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眼科救急疾患

著者: 山川良治 社会医療法人共愛会 戸畑共立病院眼科

監修: 沖波聡 倉敷中央病院眼科

著者校正/監修レビュー済:2021/07/21
患者向け説明資料

概要・推奨   

  1. コンタクトレンズによる眼障害で、角膜潰瘍を起こす原因として緑膿菌とアカントアメーバが多い。アカントアメーバ角膜炎はいったん進行すると難治であり、初期の状態で適切に診断し、早期に治療を開始することが良好な視力予後のために重要である(推奨度1)
  1. 感染性角膜疾患では必ず塗沫鏡検と培養を行う(推奨度1)
  1. 網膜中心動脈閉塞症に対する治療は、100分以内に行うべきである(推奨度1)
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
山川良治 : 特に申告事項無し[2021年]
監修:沖波聡 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 眼科救急疾患での総説の文献を追加した。
  1. アミノカプロン酸は止血薬として現在手に入らないため、代わりにトラネキサム酸を入れた。
  1. 花火による外傷の文献追加、ロケット花火では眼球破裂にいたることもある旨記載した。
  1. 外傷で異物の場合、金属片の疑いのある時はMRIは使用しないことを記載した。
  1. 感染性角膜炎では塗沫鏡検と培養が重要であることを記載した。
  1. 眼窩吹き抜け骨折について、文献を追加し手術適応について述べた。
  1. 追加記載が必要な部分や、削除してもよい部分に対応した。

病態・疫学・診察

眼科緊急疾患のまとめ  
  1. 眼科の疾患は、通常緊急対応を必要としないことが多いが、一部に、対応の遅れが恒久的な視機能障害を残す緊急疾患が存在し注意が必要である。わが国の救急外来では、休日や夜間に眼科医が常駐する病院は少なく、緊急の対応を要するかどうかの判断が必要となることが多い。
問診・診察のポイント  
問診:
  1. 視力低下の場合、突然であるか、徐々に低下をしているのか、前駆症状の有無、他の症状はないかを問診する。

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文献 

著者: S S Hayreh, H E Kolder, T A Weingeist
雑誌名: Ophthalmology. 1980 Jan;87(1):75-8.
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.

PMID 6769079  Ophthalmology. 1980 Jan;87(1):75-8.
著者: S S Hayreh, T A Weingeist
雑誌名: Br J Ophthalmol. 1980 Nov;64(11):818-25.
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.

PMID 7426553  Br J Ophthalmol. 1980 Nov;64(11):818-25.
著者: S Rumelt, Y Dorenboim, U Rehany
雑誌名: Am J Ophthalmol. 1999 Dec;128(6):733-8.
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.

PMID 10612510  Am J Ophthalmol. 1999 Dec;128(6):733-8.
著者: L A Levin, R W Beck, M P Joseph, S Seiff, R Kraker
雑誌名: Ophthalmology. 1999 Jul;106(7):1268-77.
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.

PMID 10406604  Ophthalmology. 1999 Jul;106(7):1268-77.
著者: M D Farber, R Fiscella, M F Goldberg
雑誌名: Ophthalmology. 1991 Mar;98(3):279-86.
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.

PMID 2023746  Ophthalmology. 1991 Mar;98(3):279-86.
著者: Dante J Pieramici, Morton F Goldberg, Michele Melia, Sharon Fekrat, Cynthia A Bradford, Alan Faulkner, Mark Juzych, John S Parker, Stephen D McLeod, Richard Rosen, Samuel H Santander
雑誌名: 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.

PMID 14597516  Ophthalmology. 2003 Nov;110(11):2106-12. doi: 10.1016/S・・・
著者: CRASH-3 trial collaborators
雑誌名: 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.
PMID 31623894  Lancet. 2019 Nov 9;394(10210):1713-1723. doi: 10.1016/S・・・
著者: Eric J Shiuey, Anton M Kolomeyer, Natasha Nayak Kolomeyer
雑誌名: 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.

PMID 32271352  JAMA Ophthalmol. 2020 Jun 1;138(6):618-623. doi: 10.100・・・
著者: Toshihiko Uno, Masahiko Fukuda, Yuichi Ohashi, Yoshikazu Shimomura, Yasuhisa Ishibashi, Masamaru Inaba, Yoshitsugu Inoue, Kiichi Ueda, Hiroshi Eguchi, Atsushi Shiraishi, Chie Sotozono, Yoshitsugu Tagawa, Taiichirou Chikama
雑誌名: Nihon 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.

PMID 21400916  Nihon Ganka Gakkai Zasshi. 2011 Feb;115(2):107-15.

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