehen. Alle Behandlungen sollten innerhalb einer Woche nach den Fluoreszein-Angiographien erfolgen, die die genannte Behandlungsindikation haben. Bei Nachuntersuchungen sollte zur Prüfung und Dokumentation der weiteren Behandlungsstrategie der Visus und Fundusbefund festgestellt werden sowie alle 3 Monate eine erneute Fluoreszein-Angiographie erfolgen. Schlussbemerkung: Die Empfehlungen basieren auf den derzeit verfügbaren Ergebnissen klinischer Studien zur Laser- und Pharmako-Therapie der neovaskulären AMD. Weitere Aktualisierungen dieser Empfehlungen sind vorgesehen.

Abstract

Background: Until recently, only two options were available for the treatment of choroidal neovascularization (CNV) due to age-related macular degeneration (AMD): laser photocoagulation and photodynamic therapy (PDT) with verteporfin. However, potential new treatments for CNV are under development, and data from phase III clinical trials are now available. Referring to these data, expert guidance is required to supply ophthalmologists with expertise in the management of AMD to select and use the most appropriate therapies in the treatment of neovascular AMD. Methods: The therapeutic modalities discussed include thermal laser photocoagulation, PDT with verteporfin, triamcinolone acetonide and the possible combination with PDT, anecortave acetate, pegaptanib sodium and ranibizumab. After a short description of the treatment principles, a summary of the discussion of all relevant study results of the different treatment options with respect to the different subtypes of neovascular AMD is presented. These discussions resulted in an „up-to-date” recommendation of therapeutical strategies in neovascular AMD. Results: For subfoveal lesions with predominantly classic CNV, or with occult with non-classic CNV and a lesion size ≤ 4 macular photocoagulation study (MPS) disc areas (DA), PDT with verteporfin is recommended; for subfoveal lesions with minimally classic CNV, treatment with PDT or pegaptanib sodium is possible, even if there are some problems with the statistics in the studies with both treatment modalities. PDT with verteporfin should be considered for juxtafoveal lesions that are so close to the fovea that laser photocoagulation would almost certainly extend under the center of the foveal avascular zone, and for all other juxtafoveal lesions and for extrafoveal lesions laser photocoagulation is suggested. Therapy should be performed not later than one week after the initial fluorescein angiogram upon which the clinical decision for treatment is based. At each follow-up best-corrected visual acuity and a fundus examination should be performed as well as a fluorescein angiography every three months. Conclusions: These recommendations provide good clinical guidance for the choice and use of laser and pharmacotherapies for the management of CNV due to AMD. Revisions of the recommendations will be required as new data become available.

Schlüsselwörter

Altersabhängige Makuladegeneration - photodynamische Therapie - antiangiogenetische Therapie

Key words

Age-related macular degeneration - photodynamic therapy - antiangiogenetic therapy

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