Apheresis) Therapeutical (Rheopheresis; otherapy• 46 rchapteRh

322

3

2

Figure 46.1  Blood circulation was established from one forearm to the other by bilateral insertion of needles into each antecubital vein (1). The whole blood is pumped (2) into a separate pressurized circuit. Here the plasma is driven through a two-stage filtration

process provided by the plasma separator (3) connected in series to the plasma component separator (4). Then the sieved plasma is recombined with the cellular fraction of the blood (5) to be reinfused into the patient (1).2,3

Figure 46.2  Change in visual acuity in lines (ETDRS) in patient PH, aged 66 years. Right eye initial visual acuity 20/200.

eyes (n = 29) demonstrated an average improvement of 0.7 lines of vision compared with an average loss of 0.9 lines in the control group (n = 14) (no treatment). The mean difference of 1.6 lines between the two groups is significant (P = 0.0011, repeated-measures analysis). In the subgroup of patients with baseline vision worse than 20/40, the rheophoresis-treated eyes (n = 19) demonstrated an average improvement of 1.1 lines of vision compared with an average loss of 1.9 lines in the control group (n = 7) (no treatment). Despite the relatively small sizes of the two groups, the mean difference of 3.0 lines between the two groups is statistically significant (P = 0.0014, repeated-measures analysis).2,11

In our clinic we have followed several patients over a number of years and the long-term results of treatment with rheopheresis seem promising. The decrease in visual function can be prevented and an increase in visual function can be observed for a number of years. At a certain point in time, the ongoing morphological changes again lead to a reduction in visual function. Nevertheless, these patients gained between several years and a decade of better visual function and therefore improved quality of life with reading and driving capabilities (Figures 46.2–46.4).

In our opinion, patients with the following diagnostic findings and informed consent are suitable for treatment with rheopheresis.

The eye intended for treatment should show:

●dry AMD

●soft drusen (Figure 46.3), changes in the pigment epithelium

●visual acuity of between 0.1 (20/200) and 0.63 (20/32) and no exudation, bleeding, fibrosis, or advanced atrophy.

Figure 46.3  Fundus photograph of patient PH; right eye 1997.

Figure 46.4  Fundus photograph of patient PH; right eye 2003.

Diagnosis, indication, examination, and follow-up of the patients are the responsibility of the treating ophthalmologist.

DIABETIC MACULOPATHY

The increasing incidence of type 2 diabetes leads to an astonishing number of diabetic eye disease cases, of which diabetic maculopathy is of the greatest concern. Diabetic maculopathy is by far the most common cause of poor vision in our society and among people of working age.18 The pathogenesis is not fully understood and satisfactory therapy is not yet available. Malfunction of the blood–retinal barrier plays a central role in the disease, leading to retinal edema and photoreceptor dysfunction. Diabetic vascular leakage and macular edema are regulated by a distinct combination of direct paracellular transport, alterations in endothelial intercellular junctions, and endothelial cell death. The distribution and relevance of these three factors fordiabeticmaculopathyvaryoverthecourseofthedisease.Cumulative endothelial cell death becomes more relevant after prolonged diabetic conditions.19

Unfortunately, and unlike macrovascular diseases, the medical treatment of microvascular disease in diabetes and particularly in diabetic retinopathy is still at an early stage. Given the rapid global increase in the prevalence of diabetes and the morbidity rate caused by diabetic microvascular disease, it is important to increase the efforts in this field.

There are several indications that patients with higher baseline total cholesterol, LDL cholesterol, or triglycerides are at greater risk of developing diabetic maculopathy.