今日の臨床サポート

眼の痛み

著者: 喜多美穂里 京都医療センター眼科

監修: 沖波聡 倉敷中央病院眼科

著者校正/監修レビュー済:2021/11/10
患者向け説明資料

概要・推奨   

  1. 急性原発閉塞隅角緑内障(急性緑内障発作)の治療に行うレーザー虹彩切開術にはNd-YAGレーザーを用いることが推奨される(推奨度1)
  1. 急性緑内障発作眼を含めて原発性の閉塞隅角緑内障は、白内障手術の適応となる(推奨度1)
  1. 術後細菌性眼内炎では機を逸せぬ硝子体手術が必要である(推奨度1)。
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:
喜多美穂里 : 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. 定期レビューを行い、感染症検査について加筆を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 眼の痛みは、視力障害とともに眼科臨床において最も多い訴えの1つであるが、その原因特定は必ずしも容易ではない。
  1. 顔面の痛み、頭痛、眼窩部痛、眼の痒みも、眼の痛みと表現されることがある。
  1. 痛みは自覚症状であるため、所見と必ずしも並行しているとは限らず、診断には問診の占める割合が大きい。
  1. 眼球に起因するものと、眼球外に起因するものがある。
  1. 眼科領域の疾患に加え、脳内疾患に起因する眼の痛みがある。
  1. 眼痛を生じる疾患には緊急性を要するものが含まれている。
問診・診察のポイント  
 
  1. 眼の痛みの原因は多岐にわたるため、緊急で眼科に紹介する疾患を除外したうえで、丁寧な問診・診察が必要である。

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文献 

著者: Yasuaki Yamamoto, Toshihiko Uno, Katsumi Shisida, Longquan Xue, Atsushi Shiraishi, Xiaodong Zheng, Yuichi Ohashi
雑誌名: Arch Ophthalmol. 2006 Mar;124(3):387-93. doi: 10.1001/archopht.124.3.387.
Abstract/Text OBJECTIVE: To determine the pathogenesis of the bullous keratopathy that is frequently observed in patients after argon laser iridotomy (ALI) by comparing the changes in aqueous flow after ALI with those that follow peripheral iridectomy in rabbit eyes.
METHODS: Silicone particles were injected into the anterior chamber of rabbit eyes as tracers to monitor aqueous flow. Particle tracking velocimetry with image analysis was used to determine the direction and speed of aqueous flow in 5 pigmented rabbits that underwent ALI and 5 that underwent peripheral iridectomy.
RESULTS: In the ALI group, silicone particles were found to stream through the iridotomy window against the corneal endothelium immediately after the pupil was constricted by a light stimulus. The mean +/- SD speed of the particles was 2.97 +/- 1.51 mm/s. In contrast, the mean +/- SD flow rate through the iridectomy window in the peripheral iridectomy group was significantly slower at 0.36 +/- 0.30 mm/s (P = .01).
CONCLUSION: Constriction of the pupil elicited marked aqueous streaming through the ALI window against the corneal endothelium. Clinical Relevance The mechanical stress to the corneal endothelium by the abnormal aqueous stream may be partially responsible for the corneal decompensation that follows ALI.

PMID 16534059  Arch Ophthalmol. 2006 Mar;124(3):387-93. doi: 10.1001/a・・・
著者: Yuichi Kaji, Tetsuro Oshika, Tomohiko Usui, Jun Sakakibara
雑誌名: Cornea. 2005 Nov;24(8 Suppl):S55-S58.
Abstract/Text PURPOSE: Laser iridotomy often causes bullous keratopathy; however, the mechanism is unclear. We investigated whether changes in aqueous humor hydrodynamics after laser iridotomy have any role in corneal endothelial cell loss.
MATERIALS AND METHODS: Porcine corneal endothelial cells were plated onto glass slides. Following 1 or 3 hours for adhesion, the endothelial cells were exposed to shear stresses (0.1-10 dyne/cm) for 15 minutes, and the number of detached cells was counted. In addition, the pressure and shear stress on corneal endothelial layer were calculated in a virtual model of laser iridotomy.
RESULTS: The number of detached corneal endothelial cells increased with shear stresses in a dose-dependent manner. Significant increase of rate of detached corneal endothelial cells was observed at >0.3 dyne/cm after 1-hour attachment and at 1 dyne/cm after 3-hour attachment. The maximum pressure on corneal endothelial layer was 0.007 mm Hg, which is negligible compared with intraocular pressure. However, the maximum shear stress on the corneal endothelial layer could be> dyne/cm in some conditions of laser iridotomy.
CONCLUSIONS: The resistance of corneal endothelial cell loss to shear stress is time dependent. Shear stress could be a cause of corneal endothelial cell loss in some conditions of laser iridotomy.

PMID 16227825  Cornea. 2005 Nov;24(8 Suppl):S55-S58.
著者: Jun Shimazaki, Shiro Amano, Toshihiko Uno, Naoyuki Maeda, Norihiko Yokoi, Japan Bullous Keratopathy Study Group
雑誌名: 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  Cornea. 2007 Apr;26(3):274-8. doi: 10.1097/ICO.0b013e31・・・
著者: Philipp C Jacobi, Thomas S Dietlein, Christoph Lüke, Bert Engels, Günter K Krieglstein
雑誌名: Ophthalmology. 2002 Sep;109(9):1597-603.
Abstract/Text OBJECTIVE: To evaluate the safety and efficacy of primary phacoemulsification and intraocular lens implantation (PPI) for acute angle-closure glaucoma (ACG).
STUDY DESIGN: Prospective, nonrandomized comparative trial.
PARTICIPANTS AND INTERVENTION: Forty-three eyes of 43 patients with acute ACG and uncontrolled intraocular pressure (IOP) were treated by PPI. Thirty-two eyes of 32 patients treated by conventional surgical iridectomy (CSI) constituted the control group.
MAIN OUTCOME MEASURES: Postoperative visual acuity, IOP, number of antiglaucoma medications, complications, and secondary surgical interventions, if any, required for IOP control.
RESULTS: Glaucoma control was achieved in 31 eyes (72%) in the PPI group and in 11 (35%) in the CSI group (P = 0.01). Mean preoperative IOP was 40.5 +/- 7.6 mmHg (standard deviation) and 39.7 +/- 7.8 mmHg, respectively (P = 0.46). Mean postoperative IOP was 17.8 +/- 3.4 mmHg (PPI group) and 20.1 +/- 4.2 mmHg (CSI group) after a mean follow-up of 10.2 +/- 3.4 months (P = 0.03). Postoperatively, the mean number of ocular hypotensive medications was 0.18 +/- 0.45 (PPI group) and 0.45 +/- 0.62 (CSI group) (P = 0.0001). Relative increase in postoperative best-corrected visual acuity (logarithm of the minimum angle of resolution) was 0.52 +/- 0.29 (PPI group) and 0.19 +/- 0.21 (CSI group), respectively (P = 0.0001). Additional surgery was necessary in 5 eyes (11.5%) in the PPI group and in 20 eyes (63%) in the CSI group (P = 0.01). Intraoperative and postoperative complications were few and manageable.
CONCLUSIONS: CSI in patients with acute ACG was effective in reducing IOP initially but was associated with multiple surgical reinterventions. Conversely, primary PPI turned out to be safe and effective in reducing IOP and improving visual acuity. These results affirm that lens extraction may be considered the better procedure in uncontrolled ACG when faced with options of CSI or PPI.

PMID 12208704  Ophthalmology. 2002 Sep;109(9):1597-603.
著者:
雑誌名: Arch Ophthalmol. 1995 Dec;113(12):1479-96.
Abstract/Text OBJECTIVE: To determine the roles of immediate pars plana vitrectomy (VIT) and systemic antibiotic treatment in the management of postoperative endophthalmitis.
DESIGN: Investigator-initiated, multicenter, randomized clinical trial.
SETTING: Private and university-based retina-vitreous practices.
PATIENTS: A total of 420 patients who had clinical evidence of endophthalmitis within 6 weeks after cataract surgery or secondary intraocular lens implantation.
INTERVENTIONS: Random assignment according to a 2 x 2 factorial design to treatment with VIT or vitreous tap or biopsy (TAP) and to treatment with or without systemic antibiotics (ceftazidime and amikacin).
MAIN OUTCOME MEASURES: A 9-month evaluation of visual acuity assessed by an Early Treatment Diabetic Retinopathy Study acuity chart and media clarity assessed both clinically and photographically.
RESULTS: There was no difference in final visual acuity or media clarity with or without the use of systemic antibiotics. In patients whose initial visual acuity was hand motions or better, there was no difference in visual outcome whether or not an immediate VIT was performed. However, in the subgroup of patients with initial light perception-only vision, VIT produced a threefold increase in the frequency of achieving 20/40 or better acuity (33% vs 11%), approximately a twofold chance of achieving 20/100 or better acuity (56% vs 30%), and a 50% decrease in the frequency of severe visual loss (20% vs 47%) over TAP. In this group of patients, the difference between VIT and TAP was statistically significant (P < .001, log rank test for cumulative visual acuity scores) over the entire range of vision.
CONCLUSIONS: Omission of systemic antibiotic treatment can reduce toxic effects, costs, and length of hospital stay. Routine immediate VIT is not necessary in patients with better than light perception vision at presentation but is of substantial benefit for those who have light perception-only vision.

PMID 7487614  Arch Ophthalmol. 1995 Dec;113(12):1479-96.

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