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Klin Monbl Augenheilkd 2010; 227(9): 712-720
DOI: 10.1055/s-0029-1245660
Übersicht

© Georg Thieme Verlag KG Stuttgart · New York

Diagnostik und Therapie beim nicht arteriitischen Zentralarterienverschluss

Clinical Diagnostics and Therapy for Non-Arteritic Central Retinal Artery OcclusionA. Pielen1 , B. Junker1 , L. Hansen1 , H. Agostini1 , N. Feltgen2
  • 1Universitäts-Augenklinik, Freiburg
  • 2Augenklinik, Universitäts-Klinikum, Göttingen
Further Information

Publication History

Eingegangen: 17.6.2010

Angenommen: 2.8.2010

Publication Date:
15 September 2010 (online)

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Zusammenfassung

Der akute Zentralarterienverschluss (ZAV) ist eine ophthalmologische Notfallsituation. Die häufigsten Risikofaktoren sind eine arterielle Hypertonie, Herzrhythmusstörungen, Arteriosklerose, Hypercholesterinämie und Diabetes mellitus. Besonders bei älteren Patienten muss eine arteriitische Genese ausgeschlossen werden. Bei jungen Patienten (< 45 Jahre) ohne typische Risikofaktoren kann eine Thrombophilieabklärung sinnvoll sein. Für den nicht arteriitischen ZAV existiert keine einheitliche Therapieempfehlung. In der Literatur findet man zahlreiche Ansätze. Dazu zählen die Bulbusmassage, die systemische oder lokale Senkung des Augeninnendrucks, die Antikoagulation, die venöse systemische Lysetherapie und die kathetergeführte superselektive intraarterielle Lyse. In diesem Übersichtsartikel sollen sowohl die Ursachen des ZAV, die diagnostischen Maßnahmen zur Erkennung der Ursachen als auch die in der Literatur beschriebenen Therapieformen vorgestellt und kritisch bewertet werden. Ziel ist es, eine Orientierung über die notwendigen Schritte zur interdisziplinären Diagnostik in Kooperation mit Internisten und Neurologen und über die multimodale Therapie bei Patienten mit nicht arteriitischem ZAV zu geben.

Abstract

Central retinal artery occlusion (CRAO) is an ophthalmological emergency situation. Known risk factors are arterial hypertension, cardial arrhythmia, arteriosclerosis, hypercholesterolemia and diabetes. Elderly patients should be examined for an arteritic genesis. Young patients (< 45 years) without typical risk factors may suffer from thrombophilia. There is no uniform recommendation on how to treat non-arteritic CRAO. Many different interventions have been suggested in the literature, i. e., massaging the eye, systemic or local reduction of intraocular pressure, anticoagulation, either systemically administered venous thrombolysis or supraselective intra-arterial thrombolysis. In this review we present the causes of CRAO and diagnostic means to detect causes; we also critically discuss previously described therapeutic options. It is our aim to provide a guide through the necessary interdisciplinary diagnostics in co-operation with internal medicine and neurology and to recommend a multimodal therapy in patients with non-arteritic CRAO.

Schlüsselwörter

Retina - Pathologie - Zentralarterienverschluss - Diagnostik - Therapie

Key words

retina - pathology - central retinal artery occlusion - clinical diagnostics - therapy

Literatur

  • 1 Hayreh S S, Kolder H E, Weingeist T A. Central retinal artery occlusion and retinal tolerance time.  Ophthalmology. 1980;  87 75-78
    Google Scholar
  • 2 Rumelt S, Dorenboim Y, Rehany U. Aggressive systematic treatment for central retinal artery occlusion.  Am J Ophthalmol. 1999;  128 733-738
    Google Scholar
  • 3 Feltgen N, Schmidt D, Hansen L. Occlusion of the retinal artery.  Ophthalmologe. 2003;  100 651-665, quiz 666 – 657
    Google Scholar
  • 4 Hayreh S S, Zimmerman M B. Fundus changes in central retinal artery occlusion.  Retina. 2007;  27 276-289
    Google Scholar
  • 5 Hayreh S S, Zimmerman M B. Central retinal artery occlusion: visual outcome.  Am J Ophthalmol. 2005;  140 376-391
    Google Scholar
  • 6 Lange C, Feltgen N, Junker B et al. Resolving the clinical acuity categories ”hand motion” and ”counting fingers” using the Freiburg Visual Acuity Test (FrACT).  Graefes Arch Clin Exp Ophthalmol. 2009;  247 137-142
    Google Scholar
  • 7 Augsburger J J, Magargal L E. Visual prognosis following treatment of acute central retinal artery obstruction.  Br J Ophthalmol. 1980;  64 913-917
    Google Scholar
  • 8 Schmidt D, Schumacher M, Wakhloo A K. Microcatheter urokinase infusion in central retinal artery occlusion.  Am J Ophthalmol. 1992;  113 429-434
    Google Scholar
  • 9 Arnold M, Koerner U, Remonda L et al. Comparison of intra-arterial thrombolysis with conventional treatment in patients with acute central retinal artery occlusion.  J Neurol Neurosurg Psychiatry. 2005;  76 196-199
    Google Scholar
  • 10 Atebara N H, Brown G C, Cater J. Efficacy of anterior chamber paracentesis and Carbogen in treating acute nonarteritic central retinal artery occlusion.  Ophthalmology. 1995;  102 2029-2034, discussion 2034 – 2025
    Google Scholar
  • 11 Brown G C, Magargal L E. Central retinal artery obstruction and visual acuity.  Ophthalmology. 1982;  89 14-19
    Google Scholar
  • 12 Karjalainen K. Occlusion of the central retinal artery and retinal branch arterioles. A clinical, tonographic and fluorescein angiographic study of 175 patients.  Acta Ophthalmol. 1971;  109 1-95
    Google Scholar
  • 13 Mueller A J, Neubauer A S, Schaller U et al. Evaluation of Stunden imally invasive therapies and rationale for a prospective randomized trial to evaluate selective intra-arterial lysis for clinically complete central retinal artery occlusion.  Arch Ophthalmol. 2003;  121 1377-1381
    Google Scholar
  • 14 Sharma S. The systemic evaluation of acute retinal artery occlusion.  Curr Opin Ophthalmol. 1998;  9 1-5
    Google Scholar
  • 15 Neubauer A S, Mueller A J, Schriever S et al. Minimally invasive therapy for clinically complete central retinal artery occlusion – results and meta-analysis of literature.  Klin Monbl Augenheilkd. 2000;  217 30-36
    Google Scholar
  • 16 Sanborn G ML. Arterial obstructive disease of the eye.  Duane’s clinical ophthalmology. 1990;  3 1-29
    Google Scholar
  • 17 Sharma S, Brown C. Retinal arterial obstructive disease. St. Louis: Mosby; 1994: 1361-1377
    Google Scholar
  • 18 Schmidt D, Schumacher M, Feltgen N. Circadian incidence of non-inflammatory retinal artery occlusions.  Graefes Arch Clin Exp Ophthalmol. 2009;  247 491-494
    Google Scholar
  • 19 David N J, Norton E W, Gass J D et al. Fluorescein angiography in central retinal artery occlusion.  Arch Ophthalmol. 1967;  77 619-629
    Google Scholar
  • 20 Gold D. Retinal arterial occlusion.  Trans Sect Ophthalmol Am Acad Ophthalmol Otolaryngol. 1977;  83 OP392-OP408
    Google Scholar
  • 21 Wolf S, Hoberg A, Bertram B et al. Video fluorescein angiography follow-up of patients with retinal artery occlusion.  Klin Monbl Augenheilkd. 1989;  195 154-160
    Google Scholar
  • 22 Ghazi N G, Tilton E P, Patel B et al. Comparison of macular optical coherence tomography findings between postacute retinal artery occlusion and nonacute optic neuropathy.  Retina. 2010;  30 578-585
    Google Scholar
  • 23 Duker J S, Brown G C. Iris neovascularization associated with obstruction of the central retinal artery.  Ophthalmology. 1988;  95 1244-1250
    Google Scholar
  • 24 Duker J S, Sivalingam A, Brown G C et al. A prospective study of acute central retinal artery obstruction. The incidence of secondary ocular neovascularization.  Arch Ophthalmol. 1991;  109 339-342
    Google Scholar
  • 25 Rudkin A K, Lee A W, Chen C S. Vascular risk factors for central retinal artery occlusion.  Eye. 2010;  24 678-681
    Google Scholar
  • 26 Pantenburg S, Pielen A, Junker B et al. Risk evaluation in patients with acute non-arteriitic central retinal artery occlusion. World Ophthalmology Congress. Berlin; 2010
    Google Scholar
  • 27 Klatt C, Purtskhvanidze K, Hasselbach H et al. Retrospective case analysis of ophthalmological and systemic risk factors in patients with retinal vascular occlusion.  Ophthalmologe. 2010;  107 446-451
    Google Scholar
  • 28 Wang J J, Cugati S, Knudtson M D et al. Retinal arteriolar emboli and long-term mortality: pooled data analysis from two older populations.  Stroke. 2006;  37 1833-1836
    Google Scholar
  • 29 Mirshahi A, Feltgen N, Hansen L L et al. Retinal vascular occlusions: an interdisciplinary challenge.  Dtsch Arztebl Int. 2008;  105 474-479
    Google Scholar
  • 30 Heinz J. Internistische Untersuchungen beim nicht-arteriitischen retinalen Arterienverschluss.  Ophthalmologe. 2010;  [im Druck]
    Google Scholar
  • 31 Hayreh S S, Podhajsky P A, Zimmerman M B. Retinal artery occlusion: associated systemic and ophthalmic abnormalities.  Ophthalmology. 2009;  116 1928-1936
    Google Scholar
  • 32 Nagy V, Takacs L, Steiber Z et al. Thrombophilic screening in retinal artery occlusion patients.  Clin Ophthalmol. 2008;  2 557-561
    Google Scholar
  • 33 Glueck C J, Wang P. Ocular vascular thrombotic events: a diagnostic window to familial thrombophilia (compound factor V Leiden and prothrombin gene heterozygosity) and thrombosis.  Clin Appl Thromb Hemost. 2009;  15 12-18
    Google Scholar
  • 34 Larsson J. Central retinal artery occlusion in a patient homozygous for factor V Leiden.  Am J Ophthalmol. 2000;  129 816-817
    Google Scholar
  • 35 Willeke A, Gerdsen F, Bauersachs R M et al. Rationelle Thrombophiliediagnostik.  Deutsches Ärzteblatt. 2002;  99 2111-2118
    Google Scholar
  • 36 Cahill M T, Stinnett S S, Fekrat S. Meta-analysis of plasma homocysteine, serum folate, serum vitamin B(12), and thermolabile MTHFR genotype as risk factors for retinal vascular occlusive disease.  Am J Ophthalmol. 2003;  136 1136-1150
    Google Scholar
  • 37 Miserocchi E, Baltatzis S, Foster C S. Ocular features associated with anticardiolipin antibodies: a descriptive study.  Am J Ophthalmol. 2001;  131 451-456
    Google Scholar
  • 38 Cobo-Soriano R, Sanchez-Ramon S, Aparicio M J et al. Antiphospholipid antibodies and retinal thrombosis in patients without risk factors: a prospective case-control study.  Am J Ophthalmol. 1999;  128 725-732
    Google Scholar
  • 39 Moerloose de P, Boehlen F. Inherited thrombophilia in arterial disease: a selective review.  Semin Hematol. 2007;  44 106-113
    Google Scholar
  • 40 Toole J F, Malinow M R, Chambless L E et al. Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction, and death: the Vitamin Intervention for Stroke Prevention (VISP) randomized controlled trial.  Jama. 2004;  291 565-575
    Google Scholar
  • 41 Harino S, Grunwald J E, Petrig B J et al. Rebreathing into a bag increases human retinal macular blood velocity.  Br J Ophthalmol. 1995;  79 380-383
    Google Scholar
  • 42 Frayser R, Hickam J B. Retinal Vascular Response to Breathing Increased Carbon Dioxide and Oxygen Concentrations.  Invest Ophthalmol. 1964;  3 427-431
    Google Scholar
  • 43 Deutsch T A, Read J S, Ernest J T et al. Effects of oxygen and carbon dioxide on the retinal vasculature in humans.  Arch Ophthalmol. 1983;  101 1278-1280
    Google Scholar
  • 44 Schmetterer L, Lexer F, Findl O et al. The effect of inhalation of different mixtures of O2 and CO2 on ocular fundus pulsations.  Exp Eye Res. 1996;  63 351-355
    Google Scholar
  • 45 Aisenbrey S, Krott R, Heller R et al. Hyperbaric oxygen therapy in retinal artery occlusion.  Ophthalmologe. 2000;  97 461-467
    Google Scholar
  • 46 Weinberger A W, Siekmann U P, Wolf S et al. Treatment of Acute Central Retinal Artery Occlusion (CRAO) by Hyperbaric Oxygenation Therapy (HBO) – Pilot study with 21 patients.  Klin Monbl Augenheilkd. 2002;  219 728-734
    Google Scholar
  • 47 Ffytche T J. A rationalization of treatment of central retinal artery occlusion.  Trans Ophthalmol Soc U K. 1974;  94 468-479
    Google Scholar
  • 48 Chen J C, Cheema D. Repeated anterior chamber paracentesis for the treatment of central retinal artery occlusion.  Can J Ophthalmol. 1994;  29 207-209
    Google Scholar
  • 49 Harvey P A, Winder S, Talbot J F. Trabeculectomy for central retinal artery occlusion.  Eye (Lond). 2000;  14 (Pt 2) 256-257
    Google Scholar
  • 50 Rassam S M, Patel V, Kohner E M. The effect of acetazolamide on the retinal circulation.  Eye (Lond). 1993;  7 (Pt 5) 697-702
    Google Scholar
  • 51 Opremcak E M, Benner J D. Translumenal Nd:YAG laser embolysis for branch retinal artery occlusion.  Retina. 2002;  22 213-216
    Google Scholar
  • 52 Opremcak E, Rehmar A J, Ridenour C D et al. Restoration of retinal blood flow via translumenal Nd:YAG embolysis/embolectomy (TYL/E) for central and branch retinal artery occlusion.  Retina. 2008;  28 226-235
    Google Scholar
  • 53 Reynard M, Hanscom T A. Neodymium:yttrium-aluminum-garnet laser arteriotomy with embolectomy for central retinal artery occlusion.  Am J Ophthalmol. 2004;  137 196-198
    Google Scholar
  • 54 Haritoglou C, Wolf A, Ulbig M W. Laser embolectomy for central retinal artery occlusion.  Ophthalmologe. 2010;  107 465-467
    Google Scholar
  • 55 Dutton G N, Craig G. Treatment of retinal embolus by photocoagulation.  Br J Ophthalmol. 1989;  73 580-581
    Google Scholar
  • 56 Ciulla T A, D’Amico D J, Miller J W. Laser photodisruption of visible retinal artery emboli.  Br J Ophthalmol. 1995;  79 964-965
    Google Scholar
  • 57 Garcia-Arumi J, Martinez-Castillo V, Boixadera A et al. Surgical embolus removal in retinal artery occlusion.  Br J Ophthalmol. 2006;  90 1252-1255
    Google Scholar
  • 58 Tang W M, Topping T M. Vitreous surgery for central retinal artery occlusion.  Arch Ophthalmol. 2000;  118 1586-1587
    Google Scholar
  • 59 Tang W M, Han D P. A study of surgical approaches to retinal vascular occlusions.  Arch Ophthalmol. 2000;  118 138-143
    Google Scholar
  • 60 Hayreh S S. Restoration of retinal blood flow via translumenal Nd:YAG embolysis/embolectomy (TYL/E) for central and branch retinal artery occlusion.  Retina. 2008;  28 1369-1372, author reply 1372 – 1363
    Google Scholar
  • 61 Beatty S, Au Eong K G. Local intra-arterial fibrinolysis for acute occlusion of the central retinal artery: a meta-analysis of the published data.  Br J Ophthalmol. 2000;  84 914-916
    Google Scholar
  • 62 Hattenbach L O, Kuhli-Hattenbach C, Scharrer I et al. Intravenous thrombolysis with low-dose recombinant tissue plasminogen activator in central retinal artery occlusion.  Am J Ophthalmol. 2008;  146 700-706
    Google Scholar
  • 63 Kattah J C, Wang D Z, Reddy C. Intravenous recombinant tissue-type plasminogen activator thrombolysis in treatment of central retinal artery occlusion.  Arch Ophthalmol. 2002;  120 1234-1236
    Google Scholar
  • 64 Margo C E, Mack W P. Therapeutic decisions involving disparate clinical outcomes: patient preference survey for treatment of central retinal artery occlusion.  Ophthalmology. 1996;  103 691-696
    Google Scholar
  • 65 Annonier P, Sahel J, Wenger J J et al. Local fibrinolytic treatment in occlusions of the central retinal artery.  J Fr Ophtalmol. 1984;  7 711-716
    Google Scholar
  • 66 Zeumer H, Freitag H J, Grzyska U et al. Local intraarterial fibrinolysis in acute vertebrobasilar occlusion. Technical developments and recent results.  Neuroradiology. 1989;  31 336-340
    Google Scholar
  • 67 Butz B, Strotzer M, Manke C et al. Selective intraarterial fibrinolysis of acute central retinal artery occlusion.  Acta Radiol. 2003;  44 680-684
    Google Scholar
  • 68 Richard G, Lerche R C, Knospe V et al. Treatment of retinal arterial occlusion with local fibrinolysis using recombinant tissue plasminogen activator.  Ophthalmology. 1999;  106 768-773
    Google Scholar
  • 69 Pettersen J A, Hill M D, Demchuk A M et al. Intra-arterial thrombolysis for retinal artery occlusion: the Calgary experience.  Can J Neurol Sci. 2005;  32 507-511
    Google Scholar
  • 70 Schumacher M, Schmidt D, Wakhloo A K. Intra-arterial fibrinolytic therapy in central retinal artery occlusion.  Neuroradiology. 1993;  35 600-605
    Google Scholar
  • 71 Barth H, Stein H, Fasse A et al. Intracerebral hemorrhage after systemic thrombolysis in patients with occlusion of the central retinal artery. Report of 2 cases.  Ophthalmologe. 1996;  93 739-744
    Google Scholar
  • 72 Bertram B, Wolf S, Fisches H et al. Thrombolytic treatment of retinal arterial occlusions with plasminogen activator.  Klin Monbl Augenheilkd. 1991;  198 295-300
    Google Scholar
  • 73 Tsai F Y, Wadley D, Angle J F et al. Superselective ophthalmic angiography for diagnostic and therapeutic use.  Am J Neuroradiol. 1990;  11 1203-1204
    Google Scholar
  • 74 Biousse V, Calvetti O, Bruce B B et al. Thrombolysis for central retinal artery occlusion.  J Neuroophthalmol. 2007;  27 215-230
    Google Scholar
  • 75 Aldrich E M, Lee A W, Chen C S et al. Local intraarterial fibrinolysis administered in aliquots for the treatment of central retinal artery occlusion: the Johns Hopkins Hospital experience.  Stroke. 2008;  39 1746-1750
    Google Scholar
  • 76 Schmidt D P, Schulte-Monting J, Schumacher M. Prognosis of central retinal artery occlusion: local intraarterial fibrinolysis versus conservative treatment.  Am J Neuroradiol. 2002;  23 1301-1307
    Google Scholar
  • 77 Padolecchia R, Puglioli M, Ragone M C et al. Superselective intraarterial fibrinolysis in central retinal artery occlusion.  Am J Neuroradiol. 1999;  20 565-567
    Google Scholar
  • 78 Feltgen N, Neubauer A, Jurklies B et al. Multicenter study of the European Assessment Group for Lysis in the Eye (EAGLE) for the treatment of central retinal artery occlusion: design issues and implications. EAGLE Study report no. 1: EAGLE Study report no. 1.  Graefes Arch Clin Exp Ophthalmol. 2006;  244 950-956
    Google Scholar
  • 79 Schumacher M, Schmidt D, Jurklies B et al. Central retinal artery occlusion: local intra-arterial fibrinolysis versus conservative treatment, a multicenter randomized trial.  Ophthalmology. 2010;  117 1367-1375
    Google Scholar
  • 80 Sandercock P, Gubitz G, Foley P et al. Antiplatelet therapy for acute ischaemic stroke.  Cochrane Database Syst Rev. 2003;  CD000029
    Google Scholar
  • 81 Holschermann H, Krombach C, Jung A et al. Treatment of acute central retinal artery occlusionwith the platelet glycoprotein IIb/IIIa receptor inhibitor tirofiban.  Thromb Haemost. 2005;  94 684-686
    Google Scholar
  • 82 Rufer F, Schroder A, Winter R et al. Analysis of risk factors and comparison of heparin and hemodilution therapies for retinal artery occlusion.  Ophthalmologe. 2003;  100 819-824
    Google Scholar
  • 83 Iwafune Y, Yoshimoto H. Clinical use of pentoxifylline in haemorrhagic disorders of the retina.  Pharmatherapeutica. 1980;  2 429-438
    Google Scholar
  • 84 Kieswetter H, Korber N, Jung F et al. Rheologic findings in patients with acute central retinal artery occlusion.  Graefes Arch Clin Exp Ophthalmol. 1983;  220 92-95
    Google Scholar
  • 85 Incandela L, Cesarone M R, Belcaro G et al. Treatment of vascular retinal disease with pentoxifylline: a controlled, randomized trial.  Angiology. 2002;  53 (Suppl 1) S31-S34
    Google Scholar
  • 86 Fraser S G, Adams W. Interventions for acute non-arteritic central retinal artery occlusion.  Cochrane Database Syst Rev. 2009;  CD001989
    Google Scholar
  • 87 Hausmann N, Richard G. Effect of high dose steroid bolus on occlusion of ocular central artery: angiographic study.  Bmj. 1991;  303 1445-1446
    Google Scholar
  • 88 Pettersson T, Bondesson S, Cojocaru D et al. One year follow-up of patients with refractory angina pectoris treated with enhanced external counterpulsation.  BMC Cardiovasc Disord. 2006;  6 28
    Google Scholar
  • 89 Werner D, Michalk F, Harazny J et al. Accelerated reperfusion of poorly perfused retinal areas in central retinal artery occlusion and branch retinal artery occlusion after a short treatment with enhanced external counterpulsation.  Retina. 2004;  24 541-547
    Google Scholar
  • 90 Jehle T, Wingert K, Dimitriu C et al. Quantification of ischemic damage in the rat retina: a comparative study using evoked potentials, electroretinography, and histology.  Invest Ophthalmol Vis Sci. 2008;  49 1056-1064
    Google Scholar
  • 91 Hayreh S S, Weingeist T A. Experimental occlusion of the central artery of the retina. IV: Retinal tolerance time to acute ischaemia.  Br J Ophthalmol. 1980;  64 818-825
    Google Scholar
  • 92 Hayreh S S, Weingeist T A. Experimental occlusion of the central artery of the retina. I. Ophthalmoscopic and fluorescein fundus angiographic studies.  Br J Ophthalmol. 1980;  64 896-912
    Google Scholar
  • 93 Duker J S, Brown G C. Recovery following acute obstruction of the retinal and choroidal circulations. A case history.  Retina. 1988;  8 257-260
    Google Scholar
  • 94 Ehrhardt B A, Kürzinger G RK, Lang G E. Hemodilution therapy in central retinal artery occlusion. WOC. Berlin; 2010
    Google Scholar
  • 95 Hayreh S S. Retinal arterial occlusion with LIF using rTPA.  Ophthalmology. 1999;  106 1236-1239
    Google Scholar
  • 96 Lorentzen S E. Occlusion of the central retinal artery. A follow-up.  Acta Ophthalmol (Copenh). 1969;  47 690-703
    Google Scholar

Dr. Amelie Pielen

Universitäts-Augenklinik

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79106 Freiburg

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Email: amelie.pielen@uniklinik-freiburg.de