Perioperative/postoperative antientzündliche Therapie bei/nach Hornhautchirurgie/Hornhauttransplantation

Zusammenfassung

Nach Hornhautchirurgie kommt es durch das mechanische Trauma, durch Fremdkörper wie z. B. Nähte oder Implantate oder durch Antigene bei Gewebetransplantation zu entzündlichen Reaktionen. Nach chirurgischen Eingriffen mit Abstand zum vaskularisierten Limbus verlaufen diese aufgrund des Immunprivilegs und des angiogenen Privilegs der Hornhaut in aller Regel sehr gedämpft. Hauptpfeiler in der Therapie und Prophylaxe von Entzündungen nach Hornhautchirurgie sind topische Glukokortikoide. Bei der Anwendung müssen die kataraktogene Wirkung bei Langzeitnutzung, die Möglichkeit einer steroidbedingten Augeninnendruckerhöhung als sogenannte Steroidresponse, die Erhöhung der Infektanfälligkeit und die Hemmung einer Epithelialisierung berücksichtigt werden. Die verfügbaren Glukokortikoide unterscheiden sich in ihrer Fähigkeit zur Penetration in das Auge (Prednisolon am besten), ihrer immunsuppressiven Wirkung (Dexamethason am besten) und im Risiko der Induktion einer Steroidresponse (Loteprednoletabonat und Fluorometholon am geringsten). Die unterschiedlichen Eigenschaften müssen bei der Wahl des „richtigen“ Glukokortikoids berücksichtigt werden: Bei Gefahr einer Epithelialisierungsstörung sollten topische Steroide möglichst vermieden bzw., falls zwingend erforderlich, konservierungsmittelfreies und phosphatfreies Dexamethason (Dexapos COMOD^®) verwendet werden. Bei Bedarf einer Tiefenwirksamkeit, z. B. nach perforierender Keratoplastik, sollte Prednisolonacetat verwendet werden. Bei bekannter Steroidresponse sollten Loteprednoletabonat oder Fluorometholon verwendet werden. Wenn allogenes Gewebe transplantiert wird, ist eine langfristige topische Anwendung von Glukokortikoiden über 24 Monate und länger notwendig. Nach Hochrisikokeratoplastik mit allogenem Spendergewebe ist meist eine ergänzende systemische immunsuppressive Therapie mit Calcineurininhibitoren oder Mycophenolatmofetil über 6 – 12 Monate sinnvoll.

Abstract

Surgical trauma, and foreign material – such as sutures or implants or antigens during tissue transplantation – may cause inflammatory reactions. Inflammatory reactions after surgical interventions distant from the vascularised limbus and without opening of the anterior chamber of the eye are usually very muted, because of the corneal immune and angiogenic privilege. A milestone in the therapy and prophylaxis of inflammation after corneal surgery has been the use of topical glucocorticoids since the 1950s. When these are used, it is important to consider the cataractogenic effect of long-term use, the possibility of steroid-induced increase in intraocular pressure (so-called steroid response), the increased risk for microbial infection and the inhibition of epithelialisation. The available glucocorticoids differ in their ability to penetrate into the eye (prednisolone best), their immunosuppressive activity (dexamethasone best) and their ability to induce a steroid response (loteprednol etabonate and fluorometholone least). Preservative-free formulations are only available for dexamethasone. The different properties must be taken into account when choosing the “best” glucocorticoid: If there is a risk of delay in epithelialisation of the wound, topical steroids should be avoided or if necessary, phosphate- and preservative-free dexamethasone should be used with caution. If efficiency in the posterior cornea or in the anterior chamber is important, e.g. after penetrating keratoplasty, prednisolone acetate should be used. If a steroid response is known, loteprednol etabonate or fluorometholone should be used. When allogeneic tissue is transplanted, long-term topical glucocorticoid use over 24 months or longer is necessary. After high-risk keratoplasty with allogeneic donor tissue, supplemental systemic immunosuppressive therapy with calcineurin inhibitors or mycophenolate mofetil over 6 to 12 months is recommended.

Schlüsselwörter

Entzündung - Steroide - Glukokortikoide - Keratoplastik - Steroidresponse

Key words

inflammation - steroids - glucocorticoids - keratoplasty - steroid response

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