Purdy EP: Pain in the“Normal”Eye. Focal Point Vol. 37 Number 1, American Academy of Ophthalmolgy, 2019.
臼井正彦：眼科の緊急および救急疾患の取り扱いとその対応．日本の眼科2011；82(10)：1322-1328.
日本眼科学会. 緑内障診療ガイドライン（第5版）. 日本眼科学会誌. 2022;126:85-177.
Gelston CD.
Common eye emergencies.
Am Fam Physician. 2013 Oct 15;88(8):515-9.
Abstract/Text
Ocular emergencies such as retinal detachments, mechanical globe injuries, and chemical injuries can cause permanent vision loss if they are not recognized and treated promptly. Family physicians should be familiar with the signs and symptoms associated with each condition, and be able to perform a basic eye examination to assess the situation. The assessment includes measurement of visual acuity, pupillary examination, visual field testing, slit lamp or penlight examination of the anterior segment of the eye, and direct funduscopic examination. Patients with symptomatic floaters and flashing lights require a dilated fundoscopic examination and prompt referral to an ophthalmologist for evaluation of a retinal tear or detachment. A globe laceration or rupture should be suspected in patients with a recent history of trauma from a blunt or penetrating object. Prophylactic oral antibiotics can be administered after a globe injury to prevent endophthalmitis, and the eye should be covered with a metal shield until evaluation by an ophthalmologist. Chemical injuries require immediate irrigation of the eye to neutralize the pH of the ocular surface.
Colby K: Chemical injuries of the cornea. FocalPoint vol.28 number 1, American Academy of Ophthalmology 2010.
Hayreh SS, Weingeist TA.
Experimental occlusion of the central artery of the retina. IV: Retinal tolerance time to acute ischaemia.
Br J Ophthalmol. 1980 Nov;64(11):818-25. doi: 10.1136/bjo.64.11.818.
Abstract/Text
Ophthalmoscopic, fluorescein angiographic, electrophysiological, and morphological studies on 63 eyes of rhesus monkeys with acute transient experimental occlusion of the central artery of the retina (OCAR) showed that the retina suffered irreparable damage after ischaemia of 105 minutes but recovered well after ischaemia of 97-98 minutes. The tolerance time of the brain to acute transient ischaemia is many times shorter than that of the retina. The metabolism of ischaemic neurones (in the retina and brain) is discussed with a view to explaining this difference, and also the various factors possibly responsible for the retina's longer tolerance to ischaemia, as compared to the brain.
Hayreh SS, Kolder HE, Weingeist TA.
Central retinal artery occlusion and retinal tolerance time.
Ophthalmology. 1980 Jan;87(1):75-8. doi: 10.1016/s0161-6420(80)35283-4.
Abstract/Text
Transient central retinal artery occlusion (CRAO) was produced in 63 eyes of rhesus monkeys by lateral orbitotomy and temporary clamping of the central retinal artery (CRA) for between 15 and 270 minutes. Thirty-three eyes were examined at regular intervals for 12 to 22 weeks. Color fundus photography, fluorescein fundus angiography, electroretinography (ERG) and visual evoked response (VER) were performed before and during clamping of the CRA as well as periodically after unclamping. All the eyes were examined by light and/or electron microscopy. This study revealed that the retina suffered irreparable damage after ischemia of 105 minutes, but recovered well after ischemia of 97 minutes. As a general rule, the monkey retina can tolerate up to 100 minutes of ischemia but not more.
Rumelt S, Dorenboim Y, Rehany U.
Aggressive systematic treatment for central retinal artery occlusion.
Am J Ophthalmol. 1999 Dec;128(6):733-8. doi: 10.1016/s0002-9394(99)00359-1.
Abstract/Text
PURPOSE: To report the efficacy of an aggressive systematic regimen for the treatment of acute nonarteritic central retinal artery occlusion (CRAO).
METHODS: Eleven patients who had unilateral CRAO with symptoms of fewer than 48 hours' duration were treated with an aggressive stepwise systematic regimen until retinal circulation improved or until all the treatment steps were performed. Five patients with unilateral CRAO and symptoms of fewer than 48 hours' duration were treated in the same institution in an arbitrary nonsystematic manner. The therapeutic steps of the aggressive treatment included ocular massage, sublingual isosorbide dinitrate, intravenous acetazolamide, intravenous mannitol or oral glycerol, anterior chamber paracentesis, intravenous methylprednisolone followed by streptokinase, and retrobulbar tolazoline. After each step, retinal flow was evaluated by three-mirror contact lens. The nonsystematic treatment was arbitrary and included one or several of the above. Visual acuity and complete eye examination data were recorded before and after treatment.
RESULTS: Visual acuity and retinal arterial supply were improved in eight (73%) of the 11 patients treated in the stepwise systematic manner. All eight patients in whom visual acuity improved had symptoms for fewer than 12 hours, and the presumed cause was either platelet-derived or cholesterol embolus from atheroma or the patients had glaucoma. Patients in whom visual acuity did not improve had CRAO that was attributed to calcified emboli or primary antiphospholipid antibody syndrome and had symptoms more than 12 hours before treatment. Visual acuity did not improve in all five patients with the nonsystematic treatment regardless of the presumed cause or duration of the occlusion. The success of the treatment in the systematic treatment group was statistically significantly better compared with the outcome of the nonsystematic treated group (Fischer exact test, P = .01).
CONCLUSIONS: In the treatment of CRAO, an aggressive systematic regimen including medical and mechanical means may reestablish retinal circulation and improve visual outcome. The cause of arterial occlusion, the nature of occlusive emboli, and the duration of retinal ischemia may determine the visual outcome, but a larger series is warranted to verify the effectiveness of the treatment and the prognostic factors.
Esmaili DD, Loewenstein JI. Retinal arterial occlusion. FocalPoint vol.28 number 3, American Academy of ophthalmology. 2010.
村上裕介. 網膜硝子体 網膜中心動脈閉塞症に対する適切な治療法を教えてください. 最新臨床研究から探る眼科臨床のギモンQ&A. 臨床眼科. 2022;76:225-228.
Peggy Denny. Promising Results From Emergency Protocols. EyeNet Magazine. July 2024.
Levin LA, Beck RW, Joseph MP, Seiff S, Kraker R.
The treatment of traumatic optic neuropathy: the International Optic Nerve Trauma Study.
Ophthalmology. 1999 Jul;106(7):1268-77. doi: 10.1016/s0161-6420(99)00707-1.
Abstract/Text
OBJECTIVE: To compare the visual outcome of traumatic optic neuropathy treated with corticosteroids, treated with optic canal decompression surgery, or observed without treatment.
DESIGN: Comparative nonrandomized interventional study with concurrent treatment groups.
PARTICIPANTS: A total of 133 patients with traumatic optic neuropathy (127 unilateral and 6 bilateral) who had an initial visual assessment within 3 days of injury. At least 1 month of follow-up was required for inclusion in the primary analysis.
INTERVENTIONS: On the basis of treatment received within 7 days of injury, patients with unilateral injuries were categorized as being in one of three treatment groups: untreated (n = 9), corticosteroid (n = 85), or optic canal decompression surgery (n = 33).
MAIN OUTCOME MEASURE: Visual acuity.
RESULTS: Visual acuity increased by > or = 3 lines in 32% of the surgery group, 57% of the untreated group, and 52% of the steroid group (P = 0.22). The surgery group had more patients whose initial vision was no light perception. After adjustment for the baseline visual acuity, there were no significant differences between any of the treatment groups. There was no indication that the dosage or timing of corticosteroid treatment or the timing of surgery was associated with an increased probability of visual improvement.
CONCLUSIONS: No clear benefit was found for either corticosteroid therapy or optic canal decompression surgery. The number of patients studied was sufficient to rule out major effects in the treatment groups, although clinically relevant effects in specific subgroups could have been missed. These results and the existing literature provide sufficient evidence to conclude that neither corticosteroids nor optic canal surgery should be considered the standard of care for patients with traumatic optic neuropathy. It is therefore clinically reasonable to decide to treat or not treat on an individual patient basis.
Campagna JA: Traumatic Hyphema: Current Strategies. FocalPoint vol.25 number 10 American Academy of Ophthalmology 2007.
Farber MD, Fiscella R, Goldberg MF.
Aminocaproic acid versus prednisone for the treatment of traumatic hyphema. A randomized clinical trial.
Ophthalmology. 1991 Mar;98(3):279-86. doi: 10.1016/s0161-6420(91)32299-1.
Abstract/Text
One hundred twelve patients who sustained hyphema after blunt trauma were enrolled in a double-blind randomized clinical trial to determine the relative efficacies of aminocaproic acid (Amicar) and systemic prednisone for reducing the rate of secondary hemorrhage. Fifty-six patients received an oral dosage of 50 mg/kg of aminocaproic acid every 4 hours for 5 days, up to a maximum of 30 g daily, and 56 patients received an oral dosage of 40 mg of prednisone daily (adjusted for weight) in two divided doses. Placebo pills and liquids were given to each patient to mask the treatment schedules. There were no statistically significant differences between the patient populations for any demographic or clinical characteristic (e.g., visual acuity, intraocular pressure [IOP], initial hyphema size) measured in the study. Blacks comprised 53% of the study population, and the mean age of the patients was 23.5 years. Four patients in each of the treatment groups experienced a secondary hemorrhage; the rebleed rate was 7.1% in each group.
Pieramici DJ, Goldberg MF, Melia M, Fekrat S, Bradford CA, Faulkner A, Juzych M, Parker JS, McLeod SD, Rosen R, Santander SH.
A phase III, multicenter, randomized, placebo-controlled clinical trial of topical aminocaproic acid (Caprogel) in the management of traumatic hyphema.
Ophthalmology. 2003 Nov;110(11):2106-12. doi: 10.1016/S0161-6420(03)00866-2.
Abstract/Text
OBJECTIVE: To determine the safety and efficacy of topical aminocaproic acid (Caprogel) in the management of traumatic hyphema.
DESIGN: Multicenter, randomized, double-masked, placebo-controlled clinical trial.
PARTICIPANTS: A total of 51 patients participated in this trial (power = 36%, 2-tailed test).
INTERVENTION: Patients presenting with traumatic hyphema were randomly assigned to 5-day treatment with topical aminocaproic acid or a placebo gel. Patients were monitored daily with ocular examination and vital sign testing for the 5 days of treatment and at 24 and 48 hours after treatment. General physical examination and laboratory testing were performed at baseline and day 5.
MAIN OUTCOME MEASURES: The main efficacy variable was the rate of rebleeding. Secondary efficacy variables included time to hyphema clearance, intraocular pressure, time to secondary hemorrhage, and visual acuity. Safety variables included adverse events, vital signs, and laboratory measurements.
RESULTS: Rebleeding occurred in 30% of the placebo group (8 of 27; 95% confidence interval [CI] = 14-50%), versus 8% of the treatment group (2 of 24; 95% CI = 1-27%), for an estimated continuity-corrected difference in percentage of patients with bleeding of 17% (95% CI = -3-38%). Secondary efficacy variables were similar in the groups, except that there was a trend towards more visual improvement in the topical aminocaproic acid group (54%) than in the placebo group (30%) at the last measurement (P = 0.08). Adverse events were similar.
CONCLUSIONS: This study provides evidence that topical aminocaproic acid is safe and demonstrates trends towards reducing the rebleeding rate in the management of traumatic hyphema. However, because the study was terminated before complete enrollment, more definitive recommendations will require a larger trial.
CRASH-3 trial collaborators.
Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial.
Lancet. 2019 Nov 9;394(10210):1713-1723. doi: 10.1016/S0140-6736(19)32233-0. Epub 2019 Oct 14.
Abstract/Text
BACKGROUND: Tranexamic acid reduces surgical bleeding and decreases mortality in patients with traumatic extracranial bleeding. Intracranial bleeding is common after traumatic brain injury (TBI) and can cause brain herniation and death. We aimed to assess the effects of tranexamic acid in patients with TBI.
METHODS: This randomised, placebo-controlled trial was done in 175 hospitals in 29 countries. Adults with TBI who were within 3 h of injury, had a Glasgow Coma Scale (GCS) score of 12 or lower or any intracranial bleeding on CT scan, and no major extracranial bleeding were eligible. The time window for eligibility was originally 8 h but in 2016 the protocol was changed to limit recruitment to patients within 3 h of injury. This change was made blind to the trial data, in response to external evidence suggesting that delayed treatment is unlikely to be effective. We randomly assigned (1:1) patients to receive tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Patients were assigned by selecting a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was head injury-related death in hospital within 28 days of injury in patients treated within 3 h of injury. We prespecified a sensitivity analysis that excluded patients with a GCS score of 3 and those with bilateral unreactive pupils at baseline. All analyses were done by intention to treat. This trial was registered with ISRCTN (ISRCTN15088122), ClinicalTrials.gov (NCT01402882), EudraCT (2011-003669-14), and the Pan African Clinical Trial Registry (PACTR20121000441277).
RESULTS: Between July 20, 2012, and Jan 31, 2019, we randomly allocated 12 737 patients with TBI to receive tranexamic acid (6406 [50·3%] or placebo [6331 [49·7%], of whom 9202 (72·2%) patients were treated within 3 h of injury. Among patients treated within 3 h of injury, the risk of head injury-related death was 18·5% in the tranexamic acid group versus 19·8% in the placebo group (855 vs 892 events; risk ratio [RR] 0·94 [95% CI 0·86-1·02]). In the prespecified sensitivity analysis that excluded patients with a GCS score of 3 or bilateral unreactive pupils at baseline, the risk of head injury-related death was 12·5% in the tranexamic acid group versus 14·0% in the placebo group (485 vs 525 events; RR 0·89 [95% CI 0·80-1·00]). The risk of head injury-related death reduced with tranexamic acid in patients with mild-to-moderate head injury (RR 0·78 [95% CI 0·64-0·95]) but not in patients with severe head injury (0·99 [95% CI 0·91-1·07]; p value for heterogeneity 0·030). Early treatment was more effective than was later treatment in patients with mild and moderate head injury (p=0·005) but time to treatment had no obvious effect in patients with severe head injury (p=0·73). The risk of vascular occlusive events was similar in the tranexamic acid and placebo groups (RR 0·98 (0·74-1·28). The risk of seizures was also similar between groups (1·09 [95% CI 0·90-1·33]).
INTERPRETATION: Our results show that tranexamic acid is safe in patients with TBI and that treatment within 3 h of injury reduces head injury-related death. Patients should be treated as soon as possible after injury.
FUNDING: National Institute for Health Research Health Technology Assessment, JP Moulton Charitable Trust, Department of Health and Social Care, Department for International Development, Global Challenges Research Fund, Medical Research Council, and Wellcome Trust (Joint Global Health Trials scheme).
TRANSLATIONS: For the Arabic, Chinese, French, Hindi, Japanese, Spanish and Urdu translations of the abstract see Supplementary Material.
Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.
古田 実：【眼科救急疾患2020】眼外傷 眼窩吹き抜け骨折(眼窩壁骨折を含めて)． 眼科 62:1037-1042, 2020.
恩田 秀俊：眼外傷に対する手術と治療 眼窩． 眼科手術 33:372-377, 2020.
Shiuey EJ, Kolomeyer AM, Kolomeyer NN.
Assessment of Firework-Related Ocular Injury in the US.
JAMA Ophthalmol. 2020 Jun 1;138(6):618-623. doi: 10.1001/jamaophthalmol.2020.0832.
Abstract/Text
IMPORTANCE: Fireworks are popularly used for recreation but can lead to potentially blinding injuries. Studies quantifying the trend and national prevalence of firework-related ocular injuries are limited.
OBJECTIVE: To characterize firework-related ocular injuries treated in emergency departments (EDs) in the US from 1999 to 2017.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used the National Electronic Injury Surveillance System, a stratified probability sample of more than 100 hospital-affiliated US EDs representing more than 5300 nationwide hospitals. Deidentified individuals in the National Electronic Injury Surveillance System database who experienced eye injury due to fireworks between January 1, 1999, and December 31, 2017, were included. Analysis began February 2019.
MAIN OUTCOMES AND MEASURES: Annual prevalence of firework-related ocular injury, firework type stratified by demographic information, diagnosis, event location/date, and patient disposition.
RESULTS: A total of 34 548 firework-related ocular injuries were seen in US EDs during the 19-year study period (estimated from 1007 individuals in the National Electronic Injury Surveillance System database). Overall, 664 individuals (65.9%) were 18 years or younger, 724 (71.9%) were male, and 512 (50.8%) were white. Twenty-eight patients (2.8%) sustained a ruptured globe, while 633 (62.9%) sustained ocular burn injuries, 118 (11.7%) had ocular foreign bodies, 97 (9.6%) had conjunctival irritation, and 46 (4.6%) experienced other severe eye trauma. Of 1007 individuals, 911 (90.5%) were treated and released without transfer, while 87 (8.7%) required admission or transfer to another hospital. The most common specified firework types included firecrackers (193 [19.2%]), bottle rockets (177 [17.6%]), sparklers (88 [8.7%]), roman candles (66 [6.6%]), and novelty devices (65 [6.5%]) (eg, poppers and snappers). Bottle rockets disproportionately caused the most severe injuries, including ruptured globe (odds ratio, 5.82; 95% CI, 2.72-12.46; P < .001). A total of 411 cases (74.9%) occurred at home. Injuries most commonly occurred near the time of Independence Day and New Year's Day: 707 patients (70.2%) presented in July, 74 (7.4%) in June, 101 (10.0%) in January, and 47 (4.7%) in December.
CONCLUSIONS AND RELEVANCE: These findings support that firework-related ocular injuries range from mild irritation to ruptured globe, and most occur frequently in those who are young, male, and white. Focused preventive methods and regulations may be imperative in decreasing fireworks-related ocular morbidity, namely from bottle rockets and especially near national holidays.
土至田 宏：【眼科救急疾患2020】角結膜 コンタクトレンズ関連疾患 眼科 62:1103-1110, 2020.
コンタクトレンズ診療ガイドライン（第2版） 日本眼科学会誌 118: 575-578, 2014.
稲田 紀子：【眼科救急疾患2020】角結膜 感染性疾患． 眼科 62:1095-1102, 2020.
日本眼科学会. 感染性角膜炎診療ガイドライン（第3版）. 日本眼科学会誌. 2023;127:859-895.
Uno T, Fukuda M, Ohashi Y, Shimomura Y, Ishibashi Y, Inaba M, Inoue Y, Ueda K, Eguchi H, Shiraishi A, Sotozono C, Tagawa Y, Chikama T.
[Survey of severe contact lens-associated microbial keratitis in Japan].
Nippon Ganka Gakkai Zasshi. 2011 Feb;115(2):107-15.
Abstract/Text
PURPOSE: To understand the current state of severe contact lens (CL)-associated microbial keratitis in Japan.
METHOD: The survey was conducted by the Japan Contact Lens Society and the Japanese Association for Ocular Infection in 224 facilities from April 2007 to March 2009. Patients who were diagnosed with CL-associated microbial keratitis and hospitalized for treatment were enrolled. Clinical characteristics of the keratitis, microbiologic findings and the status of CL hygiene were studied.
RESULTS: A total of 350 patients were investigated, with an average age of 28.0 (9-90) years. Acanthamoeba was identified in 85 (24.3%) corneal specimens and Pseudomonus aeruginosa in 70 (20.0%) cases. One hundred ninety six (56.0%) patients were frequent replacement soft CL users. Extended wearing of daily-use CLs was found in 77 (22.0%) patients. Only 67 cases maintained good CL hygiene by daily rubbing-washing and the poor CL care situation was reviewed.
CONCLUSION: The most frequently detected pathogenic microorganism was Acanthamoeba, followed by Pseudomonus aeruginosa. Our survey showed the importance of keeping good CL hygiene by proper lens care, and improvement of CL-related social regulations is urgently needed.
Miyake M, Nakao SY, Morino K, Yasukura S, Mori Y, Ishihara K, Muraoka Y, Miyata M, Tamura H, Sakamoto T, Tsujikawa A; Japan-Retinal Detachment Registry Group.
Effect of Duration of Macular Detachment on Visual Prognosis after Surgery for Macula-Off Retinal Detachment: Japan-Retinal Detachment Registry.
Ophthalmol Retina. 2023 May;7(5):375-382. doi: 10.1016/j.oret.2023.01.014. Epub 2023 Jan 25.
Abstract/Text
PURPOSE: To evaluate the association between the duration of macular detachment (DMD) and visual prognosis in patients with macula-off rhegmatogenous retinal detachment (RD).
DESIGN: Prospective observational cohort study.
PARTICIPANTS: This study analyzed 719 eyes with macula-off rhegmatogenous RD registered with the Japan-Retinal Detachment Registry created by the Japan Retina and Vitreous Society.
METHODS: We included patients with macular detachment without a history of prior surgery, except cataract surgery and vitrectomy. Reoperation cases, hereditary RD, and macular hole RD were excluded. We compared the visual prognosis between patients with DMD of N days or less and those with DMD of N + 1 days or more (N = 2-5). For these 4 comparisons, the inverse probability of treatment weighting (IPTW) methodology was employed, to balance 20 baseline characteristics between the shorter and longer DMD groups. The baseline characteristics included age, sex, axial length, baseline visual acuity, operative procedures, and detailed characteristics of RD. P-values < 0.01 were considered statistically significant.
MAIN OUTCOME MEASURES: The best-corrected visual acuity (BCVA) 6 months after surgery.
RESULTS: The final analysis included 719 eyes. For all comparisons, the patients' backgrounds were well balanced after IPTW with standardized differences < 0.10. The IPTW regression analysis revealed that the BCVA after 6 months was significantly better after surgeries for DMD of ≤ 2 days than that for DMD of ≥ 3 days. Similarly, the 6-month BCVA for surgeries for DMD of ≤ 3 days was significantly better than that for surgeries for DMD of ≥ 4 days (differences in logarithm of the minimum angle of resolution: -0.113, P = 9.1 × 10-7; -0.076, P = 1.6 × 10-3, respectively). On the other hand, there were no statistically significant differences for the other comparisons.
CONCLUSIONS: Earlier surgical treatment within 3 days from the onset of macular detachment should be considered, after accounting for social circumstances, such as weekends.
FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.
Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.
