水晶体温存硝子体手術における周辺硝子体切除

重症な網膜硝子体疾患に対する硝子体手術では完全な眼内郭清を行うことが前部増殖硝子体網膜症に対する予防になるため,水晶体切除を行うことが多い.しかし,50歳以下では白内障が見られないことも多く水晶体温存で行う場合もある.今回我々は硝子体手術時における眼内灌流のポート位置やポート数を変えることで水晶体を温存したまま,より確実な周辺硝子体の処理ができるかを検討した.対象は核白内障がEmery-Little分類のGrade1以下の網膜硝子体疾患18例18眼で,通常の3ポート硝子体切除術で行った群をA群,術中灌流ポート位置を変えた群をB群,4ポートで行った群をC群とした.3群について周辺硝子体切除後に硝子体可視化のためにトリアムシノロンを噴霧し残存硝子体を観察した.また,術後に水晶体の混濁を観察した.残存硝子体はA群では下方に多く見られたが,B,C群ではA群に比べ少なかった.水晶体混濁はA群では水晶体後極に2例,B群では水晶体赤道部付近に1例見られたがC群では見られなかった.これらより,水晶体温存硝子体手術では4ポートを用いることで水晶体に影響が少なくより確実な周辺硝子体の処理が可能であると考えられる.Crystalline lens excision is performed in many cases of surgery for serious vitreoretinopathy, since the purpose is the prevention of anterior proliferative vitreoretinopathy by perfect intraocular excision. However, crystalline lens preservation may be done at the age of 50 or less when cataract is not present. We studied whether processing of the peripheral vitreous body could be performed while preserving the crystalline lens by changing the port position and the number of ports of infusion in vitreous surgery. 18 vitreoretinopathy eyes that had core cataracts of one or less Grade of an Emery-Little classification were divided into 3 groups: in group A the usual 3-port vitreous surgery was performed; in group B the port position was changed during the operation; and in group C4 ports were used. For the vitreous body visualization in the three groups after peripheral vitreous body excision, triamcinolone acetonide was injected and the residual vitreous body was observed. Cloudiness of the crystalline lens was also observed after the operation. Crystalline lens clouding on the posterior pole was seen in two examples of group A. In group B, one example was seen near the crystalline lens equatorial part. Cloudiness was not seen in group C. Therefore, the crystalline lens in not affected if 4 ports are used in crystalline lens preservation vitreous surgery

成熟哺乳動物網膜の神経突起再生と神経栄養因子

近年,神経の分化や生存維持などにかかわる種々の因子が同定され,そのなかで特に神経栄養因子と呼ばれる一群の物質が様々な効果を神経に及ぼしていることがわかってきた.私達は視神経の再生を目標としてその一助となる薬剤の評価をするための実験系を組み立て,神経栄養因子の評価を行った.成熟ラットの網膜を用い,コラーゲンゲル中で網膜神経節細胞の組織培養を行った.培養液は無血清培養液を用い,その中に各種神経栄養因子nerve growth factor(NGF),brain-derived neurotrophic factor(BDNF),neurotrophin-3(NT-3),neurotrophin-4(NT-4)およびciliary neurotrophic factor(CNTF)を添加した.その後,再生してくる網膜神経節細胞の神経突起数を経時的に計測,比較することにより,各神経栄養因子が網膜神経節細胞の神経突起再生に与える効果を評価した.その結果,培養2日目から単離した網膜神経節細胞より再生神経突起が伸長するのが観察された.免疫組織染色によりこれらは中枢神経である網膜神経節細胞の再生神経突起であることがわかった.この再生神経突起の本数を比較したところ,BDNFおよびNT-4添加培養液では培養期間を通して神経突起の再生促進効果がみられた.NGF添加培養液では,培養早期には促進効果がみられたが,徐々にその効果は減弱した.NT-3およびCNTF添加培養液では,神経突起再生促進効果はみられなかった.BDNFを培養初期に投与したものと培養中期以降に投与したものを比較検討したところBDNFは培養初期に投与された時に神経突起再生促進効果が比較的大きいことが示唆された.Recent studies identified different factors involved in differentiation or survival of nerve cells. A particular group of substances, I.e., neurotrophic factors, has been found to affect nerve cells in various ways. Targeting the regeneration of optic nerve cells, we developed an assay system to evaluate drugs that support optic nerve regeneration and evaluated the neurotrophic factors. Retinal ganglion cells were removed from mature rats and incubated in collagen gels. A serum-free culture medium was spiked with various nerve growth factors (NGFs) including brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3), neurotrophin-4 (NT-4), and ciliary neurotrophic factor (CNTF). Regenerated neurites were counted within retinal ganglion cells and the number was compared with baseline values to evaluate the effect of each nerve growth factor on neurite regeneration in retinal ganglion cells. Regenerated neurites extended from isolated retinal ganglion cells from Day 2 of incubation. Immunohistological staining revealed that these regenerated neurites originated from retinal ganglion cells that are a part of the central nerves. Comparing the number of regenerated neurites, neurite regeneration was stimulated throughout the incubation period in culture media spiked with BDNF or NT-4. In the NGF-added medium, regeneration was promoted soon after the start of incubation, but the effect gradually diminished. In media spiked with NT-3 or CNTF, neurite regeneration was not stimulated. Comparing the effect of BDNF addition between early and intermediate/late stages of incubation, neurite regeneration was more stimulated extent when the medium was spiked with BDNF soon after the start of incubation

正常眼圧緑内障患者の眼圧日内変動と血圧との関係

正常眼圧緑内障の危険因子として唯一エビデンスが確立されているのは眼圧だけであり,その眼圧の高い値と大きな変動幅が疾患の進行に関与すると言われている.今回筆者らは血圧が正常眼圧緑内障進行の危険因子となりうるか否を検討した.対象は未治療の正常眼圧緑内障患者81例とし各患者の最高眼圧を示す時間帯および,眼圧変動幅を決定した.血圧の検討は収縮期140mmHgあるいは拡張期90mmHg以上を示す患者を高血圧群,収縮期血圧100mmHg以下を示す患者を低血圧群,それ以外の患者を正常血圧群と定義し各群における最高眼圧を示す時間帯,眼圧変動幅を比較した.全81例における平均日内変動幅は4.9mmHgであった.眼圧日内変動測定の結果眼圧が21mmHg以上で開放隅角緑内障と診断名が変更された症例は10例(12%)であった.最高眼圧を示す時間帯では午前型が35例(43.2%),午後型が16例(19.8%),夜型が5例(6.2%),深夜早朝型が21例(25.9%)であった.一方,日内変動幅が3mmHg未満で平坦型と分類されたのは4例(5%)であった.患者血圧群別の分類と眼圧変動幅は低血圧群15例で6.3mmHgと,正常血圧群10例の4.6mmHg,高血圧群56例の4.4mmHgと比較して有意に大きな変動幅を示した.(p<0.05).以上の結果から外来時眼圧が正常眼圧でも,再検で開放隅角緑内障と診断される症例があること,そして低血圧の症例では眼圧変動幅が大きい高いため低血圧が正常眼圧緑内障進行の一つの危険因子になりうると考えられた.Normal tension glaucoma is seen in many cases of glaucoma in Japan. Although this type of glaucoma may cause blindness, the mechanism leading to vision loss has yet to be explained. This disease has no effective treatment or prevention. No evidence exists for other risk factors except for intraocular pressure (IOP). Higher IOP and larger variability of IOP are known to be involved in progression. This study investigated whether blood pressure might be a risk factor for progression of normal tension glaucoma. The subjects were 81 patients with untreated normal tension glaucoma, and diurnal variation of intraocular pressure (IOP) and blood pressure were monitored. As for IOP, the period of time to reach the peak and diurnal variation of IOP were identified. The patients were classified by blood pressure: hypertension group (systolic ≧ 140 mmHg or diastolic ≧ 90 mmHg), hypotension group (systolic ≦ 100 mmHg) and normotension group (not applicable for the above two groups), and the time of the day when peak IOP was reached and diurnal variation of IOP were compared among the three groups. The mean diurnal variation of IOP in the 81 patients was 4.9 mmHg. Ten patients (12%) were diagnosed with open-angle glaucoma, not normal tension glaucoma, because they had IOP of ≧ 21 mmHg. Of 51 patients with a peak IOP in the daytime, 35 patients (43.2%) were morning type (9am - 12noon) and 16 patients (19.8%) were afternoon type (3pm - 6pm). Twenty-six patients had their peak at night: 5 patients (6.2%) were night type (9pm - Oam) and 21 patients (25.9%) were after-midnight to early morning type (3am - 6am) . The remaining 4 patients (5%) were regarded as flat type since their diurnal variations were 3 mmHg or lower. Comparing mean diurnal variations among the three blood pres-sure groups, the hypotension group (6.3 mmHg; n=15) was significantly larger than the normotension group (4.6 mmHg; n=10) and the hypertension group (4.4 mmHg; n=56) (p < 0.05). In conclusion, these results suggest that some patients may be found to have open-angle glaucoma in re-examination even if their IOPs in an outpatient clinic are normal, and that hypotension is potentially a risk factor for progression of normal tension glaucoma because many patients with hypotension show large diurnal variations

白内障術前後の高次収差の変化

視機能の評価は視力をはじめコントラスト感度などのさまざまな面から評価できる.健常者では光学系は理想的バランスに近い状態であり,屈折的に調整された状態では網膜にきれいな像を作る.白内障発症により光学特性は変化渉ると考え,光学的特性のずれを生じる.そのずれを収差(abrration)という.収差の面から,白内障術前後で比較検討した.白内障患者37眼の術前後収差を波面センサーOPD-Scan^(NIDEK社)を用い測定した.瞳孔径を4mmと設定し,検査値としては術前術後3回の平均値にて検討した.収差は低次収差と高次収差に分けられ,低次収差は眼鏡で矯正可能な成分である一方,高次収差は矯正不能である.高次収差の各成分(コマ様収差・球面様収差)においての変化量を算出した.高次収差は術前平均0.390(±1.51)μmが術後0.237(±0.097)μmと改善した.コマ様収差(S3+S5+S7)は術前平均0.373(±0.228)μmが術後0.222(±0.103)μmと改善した.球面様収葦(S4+S6+S8)は0.096(±0.078)μmが術後0.069(±0.030)μmと改善した.白内障症例の水晶体ではコマ様収差・球面様収差成分が増加している可能性が示唆された.We can evaluate visual quality in many ways, for example by examining contrast sensitivity. Objective measurements of retinal image quality is good in young people. Visual performance degrade with cataract. We evaluated change of aberration in eyes before and after cataract surgery. 37 eyes were examined with an OPD-Scano^ (NIDEK) aberrometer. Measurements were made 3 times for each before and after surgery. We used biconvex lenses with spherical surfaces (SI-40e, AMO). Higher order aberrations were decreased (-0.153μm, 4mm pupil). Spherical aberrations (S4+S6+S8) were also decreased (-0.027μm), as were Coma and trefoil aberrations (S3+S5+S7) (-0.151μm). These results indicate that higher order aberrations increase in eyes of cataract patients

ウサギ前房内接種型腸球菌眼内炎に対するガチフロキサシンの結膜下注射および点眼の抑制効果

正常ヒト結膜から分離した腸球菌(Enterococcus faecalis)をウサギ前房内に接種して眼内炎モデル(1群7匹7眼)を作製し,0.3%ガチフロキサシン(GFLX)の点眼及び結膜下注射を用いた眼内炎抑制効果を,生理食塩液を対照として検討した.点眼は腸球菌前房内接種30分前,直後及び1時間後,翌日からは4時間間隔にて1日3回3日間投与した.一方,結膜下注射は腸球菌前房内接種直後に一回だけおこない前房混濁のスコア及び眼内の生菌数を比較検討した.接種24時間後からみられた前房混濁を,GFLX点眼および結膜下注射は同等にすべての観察時点で生理食塩液に比較して有意に抑制した.また生理食塩液点眼群および結膜下注射群では7眼のうち4眼ずつで房水から細菌が検出されたが,GFLX点眼群および結膜下注射群ではそれぞれ1眼からも検出されなかった.以上の結果から,GFLXの点眼および結膜下注射は術後眼内炎の発症抑制に有効であると考えられ,方法としての結膜下注射は周術期感染予防のための抗菌薬使用法の一つの選択肢となりうることが示唆された.Two methods, eye drops and subconjunctival injection, of topical use of gatifloxacin were compared in a rabbit experimental endophthalmitis model. Enterococcus faecalis isolated from the normal human conjunctiva was inoculated into the rabbit anterior chamber to induce endophthalmitis. Test drugs were topically applied with eye drops 0.5 hours before inoculation, just after inoculation and at 1 hour after inoculation, then 3 times a day at 4-hour intervals for 3 subsequent days. In the case of subconjunctival injection, drugs were applied just after inoculation. Anterior chamber opacity and viable bacterial count in the aqueous humor were evaluated. Both methods significantly suppressed the inflammation at almost all the time points, in comparison with physiological saline. Viable bacteria were detected in the aqueous humor from 4 of 7 eyes receiving physiological saline, but non in the eyes treated with gatifloxacin. These results suggest that subconjunctival injection of gatifloxacin lowers endophthalmitis risk, as well as topical application with eye drops. Subconjunctival injection of gatifloxacin might be useful protect from post surgical endophthalmitis