第14回 冬季ヨーロッパ白内障・屈折手術学会(ESCRS)参加:お知らせ

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2010年2月2日

第14回 冬季ヨーロッパ白内障・屈折手術学会(ESCRS)参加

カテゴリー: お知らせ, 学会 — admin

第14回 冬季ヨーロッパ白内障・屈折手術学会(ESCRS)の為、ハンガリーの首都ブダペストに、2月12~14日訪れました。

参加するだけでなく、「ブロードビームレーザーを使用したスーパーPRK」についての報告をして参りました。

当地は、13年前、イントラレーシック発生の地であり、その開発発展に協力を要請された故S.フィヨドロフ博士と前後して訪れました。

開発した仲間のドクターイワンとの久しぶりの再会を満喫しました。

2006年6月23日

第8回ISAM(環境適応医学国際学会)

カテゴリー: 学会 — admin

nternational Society For
Adaptive Medicine (ISAM)
Moscow, RUSSIA
June21-24,2006

June 23, Friday 9:00 – 9:30
PLENARY LECTURE(lecture-room No. 1)
Chairs.: Okuyama K. (Japan);
Manukhina Eu. (Russia)
PL-7. MITOCHONDRIAL PROLIFERATION AS
ADAPTATION MECHANISM IN VARIOUS
DISEASES

Sukhorukov V.S., Russia
2006年6月23日

第8回ISAM(環境適応医学国際学会)に発表

Intermittent Hypoxic Training (IHT) as a Clinical Treatment

低酸素環境が、臨床に及ぼす影響を唾液腺、涙液腺中のアミラーゼ含有量を介した研究。

経過は、低酸素環境は一過性のストレスになるが、速やかに正常状態に回復することをもって特長とする。

2003年12月11日

Wave-front and Fourier Analysis of the High Myopia Transepithelial PRK on Profile-500

カテゴリー: 学会 — admin

Wave-front and Fourier Analysis of the High Myopia Transepithelial PRK on Profile-500

Author(s):Kodo Okuyama,Viktor Movshev
Hospital or Institution:Sangubashi Eye Clinic,IRTC Microsurgery
Address for Correspondence: 1-2-15-201 Higashigotanda Shinagawa-ku Tokyo JAPAN
Tel : 81+3+34463902Fax : 81+3+3782178
Email:okuyama@k.email.ne.jp

Purpose: To evaluate the predictability, safety, and long term stability of transepithelial PRK for the correction of the high and very high myopia and astigmatism using the Profile-500 Gaussian beam excimer laser.

Methods: We choose at random 10 patients,18 eyes,with high(8 eyes)and very high myopia(10eyes).Among the 7 females and 3 males.Mean age was37.7 years. Before the transepithelial PRK there was routine refractive examinations,contrast sensitivity and endothelial cell counts. After the operation we tried to evaluate the operation,using by KR-9000 PW Wavefront analyzer and TMS-2N videokeratotopograph.

Results:Mean Spherical Equivalent before the operation was -11.5+/-0.38D,after the operation was -1.75+/-0.42D. Three eyes were operated twice due to haze classified as Fantes 1 to 2. Wavefront analyzer and Fourier Analysis show the appearance of prismatic effect. There is not significant high order irregularity. After the second operation all three eyes decrease haze level to Fantes 0.5.

Conclusion : Ablation patterns of the Gaussian beam at a given fluence level of the Profile-500 gives us aspherical surfaces with optimal balance between defocusing and spherical aberration for patient with high myopia. We can not see significant reduction of contrast sensitivity. In some case with haze for 3 to 12 months contrast sensitivity reduced, however after disappearing of haze the contrast sensitivity returned to the previous level.

Biochemical Investigations of Lacrima in Early Diagnosis of Keratoconus
Author(s): Leonid Legkikh1, M. Koledintsev2, A. Semenova2, K.Okuyama3

Hospital or Institution: 1. Svyatoslav Fyodorov S.I. Eye Microsurgery complex, Beskudnikovsky Blvd.59A 127486, Moscow, Russia Moscow, Russia

2. Moscow Medical Stomatological University, Moscow, Russia

3.Sangubashi Eye Clinic, Tokyo, Japan

Purpose: To study results of biochemical investigation of lacrimal fluid in patients with initial keratoconus to develop tests of early diagnosis of disease.

Methods: 26 patients with initial keratoconus aged from 16 to 44 years were examined The control group consists of 20 practically healthy people in the same age. The biochemical investigation of lacrima was performed with the biochemical analyzer.

Results : The biochemical analysis of lacrima showed, that an increase of activation of Lactate dehydrogenase, creatine phosphokinase, amylase etc. These data in combination with an increase of general protein and products of albuminolysis(urea, uric acid) compared with the control group is notable for patients with initial keratoconus.

Conclusion: The method of biochemical analysis of lacrimal fluid can be used in the early diagnosis of keratoconus.

Immunologic Investigations of Lacrima in early Diagnosis Keratoconus
Author(s): Anna Semenova 1, M. Koledintsev 2, L. Legkikh 1, K. Okuyama 3

Hospital or Institution: Svyatoslav Fyodorov S.I.”Eye Microsurgery Complex

Address for Correspondence: Beskudnikovsky Blvd. 59A, 127486, Moscow, Russia

E-mail :semenaru @yahoo.com

Tel: (095) 488-8424 Fax: (095) 905-5333

Purpose: To study results of immunologic investigations of lacrima in patients with initialkeratoconus for development of tests of early diagnosis of disease
Setting/Venue:1.Svyatoslav Fyodorov S.I. Eye Microsurgery Complex,Moscow,Russia

2.Moscow Medical Stomatological University.

3.Sangubashi Eye Clinic,Tokyo,Japan.

Methods: 26 patients with initial keratoconus aged from 16 to 44 years were examined. The Control group consists of 20 practically healthy people of the same age. The immunologic investigation of lacrima included a determination of concentration of A,M,G immunoglobulins by method of Manchini G.Radial immunodiffusion.

Results: The immunologic investigation of lacrima showed a significant Ig A increase in18 of 26 patients(69.2%). A significant increase Ig G in 53.8%.

We noted a tendency to increase of Ig M compared with the control. The difference was not significant. Thus, considerable differences in the level of immune proteins of lacrima were noted in patients with keratoconus compared with the control..

Conclusions: Methods of immunologic investigation of lacrima can be used in the early diagnosis of keratoconus.

2003年8月20日

Induction of the heat shock protein in rat lungs following intermittent hypoxic training

カテゴリー: 学会 — admin

Induction of the heat shock protein in rat lungs following intermittent hypoxic training

KoDo Okuyama 1), Jingtao Jiang 2)
Clinical Research Laboratory of ‘Mountain Air’ Therapy 2-21-15 Shimouma Setagaya-ku Tokyo JAPAN
Central Institute for Electron Microscopic Researches, Nippon Medical School, Sendagi, Bunkyo-ku, Tokyo, Japan.

Abstract

In order to demonstrate the mechanism of intermittent hypoxic training (IHT), we studied the expression of HSP70 by immunohistochemistry using the Streptavidin Biotin Peroxidase Complex(SABC) Method on alveolar type I , type II epithelial cells, macrophages from rats with IHT. The expression of HSP70 in IHT in comparison with control was significantly increased on alveolar type I , type II epithelial cells, macrophages and was significantly correlated with the duration of IHT.
This study demonstrates that expression of HSP70 may be a mechanism of adaptation of hypoxia by IHT.
Key words: Intermittent hypoxic training HSP70 Electron microcopy Immunohistochemistry
lntroduction
Intermittent hypoxic training (IHT), with repeated short-term inhalation of hypoxic mixtures, has been used to treat and prevent certain diseases and has a very favorable effect for the exercise of athletes 1,2. Investigations of IHT have showed that increased hypoxic ventilatory response (HVR) 3,4 is an important physiological response. Resent studies have displayed that IHT inhibits the free radical production, which gives harmful effect to the cells and tissues, and raise the metabolic rate as a result of sympathetic nervous system activation 5,6. Rats trained to intermittent normobaric hypoxia developed an increase of the glycogen contents in the heart and liver parenchymatous cells and offered as many beneficial effects in protecting against myocardial injuries 7,8. Antixidant enzymes and stress proteins may be part of the mechanisms contributing to the cardioprotection of the intermittent hypoxic adaptation 7.Heat shock causes intracellular expression of a specific group of proteins called heat steins (HSPs) that have broad cytoprotective properties 9,10. The first demonstration of HSP- mediated cytoprotection involved the phenomenon of thermotolerance, whereby a brief heat shock conferred protectionagainst subsequent exposure to otherwise lethal hyperthermia 11. Subsequent studies demonstrated that induction of HSPs also protected cells and whole organs against nonthermal cytotoxic agents such as oxidants, nitric oxide, tumor necrosis factor-α, and endotoxin 12-14. Previous studies also demonstrated that induction of HSPs protected against in vitro and in vivo models of acute lung injury and may have therapeutic value for attenuating acute lung injury . HSP 70 has been shown to be protective following ischemic injury. Similarly, a member of the small heat shock family, HSP27 has been shown to play a role in cellular repair and mechanisms of protection against cell stress. In this study, we are used monoclonal antibody to heat shock protein 70 to investigate whether IHT induces the expression of HSP70 in lungs.

Materials and methods

1. Animals
A total of 18 male Wistar rats, aged 12 weeks were used: three animals for control and rest for the experimental groups. They were allowed free access to food and water during intermittent hypoxic training.
2.Intermittent hypoxic training:
Hypoxia was induced by exposure to 10% oxygen with machine. The rats were sustained hypoxia for 15min one time a day for 3, 7, or 21 consecutive days, respectively. Control rats exposured toroom air.
3. Light and electron microscopy.
At 3D, 7D and 21 Days after intermittent hypoxic training (IHT), the animals were anesthetized with pentobarbital sodium (50mg/kg) and lungs were removed. For light microscopic examination, the tissues were fixed with 10% formalin in phosphate buffer solution, and embedded in paraffin.
Then paraffin sections of 2 μm in thickness were prepared and stained with hematoxylin and eosin. For electron microscopic examination, rat lung specimens were cut into 2mm3 blocks, fixed 2.5% glutaraldehyde in 0.1M phosphate buffer and
postfixed with 1% osmium tetroxide, dehydrated in a graded alcohol series and embedded in Epon 812. Semithin sections stained with toluidine blue were used for high light microscopy and selection of areas for thin sectioning. Thin sections were cut with 5000 Ultrotome, stained with uranyl acetate and lead citrate. The sections were examined under a JEM- 1010 transmission electron microscope.
4. Immunohistochemistry
The Streptavidin Biotin Peroxidase Complex (SABC) Method was employed for immunohistochemistry for heat shock protein (HSF70). Briefly, deparaffinized sections were treated for 30 min with 0.3% H2O2 to block endogenous peroxidase and rinsed again 3×5 min inPBS. Sections were then incubated for 30 min with block nonspecific reactive sites by applying 1 :20 normal goat serum and incubated with Monoclonal anti-HSP antibody (NOVO) diluted 1:40 in PBS for 60 min. After washing in PBS, they were incubated with goat anti-mouse immunoglobulins for 10 min and then incubated with a mixture of streptavidin and biotinylated horseradish peroxidase for 5 min. After washing in PBS, reacted with 0.05% 3 – 3′ diaminobenzidine (DAB) containing 0.01 %H2O2.

Results

Light microscopic observations
The morphological observations in the control group were normal from 3 days to 21 days. After three days IHT, the remarkable interstitial edema,increased thickness of the alveolar septa, marked capillary dilatation,proliferation of interstitial cells, the collapse of alveoli and dilation of the alveolar ducts were observed compared with controls (Fig. 1A). After 7 days IHT, those pathologic changes decreased than 3 days (Fig.1B). After 21 days of IHT, the nearly normal structure of lungs was observed (Fig.1C).

Immunohistochemical observation

The heat shock protein 70 monoclonal antibody was used to stain the lung tissue from the control and IHT rats immunohistochemically. In control lungs, there are weak positive staining for HSP70 observed in the bronchial epithelial cells as well as in some alveolar type II epithelial cells.
After 3 days IHT, HSP70 was moderately expressed in alveolar type I ,type II epithelial cells, macrophages and bronchial epithelial cells. HSP70 expressed in cytoplasm and nuclei (Fig.2A). After 7 days IHT, expression of HSP70 was same as 3 days IHT (Fig.2B). After 21 days IHT, there was strong septa also were displayed. By 7 days, the congestion of capillary, type II cell proliferation, and lipid drops in alveolar septa were observed. By 21 days,congestion of capillary, increased capillaryendothelial volume, lipid drops in the alveolar septa and proliferation of alveolar type II cells were noted(Fig.3B).

Discussion :

The principle of intermittent hypoxic training (IHT), with repeated short-term inhalation of hypoxic mixtures had been proposed by S. Strelkov and his associates in the early of 1980’s based on their obstetrical practice. Intermittent hypoxic training (IHT) has showed promise for prevention and treatment of some diseases and efficiently produces great advancement in athletic training 1,2. The mechanism of IHT remains unidentified. A number of mechanisms have been postulated including optimizing both hypothalamic-pituitary-adrenal axis functioning and free radical-mediated process control 5, increase of the quantity and secretory activity of peptidergic neurons of the paraventricular hypothalamic nucleus (PHN) 16,enhancement of neurotransmission in the carotid body (CB) as well as in central
structures through NADPH oxidase stimulation 17, increase in ventilatory response under repetitive hypoxia, changes in suprapontine facilitation of resporatory activity and Changes in monoamine metabolism or release 18, and raise the metabolic rate as a result of sympathetic nervous system activation 6.
In our clinical practice, we found that IHT could release the stress in some patients. In this study, we found that IHT induced the expression of HSP70. The response of cells or organisms to stress such as exposure to heat or chemicals is associated with the induction of heat shock proteins (HSPs). Heat shock proteins (HSPs) are an evolutionarily conserved group of proteins that are highly inducible by a wide variety of stressors. HSPs are grouped by molecular weight and amino acid sequence similarity into five main families: The high molecular weight 100-110kDa family; the 83-90kDa family; the 70kDa family ranging from 66 to 78kDa and containing the highly inducible HSP 70; the 60kDa family present in bacteria,mitochondria, and chloroplasts; and a diverse group of small HSPs ranging from 15 to 30kDa. Of great interest are observations demonstrating that once a heat shock response has been induced, the cells or organs can show remarkable resistance to subsequent metabolic stress. Heat shock protein 70 (HSP70) has been shown to have a protective role in ischemic disease,inflammation, infection and a potential role in antigen processing as well as a possible regulatory role in cytokine biosythesis 13,14. HSP70 exists in the cell in equilibrium between its free state, in the cytoplasm, and its bound state, protecting proteins in the nucleolus, perhaps either by helping refold some of the unfolded ribosomal proteins or by solubilising the denatured ribosomal proteins to facilitate their turnover. During release from heat shock and as the nucleoli begin to recover their normal activities, most of the HSP 70 returns to the cytoplasm. Stress proteins have an important role in normal cellular physiology apart from participation in the stress response. Under normal conditions, stress proteins are involved in the successful folding, assembly, intracellular localization, and secretion of nascent protein chains as they emerge from the ribosome. Stress proteins also function to regulate the degradation of proteins to prevent the accumulation of protein aggregates within the cell. Cultured bovien and ovine pulmonory artery endothelial cells and guinea pig airway epithelial cells and alveolary macrophages expressed abundant HSP 70 after thermal stress14, 19, 20. In rabbit alveolar type II cells, the process of cell isolation itself induced stress protein expression 21. In vivo thermal stress increased stress protein expression in the lungs and other organs of rats, and the time courses and relative magnitudes of expression differed among organs 22,23. Bonay et al demonstrated limited stress protein expression in normal human lungs. HSP90, HSP 70 and HSP63 were selectively expressed in proximal bronchiolar epithelium and alveolar macrophage. In contrast, more distal bronchiolar epithelium, type I and type II alveolar cells, and stromal cells did not express stress proteins 24. HSP 70 expression was substantially increased in airway epithelium and alveolar macrophages of patients with asthma compared with control subjects 25. In this study, we observed the morphologic changes of lungs and expression of HSP70 after rat IHT. We found that that pulmonary damage occurred at 3 days IHT, one week IHT later, the pulmonary damage repaired in hypoxic animals. The expression of HSP70 observed in alveolar type I, type IIepithelial cells,macrophages and bronchial epithelial cells after 3 dr 3 days IHT, andcontinually expressed until 2l days IHT. Expression of HSP 70 in 21 days IHT was stronger than 3 days IHT. This revealed that IHT could induce HSP70 in alveolar type I , type II epithelial cells, macrophages and bronchial epithelial cellsveolar type I, type II epithelial cells, macrophages and bronchial epithelial cells after IHT. HSP70 expressed after 3 days IHT, and continued to 21 days IHT. Although the exact significance of these data is still unresolved, it is proposed expression of HSP may be a mechanism of adaptation of hypoxia with IHT.

Reference

1 Serebrovskaya T, Swanson R, Karaban IN, Serebrovskaya Z, Kolesnikova EE. Intermittent hypoxia alters hypoxic ventilatory responses. Fiziol Zh. 45(5): 9-18, l999
2 Serebrovskaya T, Swarotective effect of stress protein induction in a rat model of acute lung injury caused by intratracheal administration of phospholipase A1 and systemic administration of endotoxin 22,23.This study is the first to demonstrate an expression of HSP 70 in abbins PA.Alterations in respiratory control during 8 h of isocapnic and poikilocapnic hypoxia in humans. J Appl Physiol. 78: 1098-107,1995
4 Schoene RB, Roach RC, Hackett PH, Sutton JR, Cymerman A, Houston CS, Operation Everest II: ventilatory adaptation during gradual decompression to extreme altitude. Med Sci Sports & Exercise. 22:804- 10,1990
5 Adiiatulin AI, Piliavskaia AN, Takchuk EN, Guliaeva NV, [Various mechanisms of protective action of interval hypoxic training during preparation for abdominal dapy. Adaptation Biology and Medicine(Vol.3).
6 Cao KY, Zwillich CW, Berthon-Jones M, Sullivan CE. Increased normoxic ventilation induced by repetitive hypoxia inconscious dogs. J  Appl Physiol. 73:2083.8, l992
7. Zhuang J, Zhou Z. Protective effects of intermittent hypoxic adaptation on
myocardium and its mechanisms. Biol Sinals Recept. 8:316-22,1999.Review.
8. Lebkova NP, Chizhov AI, Bobkov II. The adaptational intracellular mechanism regulating energy homeostasis during intermittent normobaric hypoxia. Ross Fiziol Zh lm I M Sechenova. 85:403-11, 1999
9. Minowada G, Welch WJ: Clinical implications of the stress response. J Clin. Invest. 95:3-12, 1995
10. Wang HR, Eispe JR: The stress response and the lung. Am J Physiol 273: L1-9, l997
11. Gerner EW, Schneider MJ: Induced thermal resistance in Hela cells. Nature 256:500-2, 1975
12. Meerson FZ, Malyshev I Yu, Zamotrinsky AV. Differences in adaptive stabilization of structures in response to stress and hypoxia relate with the accumulation of hsp 70 isoforms. Mol Cell Biochem. 111:87-95, 1992
13. Koh Y, Lim CM, Kim MJ, Shin TS, Lee SD, Kim WS, Kim DS, Kim WD. Heat shock response decrease endotoxin-induced acute lung injury in rats. Respirology.4:325-30, 1999
14. Wong HR, R.J Mannix, J.M. Rusnak, A. Boota, H. Zar, S. C. Watkins, J.S. Lazo,B.R. Pitt. The heat shock response attenuates lipopolysaccharide-mediated apoptosis in cultured sheep pulmonary artery endothelial cells. Am. J. Respir. Cell Mol. Biol. :745-51, 1996
15. Wong HR, Ryan M, Menedez IY, Denenberg A and Wispe JRlar hypothalamic nucleus and brain stem neurons in rats]. [Russian] Ross Fiziol Zh lm I. M. Sechenova. 84(3): 173-81, 1998
17 0lano M, Song D, Murphy S, Wilson DF, Pastuszko A. Relationships of dopamine, cortical oxygen pressure, and hydroxyl radicals in brain of newborn piglets during hypoxia and posthypoxic recovery. J Neurochem. 65(3):1205-12, 1995
18. Soto-Arape I, Burton MD, Kazemi H. Central amino acid neurotransmitters and the hypoxic ventilatory response. American J Respir Crit Care Med. 151(4):1113-20, 1995
19. Rinaldo J. E, M. Gorry R, Stricter H, Cowan R, Abdolrasulnia V. Shepard. Effect of endotoxin-induced cell injury on 70-kD heat shock proteins in bovine lung endothelial cells. Am. J. Respir. Cell Mol. Biol. 3:207-16, 1990
20. Cohen D.S, E. Palmer WJ, Welch, D. Sheppard. The respose of guinea pig airway epithelial cells and alveolar macrophages to environmental stress. Am. J. Respir. Cell Mol. Biol. 5:133-43, 1991
21. Brandes M. E, J. N Finkelstein. Induction of the stress response by isolation of rabbit type II pneumocytes. Exp. Lung.Res. 15: 93-111, 1989.
22. Villar J, J. D. Edelson, M. Post, B. Mullen, A. S. Slutsky. Induction of heat Stress proteins is associated with decreased mortality in an animal model of acute lung injury. Am. Rev. Respir. Dis. l47:177-81, l993.
23. Villar J.,S.P.Ribeiro,J.B.M.Mullen,M.Kuliszewski,M.Post,A.S.Slutsky.Induction of the heat shock response reduces mortality rate and organ damage in a sepsis-induced acute lung injury model. Crit. Care Med. 22:9 B ± through preventing I o B kinase activation in 0respiratory epithelial cells. J. Immunol 164:541 6-23, 2000
27. Yoo, C.G., Lee S., Lee C. T., Rim Y. W., Ham S. K., and Shin Y. S. Anti-inflammatory effect of heat shock protein induction is related to stabilization of I κ B α through preventing I κ B kinase activation in respiratory epithelial cells. J. Immunol 164:5416-23, 2000
28. Simon M. M, A. Reikerstolfer, A. Schwarz, C. Kronis, T. G.Lunger, M. Jaatela, T. Schwarz. Heat shock protein 70 overexpression affects the response to ultraviolet light in murine fibroblast. J. Clin. Invest. 95:926-933,1995

Figure Legends

Fig 1 Change of light microscope in IHT rat lungs. A: 3 days IHT. B:7days IHT.
C: 21 days IHT.

Fig 2 Immunohistochemical staining of rat lung with anti-HSP70 after IHT.
A: 3 days IHT. B: 7 days IHT. C: 21 days IHT.

Fig 3 Ultrastructural changes of lung in IHT: A: 3 days IHT. B: 21 days IHT

2001年7月2日

Ophthalmosurgery

カテゴリー: 学会 — admin

OphthalmosurgeryA.D. Semyonov, A.V.Doga, G.F.Kachalina,
K.Okuyama, I.A.Alisov, N.A.Semyonova

Specific Features of Clinical Course in Photoastigmatic Refractive Keratectomy with the “Profil-500″at Different Terms Postoperatively

The work analyzes the clinical course of PARK performed using the “Profil-500″ in 250 eyes with compound myopic astigmatism to 5.0D with myopia to 10.0D. Operation was done through transepithelial access. ln all cases complete epithelialization of the cornea was recorded within 24-48h. By 6-12 months postoperatively and until 3years of follow-up the cornea of eyes operated on was comPletely transparent in 91.2% of cases; opacities of 0.5-1 degree Were found in 8.8% of cases which did not affect final refractive result.

Numerous studies investigating the condition of the cornea at different terms after photorefractive keratectomy(PRK) and photoastigmatic refractive Keratectomy(PARK) indicate tnat tne corneal syndrome is the typical feature of clinical course in the early postoperative period of these excimerlaser interventions in myopia and myopic astigmatism. The degree of syn drome indetermined by the type and area of erosion surface,time and period of cornea epithelialization,and condition of corneal epithelium anu stroma by the moment of completing epithelialization. Many authors consider the above facts to play an important role in the further development of subepithelial fibroplasia which forms corneal opacities of different degrree leading to unpredictable regression of postoperative refractive result[1,3,6,9,12,13]

Notably, from literature, the techniques of PRK and PARK with different foreign excimer laser devices are performed with preliminary scarification of the corneal epithelium [4,5,7,8]. Thus, it’s necessary to stress that the device “Profil-500″ elaborated at the Center of Laser Surgery of the Eye Microsurgery Complex, like all previous Profil models of several generations ,allows transepithelial correction of myopia and myopic astigmatism i.e., without preliminary scarification of epithelium.
The objective of the work is to study clinical course of the postoperative period after transepithelial PARK with “Profil-500″ on the basis of postoperative results.

Material and methods

PARK was performed in 250 eye sof 131 patients aged 18 to 45 years with compound myopic astigmatism to 5.OD with myopia to 1O.OD. The follow-up was 3 years.
In all cases the operation was performed by transepithelial method, i.e., with subsequent evaporation of epithelium, Bowman’s membrane and superficial layers of the corneal stroma. The operation lasted not more than 1.5 min. No intraoperative complications were recorded.
Biomicroscopy of the anterior sector in eyes operated on was performed using slit-lamp(“opton”,Germany). To evaluate tne pattern and duration of corneal epithelialization and find defects in it, we used fluorescein probe according to routine method with the
use of 1% fluorescein solution.
We evaluated in the postoperative period(a) the degree of corneal syndrome and subepithelial fibroplasia according to the classification developed at the Eye microsurgery Complex(Kornilovsky I.M.,1995) [2]; (b) degree of corneal opacities according to the world numeric classification accepted in excimer laser practice.

Results and discussion

In most eyes operated on (184eyes-73.6%),irrespective of the degree of initial astigmatism and sphere equivalent(SE),We found epithelial form of corneal syndrome manifested by minimal involvement of corneal stromal layers adjacent to ablation zone. In these cases ablation zone was completely covered with epithelium within 24-36h postoperatively; edema of superficial corneal stromal layeres adjacent to intervention zone was rather mild or almost absent. Photophobia and lacrimation disappeared 1-2 days postoperatively as a rule. In 66 eyes(26.4%) stromal type of the corneal syndrome was recorded which was accompanied by moderate edema of all stromal layers in ablation zone. Notablv, in these eves the initial SE varied from 8.25 to 15.0 D, being more than 10.0 D on average. This required the removal of great volume of tissue and, thus, the use of greater energy and pulse number for photochemical evaporation of the cornea. Complete epithelialization in these eyes was recorded 36-48 h postoperatively; stromal edema gradually decreased with epithelialization and almost disappeared by day 5-7 postoperatively. Notably, we found no cases of mixed type of the corneal syndrome consisting in longer epithelialization to 72 and more hours postoperatively and pronounced stromal edema of entire ablation zone with signs of descemetitis. This was confirmed by fluorescein probe allowing detailed evaluation of corneal epithelialization and exclusion of uneven and chaotic epithelialization with poorly fixed and mobile epithelium. Thus, uncomplicated postoperative course after transepithelial PARK was recorded in almost all cases By day 5-7 postoperatively the anterior eye sector was calm, the cornea was smooth, bright and transparent. Only in some cases biomicroscopy revealed slightly thickened epithelial layer of the cornea with mild subep ithelial opalescence; its intensification accompanied by appearance of whitish inclusions in the cornea are considered to be the first signs of development of subep ithelial fibroplasia [2]. We analyzed clinical course of transepithelial PARK at different terms of postoperative period and recorded no visible signs of fibroplasia(degree 0) in 136(54.4%) eyes from the first days after surgery and during the whole follow-up to 3 years. As a rule, SE in these cases did not exceed 8.5 D. In 92(36.8%)eyes 8-14 days postpperatively and irrespective of the value of initial refraction, reversible form of subepithelial fibroplasia was recorded. Its symptoms intensified during 1-3 months postoperatively and gradually disappeared by 6-12 months postoperatvely. From our viewpoint, timely and correct topical corticosteroid and resolving therapy affected the rate of fibroplasia regression that in agreement with data of other authors[10, 11] Partially reversible type of fibroplasia was recorded in 22(8.8%) eyes. Average SE was higher tnan 10.0 D ln these eyes. Due to medication (corticosteroid and resolving therapy) only delicate and spotty opacities of 0.5-1 degree remained at tne periphery and in tne center of ablation zone by 6-l2 months after PARK which almost did not affect postoperative visual acuity and did not cause its decrease as compared to that with glasses preoperatively.

We found irreversible subepithelial fibroplasia with signs of pronounced fibrosis in the corneal stroma and accompanied by significant decrease of refractive effect in none of the cases. This data correlate with results of clinical observations at the Center of Laser Surgery of Eye Microsurgery Complex analyzing 40,000 PRK and indicating that this type of fibroplasia is rather rare and its occurrence is not more than 1.4% of cases. The degree of manifestation of postoperative corneal opacities in ablation zone is presented in Table.
Thus, 6-12 months after PARK and during the further follow-up until 3 years corneal opacities caused by subePithelial fibroplasia were recorded in only 8.8% of cases. Transepithelial access in PARK technique using “Profil-500″ allows significant degrease of degree and duration of corneal syndrome and decreases 1.5-2 times the period of complete epithelialization of the cornea that, in turn, sharply reduces the degree of subepithelial fibroplasia in postoperative period and significantly increases the percentage of high and stable refractive results.

2000年4月2日

Ophthalmosurgery

カテゴリー: 学会 — admin

A.D. Semyonov, A.V. Doga, G.F. Kachalina, K. Okuyama,
I.A. Alisov, V.S. Tyurin, V.A. Sugrobov, A.G. Evsyukov

OphthalmosurgeryPhotoastigmatic Refractive Keratectomy
with the“Profil-500”for Correction
of Compound Myopic Astigmatism

The paper analyses clinical and functional results of the transepithelial PARK with the excimerlaser device “Profi1-500″ performed in 250 eyes of 131 patients between the ages of 18 and 45 with compound myopic astigmatism to 5.0 D and myopia to 10.0D.The follow-up was 3years. In 90% of cases visual acuity of 0.5-1.0 without correction or with weak myopic correction not more than -2.0D was achieved by the operation. Complete correction of astigmatism was obtained in 74% of cases, residual astigmatism from -0.5 to -0.75D(physiological) was found in 22.8% of cases, from -1.0 to -1.5D in only 3.2% of cases and only in eyes with initial astigmatism of 4.0-5.0 D. The refractive result agreed with the calculated data in 96.1% of cases.

The method of excimerlaser correction of compound myopic astigmatism,i.e.,Photo astigmatic refractive keratectomy(PARK),acquires the growing popularity among eye surgeons in Russia and worldwide.
However most specialists dealing with this problem and using different excimer laser devices agree that the most accurate and predicted result is achieved in spherical rather than in cylindric refraction component. From literature, PARK decreases spherical refraction component by 75-95%, on average, and cylindric one by 47-81%. After operation, the best visual functions are recorded, as a rule, in correction of astigmatism to 2.0 D with myopia to 6.0 D [2-9].
It’s should be stressed that from 1986 workers of the Center of Laser Surgery at the Svyatoslav Fyodorov SI IRTC “Eye microsurgery” have pioneer inventions of several generations of ophthalmic laser devices “Profil”.
In 1995 the forming optical system of “Profil-400″ which worked on the basis of absorptive gas cell was modified. “Profil-500″ contains basically new laser system* which was created in cooperation with the Center of Physics lnstrument-making at the Institute of General Physics of Russian Academy of Sciences headed by the Nobel Prize winner A.M. Prokhorov. This device allows simultaneous correction of not only myopia of any value [1] but correction of compound myopic astigmatism due to formation of ellipsoid profile of laser ray distribution with the set spatial configuration and selective reprofiling of the corneal surface.
The objective of the study is the analysis of clinical and functional results of PARK in correction of compound myopic astigmatism with the “Profil-500″ with the follow-up of 3 years.

* Patent of RF, 24.06.98

Material and methods
Preoperatively, we examined 250 eyes of 131 patients between the ages of 18 and 45 with compound myopic astigmatism to 5.0 D and myopia to 10.0 D. The first group comprised 54(21.6%) eyes with initial astigmatism to -1.5 D, the second 135 (54.1%) eyes with astigmatism from -1.75 to -3.0 D (Fig. 1), the third 61(24.3%) eyes with astigmatism from -3.25 D to -5.0 D.
Direct astigmatism was foundiin 185(74%) eyes and reverse one in 65(26%) eyes. Spherical refraction component to 3.0 D was recorded in 31(12.4%) eyes, from 3.25 to6.0 D in 137(54.8%), and from 6.25 to 10.0 D in 82(32.8%) eyes.
Visual acuity without correction exceeded 0.05 in none of the cases. Visual acuity with maximal glass correction was 0.1-0.2 in 7 (2.8%) eyes, 0.3-0.4 in 33(13.2%) eyes, 0.5-0.7 in 139 (55.6%), and 0.8-1.0 in 71 (28.4%) eyes. Thus, corrected visual acuity of 0.5-1.0 was recorded in 210 (84%) eyes preoperatively. The similar retinal visual acuity was. in 235 (94%) eyes.

In all cases PARK was performed by transepithelial method, i.e., with subsequent evaporation of epithelium, Bowman’s membrane, and superficial layers of the corneal stroma. Refraction effect was calculated using software elaborated at the Center of Laser Surgery of the SI IRTC “Eye microsurgery” in Windows system.
The operation lasted not more than 1.5 min without any intraoperative complications.

Results and discussion
Complete correction of astigmatism by 6-l2 months and more after PARK was recorded in 48 (89.2%) eyes from the 1st group, in 98 (72.6%) from the 2nd group, and in 39 (63.9%) eyes from the 3rd group.
Residual astigmatism in groups at the same time postoperatively was the following: in the 1st group astigmatism to -0.5 D was found in 6(10.8%) eyes; in the 2nd group astigmatism to -0.5 D was recorded in 22 (16.3%) eyes (Fig. 2), -0.75 D in 15 (11.1%) eyes, in the 3rd group astigmatism to -0.5 D was found in 6 (9.8%) eyes, -0.75 D in 8 (13.2%), -1.0 D in 5 (8.2%) and -1.5 D in 3 (4.9%) eyes. Data are presented in Table 1.

Thus, from the total number of eyes operated on, by 6-12 months after PARK full correction of astigmatism was diagnosed in 185 (74%) eyes, residual astigmatism -0.5 and -0.75 D, regarded as physiological, in 57 (22.8%) eyes, from -1.0 to -1.5D in only 8 (3.2%) eyes from the third group with the high initial astigmatism. In none of the cases astigmatism exceeded -1.5 D.
In 65 eyes with residual astigmatism from -0.5 to -1.5 D, its axis remained stable in 35 (14%) eyes and changed within 5-10゚ in 30 (12%) eyes. In none of the cases deviation of the residual astigmatism axis exceeded 10゚.
From the total number of eyes operated on complete correction of the spherical component of refraction was achieved in 124 (49.6%) eyes, residual sphere -0.5 D in 87 (34.8%) eyes, sphere from -0.6 to 2.0 D in 39 (15.6%) eyes. Notably, weak myopic refraction found 6 months – 3 years postoperatively coincided with the calculated, i.e., planned, one in 96.1% of cases. Such “planned undercorrection” was related to the age of patients, their social demands and refraction of the fellow eyes. In none of the cases undercorrection was more than -2.0 D (Table2).

Hypercorrection up to +0.25 D from emmetropia, which did not affect postoperative visual acuity, was found in only 3 eyes 6-l2 months after PARK and only using refractometry in conditions of cycloplegia (1.2% of cases). It’s should be noted that 1.5-2 years postoperatively, hypercorrection was not already found in these eyes.
By 6-l2 months postoperatively and during the whole follow-up, visual acuity 0.5-I.0 without correction or with weak myopic predicted correction was achieved in 94.4% of cases in the 1st group, in 94% in the 2nd, and in 77% of cases in the 3rd group. On the whole, there are 225 (90%) eyes as compared to 210 (84%) eyes with the same visual acuity in glasses preoperatively (Table 3).

The correspondence of this visual acuity to the analogous retinal one was recorded in 95.7% of cases. It is because of the fact that postoperatively, we found increase of visual actlity in 30 eyes by 0.1-0.2 as compared to the analogous visual acuity with glass correction preoperatively.
Dynamics study showed that the corneal refraction, according to the data of ophthalmometry, by 6-12 months postoperatively and during the whole follow-up to 3 yearswas 37.59 ± 0.72 D, on average. Thickness of the corneain the centerwas not less than 300 um in any case that showed correct choice of individual ablation
reglmen.
Clinical and functional results of the study are confirmed by the data of keratotopographical examinations indicating the following things: achievement of the smooth ablation profile of the cornea with the maximal refractive effect in the central zone and gradual change of the corneal refraction in the each point of the cornea along the entire zone of the excimer laser influence in all cases; symmetrical flattening of the cornea along the axis which has had the greatest refraction preoperatively; multifocali-zones with smooth over fall of refraction from 1.0 to 3.0 D without sharp intermediate zones both inside each zone and between them, along the whole zone of influence; absence of defects in keratotopographic images such as “crescent”, “key-hole”, and “central islets”; rear decentrations of ablation zone with regard to the center of the pupil and the cornea not greater than 0.75 mm and 0.18-0.32 mm, on average.
The above data of keratotopography which was performed at different terms after transepithelial PARK using “Profil-500″ explain the fact that most patient did not complain of negative subjective feelings as lights, crepe, dazzling, and halos and, besides, many of them did not use glasses for the work at near distance [1].
Thus, the results obtained show that the developed technology of transepithelial PARK using “Profil-500″ is safe, highly effective and predictable refractive excimer laser interference which allows simultaneous complete correction of myopia and compound myopic astigmatism of different degree.

1999年1月29日

第22回日本眼科手術学会総会 東京

カテゴリー: 学会 — admin

ガウス曲線分布立体照射方式エキシマレーザーによる角膜屈折手術

眼科手術1月29日 発表  奥山 公道(参宮橋アイクリニック)

目的:エキシマレーサーの照射方式には面照射方式と、走査型が広く知られているが、その他にエキシマレーサーエネルギーをガウス曲線分布により三次元的蒸散方式のレーザー装置(プロファイル400)がある.1988年フイヨドロフとノーベル物理学者バラホーロフが共同開発し、1993年、露国保険省により、エキシマレーザーによる角膜治療(PTK)及び、角膜屈折矯正(PRK)機械の製造販売の認可を取得.この装置使用例の5年経過について、安全性を中心にその効果とともに検討する.

対象と方法:対象は1993~1998年の5年間の被術例より無作為に20名、40眼を選別.レーザー照射はPRKモードで行い、照射条件は、エネルギー密度175-250mj/cm2可変、反復周波数10Hz、照射径6.7mm、1発の蒸散量を0.25マイクロンとした.スベキュラーマイクロスコピー、ケラトトポグラフイー等の検査を実施.

結果:術前術後5年経過の角膜内皮細胞密度の変化は認められなかった.視力、屈折力の変化は術後1年以降の変化は認められなかった.術後l年以上で、矯正視力低下をもたらすへイズの存在はなく、術後の矯正視力低下例もなかった.

結論:プロファイル400使用のPRKによる屈折矯正達成率は、93%であった.-5.5D以上の強度近視矯正例の平均到達球面度数は7.8Dであった.術後5年の視力、屈折カは術後l年と比較して変化なく矯正効果は安定.内皮細胞密度の変化もなかった.長期的安全性が示唆される.今後更に経過観察を要する.

放射状角膜切開術後15年の経過

1月30日 発表  奥山 公道

目的:放射状角膜切開術(RK術)後15年の経過について安全性を中心にその効果とともに検討する.

対象と方法:RK後15年を経過する元患者9人、17眼、内男性6人、12眼.女性3人、5眼.平均年齢44.5才であった.スペキュラーマイクロスコピー、ケラトトポグラフィーを中心に検査した.対象
全員は、フィヨドロフ式RK手術を、術前の説明を口頭で受けた後に被術していた.

結果:術直後の感染合併1症例を除き、前例で角膜内皮細胞密度2000/mm2以上、六角細胞数頻度55%以上.細胞損失率は3.8%.平均矯正等価球面度数は5.8Dであった.

結論:RK後15年を経過した元患者9人、17眼の安全性と効果について現持点では保たれていると考えられた.術直後感染1症例を中心に、今後も経過観察を要する.

1997年12月2日

照明学会 高齢者の視覚特性と照明

カテゴリー: 学会 — admin

照明学会 高齢者の視覚特性と照明高齢者の視覚特性と照明条件
奥山 公道

1.はじめに

本稿は,先端医療技術開発研究会と照明学会との共催シンポジウム「どうする,どうなる医療照明・福祉照明」での講演内容をまとめたものである.
われわれは,視力や色彩は客観的であり,かつ一定のものであると思い込みがちである.しかしながら,眼科臨床の現場において時として患者より思いがけない指摘を受けることがある.一例を挙げると浮腫による散乱、フレアあるいは角膜混濁による透過率の低下を想起したい.典型として白内障がある.

2.白内障

白内障における水晶体置換手術後,視野がブルーがかっているという訴えが聞かれることがある.これは水晶体が除去されたことにより,散乱の強いブルーの光が強く黄斑部に到達するために起こることである.われわれは生誕時より次第に黄色みがかって物を見るようになる.これは角膜などが酸化の影響を受けるためである.原因として例えば紫外線であるが,高地民族のネパール人には短波長の紫外線による白内障が多発している.高地民族のみらなず,戸外で農作業を行う人々の白内障の発病率は高いことがよく知られている.
可視光線は380nmから780nmの間の電磁波であるが,最近UV400などと銘打って400nm程度の紫外線をカットするサングラスができているのは,上記の理由により白内障防止の役割を担わせるためである.すなわち紫外線カットにより過酸化状態を防ぐのである.白内障による(水晶体)混濁は光の散乱の原因となる.

3.光の散乱

レーリーの散乱の法則というのは,散乱体の大きさが波長に対して小さい場合を言うのである.よって散乱そのものの光散乱,散乱体が波長に匹敵する場合のミー散乱,レーリ一散乱の3種類のグラフを示す.
光の散乱という性質が濁った角膜や水晶体で起こり,それが網膜に到達する時に視覚上眩しいあるいは形状がぼやけるというグレア現象として捉えられる.また散乱や吸収により,最も敏感な黄斑に達する光の量が減少し,コントラスト感度が下がる。グレアやコントラスト感度という概念は従来の視力の概念とは異なるものであり,従来の方法では測定できない.

光の散乱

4.視力

従来の視力の概念とは,単純に一定の照度、距離のもと(5m,視表面照度200lx,室内照度500lx)で片目ずつ測定するものである.眼科的に言うならば,ランドルト環やスネーレン視力表を使って,5mから視認させる方法により遠方視力検査を実施し,30cmの近方視力は近方視力検査を行って視力を確認してきた.視力表による視力検査というのは,あくまでも一定の条件下で得られる測定値である.絶対的には被験者と視力を確認する物体との距馳が長ければ長ほど,そして物体が小さければ小さいほど視力が良いことになる.しかし現実的ではないので,日常の外来の検査では5mのランドルト環を使って視力を測定している.

視力検査表が読めない場合はいくつかの原因を眼料学的に考察せねばならない.人間の眼はよくカメラに例えられるが,カメラのピントを合わせるレンズの異常,これを屈折異常と呼んでいる.無限大の距離を,水晶体が安静にしている状態で見る力の状態を正視と言う.それに対し,物を見ている対象の事物の結像(焦点)が網膜の手前で得られる状態が近視であり,網膜より遠方で焦点が得られる状態が遠視である.また,部分的に水晶体や角膜の歪みにより網膜の前方あるいは後方に焦点がくる乱視の状態がある.近視は網膜の前方に焦点がくるのであるから,原因としては光が眼球を通過する時に過剰に屈折する屈折性の近視と,眼球自体の奥行が伸びて,角膜から網膜までの距離が延長し眼軸が進展する軸性近視の2つが考えられる.逆に遠視の場合は,角膜の表面が扁平である屈折性と,眼球の軸が短いことによる軸遠視の2つが考えられる.
新生児の眼軸長は20~21mmであるが,発育とともに伸び,18歳前後になると24mm前後になる.したがって5歳位だと遠視の状態ということが臨床的に広く認められるが,軸長の成長によって正視になる場合がほとんどである.しかし中には軸長23mm前後で遠視の状態が成人後も残る場合がある.

5.角膜屈折矯正手術

網膜の前方または後方で結像が行われる屈折異常を矯正する,角膜屈折矯正手術を行う本邦唯一の眼科屈折矯 正手術専門医療機関として14年前、1983年に参宮橋アイクリニックを設立する。
自分が5.5デイオプタの屈折性近視であったので,自ら手術を受け,しかる後,家族10人も手術を受け,安全性と有効性を1年間確認する。その上で一般の患者を対象として手術する眼科専門医療機関として開設する。
角膜屈折手術は1940年代に,順天堂医科大学の佐藤勉教授が発明する。
佐藤教授は円錐角膜の患者が治癒過程において,一時的に屈折異常が軽減されることにヒントを得る。
円錐角膜は角膜が通常は中央部の最も薄い部分で500ミクロンで周辺部が7~800ミクロンあるのに,中央部で400ミクロン以 下になることにより,中央部が突出する病気である。
進行すると,角膜の第4層のデスメ膜およぴ,第5層の内皮細胞を穿孔し,内部の房水が角膜実質内へにじみ出る。それにより,角膜のシャープな形が扁平化し,近視の状態が軽減され,視力の向上に結び付くケースがある。
佐藤教授は近視の患者に対して角膜の前方,あるいは後方から切開を入れることにより角膜の扁平化を図り,近視度を軽減する。
しかし、当時は角膜が5層からなることも、最内層に角膜内皮細胞が存在することも知られていなかった。角膜内皮細胞は,角膜よりさらに内側にある前房から前房水を汲み揚げて養分と酸素を吸収し,角膜実質内の老廃物を、排出するポンプの役割を担う細胞である。例えるなら木の根のような細胞である。

佐藤教授は角膜後面より切開を行ったため,「言わば木の根を剥ぐ結果」となり,佐藤式放射状角膜切開手術(旧 RK手術)は、数年を経て角膜に混濁をきたす結果となった.角膜移植を必要とする患者が,700名中170名発生したことにより,この手術は中断のやむなきに至る。
佐藤教授は1960年に他界する。
その後1960年になると,混濁した水晶体を除去して人工水晶体と置換する人工水晶体移植手術が盛んに行われるようになる。その際、前房固定人工水晶体レンズの一部が角膜内皮細胞障害を起こし,佐藤教授の旧RK手術後と同様の,水泡性角膜変性症が続出する。
これより,内皮細胞の存在意義が強く認識されるようになり,角膜内皮細胞に障害を与えない眼科顕微鏡手術が開発される。
1973年、恩師スビャトスラフ・ニコライビッチ・フイヨドロフ教授は,安全なフイヨドロフ式RK手術を発明する。
きっかけは,眼鏡をかけた少年が自転車に乗っていて転倒し、眼鏡のガラスが割れ,破片により角膜に切開が入り,治癒する過程で近視の視力が向上したことによる。
フイヨドロフ教授は、故佐藤教授の文献を調べ,内皮細胞を傷付けずに角膜矯正手術ができないかを検討する。1974年にフェイススリーの臨床手術が行われる。教授の功績は内皮細胞を傷付けづずに、角膜前面から放射状切開手術を定量的に行ったことである。
中央部の光学的に物を見るゾーンに切開を加えず、周辺部から傍中央部に4本から16本の放射状切開を一定の深さで,一定の長さに入れることにより,定量的な近視矯正に成功する。
切開の長さを変化させるため、教授は中央の光学域の大ききを変化させる。3mmから4.5mmまでのバリエーションと切開の本数、深さによる近視矯正のノモグラムを作成する。
フイヨドロフ教授は恩師であるのみならず,1983年には執刀医としてモスクワ顕微手術眼科研究所において,私の両眼の近視性屈折異常に対しRK手術をして下さる。
1987年、教授のもとで紫外線領域の熱を持たないエキシマレーザ手術が開発された。
フォトレフラクティブケラトトミーと呼ばれる、193nmの領域のPRK手術である。
本邦初のRK近視手術専門眼科・参宮橋アイクリニックが生まれ14年が経過 し8000眼のRK手術と,2000眼のPRK手術が行われる。RK手術は角膜をダイヤモンドメスで切開することにより,角膜周辺部を扁乎化させるが,PRKエキシマレーザ角膜切除術は,エキシマレーザにより分子間結合を分断し角膜中央部を蒸散させ扁平化させる。エキシマレーザエネルギーについては,粒子光学特性を使ったファントムオプティックスという領域で後に言及する。

次に視力の低下をきたす光学的異常状態は,角膜を含む透光体が濁るという現象がある。レンズのパワーの問題でなく,レンズ自身が混濁する。したがって眼鏡やコンタクトレンズでは矯正不能である.また,高齢者では白内障がこれにあたる。老眼鏡の効果がなく,窓際に立っている人の輪郭がポーツとにじんで見えるような散乱状態である.この場合はいくら高齢者に優しいといわれる照明を行っても視力は改善しない。
同様にカメラに例えると,フィルムに傷が付く状態として、視力低下する網膜あるいは視神経の疾病がある。代表例として、黄斑部変性症が挙げられる.円形の黄斑部変性症は老人に多く,視野が段々小さくなっていくような不安な状態が続き,失明につながる.ここでそういった高齢者や有疾病者に対しての照明の考察を行う.まず瞳孔の大きさについてであるが,瞳孔が小さく2mmくらいになると光の回折現象が起きてくる.回折という現象はその現象が起きる距離によりフレスネル回折、フラウンホーファ回折などが挙げられる.回折は光源を見た時の,グレア現象にあたる。

6.光の回折

回折

視力検査時は,明所では縮瞳するので水晶体の焦点深度が深くなり遠方視力が向上する.しかしながら,2mm以下では回折の影響を受けるので視力的には 4.0あたりが限界と考えられる.ところが数年前、参宮橋アイクリニックにアフリカ出身の芸能人が来院して8.0の視力が0・8に下がったと訴える。 8.0の視力とは,通常5mで一番下のランドルト環が視認できれば2.0であるのに,その4倍の距離の20mから一番下のランドル環が視認できることになる.理論的には可能であろう。視力における分解能力は視力表以前の問題であり,人間の視力における分解能カは,1分くらいまで可能である。また,前述の理由により,1分以下は無理である。
物を見る能力は,眼底黄斑部に散在する錐体とカン体、すなわち光の受容体に由来する。錐体の大きさは2ミクロンm 程度であり,錐体間の距離が小さいほど視力における分解能カは向上する.病理的に錐体が死滅してゆくと,錐体間の距馳が増大するため,受容体としての感度が低下する.よって,くだんのアフリカ出身の芸能人は,錐体がびっしりと隙間無く存在する目を持っていると考えられる。
カン体は周辺部の大まかな視覚と白黒のようなコントラストの認識にあずかる。コントラスト感度あるいは,グレア現象は視力表以外の手段により調べねばならない。ゆえにMTFと呼ばれる空間周波数関数を用いて表示する。これはコントラスト感度曲線により表され,y軸に輝度(コントラストの強さ),Ⅹ軸に周波数をとる。意味あいとしては周波数が低い部分でコントラスト感度が下がっている場合には.角膜を含め透光体に混濁があることが読み取れる。一方 周波数が高い部分でコントラスト感度が低下する場合は,網膜あるいはカメラでいえばフィルムの部分が障害されていることが読み取れる。

以上 カメラに例えるとレンズの汚れ,酸化による経時的変化となる水晶体、角膜の混濁、また,フィルムの劣化となる網膜,視神経の変性について述べてきた.既述のごとく,視力低下の原因は大きく分けて3つである。
しかしながら,結局は分解能力の劣化という点で同一である。
人間が生きとし生けるものであるからには,老化は避けられない。老化、言うならば経年変化を少しでも遅らせるには,照明が極めて重要な位置を占めることは論を待たない.少なく見積って人生の1/3は照明の下で暮らしている。オフィスワークの多い現代人は,ほとんどの人生を照明の下で送っていると言っても過言ではなかろう.

7.おわりに

この度、照明学会のシンポジウムに出席させていただき,高齢者収容施設を設計された照明のプロのお話が印象的であった。老人の精神心理状態に配慮した,直接、間接照明使用度の比率,特に間接照明に重点が置かれ過ぎていることで,全体が暗いという印象になり,適当なスポット照明が非常に重要となり、反省の時期が訪れているとの話であった。反面,廊下の天井にスポット光を使用すると,ストレッチャであおむけに寝ている患者さんの目を射ることになり,間接光でなければならない。同様に,段差があるフロアの境目に間接照明を使用するなどの細心の気配りについての話が印象深い。
理想の照明は,「薄曇りの太陽光(間接照明ではあるが非常に明るい)であるべき」との認識で参加者全員の意見が一致したように思う.

参考文歓

(1)西信元嗣:眼光学の基礎 金原出版(1990)
(2)坪田一男:近視を治す,講談社(1996)
(3)奥山公道:実技 角膜屈折手術 南山堂(1997)
(4)奥山公道:近視を治したいあなたに,三一新書(1994)

1997年11月2日

日本レーザー学会 エキシマレーザーの蒸散作用による近視手術

カテゴリー: 学会 — admin

1997年11月 日本レーザー学会発表
エキシマレーザーの蒸散作用による近視手術

奥山 公道                     S・フィヨドロフ
参宮橋アイクリニック           モスクワ顕微手術眼科研究所
Excimer laser ablation in Refractive Surgery of myopic eye.

Abstract         I

Excimer Laser Ablatiorn used in Refractive Corneal Surgery, named Photo Refractive Keratectomy(PRK). PRK is an eye operation that reshapes or flattens the cornea, which changes the focus point and will decrease myopia. Since 1993, I have operated on more than 1600 eyes with myopia of 1-25D. 65% have been male and 35% have been female.
I used Lambda Phisics LPX301 Excimer Laser, with Fyodorov delivery gas cell system. Under the following conditions; energy density 175-250mj/cm2, 10Hz/sec frequency number of pulses needed 400-800 pulses working diameter 6. 3mm. With myopia from 1-12D, one PRK operation gives a good result. With a myopia of 12D or more it may be necessary to have two PRK operations, with an interval of not less ttlan 6 months. My PRK hit rate for
士0.5D is 86.5%. The other l3.5% has a hit rate of 士2.0D, due to varying degrees of subepitelial hyperplasia-corneal haze.
Corneal haze is temporary and subsides over a period of time. Even with a high degree of corneal haze, the patient can be reoperated on using PTK(Photo Therapecitic Keratectomy). However, at this moment prevention of haze is a major stepping stone.

「まえがき」
1963年にノーベル物理学賞を(露)バーソフ、プロホロフそして(米)タウンズの3氏が受賞した。1973年バーソフ氏が紫外線エキシマレーザーを発明、1983年、米国の眼科医トロッケル氏が近視の治療に応用し、現在までに世界で100万人余が体験した.
エキシマレーザーはフッ素とアルゴンガスによる励起二量体形成後に発生する6.4electronⅤ.エネルギーの波形を加工した上で、角膜上皮から実質にかけて蒸散し、球面の形状を変化させる矯正手術である.
エキシマレーザーによる角膜屈折矯正手術(Photorefractive Keratectomy、以下PRKと略す)の臨床を中心に報告する.

1996年1月26日

第19回日本眼科手術学会総会 岐阜 熱形成遠視矯正手術後6年目の症例

カテゴリー: 学会 — admin

熱形成遠視矯正手術後6年目の症例1月26日 学術展示

熱形成遠視矯正術後6年目の症例
奥山 公道(参宮橋眼科)

目的:熱形成遠視矯正手術ITK(INFRARED THERMAL KERATOPLASTY)の20ケ月後の経過について、第18回京都APAOで報告した.その後、ITK後の長期経過において屈折矯正効果減少の報告が相次いだ.ITKはLTK(LASER THERMAL KERATOPLASTY)の原型であり、長期的な安全性と効果について検討したので報告する.

方法:1981年、フィヨドロフ、グドチコフ等により開発されたITK原法を用いて、1989年に67才の女性の右眼を実施.左眼は対照眼として貰った。 ITK及び対照眼に関する術前のインフォームドコンセントは口頭及び文書で十分に行った.
術前後に屈折矯正手術に関連する全ての検査及び角膜内皮細胞の検査を行った.

結果:ITK後6年を経過しても被手術眼は対照眼に比し、等価球面度数で有意(1.30D)な差を保ち続け、しかも角膜内皮細胞の減少においても左右差を含む好学は認められなかった.

結論:ITKを原法に忠実に行えば、術直後のREGRESSIONは、他の屈折矯正手術同様に認めらわるものの、一定の効果を長期的安全性の上に得られることが証明された.

—————————————————————————–

1月27日 ビデオ講演

熱形成遠視矯正手術の実技
奥山 公道(参宮橋眼科)

目的:熱形成遠視矯正手術 ITK (INFRARED  THERMAL  KERATOPLASTY) は、LTK (LASER  THERMAL KERATOPLASTY)の原型であり、その実技を供覧する。

方法:1981年、フィヨドロフ、グドチコフ等により開発された原法のテクニックによる。

結果:ITKにより、ケラト値、ケラトトポグラフィ形状が、中央光学領域を5.5mm以上に設定すれば、同領域が急峻な形状として得られた。

結論:中央光学領域を急峻な形状とすることで、屈折矯正上、近視化し得る事を証明した。

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