| V. ガイドライン | | | | IV.手術 | | | | 2.手術 | |
3)切開創・眼内レンズ | | | |
勧告(ガイドライン) | | a | 超音波乳化吸引術に際し術後惹起乱視を考え、小切開創とfoldable眼内レンズを選択する(グレードA)。 | | ※ | 多焦点眼内レンズの有効性については明らかでない。 |
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エビデンス |
白内障手術では切開創が計画的嚢外摘出術よりも小さい超音波乳化吸引術のほうが術後惹起乱視が少なく1)(II)、超音波乳化吸引術の中でも切開創が小さい術式のほうが術後惹起乱視は少ない2,3,4,5,6,7,8,9)(II-III)。
小切開白内障手術は縫合が不要である。縫合、無縫合で比較しても裸眼視力・術後乱視に差はなかった10)(III)。
また、切開創がさらに小さくなるとフレア値が低下し、裸眼視力も良かった7,12)(II-III)。
小切開白内障手術の切開位置は、上方切開では倒乱視化し、耳側切開では直乱視化する13,14,15)(III)。
切開位置では上方、9時と12時の間、耳側の順に惹起乱視は少ない16)(III)。
術後のフレア値は強膜切開よりも角膜切開が若干低い17)(II)が、術後惹起乱視は強膜切開より角膜切開のほうが大きい18)(III)。
4mmの上方角膜切開で約1.52D、上方強角膜切開で約0.69D、耳側角膜切開で約0.69Dの術後惹起乱視を生じる19)(III)。
眼内レンズ別の比較では、PMMA眼内レンズより小切開で手術が行えるアクリル、シリコーン眼内レンズのほうが術後惹起乱視が少ない1,7,11,20)(II-III)。
白内障術後前嚢収縮はPMMA、アクリル、シリコーン眼内レンズのなかでシリコーン眼内レンズの前嚢収縮が最も高度であった21,22)(III)。
術後の眼内レンズ傾斜・偏心はPMMA、シリコーン、アクリル眼内レンズ間で差はなかった23)(II)。
角膜内皮細胞減少率は眼内レンズ間で差はなかった24)(III)。
ヘパリンコート眼内レンズは術後眼内レンズ上の細胞沈着を抑制する。
糖尿病症例や緑内障症例でも術後3〜6ヶ月に眼内レンズ上の細胞沈着がヘパリンコートしていない眼内レンズに比べて有意に低下していた25,26,27)(III)。
多焦点眼内レンズは単焦点眼内レンズに比べ裸眼視力がよく、術後日常生活上眼鏡を必要としない率が高い28,29)(II-III)。
遠見、近見ともに良好な視力を得ることができる30,31)(II)。
しかし、多焦点眼内レンズは術後にグレアやハローが生じることが多い28,31,32)(II,IV)。
多焦点眼内レンズを使用する場合は両眼挿入例で視機能が良かった33)(IV)。 | | | | | | 1) | Leen MM, Ho CC, Yanoff M: Association between surgically-induced astigmatism and cataract incision size in the early postoperative period. Ophthalmic Surg 24 (9): 586-592, 1993 | | 2) | Olson RJ, Crandall AS: Prospective randomized comparison of phacoemulsification cataract surgery with a 3.2-mm vs a 5.5-mm sutureless incision. Am J Ophthalmol 125 (5): 612-620, 1998 | | 3) | Dam-Johansen M, Olsen T: Induced astigmatism after 4 and 6 mm scleral tunnel incision. A randomized study. Acta Ophthalmol Scand 75 (6): 669-674, 1997 | | 4) | Kohnen T, Dick B, Jacobi KW: Comparison of the induced astigmatism after temporal clear corneal tunnel incisions of different sizes. J Cataract Refract Surg 21 (4): 417-424, 1995 | | 5) | Hayashi K, Hayashi H, Nakao F, Hayashi F: The correlation between incision size and corneal shape changes in sutureless cataract surgery. Ophthalmology 102 (4): 550-556, 1995 | | 6) | Levy JH, Pisacano AM, Chadwick K: Astigmatic changes after cataract surgery with 5.1 mm and 3.5 mm sutureless incisions. J Cataract Refract Surg 20 (6): 630-633, 1994 | | 7) | Oshika T, Tsuboi S, Yaguchi S, Yoshitomi F, Nagamoto T, Nagahara K, Emi K: Comparative study of intraocular lens implantation through 3.2- and 5.5-mm incisions. Ophthalmology 101 (7): 1183-1190, 1994 | | 8) | Davison JA: Keratometric comparison of 4.0 mm and 5.5 mm scleral tunnel cataract incisions. J Cataract Refract Surg 19 (1): 3-8, 1993 | | 9) | Martin RG, Sanders DR, Van der Karr MA, DeLuca M: Effect of small incision intraocular lens surgery on postoperative inflammation and astigmatism. A study of the AMO SI-18NB small incision lens. J Cataract Refract Surg 18 (1): 51-57, 1992 | | 10) | Mendivil A: Frequency of induced astigmatism following phacoemulsification with suturing versus without suturing. Ophthalmic Surg Lasers 28 (5): 377-381, 1997 | | 11) | Oshika T, Yoshimura K, Miyata N: Postsurgical inflammation after phacoemulsification and extracapsular extraction with soft or conventional intraocular lens implantation. J Cataract Refract Surg 18 (4): 356-361, 1992 | | 12) | Oshika T, Nagahara K, Yaguchi S, Emi K, Takenaka H, Tsuboi S, Yoshitomi F, Nagamoto T, Kurosaka D: Three year prospective, randomized evaluation of intraocular lens implantation through 3.2 and 5.5 mm incisions. J Cataract Refract Surg 24 (4): 509-514, 1998 | | 13) | Oshika T, Sugita G, Tanabe T, Tomidokoro A, Amano S: Regular and irregular astigmatism after superior versus temporal scleral incision cataract surgery. Ophthalmology 107 (11): 2049-2053, 2000 | | 14) | Cillino S, Morreale D, Mauceri A, Ajovalasit C, Ponte F: Temporal versus superior approach phacoemulsification: short-term postoperative astigmatism. J Cataract Refract Surg 23 (2): 267-271, 1997 | | 15) | Mendivil A: Comparative study of astigmatism through superior and lateral small incisions. Eur J Ophthalmol 6 (4): 389-392, 1996 | | 16) | Wirbelauer C, Anders N, Pham DT, Wollensak J: Effect of incision location on preoperative oblique astigmatism after scleral tunnel incision. J Cataract Refract Surg 23 (3): 365-371, 1997 | | 17) | Dick HB, Schwenn O, Krummenauer F, Krist R, Pfeiffer N: Inflammation after sclerocorneal versus clear corneal tunnel phacoemulsification. Ophthalmology 107 (2): 241-247, 2000 | | 18) | Olsen T, Dam-Johansen M, Bek T, Hjortdal JO: Corneal versus scleral tunnel incision in cataract surgery: a randomized study. J Cataract Refract Surg 23 (3): 337-341, 1997 | | 19) | Roman SJ, Auclin FX, Chong-Sit DA, Ullern MM: Surgically induced astigmatism with superior and temporal incisions in cases of with-the-rule preoperative astigmatism. J Cataract Refract Surg 24 (12): 1636-1641, 1998 | | 20) | Holweger RR, Marefat B: Corneal changes after cataract surgery with 5.0 mm sutured and 3.5 mm sutureless clear corneal incisions. J Cataract Refract Surg 23 (3): 342-346, 1997 | | 21) | Zambarakji HJ, Rauz S, Reynolds A, Joshi N, Simcock PR, Kinnear PE: Capsulorhexis phymosis following uncomplicated phacoemulsification surgery. Eye 11 (Pt 5): 635-638, 1997 | | 22) | Hayashi K, Hayashi H, Nakao F, Hayashi F: Reduction in the area of the anterior capsule opening after polymethylmethacrylate, silicone, and soft acrylic intraocular lens implantation. Am J Ophthalmol 123 (4): 441-447, 1997 | | 23) | Hayashi K, Harada M, Hayashi H, Nakao F, Hayashi F: Decentration and tilt of polymethyl methacrylate, silicone, and acrylic soft intraocular lenses. Ophthalmology 104 (5): 793-798, 1997 | | 24) | Hayashi K, Hayashi H, Nakao F, Hayashi F: Corneal endothelial cell loss in phacoemulsification surgery with silicone intraocular lens implantation. J Cataract Refract Surg 22 (6): 743-747, 1996 | | 25) | Trocme SD, Li H: Effect of heparin-surface-modified intraocular lenses on postoperative inflammation after phacoemulsification: a randomized trial in a United States patient population. Heparin-Surface-Modified Lens Study Group. Ophthalmology 107 (6): 1031-1037, 2000 | | 26) | Borgioli M, Coster DJ, Fan RF, Henderson J, Jacobi KW, Kirkby GR, Lai YK, Menezo JL, Montard M, Strobel J, et al.: Effect of heparin surface modification of polymethylmethacrylate intraocular lenses on signs of postoperative inflammation after extracapsular cataract extraction. One-year results of a double-masked multicenter study. Ophthalmology 99 (8): 1248-1254; discussion 1254-1255, 1992 | | 27) | Philipson B, Fagerholm P, Calel B, Grunge A: Heparin surface modified intraocular lenses. Three-month follow-up of a randomized, double-masked clinical trial. J Cataract Refract Surg 18 (1): 71-78, 1992 | | 28) | Javitt JC, Steinert RF: Cataract extraction with multifocal intraocular lens implantation: a multinational clinical trial evaluating clinical, functional, and quality-of-life outcomes. Ophthalmology 107 (11): 2040-2048, 2000 | | 29) | Walkow T, Liekfeld A, Anders N, Pham DT, Hartmann C, Wollensak J: A prospective evaluation of a diffractive versus a refractive designed multifocal intraocular lens. Ophthalmology 104 (9): 1380-1386, 1997 | | 30) | Javitt J, Brauweiler HP, Jacobi KW, Klemen U, Kohnen S, Quentin CD, Teping C, Pham T, Knorz MC, Poetzsch D: Cataract extraction with multifocal intraocular lens implantation: clinical, functional, and quality-of-life outcomes. Multicenter clinical trial in Germany and Austria. J Cataract Refract Surg 26 (9): 1356-1366, 2000 | | 31) | Allen ED, Burton RL, Webber SK, Haaskjold E, Sandvig K, Jyrkkio H, Leite E, Nystrom A, Wollensak J: Comparison of a diffractive bifocal and a monofocal intraocular lens. J Cataract Refract Surg 22 (4): 446-451, 1996 | | 32) | Shoji N, Shimizu K: Clinical evaluation of a 5.5 mm three-zone refractive multifocal intraocular lens. J Cataract Refract Surg 22 (8): 1097-1101, 1996 | | 33) | Jacobi FK, Kammann J, Jacobi KW, Grosskopf U, Walden K: Bilateral implantation of asymmetrical diffractive multifocal intraocular lenses. Arch Ophthalmol 117 (1): 17-23, 1999 |
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その他の参考文献 | | ・ | Kurimoto Y, Komurasaki Y, Yoshimura N, Kondo T: Corneal astigmatism after cataract surgery with 4.1 mm BENT scleral and 4.1 mm plus meridian corneal incisions. J Cataract Refract Surg 25 (3): 427-431, 1999 | | ・ | Wang MC, Woung LC, Hu CY, Kuo HC: Position of poly (methyl methacrylate) and silicone intraocular lenses after phacoemulsification. J Cataract Refract Surg 24 (12): 1652-1657, 1998 | | ・ | Sickenberg M, Gonvers M, van Melle G: Change in capsulorhexis size with four foldable loop-haptic lenses over 6 months. J Cataract Refract Surg 24 (7): 925-930, 1998 | | ・ | Oshima Y, Tsujikawa K, Oh A, Harino S: Comparative study of intraocular lens implantation through 3.0 mm temporal clear corneal and superior scleral tunnel self-sealing incisions. J Cataract Refract Surg 23 (3): 347-353, 1997 | | ・ | Pfleger T, Scholz U, Skorpik C: Postoperative astigmatism after no-stitch, small incision cataract surgery with 3.5 mm and 4.5 mm incisions. J Cataract Refract Surg 20 (4): 400-405, 1994 |
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