Therapeutische Excimerlaserchirurgie der Hornhaut

Zusammenfassung

Parallel zu kontinuierlichen Innovationen im Bereich der refraktiven Excimerchirurgie findet auch die phototherapeutische Keratektomie (PTK) eine zunehmende Verbreitung und neue Einsatzmöglichkeiten wie die topografiegeführte Laserbehandlung. Die PTK ist heutzutage eine effektive Behandlungsmethode von Erkrankungen der Hornhautoberfläche. Hauptindikationen sind epitheliale Anhaftungsprobleme, oberflächliche Trübungen und Irregularitäten. Entscheidend für den Therapieerfolg der PTK sind das Wissen um die Tiefen- und Flächenausdehnung der Läsionen, die Natur der Grunderkrankung (Rezidivwahrscheinlichkeit) sowie der refraktive Status des Patienten. Ergänzend zur Spaltlampenmikroskopie dienen die Topografie, die konfokale Mikroskopie und besonders das Vorderabschnitts-OCT zur Objektivierung und Planung des Eingriffs. Dem Operateur steht bei der Durchführung der PTK ein breites Spektrum zur Verfügung: Der Gewebsabtrag kann je nach Pathologie mit einem manuell-chirurgischen Gewebeabtrag kombiniert werden oder komplett mittels Excimerlaser durchgeführt werden. Bei unregelmäßiger Oberfläche können je nach zugrunde liegender Pathologie maskierende Substanzen die Effektivität der PTK verbessern oder topografiegeführte Ablationsprofile zu einer deutlichen Regularisierung der Hornhautoberfläche führen. Zur Vermeidung von Haze und Rezidivprophylaxe hat sich in den letzten Jahren Mitomycin C in einer Konzentration von 0,02 % und einer Applikationsdauer von 20–60 s als sicheres und effektives Verfahren herausgestellt. Berücksichtigt man alle patientenbezogenen Faktoren und gelingt es dem Operateur, die Möglichkeiten der PTK effektiv einzusetzen, stellt sie in vielen Fällen eine höchst individualisierte und minimalinvasive Alternative zur lamellären oder perforierenden Hornhauttransplantation dar. Im Gegensatz zur refraktiven Chirurgie ist die phototherapeutische Keratektomie und die topografiegeführte Laserbehandlung keine automatisierte und keine standardisierte OP-Technik, sondern vielmehr eine „customized procedure“, um im refraktiven Sprachgebrauch zu verbleiben.

Abstract

Concomitant with new innovations in the field of refractive surgery, therapeutic excimer laser applications like phototherapeutic keratectomy (PTK) and topography-guided customised ablation treatment are gaining high importance and undergoing rapid evolution. Nowadays, PTK is an effective treatment modality for superficial corneal pathologies. Primary indications are decreased epithelial adherence, superficial opacifications and an irregular corneal surface. For the right indication and successful treatment of corneal pathologies with PTK, a knowledge of the size, depth and nature of the pathology, as well as the refractive status of both eyes is important. Next to slit-lamp examination, objective measuring systems like the topography, confocal microscopy and the anterior segment OCT facilitate presurgical planning. Regarding the treatment procedure the surgeon can choose between a variety of methods. PTK can be combined with manual epithelial debridement or done by only using the excimer laser. In the case of an irregular corneal surface, depending on the pathology, masking fluids or topography-guided custom ablation protocols can increase the visual outcome. To avoid recurrence of the underlying pathology (e.g., corneal dystrophy, haze), the topical application of 0.02 % mitomycin C for 20–60 seconds has proved to be a safe and effective procedure. If the surgeon considers all the patient-related factors carefully and manages to combine the available treatment options correctly, PTK embodies an effective and minimally invasive alternative to lamellar or penetrating keratoplasty.

Schlüsselwörter

PTK - Laserbehandlung - Hornhautdystrophie - Narbe

Key words

PTK - laser surgery - corneal dystrophy - corneal scars

• Literatur

• 1 Trokel SL, Srinivasan R, Braren B. Excimer laser surgery of the cornea. Am J Ophthalmol 1983; 96: 710-715
• 2 Seiler T, Bende T, Wollensak J. [Correction of astigmatism with the Excimer laser]. Klin Monatsbl Augenheilkd 1987; 191: 179-183
• 3 Sekundo W, Geerling G. [Phototherapeutic keratectomy. Basic principles, techniques and indications]. Ophthalmologe 2006; 103: 563-569
• 4 Vinciguerra P, Munoz MI, Camesasca FI et al. Long-term follow-up of ultrathin corneas after surface retreatment with phototherapeutic keratectomy. J Cataract Refract Surg 2005; 31: 82-87
• 5 Ginis HS, Katsanevaki VJ, Pallikaris IG. Influence of ablation parameters on refractive changes after phototherapeutic keratectomy. J Refract Surg 2003; 19: 443-448
• 6 Kornmehl EW, Steinert RF, Puliafito CA. A comparative study of masking fluids for excimer laser phototherapeutic keratectomy. Arch Ophthalmol 1991; 109: 860-863
• 7 Fagerholm P. Phototherapeutic keratectomy: 12 years of experience. Acta Ophthalmol Scand 2003; 81: 19-32
• 8 Zalentein WN, Holopainen JM, Tervo TM. Phototherapeutic keratectomy for epithelial irregular astigmatism: an emphasis on map-dot-fingerprint degeneration. J Refract Surg 2007; 23: 50-57
• 9 Eschstruth P, Sekundo W. [Recurrent corneal erosion. Different treatment options with the excimer laser with emphasis on aggressive PTK]. Ophthalmologe 2006; 103: 570-575
• 10 Chow AM, Yiu EP, Hui MK et al. Shallow ablations in phototherapeutic keratectomy: long-term follow-up. J Cataract Refract Surg 2005; 31: 2133-2136
• 11 Holzer MP, Auffarth GU, Specht H et al. Combination of transepithelial phototherapeutic keratectomy and autologous serum eyedrops for treatment of recurrent corneal erosions. J Cataract Refract Surg 2005; 31: 1603-1606
• 12 Baryla J, Pan YI, Hodge WG. Long-term efficacy of phototherapeutic keratectomy on recurrent corneal erosion syndrome. Cornea 2006; 25: 1150-1152
• 13 Orndahl MJ, Fagerholm PP. Phototherapeutic keratectomy for map-dot-fingerprint corneal dystrophy. Cornea 1998; 17: 595-599
• 14 Ohman L, Fagerholm P. The influence of excimer laser ablation on recurrent corneal erosions: a prospective randomized study. Cornea 1998; 17: 349-352
• 15 Seitz B, Langenbucher A, Hafner A et al. [Phototherapeutic keratectomy for recurrent corneal erosion syndrome (e-PTK). Report on 116 consecutive interventions]. Ophthalmologe 2002; 99: 703-708
• 16 Maini R, Loughnan MS. Phototherapeutic keratectomy re-treatment for recurrent corneal erosion syndrome. Br J Ophthalmol 2002; 86: 270-272
• 17 Linke S, Kugu C, Richard G et al. An in vivo confocal microscopic analysis of Salzmannʼs nodular degeneration: pre- and post-surgical intervention. Acta Ophthalmol 2009; 87: 233-234
• 18 Khaireddin R, Katz T, Baile RB et al. Superficial keratectomy, PTK, and mitomycin C as a combined treatment option for Salzmannʼs nodular degeneration: a follow-up of eight eyes. Graefes Arch Clin Exp Ophthalmol 2011; 249: 1211-1215
• 19 Steinert RF, Ashrafzadeh A, Hersh PS. Results of phototherapeutic keratectomy in the management of flap striae after LASIK. Ophthalmology 2004; 111: 740-746
• 20 Kapadia MS, Wilson SE. Transepithelial photorefractive keratectomy for treatment of thin flaps or caps after complicated laser in situ keratomileusis. Am J Ophthalmol 1998; 126: 827-829
• 21 Orndahl MJ, Fagerholm PP. Treatment of corneal dystrophies with phototherapeutic keratectomy. J Refract Surg 1998; 14: 129-135
• 22 Dinh R, Rapuano CJ, Cohen EJ et al. Recurrence of corneal dystrophy after excimer laser phototherapeutic keratectomy. Ophthalmology 1999; 106: 1490-1497
• 23 Seitz B, Lisch W. Stage-related therapy of corneal dystrophies. Dev Ophthalmol 2011; 48: 116-153
• 24 Lisch W, Seitz B. [New international classification of corneal dystrophies (CD)]. Ophthalmologe 2011; 108: 883-896 quiz 97
• 25 Das S, Langenbucher A, Seitz B. Excimer laser phototherapeutic keratectomy for granular and lattice corneal dystrophy: a comparative study. J Refract Surg 2005; 21: 727-731
• 26 Kim TI, Pak JH, Chae JB et al. Mitomycin C inhibits recurrent Avellino dystrophy after phototherapeutic keratectomy. Cornea 2006; 25: 220-223
• 27 Miller A, Solomon R, Bloom A et al. Prevention of recurrent Reis-Bucklers dystrophy following excimer laser phototherapeutic keratectomy with topical mitomycin C. Cornea 2004; 23: 732-735
• 28 Hafner A, Langenbucher A, Seitz B. Long-term results of phototherapeutic keratectomy with 193-nm excimer laser for macular corneal dystrophy. Am J Ophthalmol 2005; 140: 392-396
• 29 Fagerholm P, Fitzsimmons TD, Orndahl M et al. Phototherapeutic keratectomy: long-term results in 166 eyes. Refract Corneal Surg 1993; 9 (Suppl. 02) S76-S81
• 30 Hahn TW, Sah WJ, Kim JH. Phototherapeutic keratectomy in nine eyes with superficial corneal diseases. Refract Corneal Surg 1993; 9 (Suppl. 02) S115-S118
• 31 Maloney RK, Thompson V, Ghiselli G et al. A prospective multicenter trial of excimer laser phototherapeutic keratectomy for corneal vision loss. The Summit Phototherapeutic Keratectomy Study Group. Am J Ophthalmol 1996; 122: 149-160
• 32 Rapuano CJ. Excimer laser phototherapeutic keratectomy: long-term results and practical considerations. Cornea 1997; 16: 151-157
• 33 Seitz B, Langenbucher A, Kus MM et al. Experimental correction of irregular corneal astigmatism using topography-based flying-spot-mode excimer laser photoablation. Am J Ophthalmol 1998; 125: 252-256
• 34 Pasquali T, Krueger R. Topography-guided laser refractive surgery. Curr Opin Ophthalmol 2012; 23: 264-268
• 35 Knorz MC, Jendritza B. Topographically-guided laser in situ keratomileusis to treat corneal irregularities. Ophthalmology 2000; 107: 1138-1143
• 36 Lin DT, Holland S, Tan JC et al. Clinical results of topography-based customized ablations in highly aberrated eyes and keratoconus/ectasia with cross-linking. J Refract Surg 2012; 28: S841-S848
• 37 Lin DT, Holland SR, Rocha KM et al. Method for optimizing topography-guided ablation of highly aberrated eyes with the ALLEGRETTO WAVE excimer laser. J Refract Surg 2008; 24: S439-S445
• 38 Krueger RR. Corneal topography vs. ocular wavefront sensing in the retreatment of highly aberrated post surgical eyes. J Refract Surg 2006; 22: 328-330
• 39 Cummings AB, Mascharka N. Outcomes after topography-based LASIK and LASEK with the wavelight oculyzer and topolyzer platforms. J Refract Surg 2010; 26: 478-485
• 40 Ohno K. Customized photorefractive keratectomy for the correction of regular and irregular astigmatism after penetrating keratoplasty. Cornea 2011; 30 (Suppl. 01) S41-S44
• 41 Toda I, Yamamoto T, Ito M et al. Topography-guided ablation for treatment of patients with irregular astigmatism. J Refract Surg 2007; 23: 118-125
• 42 Kanellopoulos AJ, Binder PS. Collagen cross-linking (CCL) with sequential topography-guided PRK: a temporizing alternative for keratoconus to penetrating keratoplasty. Cornea 2007; 26: 891-895
• 43 Kanellopoulos AJ, Binder PS. Management of corneal ectasia after LASIK with combined, same-day, topography-guided partial transepithelial PRK and collagen cross-linking: the athens protocol. J Refract Surg 2011; 27: 323-331
• 44 Kymionis GD, Portaliou DM, Kounis GA et al. Simultaneous topography-guided photorefractive keratectomy followed by corneal collagen cross-linking for keratoconus. Am J Ophthalmol 2011; 152: 748-755
• 45 Kanellopoulos AJ. Comparison of sequential vs. same-day simultaneous collagen cross-linking and topography-guided PRK for treatment of keratoconus. J Refract Surg 2009; 25: S812-S818
• 46 Shalaby A, Kaye GB, Gimbel HV. Mitomycin C in photorefractive keratectomy. J Refract Surg 2009; 25 (Suppl. 01) S93-S97
• 47 Raviv T, Majmudar PA, Dennis RF et al. Mytomycin-C for post-PRK corneal haze. J Cataract Refract Surg 2000; 26: 1105-1106
• 48 Majmudar PA, Forstot SL, Dennis RF et al. Topical mitomycin-C for subepithelial fibrosis after refractive corneal surgery. Ophthalmology 2000; 107: 89-94
• 49 Shah RA, Wilson SE. Use of mitomycin-C for phototherapeutic keratectomy and photorefractive keratectomy surgery. Curr Opin Ophthalmol 2010; 21: 269-273
• 50 Thomann U, Meier-Gibbons F, Schipper I. Phototherapeutic keratectomy for bullous keratopathy. Br J Ophthalmol 1995; 79: 335-338
• 51 Thomann U, Niesen U, Schipper I. Successful phototherapeutic keratectomy for recurrent erosions in bullous keratopathy. J Refract Surg 1996; 12: S290-S292
• 52 Lin PY, Wu CC, Lee SM. Combined phototherapeutic keratectomy and therapeutic contact lens for recurrent erosions in bullous keratopathy. Br J Ophthalmol 2001; 85: 908-911
• 53 Maini R, Sullivan L, Snibson GR et al. A comparison of different depth ablations in the treatment of painful bullous keratopathy with phototherapeutic keratectomy. Br J Ophthalmol 2001; 85: 912-915
• 54 Campos M, Nielsen S, Szerenyi K et al. Clinical follow-up of phototherapeutic keratectomy for treatment of corneal opacities. Am J Ophthalmol 1993; 115: 433-440
• 55 Fagerholm P, Ohman L, Orndahl M. Phototherapeutic keratectomy in herpes simplex keratitis. Clinical results in 20 patients. Acta Ophthalmol (Copenh) 1994; 72: 457-460
• 56 Binder PS, Anderson JA, Rock ME et al. Human excimer laser keratectomy. Clinical and histopathologic correlations. Ophthalmology 1994; 101: 979-989
• 57 Quentin CD, Tondrow M, Vogel M. [Phototherapeutic keratectomy (PTK) after epidemic keratoconjunctivitis]. Ophthalmologe 1999; 96: 92-96
• 58 Geerling G, Sekundo W. [Phototherapeutic keratectomy. Undesirable effects, complications, and preventive strategies]. Ophthalmologe 2006; 103: 576-582