今日の臨床サポート

飛蚊症

著者: 北岡隆 長崎大学 医療科学専攻展開医療科学講座眼科・視覚科学教室

監修: 沖波聡 倉敷中央病院眼科

著者校正/監修レビュー済:2021/10/27
患者向け説明資料

概要・推奨   

  1. 飛蚊症の訴えがあった場合、急に生じたものは眼科専門医を紹介する(推奨度1)(治療すべき疾患が見つかった場合は各疾患ごとの推奨に準じる)
  1. 生理的飛蚊症の場合、まずは経過観察する(推奨度1
  1. 生理的飛蚊症で、QOLに影響を与える場合、硝子体手術やYAGレーザーによる硝子体混濁の除去を考慮する(推奨度3
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:
北岡隆 : 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、YAGレーザーによる飛蚊症治療の項目を追加した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 飛蚊症は眼科疾患のなかで比較的多い訴えで、典型的には「目の前に虫のような黒いものが浮かんで見える」という。原因としては、硝子体疾患、眼底疾患、ぶどう膜炎などぶどう膜疾患、感染性のものがある。
  1. ほとんどは硝子体の融解による液化や濃縮による生理的飛蚊症で治療の必要はないが、ときに重篤な疾患が潜んでいる場合があり、注意が必要である。
  1. 眼内の多くの部分を占める硝子体ゲルが虚脱し、網膜から分離する後部硝子体剝離によるものも多い。
  1. 後部硝子体剝離に起因するものでは、視神経乳頭近傍に輪状の混濁が生じることが多いが、後部硝子体剝離に伴い微小な血管が破綻し硝子体出血を生じるもの、網膜裂孔が生じ血管が破綻するものがある。
  1. 眼底疾患としては、網膜静脈閉塞症、糖尿病網膜症、加齢黄斑変性、コーツ病などで眼底出血が硝子体に波及したものがある。
  1. ぶどう膜炎では炎症の波及による硝子体炎で飛蚊症を生じる。
  1. 感染性眼内炎は内因性と外因性があり、放置すると失明する。
  1. 網膜裂孔から網膜剝離に進展する場合があり、緊急に加療が必要で、放置すると失明する。
問診・診察のポイント  
 
  1. いつからの発症か不明で、飛蚊症の数も変わらないものは、生理的飛蚊症のことが多い。

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文献 

著者: Ajeet M Wagle, Wei-Yen Lim, Tiong-Peng Yap, Kumari Neelam, Kah-Guan Au Eong
雑誌名: Am J Ophthalmol. 2011 Jul;152(1):60-65.e1. doi: 10.1016/j.ajo.2011.01.026. Epub 2011 May 12.
Abstract/Text PURPOSE: To ascertain the health-related quality of life associated with symptomatic degenerative vitreous floaters.
DESIGN: Cross-sectional questionnaire survey.
METHODS: In this institution-based study, 311 outpatients aged 21 years and older who presented with symptoms of floaters were enrolled. Data from 266 patients (85.5%) who completed the questionnaire were analyzed. Utility values were assessed using a standardized utility value questionnaire. The time trade-off (TTO) and standard gamble (SG) for death and blindness techniques were used to calculate the utility values. Descriptive, univariate, and multivariate analyses were performed using Stata Release 6.0.
RESULTS: The mean age of the study population was 52.9 ± 12.02 years (range, 21-97). The mean utility values were 0.89, 0.89, and 0.93 for TTO, SG (death), and SG (blindness), respectively. Patients aged ≤55 years reported significantly lower SG (blindness) utility values when compared with patients above 55 years of age (age ≤55 = 0.92, age >55 = 0.94, P = .007). Utility measurements did not demonstrate significant relationship with any of the other socio-demographic variables examined in this study. The utility values did not demonstrate any significant relationship with other ocular characteristics such as duration of symptoms, presence of a posterior vitreous detachment, and presence or severity of myopia.
CONCLUSIONS: Symptomatic degenerative vitreous floaters have a negative impact on health-related quality of life. Younger symptomatic patients are more likely to take a risk of blindness to get rid of the floaters than older patients.

Copyright © 2011 Elsevier Inc. All rights reserved.
PMID 21570045  Am J Ophthalmol. 2011 Jul;152(1):60-65.e1. doi: 10.1016・・・
著者: M M Brown, G C Brown, S Sharma, G Shah
雑誌名: Am J Ophthalmol. 1999 Sep;128(3):324-30.
Abstract/Text PURPOSE: To ascertain the utility values associated with diabetic retinopathy and varying degrees of visual loss.
METHODS: One hundred consecutive patients with diabetic retinopathy and best-corrected visual acuity decreased to 20/40 or worse in at least one eye occurring primarily as a result of diabetic retinopathy were evaluated in a cross-sectional study. Utility values were ascertained in five groups using both the time trade-off and standard gamble methods: group 1 (best-corrected visual acuity in the better eye of 20/20 to 20/25), group 2 (best-corrected visual acuity in the better eye of 20/30 to 20/50), group 3 (best-corrected visual acuity in the better eye of 20/60 to 20/100), group 4 (best-corrected visual acuity in the better eye of 20/200 to 20/400), and group 5 (best-corrected visual acuity in the better eye of counting fingers to hand motions).
RESULTS: The mean utility value for the diabetic retinopathy group as a whole was 0.77 (SD = 0.21; 95% confidence interval [CI], 0.73 to 0.81) with the time trade-off method and 0.88 (SD = 0.20; 95% CI, 0.84 to 0.92) with the standard gamble method. Employing the time trade-off method correlated with the best-corrected visual acuity in the better eye, the mean utility results were as follows: group 1 = 0.85 (95% CI, 0.75 to 0.95), group 2 = 0.78 (CI, 0.72 to 0.84), group 3 = 0.78 (CI, 0.67 to 0.89), group 4 = 0.64 (CI, 0.53 to 0.75), and group 5 = 0.59 (CI, 0.23 to 0.95). Thus, patients in group 1 (best-corrected visual acuity of 20/20 to 20/25 in the better eye) were willing to trade a mean of 15% of their remaining years of life in return for perfect vision in each eye, whereas those in group 5 (best-corrected visual acuity of counting fingers to hand motions in the better eye) were willing to trade a mean of 41% of their remaining years in return for perfect vision in each eye. There was no significant difference in mean utility values between patients who had decreased visual acuity from diabetic retinopathy for 1 year or less compared with those with decreased acuity for more than 1 year. There was also no significant difference in mean utility values between those with a 12th grade education or less compared with those with more than a 12th grade education.
CONCLUSION: Visual loss occurring secondary to diabetic retinopathy is associated with a substantial decrease in patient utility value (and quality of life). The utility value is directly dependent on the degree of visual loss associated with the disease. The length of time of visual loss and amount of formal education do not appear to affect the utility value.

PMID 10511027  Am J Ophthalmol. 1999 Sep;128(3):324-30.
著者: Karlijn F de Nie, N Crama, Maurits A D Tilanus, B Jeroen Klevering, Camiel J F Boon
雑誌名: Graefes Arch Clin Exp Ophthalmol. 2013 May;251(5):1373-82. doi: 10.1007/s00417-012-2205-3. Epub 2012 Dec 19.
Abstract/Text BACKGROUND: Primary vitreous floaters can be highly bothersome in some patients. In the case of persistently bothersome floaters, pars plana vitrectomy may be the most effective treatment. The aim of this study is to evaluate the incidence of complications, and patient satisfaction, after pars plana vitrectomy for disabling primary vitreous opacities.
METHODS: We included a total of 110 eyes that underwent pars plana vitrectomy between February 1998 and August 2010. Fifty-seven eyes (51.8%) underwent 20-gauge vitrectomy, whereas 53 eyes (48.2%) underwent 23-gauge vitrectomy. In a retrospective manner, we assessed intraoperative and postoperative complications. There was a considerable range of time between surgery and questionnaire (range: 4-136 months). Patient satisfaction was assessed by a questionnaire based on a modified NEI VFQ-25 questionnaire.
RESULTS: A retinal detachment occurred in 10.9% of cases, and the incidence did not differ significantly between the 20-gauge and 23-gauge vitrectomy groups. In 4.5% of the eyes, a retinal detachment developed within the first 3 months, and 6.4% occurred later in the postoperative period. Cystoid macular edema occurred in 5.5%, and an epiretinal membrane was seen postoperatively in 3.6% of cases. Development of glaucoma requiring glaucoma surgery, a macular hole, and postoperative scotoma, each occurred in 0.9% of cases. No cases of endophthalmitis occurred. Eighty-five percent of patients were satisfied or very satisfied with the results of the vitrectomy. Eighty-four percent of all patients were completely cured from their troublesome vitreous floaters, and an additional 9.3% of patients were less troubled by vitreous floaters. Ten patients (9.3%) were dissatisfied, and six of these patients (5.6%) had a serious complication that resulted in permanent visual loss.
CONCLUSIONS: Pars plana vitrectomy is an effective approach to treat primary vitreous floaters, resulting in a high rate of patient satisfaction. Postoperative complications may be more frequent than previously reported, so patients should be well-informed about the complication rate before reaching informed consent about this surgical intervention. Additional preventive measures should be considered to reduce this complication rate.

PMID 23250478  Graefes Arch Clin Exp Ophthalmol. 2013 May;251(5):1373-・・・
著者: John O Mason, Michael G Neimkin, John O Mason, Duncan A Friedman, Richard M Feist, Martin L Thomley, Michael A Albert
雑誌名: Retina. 2014 Jun;34(6):1055-61. doi: 10.1097/IAE.0000000000000063.
Abstract/Text PURPOSE: To determine the safety, efficacy, and quality of life improvement following sutureless 25-gauge pars plana vitrectomy for symptomatic floaters.
METHODS: Patients with symptomatic vitreous floaters who underwent sutureless vitrectomy between January 2008 and January 2011 were included. Data were collected regarding baseline preoperative characteristics, postoperative outcomes, complications, and a nine-item quality-of-life survey completed by each patient.
RESULTS: One hundred and sixty-eight eyes (143 patients) underwent sutureless 25-gauge pars plana vitrectomy for symptomatic vitreous floaters. Mean Snellen visual acuity was 20/40 preoperatively and improved to 20/25 postoperatively (P < 0.0001). Iatrogenic retinal breaks occurred in 12 of 168 eyes (7.1%). Intraoperative posterior vitreous detachment induction was not found to increase the risk of retinal breaks (P = 1.000). Postoperative complications occurred in three eyes, of which one had transient cystoid macular edema and two had transient vitreous hemorrhage. Approximately 88.8% of patients completed a quality-of-life survey, which revealed that 96% were "satisfied" with the results of the operation, and 94% rated the experience as a "complete success."
CONCLUSION: Sutureless 25-gauge pars plana vitrectomy for symptomatic vitreous floaters improved visual acuity, resulted in a high patient satisfaction quality-of-life survey, and had a low rate of postoperative complications. Sutureless pars plana vitrectomy should be considered as a viable means of managing patients with symptomatic vitreous floaters.

PMID 24384616  Retina. 2014 Jun;34(6):1055-61. doi: 10.1097/IAE.000000・・・
著者: Chirag P Shah, Jeffrey S Heier
雑誌名: JAMA Ophthalmol. 2017 Sep 1;135(9):918-923. doi: 10.1001/jamaophthalmol.2017.2388.
Abstract/Text Importance: Vitreous floaters are common and can worsen visual quality. YAG vitreolysis is an untested treatment for floaters.
Objective: To evaluate YAG laser vitreolysis vs sham vitreolysis for symptomatic Weiss ring floaters from posterior vitreous detachment.
Design, Setting, and Participants: This single-center, masked, sham-controlled randomized clinical trial was performed from March 25, 2015, to August 3, 2016, in 52 eyes of 52 patients (36 cases and 16 controls) treated at a private ophthalmology practice.
Interventions: Patients were randomly assigned to YAG laser vitreolysis or sham YAG (control).
Main Outcomes and Measures: Primary 6-month outcomes were subjective change measured from 0% to 100% using a 10-point visual disturbance score, a 5-level qualitative scale, and National Eye Institute Visual Functioning Questionnaire 25 (NEI VFQ-25). Secondary outcomes included objective change assessed by masked grading of color fundus photography and Early Treatment Diabetic Retinopathy Study best-corrected visual acuity.
Results: Fifty-two patients (52 eyes; 17 men and 35 women; 51 white and 1 Asian) with symptomatic Weiss rings were enrolled in the study (mean [SD] age, 61.4 [8.0] years for the YAG laser group and 61.1 [6.6] years for the sham group). The YAG laser group reported greater symptomatic improvement (54%) than controls (9%) (difference, 45%; 95% CI, 25%-64%; P < .001). In the YAG laser group, the 10-point visual disturbance score improved by 3.2 vs 0.1 in the sham group (difference, -3.0; 95% CI, -4.3 to -1.7; P < .001). A total of 19 patients (53%) in the YAG laser group reported significantly or completely improved symptoms vs 0 individuals in the sham group (difference, 53%; 95% CI, 36%-69%, P < .001). Compared with sham, NEI VFQ-25 revealed improved general vision (difference, 16.3; 95% CI, 0.9-31.7; P = .04), peripheral vision (difference, 11.6; 95% CI, 0.8-22.4; P = .04), role difficulties (difference, 17.3; 95% CI, 8.0-26.6; P < .001), and dependency (difference, 5.6; 95% CI, 0.5-10.8; P = .03) among the YAG laser group. Best-corrected visual acuity changed by -0.2 letters in the YAG laser group and by -0.6 letters in sham group (difference, 0.4; 95% CI, -6.5 to 5.3; P = .94). No differences in adverse events between groups were identified.
Conclusions and Relevance: YAG laser vitreolysis subjectively improved Weiss ring-related symptoms and objectively improved Weiss ring appearance. Greater confidence in these outcomes may result from larger confirmatory studies of longer duration.
Trial Registration: clinicaltrials.gov NCT02897583.

PMID 28727887  JAMA Ophthalmol. 2017 Sep 1;135(9):918-923. doi: 10.100・・・
著者: M R Dayan, D G Jayamanne, R M Andrews, P G Griffiths
雑誌名: Eye (Lond). 1996;10 ( Pt 4):456-8. doi: 10.1038/eye.1996.100.
Abstract/Text PURPOSE: The aim of the study was to determine whether patients presenting with an isolated posterior vitreous detachment require follow-up to identify retinal breaks not apparent at presentation and whether some histories are more predictive of associated serious posterior segment pathology.
METHODS: The notes of 295 patients presenting to eye casualty with flashes and/or floaters were reviewed.
RESULTS: One hundred and eighty-nine patients (64%) had isolated posterior vitreous detachments, 49 (16.6%) had retinal detachments and 31 (10.5%) had flat retinal tears. Three new breaks (3.3% of all tears found, 1.9% of review appointments) were identified only at follow-up. Although a subjective reduction in vision and a history of less than 6 weeks' duration were strongly predictive of retinal breaks, the large group of patients presenting with floaters alone (124/295, 42%) still harboured a significant proportion (26.7%) of the retinal breaks.
CONCLUSIONS: A follow-up visit for patients with an isolated posterior vitreous detachment can be justified to detect the small percentage of asymptomatic retinal breaks. Although a subjective reduction of vision is the symptom most predictive of serious posterior segment pathology, it would be unsafe to identify particular subgroups of patients alone for careful examination.

PMID 8944097  Eye (Lond). 1996;10 ( Pt 4):456-8. doi: 10.1038/eye.199・・・
著者: H Stevie Tan, Marco Mura, Sarit Y Lesnik Oberstein, Heico M Bijl
雑誌名: Am J Ophthalmol. 2011 Jun;151(6):995-8. doi: 10.1016/j.ajo.2011.01.005. Epub 2011 Mar 31.
Abstract/Text PURPOSE: To assess the risks of vitrectomy for the removal of primary and secondary vitreous opacities.
DESIGN: Retrospective, nonrandomized, interventional case series.
METHODS: We reviewed the results of 116 consecutive cases of vitrectomy for vitreous floaters. Eighty-six cases were primary and 30 cases were secondary floaters. Main outcome measures were the incidence of iatrogenic retinal breaks and postoperative rhegmatogenous retinal detachments.
RESULTS: We found iatrogenic retinal breaks in 16.4% of operations. There was no statistically significant difference in risk between cases of primary and secondary floaters. Intraoperative posterior vitreous detachment induction was found to increase significantly the risk of breaks. Retinal detachment occurred in 3 cases (2.5%), all after operations for primary floaters. One case of complicated retinal detachment ended with a low visual acuity of hand movements. Cataract occurred in 50% of phakic cases. Transient postoperative hypotony was found after 5.2% of our operations, and transient postoperative high intraocular pressure was encountered in 7.8%. An intraoperative choroidal hemorrhage occurred in 1 case, which resolved spontaneously. The mean visual acuity improved from 0.20 to 0.13 logarithm of the minimal angle of resolution units.
CONCLUSIONS: The risk profile of vitrectomy for floaters is comparable with that of vitrectomy for other elective indications. Retinal breaks are a common finding during surgery and treatment of these breaks is crucial for the prevention of postoperative retinal detachment. Patients considering surgery for floaters should be informed specifically about the risks involved.

Copyright © 2011 Elsevier Inc. All rights reserved.
PMID 21457930  Am J Ophthalmol. 2011 Jun;151(6):995-8. doi: 10.1016/j.・・・

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