Zusammenfassung
Venenverschlüsse sind die zweithäufigsten visusrelevanten Gefäßerkrankungen am Auge.
Die therapeutischen Möglichkeiten waren bis vor kurzem bei allen Formen der retinalen
Gefäßverschlüsse (Venenastverschluss, Stammvenenverschluss, Zentralvenenverschluss)
äußerst limitiert. Auch Pathomechanismus und Risikofaktoren sind bis heute nicht klar
definiert. Koagulationsbehandlungen mit dem Argon-Laser waren zwar geeignet, Spätkomplikationen
in Form von Gefäßneubildungen vorzubeugen bzw. diese zur Rückbildung zu bringen führten
aber nur selten zu einer signifikanten Funktionsverbesserung. Rheologische Therapieverfahren
sind in ihrer Effektivität bis heute umstritten. Thrombolytika sind bei intraokulärer
Applikation möglicherweise von Nutzen. Eine systemische Anwendung wird wegen der erheblichen
Komplikationsrate und der fraglichen Effektivität kaum noch durchgeführt. Versuche,
mittels Laser Anastomosen zur Chorioidea zu induzieren, wurde wegen häufiger Komplikationen
wieder verlassen. Seit 1999 finden sind in der Literatur zahlreiche Berichte über
erfolgreiche chirurgische Methoden, zunächst bei Venenastverschlüssen. Es konnte gezeigt
werden, dass eine Auftrennung der gemeinsamen Adventitiascheide (Sheathotomy) an der
Kreuzungsstelle von Arterie und Vene zu einer Reperfusion im Verschlussbereich mit
Rückbildung des Makulaödems und Visusanstieg führen kann. Noch unklar ist zzt., welcher
der Operationsschritte bei dieser Technik der entscheidende ist. Ein neuerer chirurgischer
Therapieansatz bei Zentral- und Stammvenenverschluss besteht in der Spaltung der Optikusscheide
(radiäre Optikusneurotomie, RON). Nachdem hierbei zunächst ein Wirkmechanismus in
Form einer Dekompression der Vene postuliert wurde, erscheint derzeit eher eine retinochorioidale
Anastomosenbildung für die beschriebenen erfolgreichen Eingriffe wahrscheinlich. Die
Datenlage zu diesem Eingriff ist jedoch noch rudimentär. Eine weitere Option ist die
Punktion der retinalen Gefäße über einen glaskörperchirurgischen Eingriff. Die technischen
Möglichkeiten dazu sind vorhanden, die klinische Bestätigung steht noch aus. Obwohl
die chirurgischen Therapieverfahren bei retinalen Venenverschlüssen noch viele offene
Fragen aufweisen, zeigen sie doch vielversprechende Ansätze, die weitgehende therapeutische
Hilflosigkeit der Vergangenheit zu überwinden.
Abstract
Retinal vein occlusions are the second most common vision threatening retinal vascular
disorders. Our therapeutic armamentarium for functional improvement was very limited
in the past for all types of retinal vein occlusions (branch, central and hemi-central
retinal vein occlusion). Also pathomechanism and risk factors are not completely understood
yet. Argon-laser-photocoagulation can prevent the development and treat neovascularizations
successfully, but is unable to improve visual function in most cases. Thrombolytic
therapy applied systemically is limited due to serious side effects but may be helpful
when injected intraocularly. Isovolemic hemodilution may be efficacious in central
retinal vein occlusion (CRVO). The creation of a laser-induced chorioretinal venous
anastomosis showed serious complications. Since 1999 numerous reports on successful
surgical techniques were published. It could be shown that the dissection of the adventitial
sheath with separation of the artery from the vein at the arteriovenous crossing where
branch retinal vein occlusion occurs can re-establish the retinal blood flow with
reduction of macular edema. But it is still unclear which step of the surgery (vitrectomy,
ILM-peeling, sheathotomy) is causative for the results. A new surgical approach in
CRVO is the radial optic neurotomy (RON). This technique was primarily performed under
the hypothesis of decompression of the central vein by cutting the scleral ring. Meanwhile
there is some evidence that the formation of chorioretinal shunts may be the decisive
factor in cases of successfully performed RON. Due to inconsistent and rare data this
surgical procedure needs further evaluation. Another surgical option is the cannulation
of the occluded vein. This technique seems to be feasible but the clinical results
still have to be proved. Despite several uncertainties and open questions, surgical
techniques are likely to overcome the desolate therapeutic situation for retinal vein
occlusion of the past.
Schlüsselwörter
Retinale Venenverschlüsse - Vitrektomie - AV-Dekompression - radiäre Optikusneurotomie
- Thrombolyse
Key words
Retinal vein occlusion - vitrectomy - sheathotomy - radial optic neurotomy - thrombolysis
Literatur
- 1
Amirikia A, Scott I U, Murray T G. et al .
Outcome of vitreoretinal surgery for complications of branch retinal vein occlusion.
Ophthalmology.
2001;
108
372-376
- 2
Avci R, Kaderli B, Avci B. et al .
Pars plana vitrectomy and removed of the internal limiting membrane in the treatment
of chronic macular edema.
Graefe’s Arch Clin Exp Ophthalmol.
2004;
242
845-852
- 3
Bakri S J, Beer P M.
Choroidal neovascularization after radial optic neurotomy for central retinal vein
occlusion.
Retina.
2004;
24
610-611
- 4
Barbazetto I A, Schmidt-Erfurth U M.
Evaluation of functional defects in branch retinal vein occlusion before and after
laser treatment with scanning laser perimetry.
Ophthalmology.
2000;
107
1089-1098
- 5
Becquet F, Le Rouie J F, Zanlonghi X. et al .
Efficiency of surgical treatment for chronic macular edema due to branch retinal vein
occlusion.
J Fr Ophthalmol.
2003;
26
570-576
- 6
Bertram B, Haase G, Remky A. et al .
Anti-Cardiolipin-Antikörper bei Gefäßverschlüssen am Auge.
Ophthalmologe.
1994;
91
768-771
- 7
Branch V ein Occlusion Study Group.
Argon laser photocoagulation for macular edema in branch retinal vein occlusion.
Am J Ophthalmol.
1984;
98
271-282
- 8
Branch Vein Occlusion Study Group .
Argon laser scatter photocoagulation for prevention of neovascularisation and vitreous
hemorrhage in branch retinal vein occlusion.
Arch Ophthalmol.
1986;
104
34-42
- 9
Brown B A, Marx J L, Ward P T. et al .
Homocystein: A risk factor for retinal venous occlusive disease.
Ophthalmology.
2002;
109
287-290
- 10
Browning D J, Antoszyk A N.
Laser chorioretinal venous anastomosis for nonischemic central retinal vein occlusion.
Ophthalmology.
1998;
105
670-679
- 11
Cahill M T, Kaiser P K, Sears J E. et al .
The effect of arteriovenous sheathotomy on cystoid macular oedema secondary to branch
retinal vein occlusion.
Br J Ophthalmol.
2003;
87
1329-1332
- 12
Central vein occlusion study group .
Evaluation of grid pattern photocoagulation for macular edema in central vein occlusion.
Ophthalmology.
1995;
102
1425-1433
- 13
Chalam K V, Shah V A.
A newly designed guarded radial optic neurotomy knife.
Retina.
2004;
24
817-818
- 14
Charbonnel J, Glacet-Bernard A, Korobelnik J F. et al .
Management of branch retinal vein occlusion with vitrectomy and arteriovenous adventitial
sheathotomy, the possible role of surgical posterior vitreous detachment.
Graefe’s Arch Clin Exp Ophthalmol.
2004;
242
223-228
- 15
Chen H C, Wiek J, Gupta A. et al .
Effect of isovolemic haemodilution on visual outcome in branch retinal vein occlusion.
Br J Ophthalmol.
1998;
82
162-167
- 16
Chen S DM, Lochhead J, Patel C K. et al .
Intravitreal triamcinolone acetonide for ischaemic macular oedema caused by branch
retinal vein occlusion.
Br J Ophthalmol.
2004;
88
154-155
- 17
Christoffersen N L, Larsen M.
Pathophysiology and hemodynamics of branch vein occlusion.
Ophthalmology.
1999;
106
2054-2062
- 18
Czajka M P, Cummings T J, McCuen I I BW. et al .
Radial optic neurotomy in the porcine eye without retinal vein occlusion.
Arch Ophthalmol.
2004;
122
1185-1189
- 19
Danis R P, Wallow H L.
Microvascular changes in experimental branch retinal vein occlusion.
Ophthalmology.
1987;
94
1213-1221
- 20
Dithmar S, Hansen L L, Holz E G.
Venöse retinale Verschlüsse.
Ophthalmologe.
2003;
100
561-578
- 21
Duff I F, Falls H F, Linman J W.
Anticoagulant therapy in occlusive vascular disease of the retina.
Arch Ophthalmol.
1951;
46
601-617
- 22
Elman M J.
Thrombolytic therapy for central retinal vein occlusion: results of a pilot study.
Trans Am Ophthalmol Soc.
1996;
94
471-504
- 23
Faude F, Faude S, Siegemund A. et al .
Faktor-VIII Aktivität bei Patienten mit Zentralvenenverschluss im Vergleich zu Patienten
mit tiefer Becken- und Beinvenenthrombose und gesunder Kontrollgruppe.
Klin Monatsbl Augenheilk.
2004;
221
862-866
- 24
Fekert S, de Juan E.
Chorioretinal venous anastomosis for central retinal vein occlusion: transvitreal
venipucture.
Ophthalmic Surg Lasers.
1999;
30
52-55
- 25
Finkelstein D.
Ischemic macular edema. Recognition and favorable natural history in branch retinal
vein occlusion.
Arch Ophthalmol.
1992;
110
1427-1434
- 26
Figueroa M S, Torres R, Alvarez M T.
Comparative study of vitrectomy with and without vein decompression for branch retinal
vein occlusion: a pilot study.
Eur J Ophthalmol.
2004;
14
40-47
- 27
Frangieh G T, Green W R, Barraquer-Sommers E. et al .
Histopathologic study of nine branch retinal vein occlusion.
Arch Ophthalmol.
1982;
100
1132-1140
- 28
Gandorfer A, Messmer E M, Ulbig M W. et al .
Resolution of diabetic macular edema after surgical removal of the posterior hyaloid
and the inner limiting membrane.
Retina.
2000;
20
126-133
- 29
García-Arumí J, Boixadera A, Martinez-Castillo V. et al .
Chorioretinal anastomosis after radial optic neurotomy for central retinal vein occlusion.
Arch Ophthalmol.
2003;
121
1385-1391
- 30
García-Arumí J, Martinez-Castillo V, Boixadera A. et al .
Management of macular edema in branch retinal vein occlusion with sheathotomy and
recombinant tissue plasminogen activator.
Retina.
2004;
24
530-540
- 31
Glacet-Bernard A, Coscas G, Chabanel A. et al .
Prognostic factors for retinal occlusion: prospective study of 175 cases.
Ophthalmology.
1996;
103
551-560
- 32
Glacet-Bernard A, Zourdani A, Milhoub M. et al .
Effect of isovolemic hemodilution in central retinal vein occlusion.
Graefe`s Arch Clin Exp Ophthalmol.
2001;
239
909-914
- 33
Green W R, Chan C C, Hutchins G M. et al .
Central retinal vein occlusion: a prospective histopathologic study of 29 eyes in
28 cases.
Trans Am Ophthalmol Soc.
1981;
79
371-422
- 34
Gutman F A, Zegarra H.
The natural course of temporal retinal branch vein occlusion.
Trans Am Acad Ophthalmol Otolaryngol.
1974;
78
OP178-192
- 35
Han D P, Bennett S R, Williams D F. et al .
Arteriovenous crossing dissection without separation of the retina vessels for treatment
of branch retinal vein occlusion.
Retina.
2003;
23
145-151
- 36
Hattenbach L O, Steinkamp G, Scharrer I. et al .
Fibrinolytic therapy with low-dose recombinant tissue plasminogen activator in retinal
vein occlusion.
Ophthalmologica.
1998;
212
394-398
- 37
Hayreh S S, Zimmermann M B, Podhajsky P.
Incidence of various types of retinal vein occlusion and their recurrence and demographic
characteristics.
Am J Ophthalmol.
1994;
117
429-441
- 38
Hayreh S S.
Radial optic neurotomy for nonischemic central retinal vein occlusion (letter).
Arch Ophthalmol.
2004;
122
1572-1573
- 39
Ip M S, Kumar K S.
Intravitreal triamcinolone acetonide as treatment for macular edema from central retinal
vein occlusion.
Arch Ophthalmol.
2002;
120
1217-1219
- 40
Jonas J B, Kreissig I, Degenring R F.
Intravitreal triamcinolone acetonide as treatment for macular edema in central retinal
vein occlusion.
Graefe’s Arch Clin Exp Ophthalmol.
2002;
240
782-783
- 41
Karacorlu M, Özdemir H, Karacorlu S.
Intravitreal triamcinolone acetonide for the treatment of central retinal vein occlusion
in young patients.
Retina.
2004;
24
324-327
- 42
Klein M L, Finkelstein D.
Macular grid photocoagulation for macular edema in central retinal vein occlusion.
Arch Ophthalmol.
1989;
107
1297-1302
- 43
Kohner E M, Pettit J E, Hamilton A M. et al .
Streptokinase in central retinal vein occlusion: a controlled clinical trial.
Br J Med.
1976;
1
550-553
- 44
Kuhli C, Scharrer I, Koch F. et al .
Factor XII deficiency: a thrombophilic risk factor for retinal vein occlusion.
Am J Ophthalmol.
2004;
137
459-464
- 45
Kuhn K, Kiss G, Mester V. et al .
Vitrectomy with internal limitin membrane removed for clinically significant macular
oedema.
Graefe’s Arch Clin Exp Ophthalmol.
2004;
242
402-408
- 46
Kumar B, Yu D, Morgan W H. et al .
The distribution of angioarchitectural changes within the vicinity of arteriovenous
crossing in branch retinal vein occlusion.
Ophthalmology.
1998;
105
424-427
- 47
Lahey J M, Fong D S, Kearney J.
Intravitreal tissue plasminogen activator for acute central retinal vein occlusion.
Ophthalmic Surg Lasers.
1999;
30
427-434
- 48
Lam H D, Blumenkranz M S.
Treatment of central retinal vein occlusion by vitrectomy with lysis of vitreopapillary
and epipapillary adhesions, subretinal periphapillary tissue plasminogen activator
injection, and photocoagulation.
Am J Ophthalmol.
2002;
134
609-611
- 49
Lang G E, Freißler K.
Klinische und fluoreszeinangiographische Befunde bei Patienten mit retinalen Venenastverschlüssen.
Klin Monatsbl Augenheilk.
1992;
201
234-239
- 50
Lang G E, Händel A.
Ergebnisse der Laserkoagulation retinaler Venenastverschlüsse.
Klin Monatsbl Augenheilkd.
1993;
203
180-188
- 51
Lee W H, Thompson J T, Sjaarda R N.
Visual acuity results in arteriovenous sheathotomy versus grid laser photocoagulation
in branch retinal vein occlusion.
Presented at the ARVO.
2001;
abstract No. 3862
- 52
Lerche R C, Richard G.
Adventitiaspaltung bei Venenastthrombose.
Klin Monatsbl Augenheilkd.
2004;
221
479-484
- 53
Mandelcorn M S, Nrusimhadevara R K.
Internal limiting membrane peeling for decompression of macular edema in retinal vein
occlusion: a report of 14 cases.
Retina.
2004;
24
348-355
- 54
Mason I II J, Feist R, White M. et al .
Sheathotomy to decompress branch retinal vein occlusion.
Ophthalmology.
2004;
111
540-545
- 55
McAllister I L, Constable I J.
Laser-induced chorioretinal venous anastomosis for treatment of nonischemic central
retinal vein occlusion.
Arch Ophthalmol.
1995;
113
456-462
- 56
McAllister I L, Douglas J P, Constable I J. et al .
Laser-induced chorioretinal venous anastomosis for nonischemic central retinal vein
occlusion: evaluation of the complications and their risk factors.
Am J Ophthalmol.
1998;
126
219-229
- 57
Mester U, Dillinger P.
Vitrectomy with arteriovenous decompression and internal limiting membrane dissection
in branch retinal vein occlusion.
Retina.
2002;
22
740-746
- 58
Mitchell P, Smith W, Chang H.
Prevalence and associations of retinal vein occlusion in Australia. The Blue Mountains
eye study.
Arch Ophthalmol.
1996;
144
1243-1247
- 59
Nomoto H, Shiraga F, Yamayi H. et al .
Evaluation of radial optic neurotomy for central retinal vein occlusion by Indocyanine
Green videoangiography and image analysis.
Am J Ophthalmol.
2004;
138
612-619
- 60
Ohashi H, Oh H, Nishiwaki H. et al .
Delayed absorption of macular edema accompanying serous retinal detachment after grid
laser treatment in patients with branch retinal vein occlusion.
Ophthalmology.
2004;
111
2050-2056
- 61
Opremcak E M, Bruce R A.
Surgical decompression of branch retinal vein occlusion via arteriovenous crossing
sheathotomy. A prosprective review of 15 cases.
Retina.
1999;
19
1-5
- 62
Opremcak E M, Bruce R A, Lomeo M D. et al .
Radial optic neurotomy for central retinal vein occlusion.
Retina.
2001;
21
408-415
- 63
Osterloh M D, Charles S.
Surgical decompression of branch retinal vein occlusions.
Arch Ophthalmol.
1988;
106
1469-1471
- 64
Parodi M B, Saviano S, Ravalico G.
Grid laser treatment in macular branch vein occlusion.
Graefe`s Arch Clin Exp Ophtalmol.
1999;
237
1024-1027
- 65
Rabinowicz I M, Litman S, Michaelson I C.
Branch venous thrombosis - a pathological report.
Trans Ophthalmol Soc UK.
1969;
88
191-210
- 66
Remky A, Wolf S.
Hamid M et al. Effect of hemodilution on retinal hemodynamics in retinal branch vein
occlusion.
Ophthalmologe.
1994;
91
288-292
- 67
Roveda C E, Benisek D.
Retinal breaks secondary to branch retinal vein occlusion.
Ann Ophthalmol.
1999;
31
250-253
- 68
Saika S, Tanaka T, Miyamoto T. et al .
Surgical posterior vitreous detachment combined with gas/air tamponade for treating
macular edema associated with branch retinal vein occlusion: retinal tomography and
visual outcome.
Graefe’s Arch Clin Exp Ophthalmol.
2001;
239
729-732
- 69
Samuel M A, Desai U R, Gandolfo C B.
Peripapillary retinal detachment after radial optic neurotomy for central retinal
vein occlusion.
Retina.
2003;
23
580-583
- 70 Sanborn G, Margargal L, Jaeger E. Venous occlusive disease of the retina. In: Duane’s
Clinical Ophthalmology Vol 3. Philadelphia; Lippincott 2001: 15
- 71
Shah G K, Sharma S, Findeman M S. et al .
Arteriovenous adventitial sheathotomy for the treatment of macular edema associated
with branch retinal vein occlusion.
Am J Ophthalmol.
2000;
129
104-106
- 72 Seitz R. Die Netzhautgefäße. Vergleichende ophthalmoskopische und histologische
Studien an gesunden und kranken Augen. Beihefte Klin Monatsbl Augenheilkd. Stuttgart;
Enke 1962 40
- 73 Seitz R. The crossing phenomenon. The Retinal Vessels St. Louis, Mo; CV Mosby 1964:
20-74
- 74
Spaide R F, Klancnik J M, Gross N E.
Retinal choroidal collateral circulation after radial optic neurotomy correlated with
the lessening of macular edema.
Retina.
2004;
24
356-359
- 75
Stefanson E, Novack R L, Hatchell D L.
Vitrectomy prevents retinal hypoxia in branch retinal vein occlusion.
Invest Ophthalmol Vis Sci.
1990;
31
284-289
- 76
Takahashi M K, Hikichi T, Akiba J. et al .
Role of the vitreous and macular edema in branch retinal vein occlusion.
Ophthalmic Surg Lasers.
1997;
28
294-299
- 77
Tang W M, Han D P.
A study of surgical approaches to retinal vascular occlusions.
Arch Ophthalmol.
2000;
118
138-143
- 78
The Central Vein Occlusion Study Group .
Natural history and clinical management of central retinal vein occlusion.
Arch Ophthalmol.
1997;
115
486-491
- 79
The Eye Disease Case-control Study Group .
Risk factors for branch retinal vein occlusion.
Am J Ophthalmol.
1993;
116
286-296
- 80
Traynor M P, Conway B P.
Collateral vessel formation after radial optic neurotomy.
Retina.
2004;
24
616-617
- 81
Vallée J N, Massin P, Aymard A. et al .
Superselective ophthalmic arterial fibrinolysis with urokinase for recent severe central
retinal venous occlusion: Initial experience.
Radiology.
2000;
216
47-53
- 82
Vannas S, Ritta C.
Anticoagulant treatment for occlusion of the central vein of the retina.
Acta Ophthalmol.
1968;
46
730-735
- 83
Vine A K.
Hyperhomocysteinemia: a risk factor for central retinal vein occlusion.
Am J Ophthalmol.
2000;
129
640-644
- 84
Weiss J N, Bynoe L A.
Injection of tissue plasminogen activator into a branch retinal vein in eyes with
central retinal vein occlusion.
Ophthalmology.
2001;
108
2249-2257
- 85
Williamson T H, Poom W, Whitefield L. et al .
A pilot study of pars plana vitrectomy, intraocular gas, and radial neurotomy in ischemic
central retinal vein occlusion.
Br J Ophthalmol.
2003;
87
1126-1129
- 86
Wolf S, Arend O, Betram B. et al .
Hemodilution therapy in central retinal vein occlusion.
Graefe`s Arch Clin Exp Ophthalmol.
1994;
232
33-39
- 87
Zhao J, Sastry S M, Sperduto R D. et al .
Arteriovenous crossing patterns in branch retinal vein occlusion.
Ophthalmology.
1993;
100
423-428
Prof. Dr. U. Mester
Augenklinik der Bundesknappschaft
An der Klinik 10
66280 Sulzbach/Saar
Email: sek-augen@kksulzbach.de
