続発緑内障の分類

眼圧上昇の機序により、続発開放隅角緑内障（線維柱帯～前房・線維柱帯・Schlemm管より後方に房水流出抵抗の主座が存在するもの）、続発閉塞隅角緑内障（瞳孔ブロック、虹彩－水晶体の前方移動による直接隅角閉塞、水晶体より後方に存在する組織の前方移動、周辺虹彩前癒着によるもの）に大別される。

緑内障性視野異常の程度分類

ゴールドマン動的視野検査では湖崎分類、Humphrey静的視野検査ではAulhorn 分類Greve変法あるいはHumphrey視野における視野欠損の程度分類を用いて、視野進行の病期の判定を行う。
 
参考文献：
日本緑内障学会：緑内障診療ガイドライン（第3版）、日本緑内障学会、2012:68-69
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瞳孔縁にみられる新生血管

血管新生緑内障は、予後不良となりやすい続発緑内障の代表である。このような所見をみた場合には、眼虚血を疑う。
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ぶどう膜炎続発緑内障

著明な前眼部炎症を示している。明瞭な角膜後面沈着物と虹彩後癒着が認められる。
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瞳孔縁にみられる落屑

落屑緑内障でみられる落屑物質は、瞳孔縁だけでなく、水晶体の前面にもみられることがある。
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瞳孔縁にみられる新生血管

血管新生緑内障は予後不良となりやすい続発緑内障の代表である。このような所見をみた場合には眼虚血を疑う。
出典
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ぶどう膜炎続発緑内障

著明な前眼部炎症を示している。明瞭な角膜後面沈着物と虹彩後癒着が認められる。
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Vogt-小柳-原田病に伴った急性続発閉塞隅角緑内障の超音波生体顕微鏡画像

高度な毛様体浮腫・剝離を呈しており（黄矢印）、虹彩水晶体隔膜の前方移動を生じている。
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ステロイド緑内障に対する線維柱帯切開術と線維柱帯切除術の効果

術後眼圧21mmHg以上を不成功と定義した場合、線維柱帯切開術と線維柱帯切除術の累積生存確率に統計学的有意差はみられず、同等の手術効果といえる（a）。しかしながら、18mmHg以上を不成功とした場合、線維柱帯切除術の累積生存確率は、線維柱帯切開術に比較して有意に良好な手術成績を示す（b）。
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1: Success rates of trabeculotomy for steroid-induced glaucoma: a comparative, multicenter, retrospective cohort study.
著者: Keiichiro Iwao, Masaru Inatani, Hidenobu Tanihara, Japanese Steroid-Induced Glaucoma Multicenter Study Group
雑誌名: Am J Ophthalmol. 2011 Jun;151(6):1047-1056.e1. doi: 10.1016/j.ajo.2010.11.028. Epub 2011 Mar 10.
Abstract/Text: PURPOSE: To evaluate the surgical outcomes of trabeculotomy for steroid-induced glaucoma.
DESIGN: Multicenter, retrospective cohort study.
METHODS: At 17 Japanese clinical centers, 121 steroid-induced glaucoma patients who underwent trabeculotomy between 1997 and 2006 were reviewed. Surgical failure was defined by the need for additional glaucoma surgery, deterioration of visual acuity to no light perception, or intraocular pressure ≥21 mm Hg (criterion A) and ≥18 mm Hg (criterion B). Surgical outcomes were compared with those of 108 primary open-angle glaucoma (POAG) patients who underwent trabeculotomy and 42 steroid-induced glaucoma patients who underwent trabeculectomy. Prognostic factors for failure were evaluated using the Cox proportional hazards model.
RESULTS: The probabilities of success at 3 years for trabeculotomy for steroid-induced glaucoma vs trabeculotomy for POAG was 78.1% vs 55.8% for criterion A (P = .0008) and 56.4% vs 30.6% for criterion B (P < .0001), respectively. At 3 years, the success of trabeculotomy for steroid-induced glaucoma was comparable to trabeculectomy for steroid-induced glaucoma for criterion A (83.8%; P = .3636), but lower for criterion B (71.6%; P = .0352). Prognostic factors for failure of trabeculotomy for steroid-induced glaucoma were previous vitrectomy (relative risk [RR] = 5.340; P = .0452 on criterion A, RR = 3.898; P = .0360 for criterion B) and corticosteroid administration other than ocular instillation (RR = 2.752; P = .0352 for criterion B).
CONCLUSIONS: Trabeculotomy is effective for controlling intraocular pressure <21 mm Hg in steroid-induced glaucoma eyes.

Copyright © 2011 Elsevier Inc. All rights reserved.
Am J Ophthalmol. 2011 Jun;151(6):1047-1056.e1. doi: 10.1016/j.ajo.2010...

血管新生緑内障に対するベバシズマブ硝子体注入併用線維柱帯切除術の効果

血管新生緑内障において、MMC併用線維柱帯切除術にベバシズマブ硝子体内投与を組み合わせた場合、術後早期の眼圧は有意にベバシズマブ硝子体内投与併用群（IVB Group）がコントロール群（Control Group）より低かった。しかし、長期生存をKaplan-Meier生存曲線で評価すると両者に有意な差はみられない。
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1: Combined intravitreal bevacizumab and trabeculectomy with mitomycin C versus trabeculectomy with mitomycin C alone for neovascular glaucoma.
著者: Yuji Takihara, Masaru Inatani, Takahiro Kawaji, Mikiko Fukushima, Keiichiro Iwao, Minako Iwao, Hidenobu Tanihara
雑誌名: J Glaucoma. 2011 Mar;20(3):196-201. doi: 10.1097/IJG.0b013e3181d9ce12.
Abstract/Text: PURPOSE: To evaluate the effects of intravitreal bevacizumab (IVB) before mitomycin C trabeculectomy (MMCT) for neovascular glaucoma (NVG).
METHODS: The study is a retrospective, comparative, consecutive case series. The study group consisted of 57 eyes from 50 patients with NVG who underwent a first MMCT: 33 eyes were treated with MMCT alone between June 1, 2005 and May 17, 2007 (Control Group); and, 24 eyes were treated with a combination of IVB and MMCT after May 18, 2007 (IVB Group). Surgical complications, intraocular pressure (IOP), and the probability of success were compared between the 2 groups. Surgical failure was defined as IOP ≥22 mm Hg for 2 consecutive follow-up visits, a deterioration of visual acuity to no light perception, or additional glaucoma surgeries.
RESULTS: There were no significant differences in preoperative data between the groups. Hyphema associated with MMCT occurred significantly less often in the IVB Group (P=0.006). IOPs at 7 and 10 days after MMCT were significantly lower in the IVB Group (P=0.01 and 0.02, respectively). However, Kaplan-Meier survival-curve analysis showed the probability of success 120, 240, and 360 days after MMCT of 87.5%, 79.2%, and 65.2% in the IVB Group, and 75.0%, 71.9%, and 65.3% in the Control Group. No significant difference in survival times was found between the groups (P=0.76).
CONCLUSIONS: IVB before MMCT reduced hyphema associated with MMCT for NVG. IVB provided further IOP reduction immediately after MMCT, but did not significantly improve surgical outcomes over longer periods.
J Glaucoma. 2011 Mar;20(3):196-201. doi: 10.1097/IJG.0b013e3181d9ce12....

落屑緑内障におけるラタノプロストとチモロールの眼圧下降効果

ラタノプロスト点眼群の眼圧下降効果（ベースライン眼圧：◆、治療後眼圧：■）が、0.5%チモロール点眼群の眼圧下降効果（ベースライン眼圧：▲、治療後眼圧：●）より、大きい傾向にあり、特に午前8時に設定された点眼時の眼圧下降は有意にラタノプロスト点眼群が大きい。また、有意に日内変動幅はラタノプロスト点眼群で有意に小さく抑えられる。
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1: Diurnal intraocular pressure reduction with latanoprost 0.005% compared to timolol maleate 0.5% as monotherapy in subjects with exfoliation glaucoma.
著者: A G P Konstas, N Mylopoulos, C H Karabatsas, V P Kozobolis, S Diafas, P Papapanos, N Georgiadis, W C Stewart
雑誌名: Eye (Lond). 2004 Sep;18(9):893-9. doi: 10.1038/sj.eye.6701345.
Abstract/Text: AIMS: To compare the diurnal intraocular pressure (IOP) efficacy and safety of timolol vs latanoprost in subjects with exfoliation glaucoma (XFG).
METHODS: A 3-month prospective, single-masked, active-controlled, parallel comparison performed in six centres in Greece that randomized subjects in a 1 : 1 ratio to either latanoprost in the evening (2000 hours) and placebo in the morning (0800 hours), or timolol twice daily (0800 and 2000 hours).
RESULTS: In all, 103 subjects completed the study. After 3 months of chronic dosing, the latanoprost group exhibited a trend to a greater diurnal IOP reduction from an untreated baseline (24.9+/-3.2-17.4+/-2.9) compared with timolol (24.7+/-2.8-18.3+/-1.9 mmHg) (P=0.07). Latanoprost showed a significantly greater IOP reduction at 0800 hours (-8.5 vs -6.0 mm Hg for timolol, P<0.0001) whereas no difference was observed between the two medications at 1000, 1400, and 2000 hours after a Bonferroni Correction. In addition, latanoprost demonstrated a narrower range of diurnal IOP (2.4) than timolol (3.2 mmHg)(P=0.0017). Safety was similar between groups, except there was more conjunctival hyperaemia with latanoprost (n=8) than timolol (n=1)(P=0.01).
CONCLUSIONS: This study suggests that latanoprost provides a statistically lower 08:00-hour IOP and better range of IOP than timolol in the treatment of XFG glaucoma.
Eye (Lond). 2004 Sep;18(9):893-9. doi: 10.1038/sj.eye.6701345.

落屑緑内障におけるチモロール、ドルゾラミドの眼圧下降効果

単剤治療時の0.5%チモロール点眼と2%ドルゾラミド点眼の眼圧下降効果を点眼開始後2週間、6カ月後で評価した結果、眼圧下降の程度は午前中の眼圧ピーク時および午後のトラフ時ともに、0.5%チモロールのほうが大きな眼圧下降効果を示す。
a：点眼開始後2週間
b：点眼開始後6カ月後
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1: A comparison of dorzolamide and timolol in patients with pseudoexfoliation and glaucoma or ocular hypertension.
著者: A Heijl, E Strahlman, T Sverrisson, O Brinchman-Hansen, T Puustjärvi, R Tipping
雑誌名: Ophthalmology. 1997 Jan;104(1):137-42.
Abstract/Text: PURPOSE: The purpose of the study is to compare the efficacy and safety profile of 2.0% dorzolamide (three times daily) and 0.5% timolol (twice daily) for up to 6 months in patients with glaucoma or ocular hypertension associated with pseudoexfoliation. The additive effects of dorzolamide and timolol in patients requiring add-on therapy also was evaluated.
METHODS: This was a double-masked, randomized, parallel comparison study at 15 Scandinavian sites. One hundred eighty-four patients with pseudoexfoliation and either glaucoma or ocular hypertension who were 21 to 85 years of age were studied. The treatment groups were 2.0% dorzolamide three times daily and 0.5% timolol maleate twice daily.
RESULTS: At 6 months, the mean percent reduction in intraocular pressure of 2% dorzolamide and 0.5% timolol was 24% and 29%, respectively, at morning peak and 21% and 23%, respectively, at afternoon trough. The additional intraocular pressure-lowering effect of adding 2.0% dorzolamide twice daily to patients receiving timolol was 14% and 15%, at peak and trough, respectively. There were no differences between treatment groups in the incidence of clinical adverse experiences, and dorzolamide was not associated with the systemic adverse effects typically ascribed to the use of oral carbonic anhydrase inhibitors.
CONCLUSION: Two percent dorzolamide (three times daily) was effective and well tolerated in patients with glaucoma or ocular hypertension associated with pseudoexfoliation over the course of 6 months; 0.5% timolol (twice daily) had a greater level of intraocular pressure-lowering activity than did dorzolamide, although the difference between the two treatments became less pronounced during the study period. Finally, 2.0% dorzolamide (twice daily) produced additional lowering of intraocular pressure when given with 0.5% timolol (twice daily).
Ophthalmology. 1997 Jan;104(1):137-42.

続発緑内障におけるリパスジル点眼薬の眼圧下降効果

ぶどう膜炎続発緑内障に対する手術効果

初期診療・治療の流れ

参考文献：
日本緑内障学会：緑内障診療ガイドライン（第4版）、日本眼科学会雑誌 122：5-53，2018
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