加齢黄斑変性による黄斑下出血に対するt-PA，ガス，抗VEGF薬の硝子体注射後経過

Post vitreous injection course of t-PA, gas, and anti-VEGF drugs for submacular hemorrhage due to age-related macular degeneration

要約　目的：加齢黄斑変性（AMD）による黄斑下出血は予後不良とされており，視力改善には血腫の早期除去が重要になる。黄斑下出血に対し，ラニビズマブ，モンテプラーゼ，C₃F₈の硝子体注射のみで血腫移動を行い，その治療成績を検討したので報告する。

対象と方法：対象は，2021年4月〜2022年3月に愛媛大学医学部附属病院を受診したAMDによる黄斑下出血症例，9例9眼（男性7例，女性2例，平均年齢76.4±10.7歳）。ラニビズマブ，モンテプラーゼ，C₃F₈の硝子体注射後，48時間の伏臥位を行い，6か月間観察した。

結果：発症から治療までの平均日数は17.9±26.2日。治療前の平均logMAR視力は1.2±0.5，平均中心窩網膜厚は687±306μm，平均中心窩網膜色素上皮剝離（PED）厚は337±305μmであった。

　治療後6か月の平均logMAR視力は1.1±0.6（p＝1.0），平均中心窩網膜厚は219±159μm（p＝0.04），平均中心窩PED厚は216±313μm（p＝0.6）であった。黄斑下出血に関しては，全例で下方への移動を認めた。合併症は，硝子体出血を2例認めた。追加治療として，硝子体出血を認めた2例に硝子体手術，滲出性変化を認めた7例に抗血管内皮増殖因子（VEGF）薬投与を行った。

結論：今回の検討では，注射後に伏臥位の姿勢制限を行い，黄斑下血腫は全例で下方移動した。血腫の移動方向および移動量に関しては姿勢による影響を受けるのかさらなる検討が必要。モンテプラーゼによる血腫移動の報告は少なく，投与量に関しさらなる検討が必要である。黄斑下血腫移動後も視力に影響する再出血や滲出性変化を起こす場合があり，血腫移動の方法に関してはさらなる検討が必要である。

Abstract　Purpose：Submacular hemorrhage due to age-related macular degeneration（AMD）is considered to have a poor prognosis, and early removal of the blood is important for improving visual acuity. Ranibizumab, monteplase, and C₃F₈ were injected into the vitreous humor alone for hematoma migration in submacular hemorrhage, and the results of treatment were investigated.

Subject and Method：The participants were 9 patients with submacular hemorrhage due to AMD who visited Ehime University Hospital from April 2021 to March 2022：9 eyes（7 males, 2 females, average age 76.4±10.7 years old）. After vitreal injection of ranibizumab, monteplase, and C₃F₈, the patients were placed in prone position for 48 hours and observed for 6 months.

Results：The average number of days from onset to treatment was 17.9±26.2 days. Pretreatment log MAR visual acuity was 1.2±0.5, foveal retinal thickness was 687±306 μm, and foveal PED thickness was 337±305 μm.

Six months after treatment, log MAR visual acuity was 1.1±0.6（p＝1.0）, foveal retinal thickness was 219±159 μm（p＝0.04）, and foveal PED thickness was 216±313 μm（p＝0.6）. Submacular hemorrhage showed downward movement in all cases. Complications included vitreous hemorrhage in 2 cases. As additional treatment, vitrectomy was performed in 2 patients with vitreous hemorrhage, and anti-VEGF administration was performed in 5 patients with exudative changes.

Conclusions：In this study, the patient was restricted to the prone position after injection, and the submacular hemorrhage moved downward in all cases. It is necessary to further investigate whether the movement direction and amount of bleeding are affected by posture. There have been few reports of hematoma migration due to monteplase, and further investigation of the dosage is necessary. Even after submacular hematoma migration, rebleeding and exudative changes that affect visual acuity may occur, and further investigation is required regarding the method of hematoma migration.