Zusammenfassung
Dieser Übersichtsartikel befasst sich mit den Erkrankungen der Sehbahn auf unterschiedlichen
Ebenen, ihren Auswirkungen auf alltagsrelevante Funktionen und ihrer Rehabilitation.
Infrachiasmale Läsionen gehen meist mit Zentral- oder Ringskotomen mit folgender Lesestörung
einher. Das Benutzen eines exzentrischen Fixationsorts in Kombination mit Textvergrößerung
ermöglicht den Erhalt der Lesefähigkeit. Chiasmale Läsionen können zu Orientierungsstörungen
durch bitemporale Hemianopsie und zu Leseproblemen durch Verschiebungsphänomene wegen
Fusionsmangel führen, denn die noch funktionsfähigen temporalen Netzhauthälften korrespondieren
nicht. Suprachiasmale Läsionen verursachen homonyme Gesichtsfeldausfälle. Bezüglich
der Verbesserung der hemianopen Orientierungsstörung gibt es 2 Ansätze für Trainingsmethoden,
die kontrovers diskutiert werden: Restitution des Gesichtsfelds durch visuelle Stimulation
versus Kompensation durch explorative Augenbewegungen zur hemianopen Seite mit dem
Ziel, das Blickfeld besser zu nützen. Früher beschriebene positive Effekte des explorativen
Sakkadentrainings waren mangels Kontrollgruppen noch nicht ganz überzeugend. Durch
eine neue randomisierte und kontrollierte Studie konnte die Wirksamkeit eines kompensatorischen
Sakkadentrainings nachgewiesen und gezeigt werden, dass die Patienten die erlernte
Strategie der verbesserten Exploration auch im Alltag anwenden. In der Kontrollgruppe,
die ein Gesichtsfeldstimulationsstraining – ein potenzielles Restitutionstraining
– erhielt, änderte sich weder das Explorationsverhalten noch das Gesichtsfeld. Die
hemianope Lesestörung ist abhängig vom Abstand des Gesichtsfeldausfalls zum Zentrum,
d. h. der Größe des vorhandenen Lesegesichtsfelds, der Seite des Ausfalls in Bezug
zur Leserichtung und dem Auftreten von spontanen Adaptationsstrategien wie z. B. exzentrischer
Fixation und prädiktiven Sakkaden. Spezifisches Lesetraining kann hilfreich sein.
Bei zerebral bedingten Sehstörungen finden sich außer Gesichtsfeldausfällen oft auch
Verarbeitungsstörungen in höheren kortikalen Zentren, die meist interdisziplinär behandelt
werden müssen. Untersuchungsmethoden zur Erfassung alltagsrelevanter Funktionen und
als Basis für gezielte Rehabilitationsmaßnahmen werden erörtert. Der hohe und zunehmende
Bedarf an visueller Rehabilitation stellt eine große Herausforderung dar. Die visuelle
Rehabilitation ist in vielen Fällen sehr erfolgreich und kann die Lebensqualität der
Patienten verbessern.
Abstract
This review considers diseases of the visual pathways at different levels, their consequences
for relevant everyday functions and their rehabilitation. Infrachiasmatic lesions
are mostly associated with central or ring scotomas causing reading problems. The
use of an eccentric fixation locus in combination with text magnification often allows
the patient to maintain reading ability. Chiasmatic lesions can cause orientation
disability by bitemporal hemianopia and reading problems by slide phenomena along
the vertical midline. Suprachiasmatic lesions lead to homonymous visual field defects.
Regarding the hemianopic orientation disorder, there are two different training approaches,
which have been discussed controversially: restitution of the visual field by visual
stimulation versus compensation by explorative eye movements towards the hemianopic
side. Previously described positive effects of exploration training were not entirely
convincing due to the lack of control groups. A new randomised and controlled study
has proved the effectiveness of exploration training and showed that the patients
apply the improved exploration strategy to everyday life. In the control group, which
received a visual field stimulation training – a potential restitution training –
neither exploration nor visual fields changed. The hemianopic reading disorder depends
on the distance of the field defect from the centre, i. e., the size of the reading
visual field, the side of the field defect in regard to the reading direction and
the presence of spontaneous adaptive strategies, such as eccentric fixation or predictive
saccades. Specific reading training can be helpful. Cerebral visual impairments with
visual field defects are often associated with disorders of information processing
in higher cortical areas. These complex disorders usually require an interdisciplinary
rehabilitation. Specific examination methods to assess functions of everyday relevance
and their use as a basis for rehabilitation measures are discussed. Visual rehabilitation
can be very successful in many cases and improves the patients’ quality of life. One
should expect that the demand for neuro-ophthalmological rehabilitation will increase,
because the survival rate after severe cerebral lesions and the general lifespan are
rising.
Schlüsselwörter
Neuroophthalmologie - Sehbehinderung - Lesestörung - Orientierungsstörung - Rehabilitation
Key words
neuro-ophthalmology - low vision - reading disorder - orientation disorder - rehabilitation
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Prof. Dr. S. Trauzettel-Klosinski
Sehbehindertenambulanz, Universitäts-Augenklinik Tübingen
Schleichstr. 12 – 16
72076 Tübingen
Telefon: ++ 49/70 71/2 98 47 87
Fax: ++ 49/70 71/29 51 64
eMail: susanne.trauzettel-klosinski@uni-tuebingen.de
