マイクロパルス経強膜的毛様体光凝固後に調節力低下を生じた小児の1例

A pediatric case of decreased amplitude of accommodation after micropulse transscleral cyclophotocoagulation

要約　目的：若年開放隅角緑内障（JOAG）の患者にマイクロパルス経強膜的毛様体光凝固術（MPCPC）を行った後に，可逆性の散瞳と調節力低下が出現した1例を経験したので報告する。

症例：13歳，男子。学校検診をきっかけに近医を受診した。眼圧が右34mmHg，左33mmHgと高値であったため，広島大学病院眼科を紹介されて受診した。両眼JOAGと診断し，右眼2回，左眼1回の線維柱帯切開術を行った。術後に十分な眼圧下降が得られなかったため，MPCPCを右眼2回，左眼1回行った。

所見：初回MPCPCから91日目の調節力は右眼3.7（D），左眼は63日目に4.1（D）であった。瞳孔径は5mm程度と中等度の散瞳をしていたので，MPCPCの影響と考えた。調節力は初回MPCPCから右眼は233日後，左眼は205日後に7〜8（D）に回復した。瞳孔径はMPCPC後に5mm程度と中等度の散瞳になったものの，経時的に3mm程度に回復した。右眼圧は初回MPCPC後91日に40mmHg，2回目を行った後も40mmHg台を推移した。左眼圧は初回MPCPC後63日に22mmHgと一時低下したが，147日後に37mmHgと再度上昇した。点眼治療を追加しても，右29mmHg，左27mmHgとなったため，両眼とも線維柱帯切除術を行った。以後眼圧は10mmHg台で安定している。

結論：若年者にMPCPCを行う際は一過性ではあるが調節力低下，散瞳の副反応を説明する必要がある。

Abstract　Purpose：To report a case of reversible mydriasis and decreased regulation after micropulse transscleral cyclophotocoagulation（MPCPC）in a patient with juvenile open-angle glaucoma（JOAG）.

Case：A 13-year-old boy visited his local doctor following a school checkup. Intraocular pressure（IOP）in the right eye was 34 mmHg and that in the left eye was 33 mmHg. The patient was referred to the Department of Ophthalmology, Hiroshima University Hospital, and was diagnosed with bilateral JOAG；he underwent two trabeculotomies one each for the left and right eye. The postoperative IOP remained at 20 mmHg in both eyes. MPCPC was performed twice in the right eye and once in the left eye for IOP reduction.

Findings：The amplitude of accommodation（AA）of the right eye was 3.7（D）on 91st day after MPCPC, and that in the left eye was 4.1（D）the 63rd day after MPCPC. At that time, pupil diameter（PD）was about 5 mm and moderately mydriatic. Thus, we considered it as a complication of MPCPC. AA recovered to 7-8（D）on the 233rd day and the 205 days after initial MPCPC, respectively. PD in both eyes also recovered to about 3 mm. IOP of the right eye was 40 mmHg at the 91st day after the initial MPCPC and remained in the forties even after second MPCPC. IOP of left eye was temporarily decreased to 22 mmHg on the 63rd day after initial MPCPC, but increased to 37 mmHg on the 147th day. Regardless of the prescription IOP lowering medications, the IOP was 29 mmHg and 27 mmHg. Therefore, we eventually performed trabeculectomy in both eyes. After trabeculectomy, IOP of both eyes remained between 10 and 20 mmHg.

Conclusion：When MPCPC is performed on a young patient, explaining the transient but adverse reactions of decreased regulation and mydriasis is necessary.