滲出型加齢黄斑変性に対する光線力学的療法施行例の現状

Current status of photodynamic therapy for exudative age-related macular degeneration

要約　目的：血管内皮増殖因子（VEGF）阻害療法が加齢黄斑変性（AMD）治療の主流となった今日における，光線力学療法（PDT）施行の実情調査の報告。

対象と方法：2013年以降に初回PDTを実施し，3か月以上経過観察した滲出型AMD 16例16眼が対象である。PDTの使用理由，追加治療の有無，視力予後につき診療録をもとに後ろ向きに調査した。

結果：PDT後の経過観察期間は3〜48か月（平均16.1±14.1）で，PDT施行の理由は，VEGF阻害薬に抵抗8眼，初回治療でVEGF阻害薬と併用4眼，硝子体術後4眼であった。滲出性変化はVEGF阻害薬に抵抗例の半数で消失，初回併用群や硝子体術後では再燃や無効例が多くみられた。追加治療はVEGF阻害療法15眼，PDTの追加1眼であった。平均視力はPDT前と後1，3，6，12か月で有意差はなかった。最終視力はlogMAR 0.3以上を変化ありとすると，改善12.5％，不変50％，悪化37.5％で，悪化の主な理由は線維血管性網膜色素上皮剝離や黄斑萎縮であった。

結論：VEGF阻害療法単独で治療困難な症例のなかには，PDT施行後に鎮静化が得られる症例が存在する。AMDに対するPDTの適応については，今後も検討を要する。

Abstract　Purpose：To investigate the actual state of photodynamic therapy（PDT）in the era that vascular endothelial growth factor（VEGF）inhibition therapy is the mainstream of age-related macular degeneration（AMD）treatment.

Cases and Methods：This study was made on 16 eyes of 16 cases of exudative AMD who underwent first PDT after 2013 and observed for more than 3 months. We reviewed the medical record for reasons of using PDT, presence of additional treatment, and outcome of vision.

Results：The follow-up period after PDT was 3 to 48（average 16.1±14.1）months. The reasons for using PDT were：8 eyes resistant to VEGF inhibitor, 4 eyes performed PDT combined with VEGF inhibitor at the first time of treatment, and 4 eyes after vitrectomy. Although exudative changes disappeared in 50％ of patients who resisted VEGF inhibitors, recurrence and ineffective cases were more frequent than in cases of combination therapy or vitrectomized eyes. VEGF inhibitor was administered to 15 eyes and PDT was added to one eye as additional treatment after PDT. Compared with before PDT, mean best corrected visual acuity（BCVA）did not change significantly at 1, 3, 6, 12 months after PDT. The final BCVA improved in 12.5％, unchanged 50％, deteriorated 37.5％（logMAR 0.3 or more）. The causes for deterioration of vision were fibrovascular retinal pigment epithelial detachment and macular atrophy.

Conclusion：In several cases that were difficult to treat with VEGF inhibitor alone, exudative change disappeared after PDT.