Figure 46.13  OS after 17 therapeutic apheresis with completely attached choroidea. The fundus shows the characteristic leopardiform pattern due to the long detachment of the choroidea; visual acuity: 20/50.

and safety standards in internal medicine for decades.12 Rheopheresis’s reliability has been extensively documented in the international RheoNet register, which includes data of over 7000 rheopheresis treatments, of which more than two-thirds were treatments ofAMD patients. There were no severe adverse events reported. In 5.7% of treatments adverse events occurred, but only 0.5% necessitated termination of the treatment. Transient hypotension was the most frequently reported adverse event.13,29

SUMMARY

Rheopheresis is a safe and effective method of improving rheological parameters such as erythrocyte aggregation, plasma viscosity, and whole-blood viscosity due to the elimination of high-molecular proteins and lipoproteins. The therapy is well received by patients and, as no severe side-effects are mentioned, they appear to be rare.10,12,13,25,30

Rheopheresis can eliminate known vascular risk factors and suspected pathophysiologically relevant factors of AMD, CRVO, and diabetes by decreasing plasma viscosity and depleting the serum of soluble high-molecular proteins such as immune complexes, IgM, fibrinogen, LDL and very LDL cholesterol, von Willebrand factor, and α2-macroglobulin.1,2

Friedman6 has suggested a hemodynamic model of AMD pathogenesis. He hypothesized that impaired choroidal perfusion results from increases in vascular resistance in the choroid, possibly as a consequence of decreased compliance of the sclera and choroidal vessels with increased age, combined with lipidization of Bruch’s membrane and accompanying drusen biosynthesis. Such effects would necessarily degrade the metabolic transport function of the pigment epithelium and other supporting posterior retinal tissues. Therapeutic apheresis may therefore be a way to improve the choroidal outflow. The reabsorbtion of subretinal fluid maintaining the serous choroidal and concomitant retinal detachment in uveal effusion syndrome leads to fast reattachment with good functional results, as shown in the aforementioned case.

Furthermore, inference of a possible systemic influence can be found in the reports of generalized risk factors that have been associated with AMD, CRVO, and diabetes in several trials. These risk factors include a history of smoking, systemic hypertension, increased body mass index, elevated fibrinogen levels, increased serum cholesterol, increased hemorheologic factors, elevated von Willebrand levels, and elevated α2-macroglobulin levels.15–17,25,31 Klingel and colleagues1 state that the clinical consequences of impaired microcirculation are due to the complex interactive relationships between plasma components, blood cells, cells of the vessel wall (endothelium, vascular smooth-muscle

cells, and fibroblasts), and the compartments of the surrounding tissues (cells and extracellular matrix).

Brunner and colleagues studied pulsatile ocular blood flow using a noninvasive quantitative assessment of the ciliary choroidal blood flow immediately preceding, and then subsequent to, rheopheresis treatment in 10 patients with AMD.32 They found a statistically significant 22% increase in ocular blood flow (P = 0.028).

Rheopheresis as a treatment for selective patients with dry AMD, CRVO, nonproliferative diabetic maculopathy, or idiopathic uveal effusion syndrome appears to be safe and well tolerated by most patients. Long-term results show that the treatment benefits for eyes with CRVO, nonproliferative diabetic maculopathy, or idiopathic uveal effusion syndrome generally remain stable for years, or at least delay the natural course of events, as expected with dry AMD.

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