3.5  •  Akanthamöben-Keratitis (AK) (engl. Akanthamoeba keratitis)

Ein weiterer kritischer Punkt ist, dass die Patienten zum Zeitpunkt der Diagnose meist schon antherapiert sind. Zwar wird nach antibakterieller, antiviraler, oder antifungaler Therapie oft tatsächlich eine anfängliche Besserung beobachtet (da die Trophozoiten, im Unterschied zu den Zysten, sehr wohl auf zahlreiche Therapeutika ansprechen) – insgesamt wird so aber die Diagnose erschwert und die Therapie verzögert. Gerade Kontaktlinsenträger sind leichte Augenirritationen gewöhnt und suchen deshalb im Vergleich zu Nicht-Kontaktlinsenträgern oft erst relativ spät einen Arzt auf. Wenn die Therapie verspätet begonnen wird, ist eine vollständige Wiederherstellung des Visus ohne chirurgischen Eingriff meist nicht mehr möglich.

Neue Entwicklungen

In den vergangenen Jahren wurde eine breite Palette weiterer Substanzen auf ihre Wirkung gegen Akanthamöben hin untersucht – allerdings liegen für die meisten dieser Substanzen lediglich in-vitro Daten bzw. empirische Daten aus einigen wenigen Fallberichten vor. Alkylphosphocholine sind in-vitro hochwirksam gegen Akanthamöben und gelten auch als sehr vielversprechend in der topischen Anwendung. Bisher gibt es aber nur mit Miltefosin Erfahrungen aus der Praxis. Auch Imidazole, vor allem Miconazol, Clotrimazol und Itrakonazol, zeigen eine deutliche Wirkung gegen Akanthamöben. Da sie die Amöben aber nicht abtöten, sollten sie ausschließlich als Kombinationspräparate eingesetzt werden. Dimethylsulfoxid (DMSO) gilt ebenfalls als mögliches Kombinationspräparat, da es als Trägersubstanz für PI wirkt und so dessen Effektivität erhöhen kann.

Auch Kryotherapie, Phototherapeutische Keratektomie (PTK) und Hornhautvernetzung (CXL; Riboflavin/UVA corneal cross-linking) – meist in Kombination mit antimikrobieller Therapie – wurden bereits erfolgreich in der AKTherapie eingesetzt.

Prognosefaktoren

Faktoren, die einen ungünstigern Verlauf bzw. eine deutli- -che Visusminderung aufwiesen sind:

Verzögerte Diagnose (>30 Tage zwischen Einsetzen

-Perforierende oder große Infiltrate (>3 mm) Ausdehung in tiefe Hornhautschichten Korneale Neovaskularisationder Symptome und Therapiebeginn)

Grundsätzlich ist die Prognose bei niedriger Ausgangssehschärfe, ebenso wie wenn ein chirurgischen Eingriff nötig wird, verschlechtert.

3.5.7 Praxistipps

Die Prognose ist bei der AK relativ gut, sofern die Infektion frühzeitig erkannt wird. Eine rasche Diagnose und eine möglichst sofort einsetzende Therapie sind von äußerster Wichtigkeit, weil die Amöben andernfalls bereits tief in das corneale Stroma vorgedrungen sind und dort dann als Zysten die Therapie überleben (Wiederaufflammen der Infektion!).

Eine AK kann durch strikte Kontaktlinsen-Hygiene weitgehend vermieden werden. Besonders das Übertragen von Wegwerflinsen gilt als wesentlicher Risikofaktor. Wichtig in diesem Zusammenhang sind aber auch eine sorgfältige Reinigung bzw. regelmäßige Erneuerung des Kontaktlinsenbehälters und das Verwenden geeigneter Kontaktlinsenpflegesysteme. Kontaktlinsenbehälter sind sehr häufig mit Akanthamöben kontaminiert und stellen deshalb die vermutlich wichtigste Infektionsquelle dar.

3.5.8Selbsthilfegruppen und wichtige Websites

Die Sektion Cornea hat unlängst ein Internet-Register etabliert, um die systematische Untersuchung seltener Krankheitsbilder zu forcieren; dazu zählt die Akanthamöben Keratitis. Weitere Informationen unter http://www.dog.org.

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