今日の臨床サポート

複視

著者: 三村治 兵庫医科大学 眼科学教室

監修: 沖波聡 倉敷中央病院眼科

著者校正/監修レビュー済:2020/03/26
参考ガイドライン:
  1. 日本神経学会:重症筋無力症診療ガイドライン 2014
  1. European Group on Graves' Orbitopathy(EUGOGO):The 2016 European Thyroid Association/European Group on Graves’ Orbitopathy Guidelines for the Management of Graves’ Orbitopathy
患者向け説明資料

概要・推奨   

  1. 複視の訴えで、眼運動神経麻痺を疑った場合、動眼神経麻痺および外転神経麻痺の場合には頭部MRI検査を行うことが奨められる(推奨度1)。
  1. 糖尿病、動脈硬化、高血圧、脂質異常症などを基礎疾患とする虚血性眼運動神経麻痺に薬物治療を行うかどうかは議論が分かれるところである。
  1. 動眼神経麻痺で複視がみられたら、原因検索をまず行い、6カ月待って複視が消失しなかったらプリズム眼鏡処方あるいは斜視手術を行うことが奨められる。
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  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ります。閲覧にはご契約が必要と
  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ります。閲覧にはご契
  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り
  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ります。閲
  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ります。閲覧にはご契約が必要となります。閲覧にはご契
  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ります。閲覧にはご契約が
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:
三村治 : 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. EUGOGO 2016の甲状腺眼症診療ガイドラインに基づき、ステロイド治療法について改訂を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 複視とは、両眼の視線が合わなくなるために、ものがダブって見える症状である。
  1. 問診が重要であり、複視の日内変動の有無や様式から、原因疾患が神経原性、筋原性、機械的なものかを鑑別できる。
  1. 複視の診断は、片眼を遮蔽し複視の訴えの消失を確認することにより、主として眼光学系の異常による単眼複視と鑑別され診断となる。
  1. 複視を生ずる疾患にはさまざまなものがあり、問診と視診が診断にきわめて重要で、画像検査と自己抗体検査などで確定する。
  1. 原因で最多の眼運動神経麻痺の自然回復率は比較的良好で、外傷以外では約80%の患者が平均3カ月で回復する。
  1. 甲状腺眼症の原因は自己免疫性外眼筋炎であり、腫脹した外眼筋(下直筋が最多)が伸展障害を起こすために生じる。
  1. 強度近視や高齢者で上下複視や内斜視を呈するものでは、冠状断MRI検査を行えば高率に上直筋-外直筋バンドの菲薄化がみられ、斜視は外直筋の下方移動と上直筋の内方移動に伴う眼球後方の筋円錐からの脱臼で生じる。これをsagging eye syndromeと呼ぶ。したがって、上直筋と外直筋を直接縫合する上外直筋結合術(横山法)が最も合理的な治療法となる。
  1. 眼窩筋炎も自己免疫が関与するが、腫脹した外眼筋の収縮障害を起こすために生じる。
  1. 脳動脈瘤による動眼神経麻痺は、発見次第緊急に脳神経外科に紹介すべきである。
問診・診察のポイント  
 
  1. 頭蓋内疾患、全身神経疾患のリスクを確認する。

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文献 

著者: Erdem Güresir, Patrick Schuss, Volker Seifert, Hartmut Vatter
雑誌名: J Neurosurg. 2012 Nov;117(5):904-10. doi: 10.3171/2012.8.JNS111239. Epub 2012 Aug 31.
Abstract/Text OBJECT: Resolution of oculomotor nerve palsy (ONP) after clipping of posterior communicating artery (PCoA) aneurysms has been well documented. However, whether additional decompression of the oculomotor nerve via aneurysm sac dissection or resection is superior to pure aneurysm clipping is the subject of much debate. Therefore, the objective in the present investigation was to analyze the influence of surgical strategy--specifically, clipping with or without aneurysm dissection--on ONP resolution.
METHODS: Between June 1999 and December 2010, 18 consecutive patients with ruptured and unruptured PCoA aneurysms causing ONP were treated at the authors' institution. Oculomotor nerve palsy was evaluated on admission and at follow-up. The electronic database MEDLINE was searched for additional data in published studies of PCoA aneurysms causing ONP. Two reviewers independently extracted data.
RESULTS: Overall, 8 studies from the literature review and 6 patients in the current series (121 PCoA aneurysms) met the study inclusion criteria. Ninety-four aneurysms were treated with simple aneurysm neck clipping and 27 with clipping plus aneurysm sac decompression. The surgical strategy, simple aneurysm neck clipping versus clipping plus oculomotor nerve decompression, had no effect on full ONP resolution on univariate (p = 0.5) and multivariate analyses. On multivariate analysis, patients with incomplete ONP at admission were more likely to have full resolution of the palsy than were those with complete ONP at admission (p = 0.03, OR = 4.2, 95% CI 1.1-16).
CONCLUSIONS: Data in the present study indicated that ONP caused by PCoA aneurysms improves after clipping without and with oculomotor nerve decompression. The resolution of ONP is inversely associated with the initial severity of ONP.

PMID 22937927  J Neurosurg. 2012 Nov;117(5):904-10. doi: 10.3171/2012.・・・
著者: Tadamichi Akagi, Kazuaki Miyamoto, Satoshi Kashii, Nagahisa Yoshimura
雑誌名: Jpn J Ophthalmol. 2008 Jan-Feb;52(1):32-5. doi: 10.1007/s10384-007-0489-3. Epub 2008 Mar 28.
Abstract/Text PURPOSE: To determine the cause and prognosis of neurologically isolated third, fourth, or sixth cranial nerve dysfunction in cases of oculomotor palsy, and to determine the best imaging methods to make a correct diagnosis.
METHODS: The medical records of 221 consecutive patients with oculomotor palsy caused by neurologically isolated cranial nerve dysfunction were reviewed. There were 63 cases of third, 41 of fourth, and 117 of sixth cranial nerve dysfunction. The patients were examined at the Neuro-ophthalmology Clinic of Kyoto University Hospital between 1993 and 2001.
RESULTS: Vascular disorders accounted for 34.9% of the third nerve dysfunction, and 90% of these recovered completely in 6 months. Ninety percent of the patients with an isolated third nerve dysfunction that was caused by an aneurysm also had anisocoria, and 68% of the patients with a third nerve dysfunction caused by a vascular disorder had anisocoria. In all of the vascular cases with anisocoria, the difference in the pupillary diameter was <1.0 mm. The presence of ptosis did not play an important role in making a diagnosis of third nerve dysfunction. Ninety percent of the patients with fourth nerve dysfunction and 60% of the patients with sixth nerve dysfunction recovered within 9 months.
CONCLUSIONS: The age of the patient, signs of an improvement, and associated alterations are important diagnostic markers to determine the best type of imaging methods for evaluating neurologically isolated third, fourth, and sixth cranial nerve dysfunction.

PMID 18369697  Jpn J Ophthalmol. 2008 Jan-Feb;52(1):32-5. doi: 10.1007・・・
著者: U-C Park, S-J Kim, J-M Hwang, Y S Yu
雑誌名: Eye (Lond). 2008 May;22(5):691-6. doi: 10.1038/sj.eye.6702720. Epub 2007 Feb 9.
Abstract/Text PURPOSE: Clinical features of acquired third, fourth, and sixth cranial nerve palsy showed variation among previous studies. Evaluation of natural course with objective criteria will establish accurate recovery rates and important factors for recovery.
METHODS: Retrospective chart review was performed on 206 patients who visited a neuro-ophthalmic department with acquired third, fourth, and sixth nerve palsy. Aetiology and results of ocular exam on each visit were reviewed, and multivariate logistic regression analysis was performed to identify independent factors affecting recovery.
RESULTS: The sixth cranial nerve was affected most frequently (n=108, 52.4%) and vascular disease (n=64, 31.1%) was the most common aetiology. Recovery was evaluated with change of deviation angle for 108 patients, who were first examined within a month of onset and followed up for at least 6 months. Ninety-two (85.2%) patients showed overall (at least partial) recovery and 73 (67.6%) showed complete recovery. In univariate analysis, initial deviation angle was found to be only significant factor associated with complete recovery (P=0.007) and most patients who experienced successful management of treatable underlying disease showed recovery.
CONCLUSIONS: With objective criteria based on deviation angle, overall recovery rate from the third, fourth, and sixth nerve palsy was 85.2%. Patients who had smaller initial eyeball deviation or successful management of treatable underlying disease had a high chance of recovery.

PMID 17293794  Eye (Lond). 2008 May;22(5):691-6. doi: 10.1038/sj.eye.6・・・
著者: L A Schumacher-Feero, K W Yoo, F M Solari, A W Biglan
雑誌名: Am J Ophthalmol. 1999 Aug;128(2):216-21.
Abstract/Text PURPOSE: To report the causes and the sensory, motor, and cosmetic results after treatment for oculomotor (third cranial nerve) palsy in children.
METHODS: Review of the clinical records of children with a diagnosis of third cranial nerve palsy followed up in a university-based pediatric ophthalmology practice between 1981 and 1996.
RESULTS: Forty-nine children with 53 affected eyes were followed up for a mean of 5.5 years. Third cranial nerve palsy was partial in 31 children (32 eyes) and complete in 18 children (21 eyes). The palsy was congenital in 20 eyes and caused by postnatal trauma in 17 eyes. Seventeen eyes had aberrant regeneration and four eyes with partial third cranial nerve palsy had spontaneous resolution. Thirty-six children (38 eyes) were affected before visual maturation (age 8 years), and 25 (27 eyes) had amblyopia. Of the five amblyopic eyes with quantifiable visual acuity, none had measurable improvement of Snellen visual acuity during the follow-up period. Overall, visual acuity was between 6/5 and 6/12 at the last follow-up visit in 31 eyes (58%). Ocular alignment was greatly improved after strabismus procedures, with a mean of 1.5 procedures for patients with partial third cranial nerve palsy and 2.3 procedures for those with complete palsy. Binocular function was difficult to preserve or restore but was achieved for some patients with partial third cranial nerve palsy.
CONCLUSIONS: Surgical treatment of third cranial nerve palsy is frequently necessary, especially in cases of complete palsy. Multiple strabismus procedures are often needed to maintain good ocular alignment. Surgery can result in cosmetically acceptable alignment of the eyes, but it rarely results in restoration or achievement of measurable binocular function. Treatment of amblyopia is effective in maintaining the level of visual acuity present at the onset of the third cranial nerve palsy, but improvement in visual acuity is difficult to achieve.

PMID 10458179  Am J Ophthalmol. 1999 Aug;128(2):216-21.
著者: Laura Cabrejas, Francisco J Hurtado-Ceña, Jaime Tejedor
雑誌名: J AAPOS. 2009 Oct;13(5):481-4. doi: 10.1016/j.jaapos.2009.08.008.
Abstract/Text PURPOSE: To investigate the outcomes and predictive factors of surgical treatment of oculomotor nerve palsy.
METHODS: Records of patients requiring eye muscle surgery for oculomotor nerve palsy in our institution were retrospectively reviewed. Age, sex, etiology, deviation, completeness of involvement, time between onset and surgery, botulinum toxin treatment, and number of surgical procedures were recorded as potential predictive factors. Muscle function, presence of diplopia, and torticollis were also recorded. The main outcome measure was motor function. Secondary outcome measures were presence of diplopia, torticollis, and limitation of muscle function.
RESULTS: Surgery was required in 22 patients, of whom motor success was obtained in 14 (63.6%). Frequency of diplopia and torticollis were significantly reduced by surgery. After multivariate regression analysis, longer time between onset and surgery (p = 0.03) and larger initial deviation (p = 0.05) were significantly associated with poorer postsurgical results in terms of motor function.
CONCLUSIONS: Longer time from onset to surgery and larger eye deviation are negative prognostic factors of postsurgical motor success for oculomotor nerve palsy.

PMID 19840728  J AAPOS. 2009 Oct;13(5):481-4. doi: 10.1016/j.jaapos.20・・・
著者: Luigi Bartalena, Lelio Baldeschi, Kostas Boboridis, Anja Eckstein, George J Kahaly, Claudio Marcocci, Petros Perros, Mario Salvi, Wilmar M Wiersinga, European Group on Graves' Orbitopathy (EUGOGO)
雑誌名: Eur Thyroid J. 2016 Mar;5(1):9-26. doi: 10.1159/000443828. Epub 2016 Mar 2.
Abstract/Text Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease, though severe forms are rare. Management of GO is often suboptimal, largely because available treatments do not target pathogenic mechanisms of the disease. Treatment should rely on a thorough assessment of the activity and severity of GO and its impact on the patient's quality of life. Local measures (artificial tears, ointments and dark glasses) and control of risk factors for progression (smoking and thyroid dysfunction) are recommended for all patients. In mild GO, a watchful strategy is usually sufficient, but a 6-month course of selenium supplementation is effective in improving mild manifestations and preventing progression to more severe forms. High-dose glucocorticoids (GCs), preferably via the intravenous route, are the first line of treatment for moderate-to-severe and active GO. The optimal cumulative dose appears to be 4.5-5 g of methylprednisolone, but higher doses (up to 8 g) can be used for more severe forms. Shared decision-making is recommended for selecting second-line treatments, including a second course of intravenous GCs, oral GCs combined with orbital radiotherapy or cyclosporine, rituximab or watchful waiting. Rehabilitative treatment (orbital decompression surgery, squint surgery or eyelid surgery) is needed in the majority of patients when GO has been conservatively managed and inactivated by immunosuppressive treatment.

PMID 27099835  Eur Thyroid J. 2016 Mar;5(1):9-26. doi: 10.1159/0004438・・・
著者: Mohammad Reza Akbari, Ahmad Ameri, Ali Reza Keshtkar Jaafari, Arash Mirmohammadsadeghi
雑誌名: J AAPOS. 2016 Apr;20(2):126-130.e1. doi: 10.1016/j.jaapos.2016.01.007.
Abstract/Text PURPOSE: To evaluate the rate of and predictive factors for successful treatment of restrictive myopathy in thyroid-associated orbitopathy (TAO) using botulinum toxin injection.
METHODS: Twenty patients with restrictive myopathy of TAO were enrolled in the study. Abnormal thyroid function test results were not a prerequisite for inclusion. In each extraocular muscle 25 units of botulinum toxinA were injected. The success rate, calculated at 2 years or last follow-up before surgery, was defined as proportion of the cases with esotropia of <10(Δ), vertical deviation of <5(Δ), and no diplopia in primary position and downgaze for at least 1 year. Both univariate analysis and multivariate logistic regressions were performed to identify the factors associated with success.
RESULTS: The procedure was successful in 11 cases (55%): in 8 patients with predominantly esotropia, 1 patient with predominantly hypotropia, and 2 patients of mixed type. Four factors were significantly associated with the success: type of deviation (P = 0.007), lower amounts of hypotropia (P = 0.001) and esotropia (P = 0.05), and lower degree of extorsion (P = 0.01). In the multivariate logistic regression, only lower amount of hypotropia was significantly associated with the success (P = 0.09, OR = 1.36).
CONCLUSIONS: Botulinum toxin injection can be an effective alternative for the treatment of the restrictive myopathy in TAO. The best candidates for injection of the toxin are patients with esotropia, smaller angle of horizontal and vertical deviations, and lower degree of extorsion.

Copyright © 2016 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.
PMID 27079592  J AAPOS. 2016 Apr;20(2):126-130.e1. doi: 10.1016/j.jaap・・・
著者: Kenji Ohtsuka, Akihiko Sato, Satoshi Kawaguchi, Masato Hashimoto, Yasuo Suzuki
雑誌名: Jpn J Ophthalmol. 2002 Sep-Oct;46(5):563-7.
Abstract/Text PURPOSE: To evaluate the effect of high-dose intravenous steroid pulse therapy followed by 3-month oral steroid therapy for Graves' ophthalmopathy.
METHODS: We selected 41 Japanese patients (age range, 21-76 years; mean = 49 years) who had active Graves' ophthalmopathy among 205 consecutive patients examined at Sapporo Medical University Hospital between 1997 and 1999. In a prospective study, we investigated the effect on the 41 patients of high-dose intravenous methylprednisolone pulse therapy (1 g/day x 3 days x 3 times) followed by 3-month oral prednisone therapy. Coronal computed tomography (CT) of the orbit, exophthalmometry and monocular fixation field measured by Goldmann perimetry were carried out before the steroid pulse therapy, and 1 and 6 months after the steroid pulse therapy. The maximum coronal section area of the rectus muscle in each eye was measured using an orbital CT image.
RESULTS: Extraocular muscle hypertrophy was significantly reduced 1 and 6 months after the pulse therapy (paired t-test, P <.01), and was not significantly different between 1 and 6 months after the pulse therapy. Proptosis was not significantly reduced by the pulse therapy. Monocular fixation fields were measured in 34 patients with diplopia, and limitation of eye movements was improved in 15 patients (44%) by the pulse therapy. In the other patients, improvement of the limitation was not detectable by the test of the monocular fixation field.
CONCLUSIONS: The treatment in this study is effective for extraocular muscle hypertrophy, and relapse was minimum within 6 months. However, this treatment has limited effect on limitation of eye movements and less effect on proptosis.

PMID 12457917  Jpn J Ophthalmol. 2002 Sep-Oct;46(5):563-7.
著者: K C Golnik, R Pena, A G Lee, E R Eggenberger
雑誌名: Ophthalmology. 1999 Jul;106(7):1282-6. doi: 10.1016/S0161-6420(99)00709-5.
Abstract/Text OBJECTIVE: To determine whether ice application to a ptotic eyelid can differentiate myasthenic from nonmyasthenic ptosis.
DESIGN: Prospective, multicenter, nonrandomized, comparative trial.
PARTICIPANTS: Twenty patients with myasthenia gravis (MG) and ptosis were evaluated in the neuro-ophthalmology service. CONTROL SUBJECTS: Twenty patients with nonmyasthenic ptosis evaluated in the same locale.
METHODS: Palpebral fissures were measured before and immediately after a 2-minute application of ice to the ptotic eyelid.
MAIN OUTCOME MEASURES: The difference in palpebral fissures in millimeters before and after ice application. Two or more millimeters of improvement after ice application was considered a positive ice test result.
RESULTS: A positive ice test result was noted in 16 of the 20 (80%) patients with MG and in none of the 20 patients without MG (P < 0.001). Of the 4 patients with MG and complete ptosis, 3 had a negative ice test result.
CONCLUSIONS: The ice test is a simple, short, specific, and relatively sensitive test for the diagnosis of myasthenic ptosis. The sensitivity of the ice test in patients with complete ptosis decreases considerably.

PMID 10406606  Ophthalmology. 1999 Jul;106(7):1282-6. doi: 10.1016/S01・・・
著者: M Omeed Fakiri, Dénes L J Tavy, Ako Dara Hama-Amin, Paul W Wirtz
雑誌名: Muscle Nerve. 2013 Dec;48(6):902-4. doi: 10.1002/mus.23857. Epub 2013 Sep 11.
Abstract/Text INTRODUCTION: Several studies have reported high diagnostic sensitivity and specificity for the ice test in myasthenia gravis. All of the studies employed a case-control design, in which the diagnosis was already known at the time of the test for both patients and controls, leading to case selection bias. This suggests that the available literature substantially overestimates the diagnostic utility of these tests.
METHODS: A retrospective cohort study without selection bias was performed to examine the sensitivity and specificity of the ice test. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the ice test were determined by means of a 2 × 2 table.
RESULTS: The ice test has a sensitivity of 0.92 (95% CI 0.62-1.00), specificity of 0.79 (95% CI 0.56-1.00), PPV of 0.73 (95% CI 0.48-0.90), and NPV of 0.94 (95% CI 0.70-1.00).
CONCLUSIONS: Due to its high negative predictive value the ice test is still a reliable and useful bed-side test.

Copyright © 2013 Wiley Periodicals, Inc.
PMID 23536427  Muscle Nerve. 2013 Dec;48(6):902-4. doi: 10.1002/mus.23・・・
著者: F D Ellis, C S Hoyt, F J Ellis, A R Jeffery, N Sondhi
雑誌名: J AAPOS. 2000 Oct;4(5):271-81. doi: 10.1067/mpa.2000.106204.
Abstract/Text BACKGROUND: As a result of clinical and laboratory investigations of temperature correlates of myasthenia gravis, orbital cooling (ice test) has been developed as a reliable test for ocular myasthenia diagnosis through blepharoptosis response. The test has not been utilized in a prospective manner for myasthenia diagnosis through extraocular muscle responses.
METHODS: Fifteen patients with acquired motility disorders were studied with the use of orbital cooling and other tests for myasthenia gravis. Orbital cooling was performed in a standard fashion for all patients. In 14 of 15 patients, the diagnosis of myasthenia was not established at the time the ice test was performed. Fifteen non-myasthenic patients with acquired motility disorders were also studied with use of the ice test. Temperatures during orbital cooling were measured in the superior cul-de-sac of one patient and between the lateral rectus muscle and globe in 3 patients.
RESULTS: All patients subsequently proven to have myasthenia gravis by other tests and by response to myasthenia therapy had a positive (diagnostic of myasthenia) response to the ice test. No patient had a false-positive or a paradoxical response to the ice test. No control patient had a positive blepharoptosis or motility response to orbital cooling. Temperature measurements demonstrated significant cooling effects in the superotemporal cul-de-sac and beneath the lateral rectus muscles after orbital cooling for 5 minutes.
CONCLUSIONS: Orbital cooling, within certain parameters, can be a useful clinical test for myasthenia diagnosis through motility response, as well as blepharoptosis response.

PMID 11040476  J AAPOS. 2000 Oct;4(5):271-81. doi: 10.1067/mpa.2000.10・・・
著者: Niphon Chirapapaisan, Supinda Tanormrod, Wanicha Chuenkongkaew
雑誌名: Asian Pac J Allergy Immunol. 2007 Mar;25(1):13-6.
Abstract/Text The objective of this study was to determine factors associated with pyridostigmine therapy in patients with ocular myasthenia gravis (OMG). This retrospective study included eighty-five patients with OMG who have been treated with pyridostigmine. Patients were excluded if they were diagnosed as generalized myasthenia gravis within a month after diagnosis or were treated with other medications. Forty-two patients responded to pyridostigmine and 43 patients did not. There were no significant differences in gender, age, the duration of symptoms before treatment, the dosage of pyridostigmine, and the initial presentations of ptosis or diplopia between the two groups. However, an initial presentation of concurrent ptosis and diplopia and the presence of systemic involvement after follow up were significant factors associated with an insensitivity to pyridostigmine in patients with OMG (p = 0.001 and p = 0.01, respectively). Determining these factors could help predict the pyridostigmine response in patients with OMG.

PMID 17891917  Asian Pac J Allergy Immunol. 2007 Mar;25(1):13-6.
著者: Hiroki Yano, Tomohiro Minagawa, Kana Masuda, Akiyoshi Hirano
雑誌名: J Plast Reconstr Aesthet Surg. 2009 Sep;62(9):e301-4. doi: 10.1016/j.bjps.2007.12.041. Epub 2008 May 19.
Abstract/Text Because guidelines for the treatment of blowout fractures have not been defined for urgent-care surgery, some patients retain a sight-threatening strabismus after surgery. The authors present a case involving the immediate operation of a blowout fracture based on CT findings and symptoms, demonstrating that early intervention may restore the full range of motion in the affected eye. The CT image showing the absence of the inferior rectus muscle on the orbital floor and no apparent fracture indicates the muscle strangulation. Immediate surgery must be performed to prevent irreversible muscular degeneration in such cases, rather than delaying the procedure by several days.

PMID 18490210  J Plast Reconstr Aesthet Surg. 2009 Sep;62(9):e301-4. d・・・
著者: Albert J Dal Canto, John V Linberg
雑誌名: Ophthal Plast Reconstr Surg. 2008 Nov-Dec;24(6):437-43. doi: 10.1097/IOP.0b013e31818aac9b.
Abstract/Text PURPOSE: To examine whether orbital floor and/or medial wall fracture repair delayed for 15 to 29 days is as effective as early surgery.
METHODS: A retrospective review is reported comparing outcomes of early fracture repairs (performed 1-14 days after trauma) to delayed fracture repairs (performed 15-29 days after trauma). Ocular motility, diplopia, and time to resolution of diplopia postoperatively are the main endpoints.
RESULTS: Fifty-eight patients were included in the study: 36 underwent early fracture repair (average 9 days after trauma) and 22 underwent delayed fracture repair (average 19 days after trauma). Ocular motility was equivalent in both groups, both before and after surgery. Patient reports of diplopia and frequency of strabisumus surgery were also equivalent in both groups. The time to resolution or stability of diplopia postoperatively is independent of the time to surgery within the first 29 days after trauma.
CONCLUSIONS: Although 14 days after trauma is commonly cited as a timeline target for orbital blowout repair, these data show that effective fracture repair can be performed up to 29 days after trauma. Patients with improving diplopia and at low risk for enophthalmos can therefore be observed for 3 to 4 weeks prior to undergoing surgery. This may help prevent unnecessary surgery in some cases. Fourteen days need not be considered a deadline for orbital floor and/or medial wall fracture repair.

PMID 19033838  Ophthal Plast Reconstr Surg. 2008 Nov-Dec;24(6):437-43.・・・
著者: Guy J Ben Simon, Hasan M Syed, John D McCann, Robert A Goldberg
雑誌名: Ophthalmic Surg Lasers Imaging. 2009 Mar-Apr;40(2):141-8.
Abstract/Text BACKGROUND AND OBJECTIVE: To compare early and late surgical repair of orbital blowout floor fractures.
PATIENTS AND METHODS: A retrospective, comparative interventional case series reviewed medical records of 50 consecutive patients who underwent unilateral orbital floor fracture repair in a 4-year period. Comparative analysis was performed between patients operated on within 2 weeks of injury and those operated on at a later stage.
RESULTS: Assault, motor vehicle accidents, and sports injuries were the most common causes of injury. Surgery was performed due to inferior rectus muscle entrapment and limitations in up gaze in 20 (40%) patients or to prevent enophthalmos in cases with significant bony orbital expansion in 30 (60%) patients. After surgery, enophthalmos improved an average of 0.8 mm. Limitation in ocular motility improved after surgery but was statistically significant only in up gaze. Patients who underwent early repair (within 2 weeks) achieved less improvement in enophthalmos versus patients who underwent late repair (delta enophthalmos of 0.2 +/- 1.1 vs 1.3 +/- 1.9 mm, respectively; P = .02).
CONCLUSION: In these patients, postoperative vertical ductions and postoperative enophthalmos improved after fracture repair. Surgery was associated with a low rate of postoperative complications. No apparent difference in surgical outcome was seen between early (within 2 weeks) and late surgical repair.

PMID 19320303  Ophthalmic Surg Lasers Imaging. 2009 Mar-Apr;40(2):141-・・・
著者: Masahiro Mori, Satoshi Kuwabara, Toshio Fukutake, Takamichi Hattori
雑誌名: Neurology. 2007 Apr 3;68(14):1144-6. doi: 10.1212/01.wnl.0000258673.31824.61.
Abstract/Text We analyzed clinical recovery of 92 patients with Miller Fisher syndrome who had been treated with IV immunoglobulin (IVIg; n = 28), plasmapheresis (n = 23), and no immune treatment (n = 41). IVIg slightly hastened the amelioration of ophthalmoplegia and ataxia, but the times of the disappearances of those symptoms were similar among three groups. In Miller Fisher syndrome, IVIg and plasmapheresis seem not to have influenced patients' outcomes, presumably because of good natural recovery.

PMID 17404197  Neurology. 2007 Apr 3;68(14):1144-6. doi: 10.1212/01.wn・・・

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