Periphere Netzhautdefekte — wann behandeln? Behandlungsrichtlinien der American Academy of Ophthalmology

Augenabteilung KH Hietzing Wien Österreich
Spektrum der Augenheilkunde (Impact Factor: 0.18). 12/2006; 20(6):272-274. DOI: 10.1007/BF03163642


Preferred Practice Pattern (PPP) der American Academy of Ophthalmology (AAO) sind Richtlinien, die Charakteristiken und Komponenten
hochqualitativer Augenbehandlung definieren. Sie basieren auf aktuellsten wissenschaftlichen Daten, interpretiert durch anerkannte
Spezialisten und werden regelmäßig aktualisiert (mindestens jährlich).

Die Prinzipien der PPP im Allgemeinen sind Empfehlungen, die klinisch relevant sein und sinnvolle Informationen für den Praktizierenden
liefern sollen. Die Empfehlungen sollen die Wichtigkeit für den Behandlungsprozess widerspiegeln und die Aussagekraft des
wissenschaftlichen Nachweises im Sinne einer evidence based medicine für die entsprechende Behandlung reflektieren.

Ziel der Behandlungsrichtlinien der AAO für Patienten mit peripheren Netzhautdefekten ist es, Patienten mit hohem Risiko für
Netzhautabhebung zu erkennen, zu managen, über Symptome einer hinteren Glaskörperabhebung (HGKAH), eines Netzhautdefektes
oder einer Netzhautabhebung und den Bedarf von weiteren Kontrollen aufzuklären. Weiters ist es wichtig, Patienten mit Symptomen
einer akuten HGKAH zu untersuchen und relevante Netzhautdefekte zu behandeln. Ziel der Behandlung ist die Erzeugung einer
festen chorioretinalen Adhäsion in der anliegenden Netzhaut unmittelbar um den Netzhautdefekt, soweit wie möglich in die Vitreusbasis

Die Richtlinien beruhen auf einer Medlinesuche über HGKAH, Netzhautdefekt und Lattice Degeneration für die Jahre 1997–2002.

Evidence-based-Empfehlungen existieren ausschließlich für akute symptomatische Lappenrisse. Bei anderen Läsionen muss immer
daran gedacht werden, dass die Behandlung unnötig, ineffektiv oder sogar schädlich sein kann.

Durch Identifizierung von Risikopatienten und Befolgen der Behandlungsrichtlinien können akuter Visusverlust und bleibende
Sehbeeinträchtigung vermieden werden und so die Lebensqualität erhalten bleiben.

Preferred Practice Pattern (PPP) of the American Academy of Ophthalmology (AAO) are guidelines that identify characteristics
and components of quality eye care. They are based on the best available scientific data, interpreted by panels of knowledgeable
health professional and are reviewed annually and updated accordingly.

Each PPP should be clinically relevant and specific enough to provide useful information to practitioners. Each recommendation
should also be given an explicit rating that shows the strength of evidence that supports the recommendation and reflects
the best evidence available.

The aim of the guidelines for patients with peripheral retinal breaks is to identify and manage patients at risk for rhegmatogenous
retinal detachment, and to educate high-risk patients about symptoms of posterior vitreous detachment, retinal breaks, and
retinal detachment and about the need for periodic follow up. A further goal is to examine patients with symptoms of acute
posterior vitreous detachment to detect and treat significant retinal breaks. The purpose of treatment is to create a firm
chorioretinal adhesion in the attached retina immediately adjacent to the retinal tear extending well into the vitreous base.

The guidelines are based on a detailed literature search of articles on the subject of posterior vitreous detachment, retinal
breaks, and lattice degeneration for the years 1997 to 2002.

Sufficient information for evidence-based recommendation exists only for acute, symptomatic horseshoe tears. Treating other
vitreoretinal abnormalities might be unnecessary, ineffective or harmful.

Identification of patients at risk for retinal detachment and following the guidelines for diagnosing and management prevents
visual loss and functional impairment and maintains quality of life.

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  • [Show abstract] [Hide abstract]
    ABSTRACT: To determine visual outcomes and the incidence of retinal detachment in eyes presenting with posterior vitreous separation and dense fundus-obscuring vitreous hemorrhage. Retrospective consecutive noncomparative interventional case series. Thirty-six eyes (15 right eyes and 21 left eyes) of 34 patients (18 female and 16 male) ranging in age from 42 to 94 years. Mean follow-up was 14 months. A comparison of the best-corrected initial visual acuities versus final visual acuities after spontaneous resolution of vitreous hemorrhage or surgical intervention. The number of eyes that were found to have retinal tears or that had a rhegmatogenous retinal detachment develop was documented. Logarithm of the minimum angle of resolution-converted visual acuities was used for comparison. Categorical data were analyzed by Fisher's exact test, and population means were compared by Student's t test. Final mean visual acuities, number of eyes with at least one retinal tear, location of retinal tears, number of eyes that had retinal detachment develop, and the number of eyes repaired with scleral buckling surgery and/or pars plana vitrectomy. Twenty-four of 36 eyes (67%) were found to have at least one retinal break (range, 0-4 breaks), with 88% of breaks located in the superior retina. Eleven eyes (31%) had more than one retinal break. Fourteen of 36 eyes (39%) had a rhegmatogenous retinal detachment develop that was repaired with pars plana vitrectomy and scleral buckling. An additional 14 eyes (39%) underwent vitrectomy for nonclearing vitreous hemorrhage. The incidence of retinal detachment in eyes with a history of retinal detachment in the contralateral eye was 75% (P = 0.04). Seven of 14 eyes (50%) with retinal detachment had coexisting proliferative vitreoretinopathy. Most retinal breaks and detachments occurred in emmetropic or myopic eyes. For all 36 eyes the mean preoperative visual acuity was 20/1233, and the mean final visual acuity was 20/62 (P < 0.0001). Eyes that had a macula-off retinal detachment develop had worse final visual outcomes (20/264; P = 0.01), as did eyes that had proliferative vitreoretinopathy develop (20/129; P = 0.04). Acute, spontaneous, nontraumatic posterior vitreous separation with dense fundus-obscuring vitreous hemorrhage is associated with a high incidence of retinal tears and detachment. Close follow-up with clinical examination and ultrasonography is necessary, because many of these eyes may eventually require surgical intervention. Aggressive management with early vitrectomy should be considered when there is a history of retinal detachment in the contralateral eye.
    Ophthalmology 12/2001; 108(12):2273-8. DOI:10.1016/S0161-6420(01)00822-3 · 6.14 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The purpose of the study was to ascertain the natural consequences of asymptomatic retinal breaks and to learn what effects, if any, the occurrence of posterior vitreous detachment (PVD) has on such breaks. This was a cohort study of consecutive asymptomatic phakic patients, all of whom had asymptomatic retinal breaks, observed without treatment over periods of 1 to 33 years (average, 11 years). There were 196 patients with 235 involved eyes. Periodic clinical examinations, including binocular indirect ophthalmoscopy with scleral indentation on all eyes and posterior vitreous examination on 50 eyes, were performed. In the total study period, one small peripheral retinal detachment developed, without symptoms, from a previous subclinical detachment over a period of 14 years. Nineteen eyes (8%) originally had or developed 22 areas of subclinical detachment, 2 of which were treated because of moderate extension, even though remaining subclinical and without symptoms. Ten eyes encountered acute PVDs, which caused symptomatic retinal tears in three eyes, one of which also had a clinical retinal detachment. Of the 50 asymptomatic eyes examined with Goldmann lens and slit lamp, 12 (24%) were found to have an existing PVD, which had not led to any complication of the previous retinal breaks in any eye. Asymptomatic retinal breaks discovered in phakic primary eyes do not show any significant tendency toward clinical retinal detachment, with the exception of a few of those cases that progress to subclinical retinal detachment. It is only some of these, comprising 1% to 2% of the total group, that may justify treatment. Posterior vitreous detachment coexists safely with asymptomatic retinal breaks in phakic primary eyes and shows no tendency to provoke complications to pre-existing breaks at the time of its occurrence.
    Ophthalmology 07/1998; 105(6):1045-9; discussion 1049-50. DOI:10.1016/S0161-6420(98)96006-7 · 6.14 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To assess the quality of information in the literature regarding the benefits of prophylactic treatment of asymptomatic retinal tears and lattice degeneration. Asymptomatic retinal breaks occur in approximately 7% of patients over age 40, and lattice degeneration is present in approximately 8% of the general population. Because retinal breaks cause retinal detachment and lattice degeneration is associated with approximately 30% of retinal detachments, prophylactic treatment of these lesions has sometimes been recommended. A panel of vitreoretinal experts performed a literature review of all publications regarding prevention of retinal detachment that have been published in English. These articles were then used to prepare recommendations for patient care in an American Academy of Ophthalmology Preferred Practice Pattern (PPP). Each recommendation was rated according to: (1) its importance in the care process and (2) the strength of evidence supporting the given recommendation. Most recommendations were rated as A (most important to patient care). Only a single publication was graded as I (providing strong evidence in support of a recommendation), and this was not a prospective trial. Of the few publications rated as II (substantial evidence), most were studies documenting a lack of treatment benefit. Because of an absence of level I and level II studies in the literature, level III (consensus of expert opinion) was the basis for most recommendations in the PPP. The current literature regarding prevention of retinal detachment does not provide sufficient information to support strongly prophylactic treatment of lesions other than symptomatic flap tears. Prospective randomized trials of prophylactic therapy are indicated. Eyes highly predisposed to retinal detachment should be considered for such studies.
    Ophthalmology 02/2000; 107(1):12-5; discussion 15-8. DOI:10.1016/S0161-6420(99)00049-4 · 6.14 Impact Factor
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