後発白内障治療後の黄斑円孔網膜剝離に残存水晶体囊移植と硝子体手術を行った1例

A case of residual lens capsule transplantation and vitreous surgery for macular hole retinal detachment after secondary cataract treatment

要約　緒言：黄斑円孔網膜剝離に対する硝子体手術の際に，内境界膜や水晶体後囊を用いて円孔を被覆する報告がある。今回，過去に内境界膜剝離が行われ，さらに後発白内障に対し後囊切開が行われた黄斑円孔網膜剝離症例において，残存後囊を用いた硝子体手術により良好な結果を得たので報告する。

症例：66歳，女性。9年前にA病院において右黄斑前膜と白内障にて水晶体再建術，硝子体手術と，その後に近医にて後発白内障のため後囊切開が行われた既往があった。右眼の視力低下を自覚し，近医を経て東北大学病院に紹介となった。

所見：初診時，右矯正視力は30cm手動弁，眼軸長は27.13mmであった。眼内レンズが囊内固定され，後囊中央は3〜4mmほど切除されていた。眼底は全剝離で明らかな原因裂孔は不明であったが，硝子体手術を施行したところ，術中に黄斑円孔網膜剝離であることが明らかになった。また過去の黄斑前膜手術で黄斑近傍の内境界膜が広範囲に除去されていることも判明した。そのため，残存している後囊鼻側半分を切除し，黄斑直上にその切除片を留置し，ガス置換をして終術した。その後，黄斑円孔は閉鎖し網膜剝離も復位した。術後7か月現在，右矯正視力0.4，眼内レンズの振盪は認められず，前眼部光干渉断層計では偏位0.16mm，傾斜1.1度と明らかな異常はなかった。

結論：後囊切開後でも残存した後囊を一部切除し，その切除片で黄斑円孔の被覆は可能であった。短期的には眼内レンズの固定位置への影響もなかった。

Abstract　Purpose：There have been reports of using the internal limiting membrane（ILM）or posterior capsule of the lens to cover the macular hole during vitrectomy for macular hole retinal detachment（MHRD）. Here, we report a case of MHRD in which the ILM had previously been peeled and a posterior capsulotomy had been performed for postoperative cataract. A good outcomes obtained from vitrectomy using the remaining posterior capsule.

Case：A 66-year-old woman had undergone phacoemulsification and aspiration（PEA）with intraocular lens（IOL）implantation and vitrectomy for epiretinal membrane and cataract in her right eye at another hospital 9 years earlier. She later underwent posterior capsulotomy for postoperative cataract at another clinic.

Findings and clinical course：At the initial visit, the right corrected visual acuity was hand motion at 30 cm, and the ocular axis length was 27.13 mm. The IOL was in the capsular bag, and the middle of the posterior capsule had been resected by 3 to 4 mm. Fundus findings revealed complete retinal detachment, and we could not determine the location of the retinal tear before the surgery. During surgery, we also found that extensive parts of the ILM near the macula had already been removed. Therefore, the remaining nasal side of the posterior capsule was resected, the resected piece was implanted just above the macula, and gas replacement was performed. Subsequently, the macular hole was closed and the retina was reattached. Three months postoperatively, the right corrected visual acuity was 0.4, there was no IOL donesis, and anterior-segment optical coherence tomography showed no obvious abnormalities；eccentricity was 0.16 mm and tilt angle was 1.1°.

Conclusions：Even after posterior capsulotomy, we were able to resect a portion of the remaining posterior capsule and cover the macular hole with the resected fragment. In the short term, there was no effect on the position of IOL fixation.