第18回日本眼科手術学会総会 京都 放射状角膜切開後のエキシマ手術:お知らせ

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1995年1月27日

第18回日本眼科手術学会総会 京都 放射状角膜切開後のエキシマ手術

カテゴリー: 学会 — admin

放射状角膜切開後のエキシマ手術1月27日 発表
放射状角膜切開後のエキシマ手術

奥山公道(参宮橋アイクリニック五反田)
河尻幸利
鈴木聡子

目的:放射状角膜切開術(RK)後の残留近視に対して、面照射方式エキシマレーザー(ラムダフィジック300L)による角膜表層切除術(PRK)を施行し、術後6~12ケ月における矯正効果及び、術後合併症を観察したので報告する.

方法:対象は、RK後1~3年を経過した中等度6D以上の残留近視の男性34人55眼.女性7人12眼、年齢19~57才の患者.方法はRK瘢痕.を周辺に一部含み、項軸を中心とした半径3~3.5mmに面射方式によるPRKを施術.術前・術後過、1、3、6、12ケ月に視力、屈折検査、角膜形状測定を行った.又、PRK前・後3ケ月に角膜内皮細胞検査を行った.

結果:角膜中央光学ゾーンにおける屈折力の減少は著しく、術前36.46~45.25Dが33.75~43.25Dとなり、平均5.22Dの減少となった.同様に屈折値も術前-5.75~-12Dが+1.37~-4.75Dとなり、平均改善ジオブターは5.76Dであった.

結論:PRK後の角膜上皮下混濁がHAZE INDEXで2/5以上を経験した症例は当クリニック600例中15例2.5%に認められ、今回RK後のPRK67例中皆無であったことより、むしろRK 後のPRKの方が有利と考えられる.同様に角膜厚の薄い患者で中等度以上の近視のレーザー切除においても、RKを組み合わせることにより屈折矯正の可能性が安全性と効果の点より大きくなるといえよう.角膜の危弱化は、潜在性円錐角膜状態でない限りは逆にRKの瘢痕で強化されよう.RK+PRK後の角膜内皮細胞の状態は、術前と比し特記すべく変化はなく安全と考えられた.

1月28日 発表
エキシマ手術後の乱視切開術

鈴木聡子(参宮橋アイクリニック五反田)
河尻幸利
奥山公道

目的:ラムタフィジック社の面照射型エキシマレーザー300Lをフィヨドロフ式デリバリーシステムで使用し、PRK手術にて近視矯正を行った症例に対し、残留近視と近視性乱視の矯正のための放射状角膜切開(RK)と乱視角膜切開(AK)を行った症例について報告する.

方法:対象となる症例は22才女性.エキシマレーザーによる角膜表層切除術(PRK)施行前、両眼ともに近視-6D、乱視-1.5Dであった.平成3年8 月にPRKを施行し、2週間、1ケ月、3ケ月、6ケ月と視力矯正、屈折検査等を行い、経過を観察した.10ケ月後の結果は両眼ともに近視-2D、近視性乱視-1.75Dであった.その矯正のためRK+AKを行った.その際に角膜内皮細胞検査と角膜厚測定による安全の確認を行った.

結果:術后の経過は順調で、約2ケ月後の屈折は±1D以内で正視(VD 1.5、VS 0.9).矯正視力(VS l.2)であった.

結論:PRK後のAKはより効果的な乱視矯正作用が認められると考えられた.なぜならひ薄化した直径7mmの傍abration zoneにAKを加えることでその切開のメカニズムが十分に働くと考えられるからである.角膜厚が薄く十分にabrationできない、若しくは強度近視及び乱視を伴う症例で残留近視や乱視が認められる場合にPRK+(RK+AK)は有要と考えられる.内皮細胞は現在は問題ないが、詭弱化等の問題は今後も長期的に経過観察を要する.

1994年6月17日

第9回日本眼内レンズ屈折手術学会 府中 RK後11年目の角膜内皮

カテゴリー: 学会 — admin

RK後11年目の角膜内皮6月18日 発表
RK後11年の角膜内皮細胞数

奥山 公道

RKの長期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。
RK後11年を経過する元患者9人(17眼中、男性6名、女性3名、平均年齢40.5才であった)にスペキュラーマイクロスコピー、ケラトトポグラフィー等の検査を行った。
術直後に感染症を合併した症例3例を除き、全例角膜内皮細胞数は、2000個/mm2以上で六角細胞数の頻度も55%以上であった。細胞損失率は5.7%。平均改善ジオプターは5.2Dであった。
RK後11年を経過した元患者9人17眼の安全性と効果については現時点では保たれていると考えられた。
術直後に感染合併の認められた症例3を中心に今後も経過観察を要する。

6月18日 発表
PRK213例の検討

奥山公道
PRK手術の安全と効果について検討。ラムダフィジック社のエキシマレーサー300Lを使用し、107人213例にPRKを実施した.男性75名女性 32名、年齢18~57才.1.5D~25Dまで。-10D以上の症例。6例は再手術し、1例は混濁で再手術す。術前後に角膜内皮細胞、コルネオトポグラフィー等の検査を行った。
213例中、1例に上皮下混濁が術後2週間目より合併し、再手術をした。再手術後1ケ月目で角膜上皮下混濁の程度は2/5である。角膜内皮細胞の損失率は1%であった。平均改善ジオフターは6・8Dであった.術前後の矯正視力の変化
は術后6ケ月を経た例で皆無であった。
PRK術後1年を最長とする107人213症例の安全性と効果は現時点では保たれていると考えられる。一5.5D以上の強度近視の矯正で、平均矯正ジオプトリーが7.8Dであった。段階的に再手術を実施すればさらに矯正効果が期待できる。角膜上皮下混濁を合併した1例は再手術により改善したが、今後混濁のメカニズムの解明と予防が課題となる。

1990年3月18日

ICO第26回シンガポール国際眼科学会 RK後7年の角膜内皮細胞

カテゴリー: 学会 — admin

RK後7年の角膜内皮細胞ICO第26回シンガポール国際眼科学会 シンガポール RK後7年の角膜内皮細胞

ENDOTHELIAL CELL IN ARK PRACTICE
UP TO 7 YEARS
DIRECTOR M.D.
KODO OKUYAMA
SANGUBASHI EYE CLINIC GOTANDA
Institute of Refractive Keratoplasty

Summary: In l983 I Iecived Anterior Radial Keratotomy to both eyes at the moscow Research Institute of Eye Mierosurgery from Professor S.N. Fyodorov. 1)

I want to report on the excellent results achieved over the past 7 years using ARK on patients in Japan. Also I would like to show the complete safty of this procedure. Using a speculer microscope and putting the data through corneal endothelial cell computer norphologic analyzer.
I will present the histories of 17 eyes in 9 patients. One eye was uemotropic and didn’t need correction. These 9 patients were all members of my family or my friend’s families. All these patients gave informed consent.

method : ARK was performed on l7 eyes of 9 patients. The ages of all the subjects at the time of completion of this study are over 25 years old (average 32.5 years) and all of them had more then -2.50 diopters myopia.
Three out of the nine wore contact lenses regulary. (2RL,5RL and 9RL)
All cases except 3R had no previous history of disease. Case 3R had keratitis, while wearing a hard contact lense at the age of 22. All of the patients had naked vision less than 0.3 and a corrected visual acuity of more than1.0. Before ARK a video and written matter were used to explain the procedure to the patients. All patients are given corneometry as well as the standard examinations. The standard procedure developed by Prof. Fyodorov4) usd for ARK seven years ago and photographs were obtained of corneal endothelial cells using a Konan specular microscope and a morphometric cell analyzer, used to obtain cell counted the degree of polimegethism and pleomrphism. Case 2R,5RL and 9R were reoperatet and one case 9L was reoperated twice with the purpose of increasing the effect.
The magnification is calibrated with a micrometer scale. Thirty cells are outlined. The cells are digitized by touching the cell apices with a graphic tablet pen. These coordinates are entered on to a digitizer table and analyzed by computer for cell density, standard deviation (SD), coefficient variation (CV), average of cell area (AVE), maximum of cell area (MAX), minimum of cell area (MIN), and a histogram is made. .
Cell density is calculated by dividing one milion by the mean cell area.
CV is calculated by dividing the SD of cell area by the mean cell area.
Polimegethism is assessed indipendently of cell size using a dimentionlless index for CV. ‘Normal endothelial cells are about 300 microns square in size and hexagonal. Inflamation or injury can reduce cell count, hexagonality and uniformity of size. Eyes with exessive deviation in any of the above are not considered as candidates for ARK.

Result: Visual acuity in all eyes having had ARK had stabilized after four months. (Fig.2,3 and4) Tables 3 and 4show change in corneal refraction and visual acuity before and 7 years after. According to the size of the optical zone and the number of cuts, the resulting corneal refractive power can be decreased from 1 to 8 diopters. Out of 17 cases, one case (6L) of superficial keratotitis occured. It was treated with a two week course of gentamycin subconjunctive injection and a wide-spectrum antibiotic. After 7 years there are no complications and the cornea remains transparent. (Fig. 5)
Specular microscopic analysis shows mean cell densities of 2,347 cells per square mm between the incisions, standard deviation 122, coefficient variation 3l, average of cell area 426, maxmum of cell area 658, minimum of cell area l73 microns square. (Fig.6)
Slight increases in nonhexagonal cell (pleomorphism), and a variation in cell size (polimorphism) are observed. Case 3R had a history of keratitis.(Fig.7)
Specular microscopic analysis shows mean cell densities of 1,869 cells per square mm between the incisions, standard deviation 151, coefficient variation 28, average of cell 635, maxmum of cell area 818, minimum of cell area 162 microns square.(Fig.8) As the specular microscope only became available in 1986, preoperative data is not available for l7 cases, including this case. We can keep record of yearly rates of cell loss.
For 121 eyes in 61 patients from l987 to l988 the immediate cell loss a result of operating is 5.9%.

Discussion : Since the first pioneering work done by Professor Fyodorov and others in 1974, over 327,000 people have recived ARK.3) There have been, however, only limited reports of long term effects and sporadic reports on safty and effectiveness of ARK. Because of high satisfaction and lack of complications and the subsequent non-return of patients to the clinic, ther.e is limited statistical information available. There is in the case of Japan a certain resistance in the old establishment to ARK, because of the unfortunate experience with Professor Sato’s posterior radial ke.atotomy (PRK) in 1936. Therefore I make this report.
The result of ARK remains constant between 4 months and 7 years after operating. The changing refraction is limited to 8 diopters. The patient must be informed of this prior to operating. In six cases with previous
mild myopia aged 35 to 40 years, none wore glasses or contact lenses after seven years. (3RL,4RL,5L,6R,7L and 8RL) .
In previously moderate or severe cases of myopia, low grade glasses are worn when driving, at theatre or in some cases constantly, which doesn’t affect the field of vision as those wore previously. So nine cases discontinued use of contact lenses after ARK. Those that required lenses, were first examined at eight to twelve months with a specular microscope as a precautionar.y check.
Sometimes temporary glare and or starburst effect are noted.
Post-operative astigmatism not requiring corrective lenses was noted in cases 3R, 4R and 5RL. In cases 3R and 4R are 0.75 diopters, 5R is 1.00 diopter and in 5L is 1.50 diopters.
I’d like to make one final point about endothelial cell dynamics over the long term after ARE. Bullous keratopathy is not a possible result postoperatie endothelial cell loss of 5.9% , thereafter continuing at a
normal rate coinciding with Dr.Murphy’s 0.35 to 0.71% per year.(Fig.7)
Also cases reoperated showed a similar cell loss. At this rate of endothelial cell loss, a person would have to live to the age of 166 years before the critical level of 500 cells per square mm would be reached.
So specular microscopic examination is done before operation in order to facilitate obtaining informed consent as well as obtaining data to follow up post-operative cell loss and also the yearly rate of cell loss.
In the case of finding unusualy high levels of polymegethisn or polimozphism, these people are rejected for ARK. We find as did Dr.Scott, a higher incidence of such conditions among long term contact lens wearers. (Fig.6)
This could be a result of previous histories of infection.
We mesured endothelial cell loss and plotted the information for 121 eyes in 61 patients on a graph similar to Dr.Myer’s endothelial cell depletion graph.(Fig.2) On his graph a 35 year old person will have 2700 endothelial cells per square mm. If such a person loses 5.9% as an immediate result of ARK and we calculate natural aging cell loss of 0.35 to 0.71% ( according to Dr. Murphy ), then at the age of forty-two he should have 2,457 endothelial cells per square mm. But in practice our forty-two year old patient has 2,816 endothelial cells per square mm in his right eyes and 3,355 cells in his left eye.(Fig.9,10)  In the other seven cases we recorded a similar high result. (Fig.11) One case 3R was lower and should continue to be observed over the long term.
Up till now 1,500 patients have received ARK at our clinic. (Fig.l2)

References :
i) K.Okuyama : myopia is possible to operate within 15 minutes.
Tokyo, Kobunsha p92-150, 1985
2) D.J.Mayer : Clinical wide-field specular microscopy.
Bailliere Tindall, London p52-53, 1984
3) S.N.Fyodorov, A.I.Ivashina : Microsurgery of the eye- Main aspects.
Mir. Publihers. Moscow p68-70, 1987
4) S.N.Fyodorov, V.V.Durnev : Operation of dorsaged dissection of corneal
circular ligament in cases of myopia of mild degree.
Annals of Ophthalmology p1986-1989, l979 Dec.
5) T.Yamaguchi et al. : Bullous keratopathy after anterior-posterior radial
keratotomy for myopia and myopic astigmatism.
Am. J. Opthalmol. 93:600. 1982
6) Scott M Mac Rae et al. : The effects of hard and soft contact lenses
on the corneal endothelium.
Am. J. Ophthalmol. p50-57, July 1986
7) Scott M. Mac Rae et al. : The effect of radial keratotomy on the corneal
endothelium.
Am. J. Ophthalmol. p538-542, October, l985

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奥ノ山医院
国内初の近視手術専門医院・切らないレーシック