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急性閉塞隅角緑内障

著者: 栗本康夫 神戸市立神戸アイセンター病院

監修: 沖波聡 倉敷中央病院眼科

著者校正/監修レビュー済:2022/08/03
参考ガイドライン:
  1. 日本眼科学会:緑内障診療ガイドライン(第5版)
患者向け説明資料
薬価収載情報:2022年11月16日 グラアルファ 配合点眼液(リパスジル塩酸塩水和物/ブリモニジン酒石酸塩 Rhoキナーゼ阻害薬/α2作動薬配合剤-緑内障・高眼圧症治療剤-)

概要・推奨   

  1. 閉塞隅角緑内障は早期に診断して適切に治療すれば治癒し得る緑内障病型であるが、適切な診療を怠れば視機能の予後は悪く失明リスクが高いことをしっかりと踏まえて本疾患の診療にあたらねばならない(推奨度1 S)
  1. 急性閉塞隅角症治療の初期目標は眼圧の下降と閉塞した隅角の開放である。
 
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。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※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、実際の保険適応の査定において保険適応及び保険適応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応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:
栗本康夫 : 未申告[2022年]
監修:沖波聡 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 日本緑内障学会緑内障診療ガイドラインの第5版への改訂を受けて、急性原発閉塞隅角症の予防的治療の適応や第一選択治療について加筆した。

病態・疫学・診察

疾患情報  
  1. 急性原発閉塞隅角緑内障(APACG:acute primary angle closure glaucoma)は、緑内障性視神経症を来している場合にのみ「緑内障」という用語を用い、視神経症を来していない場合、あるいは未判定の場合を含めて急性原発閉塞隅角症(APAC:acute primary angle closure)という用語が用いられる。
  1. 急性原発閉塞隅角症の一般的な診断基準は以下の1)と2)を満たすものとされている[1]
1)眼痛、吐気もしくは嘔吐、光輪視を伴う霧視の前駆症状のうち2つ以上を有する。
2)眼圧上昇(>21mmHg)と、結膜充血、角膜浮腫、中等度散瞳および対光反応消失、浅前房のうち3つ以上の所見を認める。
  1. 本症では、瞳孔ブロックにより虹彩が前方に膨隆し、虹彩周辺部が線維柱帯に押しつけられて房水の流出路である前房隅角が閉塞する。
  1. わが国の緑内障全体(40歳以上で5.0%)のなかで本病型が占める割合は高くない。原発閉塞隅角緑内障の頻度は40歳以上で0.6%、緑内障性視神経症を来していない原発閉塞隅角症を含めれば1.3%[2]。このうち、急性発作である急性原発閉塞隅角症、もしくは同緑内障を起こすものはごく一部である。リスクファクターとして浅い前房、高齢者、女性、モンゴロイドなどが挙げられる[3]
  1. 閉塞隅角緑内障そのものは失明リスクの高い緑内障病型ではあるが、急性原発閉塞隅角症は発症後早期に適切に治療されれば、多くの場合、視機能の予後は良好である。
問診・診察のポイント  
  1. 自覚症状として、眼痛、霧視、虹視、頭痛、悪心、嘔吐の有無を問診する。頻度は少ないが、両眼同時発症もあり得る。脳神経系の救急疾患を疑われて受診する場合も多いので注意が必要。

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文献 

Tetsuya Yamamoto, Aiko Iwase, Makoto Araie, Yasuyuki Suzuki, Haruki Abe, Shiroaki Shirato, Yasuaki Kuwayama, Hiromu K Mishima, Hiroyuki Shimizu, Goji Tomita, Yoichi Inoue, Yoshiaki Kitazawa, Tajimi Study Group, Japan Glaucoma Society
The Tajimi Study report 2: prevalence of primary angle closure and secondary glaucoma in a Japanese population.
Ophthalmology. 2005 Oct;112(10):1661-9. doi: 10.1016/j.ophtha.2005.05.012.
Abstract/Text PURPOSE: To determine the prevalence of primary angle-closure glaucoma (PACG), secondary glaucoma (SG), and all glaucoma in a Japanese population as a part of the Tajimi Study.
DESIGN: Population-based epidemiological survey.
PARTICIPANTS: A random sample of residents 40 years or older from Tajimi, Japan.
INTERVENTION: Each subject underwent a screening program comprising an interview and an ophthalmic examination, including Goldmann applanation tonometry, slit-lamp examination, a van Herick test, fundus photography, and a screening visual field (VF) test using frequency-doubling technology. If glaucoma was suspected, the subject was referred for a definitive examination that included slit-lamp examination, gonioscopy, intraocular pressure measurement, a VF test, and optic disc and fundus examination. A diagnosis of PACG or SG was made based on slit-lamp examination, gonioscopy, optic disc appearance, and perimetric results.
MAIN OUTCOME MEASURES: Prevalences of PACG, SG, and all cases of glaucoma.
RESULTS: Of 3870 eligible people, 3021 (78.1%) participated in the study. Estimated prevalences of PACG and SG in those over 40 years were 0.6% (95% confidence interval [CI], 0.4%-0.9%) and 0.5% (95% CI, 0.2%-0.7%), respectively. Prevalences of all glaucoma and glaucoma/suspected glaucoma were estimated to be 5.0% (95% CI, 4.2%-5.8%) and 7.5% (95% CI, 6.5%-8.4%), respectively.
CONCLUSIONS: Prevalences were 0.6%, 0.5%, and 5.0%, respectively, for PACG, SG, and all glaucoma in subjects over 40 years from Tajimi, Japan.

PMID 16111758
Mingguang He, Yuzhen Jiang, Shengsong Huang, Dolly S Chang, Beatriz Munoz, Tin Aung, Paul J Foster, David S Friedman
Laser peripheral iridotomy for the prevention of angle closure: a single-centre, randomised controlled trial.
Lancet. 2019 Apr 20;393(10181):1609-1618. doi: 10.1016/S0140-6736(18)32607-2. Epub 2019 Mar 14.
Abstract/Text BACKGROUND: Primary angle-closure glaucoma affects 20 million people worldwide. People classified as primary angle closure suspects have a higher but poorly quantified risk of developing glaucoma. We aimed to assess efficacy and safety of laser peripheral iridotomy prophylaxis against primary angle-closure glaucoma in Chinese people classified as primary angle closure suspects.
METHODS: In this randomised controlled trial, bilateral primary angle closure suspects aged 50-70 years were enrolled at the Zhongshan Ophthalmic Center, a tertiary specialised hospital in Guangzhou, China. Eligible patients received laser peripheral iridotomy in one randomly selected eye, with the other remaining untreated. The primary outcome was incident primary angle closure disease as a composite endpoint of elevation of intraocular pressure, peripheral anterior synechiae, or acute angle-closure during 72 months of follow-up in an intention-to-treat analysis between treated eyes and contralateral controls. This trial is registered with the ISRCTN registry, number ISRCTN45213099.
FINDINGS: Of 11 991 screened individuals, 889 individuals were randomly assigned from June 19, 2008 (889 treated and 889 untreated eyes). Incidence of the primary outcome was 4·19 per 1000 eye-years in treated eyes compared with 7·97 per 1000 eye-years in untreated eyes (hazard ratio 0·53; 95% CI 0·30-0·92; p=0·024). A primary outcome event occurred in 19 treated eyes and 36 untreated eyes with a statistically significant difference using pair-wise analysis (p=0·0041). No serious adverse events were observed during follow-up.
INTERPRETATION: Incidence of angle-closure disease was very low among individuals classified as primary angle closure suspects identified through community-based screening. Laser peripheral iridotomy had a modest, albeit significant, prophylactic effect. In view of the low incidence rate of outcomes that have no immediate threat to vision, the benefit of prophylactic laser peripheral iridotomy is limited; therefore, widespread prophylactic laser peripheral iridotomy for primary angle-closure suspects is not recommended.
FUNDING: Fight for Sight, the Sun Yat-Sen University 5010 Project Fund, Moorfields Eye Charity, and the National Natural Science Foundation of China.

Copyright © 2019 Elsevier Ltd. All rights reserved.
PMID 30878226
Mani Baskaran, Rajesh S Kumar, David S Friedman, Qing-Shu Lu, Hon-Tym Wong, Paul T K Chew, Raghavan Lavanya, Arun Narayanaswamy, Shamira A Perera, Paul J Foster, Tin Aung
The Singapore Asymptomatic Narrow Angles Laser Iridotomy Study: Five-Year Results of a Randomized Controlled Trial.
Ophthalmology. 2022 Feb;129(2):147-158. doi: 10.1016/j.ophtha.2021.08.017. Epub 2021 Aug 26.
Abstract/Text PURPOSE: To examine the efficacy of laser peripheral iridotomy (LPI) in patients who received a diagnosis of primary angle-closure suspect (PACS).
DESIGN: Prospective, randomized controlled trial.
PARTICIPANTS: This multicenter, randomized controlled trial (ClinicalTrials.gov identifier, NCT00347178) enrolled 480 patients older than 50 years from glaucoma clinics in Singapore with bilateral asymptomatic PACS (defined as having ≥2 quadrants of appositional angle closure on gonioscopy).
METHODS: Each participant underwent prophylactic LPI in 1 randomly selected eye, whereas the fellow eye served as a control. Patients were followed up yearly for 5 years.
MAIN OUTCOME MEASURES: The primary outcome measure was development of primary angle closure (PAC; defined as presence of peripheral anterior synechiae, intraocular pressure [IOP] of >21 mmHg, or both or acute angle closure [AAC]) or primary angle-closure glaucoma (PACG) over 5 years.
RESULTS: Of the 480 randomized participants, most were Chinese (92.7%) and were women (75.8%) with mean age of 62.8 ± 6.9 years. Eyes treated with LPI reached the end point less frequently after 5 years (n = 24 [5.0%]; incidence rate [IR], 11.65 per 1000 eye-years) compared with control eyes (n = 45 [9.4%]; IR, 21.84 per 1000 eye-years; P = 0.001). The adjusted hazard ratio (HR) for progression to PAC was 0.55 (95% confidence interval [CI], 0.37-0.83; P = 0.004) in LPI-treated eyes compared with control eyes. Older participants (per year; HR, 1.06; 95% CI, 1.03-1.10; P < 0.001) and eyes with higher baseline IOP (per millimeter of mercury; HR, 1.35; 95% CI, 1.22-1.50; P < 0.0001) were more likely to reach an end point. The number needed to treat to prevent an end point was 22 (95% CI, 12.8-57.5).
CONCLUSIONS: In patients with bilateral asymptomatic PACS, eyes that underwent prophylactic LPI reached significantly fewer end points compared with control eyes over 5 years. However, the overall incidence of PAC or PACG was low.

Copyright © 2021 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.
PMID 34453952
R F Lowe
ACUTE ANGLE-CLOSURE GLAUCOMA: THE SECOND EYE: AN ANALYSIS OF 200 CASES.
Br J Ophthalmol. 1962 Nov;46(11):641-50. doi: 10.1136/bjo.46.11.641.
Abstract/Text
PMID 18170827
Satoru Yoshimizu, Fumitaka Hirose, Seiji Takagi, Masashi Fujihara, Yasuo Kurimoto
Comparison of pretreatment measurements of anterior segment parameters in eyes with acute and chronic primary angle closure.
Jpn J Ophthalmol. 2019 Mar;63(2):151-157. doi: 10.1007/s10384-019-00651-0. Epub 2019 Jan 20.
Abstract/Text PURPOSE: To compare pretreatment anterior segment parameters between eyes with acute primary angle closure (APAC) and chronic primary angle closure (CPAC), and to identify the characteristics of eyes with APAC.
STUDY DESIGN: Retrospective.
METHODS: We measured pretreatment anterior chamber depth (ACD), iris convexity (IC), and pupil diameter in eyes with APAC and CPAC using anterior segment optical coherence tomography. The risk of APAC associated with anterior segment parameters was investigated using multiple logistic regression. Eyes with APAC were discriminated from eyes with CPAC using the receiver-operating characteristic (ROC) curve and area under the curve (AUC). The best cutoff for these variables was determined.
RESULTS: Thirty-four eyes with APAC and 60 eyes with CPAC were included. The mean intraocular pressure was 52.3 ± 12.6 mmHg in APAC and 15.5 ± 3.5 mmHg in CPAC (P < .001). Eyes with APAC had a shallower ACD (1.407 ± 0.301 mm vs. 1.960 ± 0.205 mm, P < .001) and less IC (0.233 ± 0.087 mm vs. 0.294 ± 0.068 mm, P < .001) than eyes with CPAC. In multivariate analysis, significant variables associated with APAC were ACD (P < .001) and IC (P = .001). The AUC for ACD was 0.931 and for IC, 0.742. The best cutoff for ACD was 1.699 mm (sensitivity 0.824, specificity 0.917) and for IC, 0.282 mm (sensitivity 0.853, specificity 0.533).
CONCLUSIONS: Eyes with APAC had a shallower ACD and less IC. Eyes with an ACD < 1.7 mm may be at risk for APAC.

PMID 30663014
A Shapiro, H Zauberman
Diurnal changes of the intraocular pressure of patients with angle-closure glaucoma.
Br J Ophthalmol. 1979 Apr;63(4):225-7.
Abstract/Text The diurnal curves of 21 patients (40 eyes) with angle-closure glaucoma and of 21 normotensive subjects (42 eyes) were studied. The patients with angle-closure glaucoma had a V-shaped diurnal curve that was completely different from the diurnal curve of the normotensive subjects. Most of the eyes of the patients with angle-closure glaucoma had a diurnal change of the intraocular pressure of 8 mmHg or more, while in the normotensive subjects only 1 eye had a diurnal change as large as 8 mmHg.

PMID 571286
Serge Resnikoff, Donatella Pascolini, Daniel Etya'ale, Ivo Kocur, Ramachandra Pararajasegaram, Gopal P Pokharel, Silvio P Mariotti
Global data on visual impairment in the year 2002.
Bull World Health Organ. 2004 Nov;82(11):844-51. doi: /S0042-96862004001100009. Epub 2004 Dec 14.
Abstract/Text This paper presents estimates of the prevalence of visual impairment and its causes in 2002, based on the best available evidence derived from recent studies. Estimates were determined from data on low vision and blindness as defined in the International statistical classification of diseases, injuries and causes of death, 10th revision. The number of people with visual impairment worldwide in 2002 was in excess of 161 million, of whom about 37 million were blind. The burden of visual impairment is not distributed uniformly throughout the world: the least developed regions carry the largest share. Visual impairment is also unequally distributed across age groups, being largely confined to adults 50 years of age and older. A distribution imbalance is also found with regard to gender throughout the world: females have a significantly higher risk of having visual impairment than males. Notwithstanding the progress in surgical intervention that has been made in many countries over the last few decades, cataract remains the leading cause of visual impairment in all regions of the world, except in the most developed countries. Other major causes of visual impairment are, in order of importance, glaucoma, age-related macular degeneration, diabetic retinopathy and trachoma.

PMID 15640920
H A Quigley, A T Broman
The number of people with glaucoma worldwide in 2010 and 2020.
Br J Ophthalmol. 2006 Mar;90(3):262-7. doi: 10.1136/bjo.2005.081224.
Abstract/Text AIM: To estimate the number of people with open angle (OAG) and angle closure glaucoma (ACG) in 2010 and 2020.
METHODS: A review of published data with use of prevalence models. Data from population based studies of age specific prevalence of OAG and ACG that satisfied standard definitions were used to construct prevalence models for OAG and ACG by age, sex, and ethnicity, weighting data proportional to sample size of each study. Models were combined with UN world population projections for 2010 and 2020 to derive the estimated number with glaucoma.
RESULTS: There will be 60.5 million people with OAG and ACG in 2010, increasing to 79.6 million by 2020, and of these, 74% will have OAG. Women will comprise 55% of OAG, 70% of ACG, and 59% of all glaucoma in 2010. Asians will represent 47% of those with glaucoma and 87% of those with ACG. Bilateral blindness will be present in 4.5 million people with OAG and 3.9 million people with ACG in 2010, rising to 5.9 and 5.3 million people in 2020, respectively.
CONCLUSIONS: Glaucoma is the second leading cause of blindness worldwide, disproportionately affecting women and Asians.

PMID 16488940
Dennis S C Lam, Jimmy S M Lai, Clement C Y Tham, John K H Chua, Agnes S Y Poon
Argon laser peripheral iridoplasty versus conventional systemic medical therapy in treatment of acute primary angle-closure glaucoma : a prospective, randomized, controlled trial.
Ophthalmology. 2002 Sep;109(9):1591-6.
Abstract/Text OBJECTIVE: To study whether argon laser peripheral iridoplasty (ALPI) is as effective and safe as conventional systemic medications in treatment of acute primary angle-closure glaucoma (PACG) when immediate laser peripheral iridotomy is neither possible nor safe.
DESIGN: Prospective, randomized, controlled trial.
PARTICIPANTS: Seventy-three eyes of 64 consecutive patients with their first presentation of acute PACG, with intraocular pressure (IOP) levels of 40 mmHg or more, were recruited into the study.
INTERVENTION: The acute PACG eye of each consenting patient received topical pilocarpine (4%) and topical timolol (0.5%). The patients were then randomized into one of two treatment groups. The ALPI group received immediate ALPI under topical anesthesia. The medical treatment group was given 500 mg of intravenous acetazolamide, followed by oral acetazolamide 250 mg four times daily, and an oral potassium supplement until IOP levels normalized. Intravenous mannitol also was administered to the latter group if the presenting IOP was higher than 60 mmHg. The acute PACG eye of both groups continued to receive topical pilocarpine (1%) until peripheral iridotomy could be performed.
MAIN OUTCOME MEASURES: Intraocular pressure profile, corneal clarity, symptoms, visual acuity, angle status by indentation gonioscopy, and complications of treatment.
RESULTS: Thirty-three acute PACG eyes of 32 patients were randomized to receive immediate ALPI, whereas 40 acute PACG eyes of 32 patients had conventional systemic medical therapy. Both treatment groups were matched for age, duration of attack, and IOP at presentation. The ALPI-treated group had lower IOP levels than the medically treated group at 15 minutes, 30 minutes, and 1 hour after the start of treatment. The differences were statistically significant. The difference in IOP levels became statistically insignificant from 2 hours onward. The duration of attack did not affect the efficacy of ALPI in reducing IOP in acute PACG. No serious laser complications occurred, at least in the early postlaser period.
CONCLUSIONS: Argon laser peripheral iridoplasty significantly is more effective than conventional systemic medications in reducing IOP levels in acute PACG in eyes not suitable for immediate laser peripheral iridotomy within the first 2 hours from the initiation of treatment. Argon laser peripheral iridoplasty is a safe and more effective alternative to conventional systemic medications in the management of acute PACG not amenable to immediate laser peripheral iridotomy.

PMID 12208703
Dennis S C Lam, John K H Chua, Clement C Y Tham, Jimmy S M Lai
Efficacy and safety of immediate anterior chamber paracentesis in the treatment of acute primary angle-closure glaucoma: a pilot study.
Ophthalmology. 2002 Jan;109(1):64-70.
Abstract/Text OBJECTIVE: To study the safety and effectiveness of immediate anterior chamber paracentesis, combined with antiglaucomatous medications, in the intraocular pressure control and relief of symptoms of acute primary angle-closure glaucoma (PACG).
DESIGN: Prospective noncomparative case series.
PARTICIPANTS: Eight consecutive patients with their first attack of acute PACG, with intraocular pressure > or =50 mmHg, were recruited into the study.
INTERVENTION: On presentation, each patient received topical pilocarpine (4%) and timolol (0.5%), immediate anterior chamber paracentesis, and systemic acetazolamide and mannitol as primary treatment. The intraocular pressures at 15 and 30 minutes, and then at 1, 2, 3, 12, and 24 hours, were documented by applanation tonometry.
MAIN OUTCOME MEASURES: Symptoms, visual acuity, intraocular pressure, corneal edema, angle status on gonioscopy, pupillary size, and reaction.
RESULTS: Ten eyes of eight patients seen with acute PACG were recruited. The mean intraocular pressure was reduced from 66.6 +/- 9.1 mmHg to 15.1 +/- 3.5 mmHg immediately after paracentesis, and then to 17.1 +/- 7.0 mmHg at 15 minutes, 21.7 +/- 10.2 mmHg at 30 minutes, 22.7 +/- 11.0 mmHg at 1 hour, and 20.1 +/- 14.6 mmHg at 2 hours after paracentesis. The mean intraocular pressure was less than 21 mmHg at 2 hours and beyond. There was instant symptomatic relief for all patients. No complications from the paracentesis were encountered.
CONCLUSIONS: From this preliminary study, immediate paracentesis seems to be safe and effective in controlling the intraocular pressure and eliminating symptoms in acute PACG.

PMID 11772581
Abstract/Text PURPOSE: To report quantitative changes in the anterior chamber configuration after small-incision cataract surgery with implantation of a posterior chamber intraocular lens by means of ultrasound biomicroscopy.
METHODS: We examined the anterior chamber configuration of 20 eyes of 20 patients before and 3 months after small-incision cataract surgery (phacoemulsification and aspiration plus foldable intraocular lens implantation through a 3.0- to 4.0-mm self-sealing wound) by means of ultrasound biomicroscopy. The following variables were measured: the anterior chamber depth at the center of the cornea, the angle-opening distance 250 microns from the scleral spur (AOD250), the angle-opening distance 500 microns from the scleral spur (AOD500), and the trabecular-iris angle.
RESULTS: The anterior chamber depth at the center of the cornea, AOD250, AOD500, and trabecular-iris angle increased significantly after surgery. The preoperative anterior chamber depth at the center of the cornea and trabecular-iris angle were negatively correlated with the differences between the postoperative and preoperative values (P < .01). The preoperative values of all variables examined were negatively correlated with the ratios of the postoperative value to the preoperative value (P < .002).
CONCLUSIONS: The present results showed that small-incision cataract surgery significantly deepened the anterior chamber and widened its angle. The more shallow the preoperative anterior chamber was, the greater the postoperative change of the chamber was; and the more narrow the preoperative angle was, the greater the postoperative change of the angle was.

PMID 9402823
Dennis S C Lam, Dexter Y L Leung, Clement C Y Tham, Felix C H Li, Yolanda Y Y Kwong, Thomas Y H Chiu, Dorothy S P Fan
Randomized trial of early phacoemulsification versus peripheral iridotomy to prevent intraocular pressure rise after acute primary angle closure.
Ophthalmology. 2008 Jul;115(7):1134-40. doi: 10.1016/j.ophtha.2007.10.033. Epub 2007 Dec 27.
Abstract/Text PURPOSE: To compare the efficacy of early phacoemulsification versus laser peripheral iridotomy (LPI) in the prevention of intraocular pressure (IOP) rise in patients after acute primary angle closure (APAC).
DESIGN: Prospective randomized controlled trial.
PARTICIPANTS: Sixty-two eyes of 62 Chinese subjects, with 31 eyes in each arm.
METHODS: Subjects were randomized to receive either early phacoemulsification or LPI after aborting APAC by medications. Patients were followed up on day 1; week 1; and months 1, 3, 6, 12, and 18. Predictors for IOP rise were studied.
MAIN OUTCOME MEASURES: Prevalence of IOP rise above 21 mmHg (primary) and number of glaucoma medications, IOP, and Shaffer gonioscopy grading (secondary).
RESULTS: Prevalences of IOP rise for the LPI group were 16.1%, 32.3%, 41.9%, and 46.7% for the follow-ups at 3, 6, 12, and 18 months, respectively. There was only one eye (3.2%) in the phacoemulsification group that had IOP rise at all follow-up time points (P<0.0001). Treatment by LPI was associated with significantly increased hazard of IOP rise (hazard ratio [HR], 14.9; 95% confidence interval [CI], 1.9-114.2; P = 0.009). In addition, a maximum IOP at presentation > 55 mmHg was associated with IOP rise (HR, 4.1; 95% CI, 1.3-13.0; P = 0.017). At 18 months, the mean number of medications required to maintain IOP CONCLUSION: Early phacoemulsification appeared to be more effective in preventing IOP rise than LPI in patients after abortion of APAC. High presenting IOP of >55 mmHg is an added risk factor for subsequent IOP rise. For patients with coexisting cataract and presenting IOP of >55 mmHg, early phacoemulsification can be considered as a definitive treatment to prevent IOP rise.

PMID 18164064
Leonard P K Ang, Hisayo Higashihara, Chie Sotozono, Vijay A Shanmuganathan, Harminder Dua, Donald T H Tan, Shigeru Kinoshita
Argon laser iridotomy-induced bullous keratopathy a growing problem in Japan.
Br J Ophthalmol. 2007 Dec;91(12):1613-5. doi: 10.1136/bjo.2007.120261. Epub 2007 Jun 13.
Abstract/Text AIMS: To describe the long-term risk of bullous keratopathy following argon laser iridotomy (ALI) in Japan and to compare it with other centres in the world.
METHODS: We retrospectively reviewed the case records of all patients with ALI-induced bullous keratopathy that underwent penetrating keratoplasty at Kyoto Prefectural University of Medicine (KPUM) from January 2001 to December 2004. The results were compared with the other representative centres in Singapore and the UK.
RESULTS: Thirty-nine eyes of 33 patients were included in the study. The mean age of patients was 73.3+/-6.9 years (range, 58 to 87 years). Patients developed bullous keratopathy at a mean duration of 6.9+/-4.9 years (range, 0.2 to 16 years) after the laser iridotomy procedure. The majority of eyes that developed bullous keratopathy (59.0%) occurred following prophylactic ALI. KPUM had the highest percentage of ALI-induced bullous keratopathy cases that underwent penetrating keratoplasties, as compared with other centres in Singapore and the UK (20.0%, 1.8% and 0%, respectively).
CONCLUSION: Bullous keratopathy may arise many years following ALI, and is a growing problem in Asian countries. This condition is a major cause of ocular morbidity in Japan, which has seen a worrying increase in the number of cases in recent years.

PMID 17567658
Jun Shimazaki, Shiro Amano, Toshihiko Uno, Naoyuki Maeda, Norihiko Yokoi, Japan Bullous Keratopathy Study Group
National survey on bullous keratopathy in Japan.
Cornea. 2007 Apr;26(3):274-8. doi: 10.1097/ICO.0b013e31802c9e19.
Abstract/Text PURPOSE: To present the results of a national survey on bullous keratopathy (BK) in Japan.
METHODS: A cross-sectional national survey was conducted for 963 eyes with BK seen between 1999 and 2001 by members of the Japan Cornea Society. Demographic characteristics, type of surgery, complications, and postoperative outcome were analyzed.
RESULTS: BK accounted for 24.2% (963 eyes) of total keratoplasties performed during the period. Graft clarity was maintained in 77.4% of cases, and immunologic rejection and elevated intraocular pressure was noted in 10.8% and 15.3%, respectively. Cataract surgery was the most common cause of BK (n = 428, 44.4%), and phacoemulsification and aspiration were performed in approximately 40% of cases. BK secondary to laser iridotomy (LI) was the second most common cause of BK (n = 225, 23.4%). LI was performed as a prophylactic measure in approximately one half of these cases. BK developed with a mean duration of 6.8 years after LI. Fuchs dystrophy was the cause of BK in 18 eyes (1.9%).
CONCLUSIONS: The causes of BK in Japan are considerably different from those in other Western countries. LI-related BKs showed a remarkably high number, whereas Fuchs dystrophy was observed only rarely.

PMID 17413952
Tin Aung, David S Friedman, Paul T K Chew, Leonard P Ang, Gus Gazzard, Yoke-Fong Lai, Leonard Yip, Hong Lai, Harry Quigley, Steve K L Seah
Long-term outcomes in asians after acute primary angle closure.
Ophthalmology. 2004 Aug;111(8):1464-9. doi: 10.1016/j.ophtha.2003.12.061.
Abstract/Text PURPOSE: To determine the long-term outcome of Asian eyes with an acute attack of primary angle closure (APAC) and to identify risk factors at presentation associated with the development of glaucomatous optic nerve damage.
DESIGN: Cross-sectional observational case series.
PARTICIPANTS: Ninety individuals who were initially seen with APAC 4 to 10 years previously at 2 Singapore hospitals.
METHODS: All subjects underwent a complete eye examination, including visual acuity, visual field testing, dilated eye examination, and optic nerve head photography. The optic discs were judged clinically and photographically as to whether there was glaucomatous optic neuropathy present, and visual fields were assessed for corresponding visual field loss. All visual fields and optic nerve photographs underwent a second evaluation by an experienced, but masked, glaucoma specialist, who assessed whether the changes were compatible with glaucoma.
MAIN OUTCOME MEASURES: The main outcome measures were blindness (defined as best-corrected visual acuity worse than 6/60 and/or central visual field of less than 20 degrees in the attack eye) and glaucomatous optic neuropathy (GON).
RESULTS: A total of 90 of 170 eligible subjects (65.2%) were examined. All subjects were Asian and were predominantly Chinese (78 subjects [86.7%]). There were 61 females (67.8%), and the age of the subjects was 62.0+/-9.0 years (mean +/- standard deviation) at the time of APAC, with a mean duration of 6.3+/-1.5 years from the time of the APAC episode to the study examination. Sixteen (17.8%) subjects were blind in the attack eye; half of the cases of blindness were caused by glaucoma. Forty-three subjects (47.8%) had GON, with 13 eyes (15.5%) having markedly cupped optic discs (cup-to-disc ratio >0.9). Thirty-eight eyes (58%) had best-corrected vision worse than 6/9, with cataract responsible for close to half the cases of poor vision. There were no identifiable risk factors related to the APAC episode that were significantly associated with the presence of GON.
CONCLUSIONS: Several years after being seen with APAC, 17.8% of subjects examined were blind in the attack eye, and almost half had glaucomatous optic nerve damage. Vision was also reduced in a large number of individuals, largely from unoperated cataract. Subjects with APAC would benefit from regular follow-up to monitor for visual field decline and glaucoma development.

PMID 15288972

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