今日の臨床サポート

眼精疲労

著者: 渥美一成 セントラルアイクリニック

監修: 沖波聡 倉敷中央病院眼科

著者校正/監修レビュー済:2022/05/11
患者向け説明資料

概要・推奨   

  1. 完全型のVDT症候群(Visual Display Terminal、ビジュアル・ディスプレイ・ターミナル)は存在しない。
  1. 眼精疲労を訴える患者にはまず、ドライアイがないかどうかの確認が必要である。その治療だけでかなり改善する。
  1. 屈折矯正手術後の高次収差が眼精疲労を起こすことがある。
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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:
渥美一成 : 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、コロナ禍での長時間の近距離矯正注視による眼精疲労が増加していることについて加筆した。 

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 眼精疲労と眼疲労の違いは、眼疲労は生理的な疲労であり、休息を取れば疲れが取れるのに対して、眼精疲労は病的な疲労の範疇に入り、疲れが蓄積し、翌日まで持ち越されるような疲労をいう。
  1. 眼精疲労の症状としては、眼が疲れる、眼が痛い、物が見にくくなる、頭が痛くなる、圧迫感がある、頭が重くなる、眼が乾く、涙が出る、のほか、さらには肩こり、めまい、胃部不快感など、不定愁訴が前面に出てくる場合がある。
  1. 眼疲労、眼精疲労ともに重ねた3つの輪のバランスによって、眼疲労や眼精疲労が起こるかどうかが決まると考えられる。1つは肉体的問題、1つは精神的問題、もう1つは環境・作業条件の問題である。
  1. 肉体的疲労があったとしても、その仕事に満足しており、作業環境がよければ、疲労は訴えない。
  1. つまり、3つの輪のバランスによって眼精疲労になるかどうかが決まる。
 
  1. 完全型のVDT症候群は存在しない。
  1. まとめ:
  1. VDT症候群やテクノストレス症候群社会的問題として認識されるようになってきたが、眼の症状、整形外科的症状、精神的症状をすべて兼ね備えた症例は1例もみたことがない。
  1. 代表事例:
  1. 例えば、テクノストレスでパソコン不適応の人はいるが、眼症状や、整形外科的症状はない。
  1. 結論:
  1. 現在のパソコンおよび携帯端末の使用によって、従来の頚肩腕症候群を起こすような症状は存在しない。あるとしても、電子機器との不適応があって眼が疲れるというようなパターンなので、これは、あらかじめ選別することができる。VDT作業は、もはや目新しい作業でもなく、時間さえ守れば、眼に対する影響は皆無といってよい。ただ、コロナ禍でリーモートワークやリモート授業が導入されつつあり、遊びとしての作業だけでなく、仕事、学業としての端末注視作業の時間が増えたことにより、眼精疲労が増加している。
  1. 追記:
  1. 日本産業衛生学会のように、自覚的症状で判断するだけでは、結論づけることが難しい例が多い。
問診・診察のポイント  
  1. 作業時間、作業内容も大事だが、それ以外に内環境、外環境にも注意を払う[1][2][3][4][5][6][7][8][9]
  1. 端末作業は20分連続作業したら、20秒間5~6m先を20秒間見る習慣をつけることが重要である。

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文献 

Gonzalo Muñoz, César Albarrán-Diego, Teresa Ferrer-Blasco, Hani F Sakla, Santiago García-Lázaro
Visual function after bilateral implantation of a new zonal refractive aspheric multifocal intraocular lens.
J Cataract Refract Surg. 2011 Nov;37(11):2043-52. doi: 10.1016/j.jcrs.2011.05.045.
Abstract/Text PURPOSE: To evaluate visual function after bilateral implantation of a zonal refractive aspheric multifocal intraocular lens (IOL).
SETTING: Private practice surgery center, Valencia, Spain.
DESIGN: Cohort study.
METHODS: Consecutive eyes with cataract had bilateral implantation of Lentis Mplus LS-312 multifocal IOLs. Distance, intermediate, and near visual acuities; contrast sensitivity; defocus curves; and a quality-of-vision questionnaire, including presence of halos or dysphotopsia, were evaluated 6 months postoperatively. A control group of age-matched monofocal pseudophakic patients was included to compare contrast sensitivity function.
RESULTS: In the multifocal group, the mean binocular corrected distance visual acuity (logMAR) was -0.04 ± 0.07 at 6 m, 0.11 ± 0.10 at 1 m, and 0.06 ± 0.07 at 40 cm. The defocus curve showed little intermediate vision drop off. Photopic contrast sensitivity for distance was similar to the monofocal IOL contrast sensitivity function, while photopic contrast sensitivity for near and mesopic contrast sensitivity for distance with or without glare was reduced at high frequencies. The mean patient satisfaction was 8.09 ± 1.30 (scale 0 to 10); 84.4% of patients were completely independent of spectacles. Moderate halos, glare, and night-vision problems were reported by 6.2%, 12.5%, and 15.6% of patients, respectively.
CONCLUSION: The new-generation multifocal IOL provided adequate distance, intermediate, and, to a lesser extent, near vision with high rates of spectacle freedom. Halos occurred, and other photic phenomena should be expected in a small percentage of patients.
FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.
PMID 22018366
Valdemar Portney
Light distribution in diffractive multifocal optics and its optimization.
J Cataract Refract Surg. 2011 Nov;37(11):2053-9. doi: 10.1016/j.jcrs.2011.04.038.
Abstract/Text PURPOSE: To expand a geometrical model of diffraction efficiency and its interpretation to the multifocal optic and to introduce formulas for analysis of far and near light distribution and their application to multifocal intraocular lenses (IOLs) and to diffraction efficiency optimization.
SETTING: Medical device consulting firm, Newport Coast, California, USA.
DESIGN: Experimental study.
METHOD: Application of a geometrical model to the kinoform (single focus diffractive optical element) was expanded to a multifocal optic to produce analytical definitions of light split between far and near images and light loss to other diffraction orders.
RESULTS: The geometrical model gave a simple interpretation of light split in a diffractive multifocal IOL. An analytical definition of light split between far, near, and light loss was introduced as curve fitting formulas. Several examples of application to common multifocal diffractive IOLs were developed; for example, to light-split change with wavelength. The analytical definition of diffraction efficiency may assist in optimization of multifocal diffractive optics that minimize light loss.
CONCLUSION: Formulas for analysis of light split between different foci of multifocal diffractive IOLs are useful in interpreting diffraction efficiency dependence on physical characteristics, such as blaze heights of the diffractive grooves and wavelength of light, as well as for optimizing multifocal diffractive optics.
FINANCIAL DISCLOSURE: Disclosure is found in the footnotes.

Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.
PMID 22018367
Abstract/Text PURPOSE: To assess binocular visual results in patients who were scheduled to undergo cataract/refractive lens exchange with multifocal IOL implantation using a "mix & match" approach.
METHODS: This prospective study enrolled 40 eyes of 20 patients aged between 44 and 78 years (median age = 58.1 years) implanted with a refractive multifocal IOL (ReZoom) in their dominant eye and a diffractive multifocal IOL (Tecnis) in their non-dominant eye. Near, intermediate, and distance vision were assessed at 2 months following implantation. Patients underwent refractive lens exchange or cataract surgery in the dominant eye first, followed by the non-dominant eye 1 to 2 weeks later. Emmetropia was the goal for all surgeries.
RESULTS: Preoperatively, the mean spherical equivalent refraction was +2.019 +/- 1.417 diopters (D) (median: +2.063 D). The mean binocular distance decimal visual acuity was 1.06 +/- 0.60 D, the mean binocular intermediate decimal visual acuity was 0.50 +/- 0.90 D, and the mean binocular near decimal visual acuity was 1.10 +/- 0.40 D.
CONCLUSIONS: Preliminary visual outcomes in this series of patients indicate good results at all distances.

PMID 18416266
Tetsuhiko Kakita, Takahiro Hiraoka, Tetsuro Oshika
Influence of overnight orthokeratology on axial elongation in childhood myopia.
Invest Ophthalmol Vis Sci. 2011 Apr 6;52(5):2170-4. doi: 10.1167/iovs.10-5485. Epub 2011 Apr 6.
Abstract/Text PURPOSE: This prospective study was conducted to assess the influence of overnight orthokeratology (OK) on axial elongation in children, with those wearing spectacles as controls.
METHODS: One hundred five subjects (210 eyes) were enrolled in the study. The OK group comprised 45 patients (90 eyes, age 12.1 ± 2.5 years, mean ± SD; OK group) who matched the inclusion criteria for OK. The control group comprised 60 patients (120 eyes, 11.9 ± 2.0 years) who also matched the inclusion criteria for OK but preferred spectacles for myopia correction. Axial length was measured at baseline and after 2 years using ocular biometry, and the changes were evaluated and compared between the groups.
RESULTS: Ninety-two subjects (42 and 50 in the OK and control groups, respectively) completed the 2-year follow-up examinations. At baseline, the spherical equivalent refractive error was -2.55 ± 1.82 and -2.59 ± 1.66 D, and the axial length was 24.66 ± 1.11 and 24.79 ± 0.80 mm in the OK and control groups, respectively, with no significant differences between the groups. The increase in axial length during the 2-year study period was 0.39 ± 0.27 and 0.61 ± 0.24 mm, respectively, and the difference was significant (P < 0.0001, unpaired t-test).
CONCLUSIONS: OK suppressed axial elongation in myopic children, suggesting that this treatment can slow the progression of myopia to a certain extent.

PMID 21212181
Kazuno Negishi, Kazuhiko Ohnuma, Takashi Ikeda, Toru Noda
Visual simulation of retinal images through a decentered monofocal and a refractive multifocal intraocular lens.
Jpn J Ophthalmol. 2005 Jul-Aug;49(4):281-6. doi: 10.1007/s10384-005-0194-z.
Abstract/Text PURPOSE: To evaluate the effect of decentration of a monofocal intraocular lens (IOL) and a refractive multifocal IOL on retinal image quality using a new visual simulation system.
METHODS: Using a new visual simulation system, we performed visual simulation of a monofocal and a multifocal IOL at 5, 4, 3, 2, 1, and 0.4 m with several decentered IOL positions from 0 to 1.0 mm through a 3- or 4-mm aperture using Landolt visual acuity (VA) charts. The VA was estimated under each condition from the simulated retinal image.
RESULTS: With a monofocal IOL, the image was affected minimally by decentration at 4 and 5 m; at 2 and 3 m, the image contrast decreased slightly with increased decentration. With the multifocal IOL, some loss of image contrast developed at all distances compared with the monofocal IOL; however, the images of the Landolt's rings were still recognizable under all conditions.
CONCLUSIONS: Our results suggest that up to 1.0 mm of decentration of a monofocal and multifocal IOL would not greatly affect the retinal image quality.

(c) Japanese Ophthalmological Society 2005.
PMID 16075326
Jonathan R Price, Edward Mitchell, Elizabeth Tidy, Vivien Hunot
Cognitive behaviour therapy for chronic fatigue syndrome in adults.
Cochrane Database Syst Rev. 2008 Jul 16;(3):CD001027. doi: 10.1002/14651858.CD001027.pub2. Epub 2008 Jul 16.
Abstract/Text BACKGROUND: Chronic fatigue syndrome (CFS) is a common, debilitating and serious health problem. Cognitive behaviour therapy (CBT) may help to alleviate the symptoms of CFS.
OBJECTIVES: To examine the effectiveness and acceptability of CBT for CFS, alone and in combination with other interventions, compared with usual care and other interventions.
SEARCH STRATEGY: CCDANCTR-Studies and CCDANCTR-References were searched on 28/3/2008. We conducted supplementary searches of other bibliographic databases. We searched reference lists of retrieved articles and contacted trial authors and experts in the field for information on ongoing/completed trials.
SELECTION CRITERIA: Randomised controlled trials involving adults with a primary diagnosis of CFS, assigned to a CBT condition compared with usual care or another intervention, alone or in combination.
DATA COLLECTION AND ANALYSIS: Data on patients, interventions and outcomes were extracted by two review authors independently, and risk of bias was assessed for each study. The primary outcome was reduction in fatigue severity, based on a continuous measure of symptom reduction, using the standardised mean difference (SMD), or a dichotomous measure of clinical response, using odds ratios (OR), with 95% confidence intervals (CI).
MAIN RESULTS: Fifteen studies (1043 CFS participants) were included in the review. When comparing CBT with usual care (six studies, 373 participants), the difference in fatigue mean scores at post-treatment was highly significant in favour of CBT (SMD -0.39, 95% CI -0.60 to -0.19), with 40% of CBT participants (four studies, 371 participants) showing clinical response in contrast with 26% in usual care (OR 0.47, 95% CI 0.29 to 0.76). Findings at follow-up were inconsistent. For CBT versus other psychological therapies, comprising relaxation, counselling and education/support (four studies, 313 participants), the difference in fatigue mean scores at post-treatment favoured CBT (SMD -0.43, 95% CI -0.65 to -0.20). Findings at follow-up were heterogeneous and inconsistent. Only two studies compared CBT against other interventions and one study compared CBT in combination with other interventions against usual care.
AUTHORS' CONCLUSIONS: CBT is effective in reducing the symptoms of fatigue at post-treatment compared with usual care, and may be more effective in reducing fatigue symptoms compared with other psychological therapies. The evidence base at follow-up is limited to a small group of studies with inconsistent findings. There is a lack of evidence on the comparative effectiveness of CBT alone or in combination with other treatments, and further studies are required to inform the development of effective treatment programmes for people with CFS.

PMID 18646067
M F ARMALY, N C JEPSON
Accommodation and the dynamics of the steady-state intraocular pressure.
Invest Ophthalmol. 1962 Aug;1:480-3.
Abstract/Text
PMID 13862325
F M Toates
Accommodation function of the human eye.
Physiol Rev. 1972 Oct;52(4):828-63. doi: 10.1152/physrev.1972.52.4.828.
Abstract/Text
PMID 4345068
Abstract/Text Although it is well established that autonomic control of ocular accommodation is predominantly parasympathetic, many investigators have, over the last 150 years, proposed that a supplementary sympathetic innervation should be considered. Particular attention is directed in this review to previous literature providing anatomical, physiological and pharmacological evidence for dual innervation of the ciliary muscle. Clinical and psychological evidence is shown to be equivocal. A review of recent laser optometry studies of tonic ("dark-focus") resting positions of accommodation indicates that the inhibitory nature of sympathetic innervation suggested by the majority of previous studies can be further defined with respect to specific adrenergic receptors. The implications of dual innervation relating to ocular accommodation during sustained near-vision tasks is discussed.

PMID 2872644
R F Fisher
The mechanics of accommodation in relation to presbyopia.
Eye (Lond). 1988;2 ( Pt 6):646-9. doi: 10.1038/eye.1988.119.
Abstract/Text The cause of presbyopia is closely related to the force of contraction of the ciliary muscle and the resistance to deformation of the crystalline lens. Two views are currently in conflict. The view of Donders (1864) that presbyopia is caused by a decrease in the force of contraction of the ciliary muscle with age, and the opposing view of Helmholtz (1855) that the lens becomes more difficult to deform with age due to lenticular sclerosis. The present paper shows that, in fact, the ciliary muscle undergoes a compensatory hypertrophy as accommodative amplitude decreases with age. The force of contraction is about 50% greater at the onset of presbyopia than in youth. However, because of increased lenticular resistance its effect on the amplitude of accommodation is small. It is shown that the reason the lens becomes more difficult to deform is not because of lenticular sclerosis, since the lens substance does not lose water. The increased difficulty of deformation is because the capsule loses its elastic force with age and the lens fibres, particularly in the nucleus, become more compacted.

PMID 3256503

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