Visusrehabilitation bei schwersten Veränderungen der Augenoberfläche

Zusammenfassung

Schwere Erkrankungen der Augenoberfläche, wie Stevens-Johnson-Syndrom, okuläres Schleimhautpemphigoid oder schwere Verätzungen oder Verbrennungen, können aufgrund einer irreversiblen Schädigung des Hornhaut-Stammzellpools zu einer nachhaltigen Visusbeeinträchtigung, in schweren Fällen mitunter auch zur Erblindung, führen. Ist nach einer Verätzung nur ein Auge betroffen, hat sich die autologe Limbustransplantation vom gesunden kontralateralen Auge bewährt. Beidseitig betroffene Patienten können von einer homologen Transplantation von Limbusgewebe eines Spenders profitieren, allerdings ist in diesen Fällen eine Langzeitimmunsuppression erforderlich und die Prognose im Vergleich zu den autologen Verfahren deutlich schlechter. Die Transplantation von Amnionmembran hat sich in den letzten Jahren als zusätzliches Hilfsmittel zur Oberflächenrekonstruktion etabliert. Im Falle eines wiederholten Transplantatversagens nach Keratoplastik kann seit kurzem die AlphaCor, eine „künstliche Hornhaut” aus flexiblem Acrylat, zur Visusverbesserung eingesetzt werden. Im Falle von extrem trockenen Oberflächenverhältnissen und bei vernarbenden oder chronisch-entzündlichen Erkrankungen kann als Ultima Ratio oftmals nur noch die Implantation einer Keratoprothese mit rigider Optik eine visuelle Rehabilitation ermöglichen. Hierbei hat sich die Osteo-Odonto-Keratoprothese nach Strampelli als ein Verfahren mit guten Langzeiterfolgen erwiesen. Ein eigener Zahn samt umgebenden Kieferknochen dient als „biologischer” Halteapparat (Haptik) für einen optischen Zylinder aus PMMA. Sind keine eigenen Zähne mehr vorhanden, kann alternativ die Implantation einer KPro mit Dacron-Haptik (Pintucci-KPro) oder einer Haptik bestehend aus autologem Tibiaknochen (Temprano-KPro) versucht werden.

Abstract

Severe ocular surface diseases, such as Stevens-Johnson syndrome, ocular cicatricial pemphigoid or severe ocular burns may result in a significant loss of corneal stem cells, eventually leading to vision impairment or even corneal blindness. In case of unilateral involvement, limbal autografting, by means of transplanting limbal stem cells from the healthy fellow eye, has proved to be an effective procedure for restoring the integrity of the ocular surface. Limbal allografts may be performed in patients with bilateral disease, however, systemic immunosuppression is mandatory in these cases, with a long-term outcome that is frequently reduced compared to limbal autografts due to acute or chronic graft rejection. In recent years, amniotic membrane transplantation has been successfully employed as an additional tool in ocular surface reconstruction. The AlphaCor synthetic cornea, which is made of flexible acrylic may be considered as an alternative in patients with repeated corneal graft failures. Both limbal transplantation and the AlphaCor have been shown to be effective in eyes with an adequate tear film, but are most likely to fail in severe dry eyes or in patients with cicatrising diseases. Such conditions are the domain of keratoprostheses (KPros) with rigid optics, which certainly can be considered as the ‘last resort’ to restore vision in patients with profound corneal blindness not amenable to conventional corneal and limbal grafting. The osteo-odonto-keratoprosthesis according to Strampelli and modified by Falcinelli makes use of a “biological” support consisting of a longitudinal section of one of the patient’s teeth that is also supported by the surrounding alveolar bone tissue. Compared to other devices favourable long-term results have been reported. In patients lacking any usable teeth, implantation of a keratoprosthesis with haptics made of Dacron (Pintucci-KPro) or tibial bone (Temprano-KPro) might be considered.

Schlüsselwörter

Keratoprothese - Limbustransplantation - Limbusinsuffizienz - Verätzung - Keratoplastik

Key words

Keratoprosthesis - limbal transplantation - limbal deficiency - ocular burn - keratoplasty

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