今日の臨床サポート

流涙

著者: 永原 幸 国立国際医療研究センター病院 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:2022/03/30
患者向け説明資料

概要・推奨   

  1. 多量の眼脂、眼痛、視野障害、毛様充血はred flag signであり、緊急で治療が必要になることがあり、眼科に早急にコンサルトすることが推奨される(推奨度1)
  1. 感染性眼疾患は治療が遅れると、感染リスクを増加させたり、角膜穿孔を引き起こしたりして失明に至る可能性があり、疑われた場合には早急に眼科受診を勧める(推奨度1)
  1. 薬品が眼に入った場合は、生理食塩水(2~3L、すぐにない場合は水道水)で眼洗浄を行い、薬品のpHが酸性の場合は2~3%重曹水、アルカリ性の場合は0.5%酢酸水で中和洗浄を行う(推奨度1)
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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:
永原 幸 : 特に申告事項無し[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. 定期レビューを行い、加筆修正を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. さまざまな要因で涙液の分泌と排出のバランスが崩れ、涙液が目に溜まるか、溢れる状態。
  1. 涙液が過剰に分泌される状態を分泌性流涙と呼び、生理的なもの、ウイルス、細菌、真菌などの感染による角膜の炎症によるもの、異物(睫毛)、外傷、薬品などによる角膜障害によるもの、ドライアイ、アレルギー性結膜炎、結膜結石によるもの、急性閉塞隅角緑内障によるもの、神経障害によるもの、眼窩の炎症によって生じるものなどがある。
  1. 涙道からの涙液の排出が悪い状態を導涙性流涙と呼び、先天性のもの、涙道(涙小管、総涙小管、涙嚢、鼻涙管)の閉塞(炎症、外傷、腫瘍、加齢[結膜弛緩] 、薬品)によるものがある。
 
  1. 小児の流涙(推奨度2O)
  1. 小児の流涙の発症率は5%で、性差はない[1]。成人の流涙の発症率は7.7%で女性に多い[2]
  1. 小児では眼瞼炎や結膜炎が多く(63%)、ついで鼻涙管閉塞(19%)、睫毛内反(9%)、角膜炎(4%)、角結膜異物(3%)であった。成人では導涙性流涙が多い(47.9%)。
問診・診察のポイント  
 
  1. 流涙の原因は多岐にわたるため、十分な問診と診察を行い、原因を絞り込む必要がある。

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文献 

Reiko Arita, Kouzo Itoh, Syuji Maeda, Koshi Maeda, Atsuo Tomidokoro, Shiro Amano
Efficacy of diagnostic criteria for the differential diagnosis between obstructive meibomian gland dysfunction and aqueous deficiency dry eye.
Jpn J Ophthalmol. 2010 Sep;54(5):387-91. doi: 10.1007/s10384-010-0858-1. Epub 2010 Nov 5.
Abstract/Text PURPOSE: To evaluate diagnostic criteria for obstructive meibomian gland dysfunction (MGD) using three parameters (symptom score, lid margin abnormality score, and meibomian gland morphologic change scores) for differentiating obstructive MGD from aqueous deficiency dry eye (ADDE).
METHODS: Twenty-five eyes of 25 patients (mean age, 66.6 years) diagnosed with obstructive MGD and 15 eyes of 15 patients (mean age, 61.3 years) diagnosed with ADDE were analyzed. Ocular symptoms were scored from 0 to 14 according to the number of symptoms. Lid margin abnormality was scored from 0 to 4 according to the number of abnormalities. Meibomian gland changes were scored from 0 to 6 using noncontact meibography (meibo-score). Superficial punctate keratopathy was scored from 0 to 3. Meibum was graded from 0 to 3 according to volume and quality. Tear film break-up time was measured consecutively three times after instillation of fluorescein, and the median value was adopted. Tear film production was evaluated using the Schirmer test.
RESULTS: Ocular symptom and lid margin abnormality scores and tear film break-up time did not differ significantly between the obstructive MGD and ADDE groups. The meibum score and meibo-score were significantly higher in the obstructive MGD group than in the ADDE group. The Schirmer value was significantly lower in the ADDE group than in the obstructive MGD group. When obstructive MGD was diagnosed on the basis of three scores (ocular symptom score, lid margin abnormality score, and meibo-score) all being abnormal, the sensitivity and specificity for differentiating between obstructive MGD and ADDE were 68.0% and 80%, respectively.
CONCLUSIONS: Although the criteria were moderately reliable for differentiating patients with obstructive MGD from those with ADDE when the diagnosis of obstructive MGD was made on the basis of three abnormal scores, they do not provide comprehensive diagnostic tools for differentiating MGD, ADDE, and healthy individuals. We need to add other parameters such as the Schirmer test value and the meibum score to the diagnostic criteria to enhance their reliability for differentiating MGD and ADDE.

PMID 21052898
Abstract/Text Twenty nine published clinical trials with acyclovir (ACV) ophthalmic ointment in the treatment of herpes simplex virus (HSV) corneal disease have been reviewed in which ACV has been demonstrated to be effective in the treatment of simple dendritic ulcers, geographic ulcers, deep corneal HSV infections and ocular disease associated with herpes zoster (VZV) infection affecting the ophthalmic division of the trigeminal nerve. 998 patients were studied. The most commonly occurring adverse reactions were superficial punctate keratopathy (in 9.8% of patients) and burning or stinging on application of the ointment (4%). ACV ophthalmic ointment was first licensed for the treatment of HSV infections of the eye in September 1981. Spontaneous reports of adverse reactions to ACV ophthalmic ointment to both the UK Committee on Safety of Medicines and the Wellcome Group Adverse Reactions Reporting Centre total 43 cases. These include conjunctivitis, inflammation and pain in the treated eye. In this time it is estimated that there have been approximately one million exposures to the ointment. Thus in general use, tolerance to ACV treatment has been extremely good, and clinical trial data demonstrate that it compares favourably with alternative therapies for HSV corneal disease.

PMID 3549163
Jason M Levine, Robert J Noecker, Lisa C Lane, Lisa Herrygers, David Nix, Robert W Snyder
Comparative penetration of moxifloxacin and gatifloxacin in rabbit aqueous humor after topical dosing.
J Cataract Refract Surg. 2004 Oct;30(10):2177-82. doi: 10.1016/j.jcrs.2004.06.048.
Abstract/Text PURPOSE: To evaluate the aqueous penetration of the fourth-generation fluoroquinolones moxifloxacin and gatifloxacin.
SETTING: University of Arizona, Tucson, Arizona, USA.
METHODS: Forty eyes of 20 New Zealand white rabbits were divided into 2 experimental groups. In Experiment I rabbits (20 eyes), a commercial preparation of topical gatifloxacin 0.3% was administered to 9 eyes and moxifloxacin 0.5% to 9 eyes; 2 eyes served as a control. Eyes were dosed according to a keratitis protocol; ie, every 15 minutes for 4 hours. The aqueous humor was sampled 10 minutes after the last dose. Experiment II rabbits (20 eyes) were dosed according to a cataract prophylaxis protocol; ie, 4 times a day for 10 days. The aqueous humor was sampled 1 hour after the last dose of antibiotic in 12 eyes and 24 hours after the last dose in 8 eyes. High-performance liquid chromatography was used to determine the fluoroquinolone concentration.
RESULTS: In the keratitis dosing protocol, the mean concentration of moxifloxacin in the aqueous (n=9) was 11.057 microg/mL (range 7.66 to 18.87 microg/mL), which was significantly higher than the mean concentration of gatifloxacin (n=8) (7.570 microg/mL [range 4.75 to 10.86 microg/mL]) (P=.030). In the cataract prophylaxis dosing protocol, the mean aqueous concentration of moxifloxacin (n=6) was 1.745 microg/mL (range 0.92 to 3.87 mg/mL). The mean concentration of gatifloxacin (n=6) was 1.207 microg/mL (range 0.44 to 2.44 microg/mL). The difference was not statistically significant (P=.359).
CONCLUSIONS: Higher mean levels (x1.46) of aqueous penetration were achieved with moxifloxacin than with gatifloxacin in the keratitis-dosing model. There was no statistically significant difference between the 2 drugs in the cataract prophylaxis dosing model. Both antibiotics had aqueous levels in excess of the minimum inhibitory concentration for most pathogenic organisms in both models.

PMID 15474833
Constantine D Georgakopoulos, Maria I Eliopoulou, Stavros Stasinos, Artemis Exarchou, Nikolaos Pharmakakis, Anastasia Varvarigou
Periorbital and orbital cellulitis: a 10-year review of hospitalized children.
Eur J Ophthalmol. 2010 Nov-Dec;20(6):1066-72.
Abstract/Text PURPOSE: Periorbital cellulitis is often difficult to distinguish from orbital cellulitis, which is a potentially lethal infection involving the contents of the orbit. A delay in diagnosis and appropriate treatment may result in serious complications. We studied the predisposing factors, microbiologic data, clinical features, complications, and treatment of periorbital and orbital cellulitis in childhood.
METHODS: Eighty-three medical records of patients (mean age 3.7 ± 3.1 years) admitted to the Department of Pediatrics with a diagnosis of periorbital or orbital cellulitis during the 10-year period January 1997 to December 2007 were retrospectively studied.
RESULTS: In this series, periorbital cellulitis occurred more frequently (83%) than orbital cellulitis (17%). Of the children with periorbital cellulitis, 85% were younger than 5 years of age, while 62% of the children with orbital cellulitis were older than 5 years of age. The most common predisposing factors in periorbital cellulitis were upper respiratory infection (68%) and trauma to the eyelids (20%), while sinusitis was more frequently associated with orbital cellulitis (79%). Blood and skin cultures were usually negative. The most common isolated pathogens were Staphylococcus aureus, Streptococcus pneumoniae, and Staphylococcus epidermidis. Forty-five of the 83 children were treated with intravenous ceftriaxone + clindamycin (mean duration 8.6 ± 5.5 days). Intravenous antibiotics alone was an effective management in most of the patients, but a small proportion (6%) required surgical intervention.
CONCLUSIONS: Upper respiratory infection and sinusitis are the most important predisposing factors for periocular infection. Streptococcus species are the predominant causative agents. Both diseases can usually be successfully treated with intravenous antibiotics, but some patients may require surgery to control extensive infection.

PMID 20544674
Ahmed Basheikh, Rosanne Superstein
A child with bilateral orbital cellulitis one day after strabismus surgery.
J AAPOS. 2009 Oct;13(5):488-90. doi: 10.1016/j.jaapos.2009.05.016.
Abstract/Text Orbital cellulitis is a rare complication of strabismus surgery. We report a case of a 4-year-old boy with bilateral orbital cellulitis after uneventful surgery to correct esotropia. Concomitant sinusitis was the likely source of infection. To our knowledge, this is the first case of bilateral orbital cellulitis following strabismus surgery.

PMID 19840730
Steven Gayer, Jessica Zuleta
Perioperative management of the elderly undergoing eye surgery.
Clin Geriatr Med. 2008 Nov;24(4):687-700, ix. doi: 10.1016/j.cger.2008.08.002.
Abstract/Text Eye procedures are considered to be low risk; however, many ophthalmic surgery patients are elderly and are a unique vulnerable group with a myriad of concomitant health issues that put them at greater risk for perioperative medical complications. A trend to shift operative venues from hospitals to ambulatory facilities and more recently to specialty eye-care surgery centers limits the resources available to manage major, and even minor, medical issues that arise on the day of surgery. The role of the internist in the preoperative evaluation and optimization of medical issues before surgery and availability for perioperative consultation and intercession is increasingly essential.

PMID 18984381
O Semoun, E Blumen-Ohana, N de Preobrajensky, J-P Nordmann
[Acute angle-closure glaucoma complicating an intravitreal injection of bevacizumab].
J Fr Ophtalmol. 2009 Jan;32(1):58.e1-4. doi: 10.1016/j.jfo.2008.11.002. Epub 2009 Feb 4.
Abstract/Text INTRODUCTION: The use of anti-VEGF by intravitreal injection is being generalized, and the indications are multiplying. Ocular hypertension after injection can be a classic complication.
CASE REPORT: We report the case of an acute angle-closure glaucoma that occurred immediately after an intravitreal injection of 0.05 ml of bevacizumab. The patient was suffering from intravitreal hemorrhage complicating retinal central venous occlusion. The treatment consisted of intravenous acetazolamide and mannitol, associated with a local treatment.
DISCUSSION: Elevation of intraocular pressure is frequent a short time after an intravitreal injection. However, this complication is more often moderate and transient, and does not usually require an adapted treatment. The physiopathology remains unclear. To our knowledge the occurrence of acute angle-closure glaucoma following an intravitreal injection is exceptional.

PMID 19515315
Leonard Bielory, Mitchell H Friedlaender
Allergic conjunctivitis.
Immunol Allergy Clin North Am. 2008 Feb;28(1):43-58, vi. doi: 10.1016/j.iac.2007.12.005.
Abstract/Text Allergic conjunctivitis is common, especially during the allergy season. Consultation with the allergist to perform skin tests or in vitro tests may be useful and confirmatory in the diagnosis of ocular allergy. If treatment is necessary, antihistamines, mast cell stabilizers, and nonsteroidal anti-inflammatory drugs are safe and reasonably effective. Corticosteroids are an order of magnitude more potent than noncorticosteroids; however, they have attendant side effects that are best monitored by the ophthalmologist. The development of "modified" corticosteroids has been a boon to the treatment of ocular allergy because these drugs may reduce potential side effects without sacrificing potency.

PMID 18282545
M B Limberg, C McCaa, G E Kissling, H E Kaufman
Topical application of hyaluronic acid and chondroitin sulfate in the treatment of dry eyes.
Am J Ophthalmol. 1987 Feb 15;103(2):194-7.
Abstract/Text Twenty patients with keratoconjunctivitis sicca used three different viscoelastic tear formulations and a polyvinyl alcohol artificial tear for two weeks each. Each formulation was used once every two waking hours in a controlled double-masked study. Eighteen patients reported marked improvement over the course of the study, in terms of the severity of itching, burning, and foreign body sensation. Corneal staining and mucous strand formation were also reduced in patients with these manifestations. No formulation was preferred by a majority of patients or proved superior in treating signs of keratoconjunctivitis sicca. However, patients with low Schirmer test scores uniformly preferred a solution containing chondroitin sulfate, while patients with moderate Schirmer test scores tended to prefer a solution of polyvinyl alcohol or hyaluronic acid.

PMID 3101502
L S Mengher, K S Pandher, A J Bron, C C Davey
Effect of sodium hyaluronate (0.1%) on break-up time (NIBUT) in patients with dry eyes.
Br J Ophthalmol. 1986 Jun;70(6):442-7.
Abstract/Text We evaluated the effect of 0.1% sodium hyaluronate (unpreserved) in 10 patients with dry eyes. The precorneal tear film break-up time was assessed by the non-invasive technique, and the severity of symptoms was recorded before and after treatment on a 0 to +3 scale. It was found that the tear film stability was significantly increased (p less than 0.05) in eyes treated with sodium hyaluronate. The symptoms of grittiness and burning were also significantly alleviated in the treated eyes.

PMID 3718907
Mayumi Ueta, Chie Sotozono, Norihiko Yokoi, Shigeru Kinoshita
Rebamipide suppresses PolyI:C-stimulated cytokine production in human conjunctival epithelial cells.
J Ocul Pharmacol Ther. 2013 Sep;29(7):688-93. doi: 10.1089/jop.2012.0054. Epub 2013 May 10.
Abstract/Text PURPOSE: We previously documented that ocular surface epithelial cells could regulate ocular surface inflammation and suggested that, while Toll-like receptor 3 upregulates, EP3, one of the prostaglandin E2 receptors, downregulates ocular surface inflammation. Others reported that rebamipide, a gastroprotective drug, could not only increase the gastric mucus production, but also suppressed gastric mucosal inflammation and that it was dominantly distributed in mucosal tissues. The eyedrop form of rebamipide, approved in Japan for use in the treatment of dry eye diseases, upregulates mucin secretion and production, thereby suppressing superficial punctate keratopathy on the ocular surface of patients with this disease. In the current study, we investigated whether rebamipide has anti- inflammatory effects on the ocular surface.
METHODS: To examine the effects of rebamipide on polyI:C-induced cytokine expression by primary human conjunctival epithelial cells, we used enzyme-linked immunosorbent assay and quantitative reverse transcription-polymerase chain reaction assay. We studied the effects of rebamipide on ocular surface inflammation in our murine experimental allergic conjunctivitis (EAC) model.
RESULTS: Rebamipide could suppress polyI:C-induced cytokine production and the expression of mRNAs for CXCL10, CXCL11, RANTES, MCP-1, and IL-6 in human conjunctival epithelial cells. In our EAC model, the topical administration of rebamipide suppressed conjunctival allergic eosinophil infiltration.
CONCLUSIONS: The topical application of rebamipide on the ocular surface might suppress ocular surface inflammation by suppressing the production of cytokines by ocular surface epithelial cells.

PMID 23662915
Abstract/Text BACKGROUND AND OBJECTIVES: The treatment of congenital nasolacrimal duct (NLD) obstruction continues to be a subject of controversy. Some authors advocate early probing and irrigation in an office setting, whereas others recommend that the procedure be performed under general anesthesia when the child is at least 1 year old. The focus of this study was to compare the results of probing and irrigation of congenital NLD obstruction among children younger than 1 year of age, those 1 to 2 years of age, and those older than 2 years.
PATIENTS AND METHODS: The author reviewed the records of 120 patients, ranging in age from 3 weeks to 30 years, with 153 cases of NLD obstruction. Eighty-five patients (110 cases of NLD obstruction) underwent probing and irrigation.
RESULTS: Complications of NLD obstruction occurred in 12 patients; 75% of these patients were younger than 1 year of age. In group 1 (patient age < 1 year) there were 37 probings with 1 failure (3%). Group 2 (patient age = 1-2 years) had 43 probings and 5 failures (12%). In group 3 (patient age > 2 years), 30 NLDs were probed with 2 failures (7%). However, these differences were not significant (P = .13 between groups 1 and 2; P = .42 between groups 1 and 3).
CONCLUSION: In this study, the postponement of probing and irrigation for congenital NLD obstruction beyond the age of 1 year did not result in an increased rate of failures or complications.

PMID 9387181
B J Kushner
Congenital nasolacrimal system obstruction.
Arch Ophthalmol. 1982 Apr;100(4):597-600.
Abstract/Text A series of 132 children with congenital nasolacrimal system obstruction was prospectively randomized into three groups to determine the effectiveness of different modes of nonsurgical treatment. Massaging the nasolacrimal sac in a manner that increased hydrostatic pressure and ruptured the membranous obstruction was more effective (with a high degree of statistical significance) than simple massage or no massage at all. Of those children requiring nasolacrimal probing, a high success rate was found with simple obstructions in the nasolacrimal duct. Failure of probing was more common in canalicular obstructions or generally narrow nasolacrimal ducts. Silicone intubation of the nasolacrimal system is an effective way of treating cases not cured by probing.

PMID 6896140

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