線維柱帯切除術単独と水晶体再建併用線維柱帯切除術の手術成績の比較

Comparison of surgical results of trabeculectomy alone and trabeculectomy combined with cataract surgery

要約　目的：開放隅角緑内障に対して線維柱帯切徐単独手術（単独手術群）と白内障手術を併用した場合（同時手術群）の術後成績について比較検討をした。

方法：対象は2011〜2018年に初回手術として線維柱帯切除術単独および白内障手術を併施した原発開放隅角緑内障97眼と落屑緑内障64眼の計161眼。術前後の視力，眼圧（術前，術後1週，1か月，3か月，6か月，12か月，24か月），角膜内皮細胞減少率（術前，術後1〜3か月），点眼スコア（術前，術後12か月，24か月）を比較した。眼圧は2回外来受診時に連続して基準値を超えた場合，点眼再開もしくは追加手術をした場合を死亡と定義し生存曲線を作成した。また，線維柱帯切除単独手術後に白内障手術を追加した6眼についても同様に比較検討した。

結果：眼圧基準値を14mmHgとした場合，原発開放隅角緑内障，落屑緑内障のいずれの病型においても同時手術群で術後24か月での生存率は有意に低かった（原発開放隅角緑内障群：p＝0.02，落屑緑内障群：p＝0.03）。視力，角膜内皮細胞減少率，点眼スコアに差はなかった。白内障手術を追加した群では，平均32.3か月（24〜72か月）後に手術が行われており，術後視力は有意に改善し（p＜0.01），眼圧に変化はなかった。術後合併症では，同時手術群にレーザー切糸やニードリングといった追加処置が多く，単独手術群には浅前房や脈絡膜剝離が多かった。

結論：白内障合併の緑内障患者には同時手術が行われるが，術後眼圧は高めになる点に注意する。

Abstract　Purpose：To compare surgical results between trabeculectomy alone and trabeculectomy combined with cataract surgery for eyes with open angle glaucoma.

Methods：This study investigated 161 eyes with primary open angle glaucoma（POAG）and exfoliation glaucoma（EXG）. These eyes were treated with trabeculectomy（single surgery group）or trabeculectomy combined with cataract surgery（combined surgery group）. The operation was performed between 2011 and 2018. The eyes with previous ocular surgeries were excluded. We compared the postoperative results including average visual acuity, intraocular pressure（IOP）, endothelial cell reduction rates, and eye drop score. Treatment failure was defined as IOP over two times the standard value, or need for additional medication or additional operation in the life-table analysis. We also analyzed six eyes that needed additional cataract surgery after the trabeculectomy in the single surgery group.

Results：When the standard IOP value is 14 mmHg, the survival rate of combined surgery group was significantly worse than that of single surgery group at two years after the surgery（POAG：p＝0.02, EXG：p＝0.03）. There was no significant difference in visual acuity, endothelial cell reduction rates, and eye drop score. In the cataract surgery group, visual acuity improved after the surgery and IOP remained stable. Comparison of postoperative procedures and complications showed laser suture lysis and requirement for more frequent surgery in the combined surgery group. In the single surgery group, shallow anterior chamber and choroidal detachment were more frequent.

Conclusion：Trabeculectomy combined with cataract surgery is recommended for glaucoma patient with cataract；however, postoperative IOP is higher with the combined approach than with trabeculectomy alone.