傾斜乳頭症候群に合併した黄斑円孔の1例

A case of macular hole associated with tilted disc syndrome

要約　目的：傾斜乳頭症候群（TDS）に黄斑円孔（MH）を合併した症例を経験したので報告する。

症例：60歳，女性。視力低下を主訴に来院し，両眼白内障手術を施行後，術後矯正視力は右1.0であったが，左眼はTDSに伴う下方後部ぶどう腫，またその境界に黄斑を横切る帯状の網膜色素上皮萎縮を認め，矯正視力は0.4であった。術後2年半で左眼黄斑部に一過性の漿液性網膜下液（SRF）を認め，術後4年，左眼に特発性黄斑円孔stage Ⅲを発症し，視力は（0.3），さらにその7か月後MHはstage Ⅳへ進行し，視力が（0.15）と低下した。手術適応と考え，左眼硝子体茎離断術＋内境界膜（ILM）翻転法＋20％ SF₆ガス置換術を施行した。TDSに伴う下方後部ぶどう腫合併例であったため，ILM剝離はMHの上方のみにとどめ，剝離したILMを下方ぶどう腫側に翻転する術式を選択した。術後9日目にはMHの閉鎖が確認され，MH術後2か月で白内障手術直後の視力（0.4）にまで回復した。

結論：TDSに合併した特発性MHには，上方から下方へのILM翻転法が，円孔の閉鎖に有効である可能性が示唆された。

Abstract　Purpose：To report a case of macular hole（MH）associated with tilted disc syndrome.

Case：A 60-year-old woman presented with vision loss and underwent cataract surgery in both eyes. The postoperative corrected visual acuity was 1.0 in the right eye, and 0.4 in the left eye due to posterior staphyloma and retinal pigment epithelial atrophy across the macula associated with tilted disc syndrome.

　Two and a half years after surgery, optical coherence tomography（OCT）revealed transient serous subretinal fluid（SRF）in the macula of the left eye. Four years after cataract surgery, an idiopathic MH stage Ⅲ was observed in the left eye and visual acuity was slightly reduced to 0.3. Seven months later, the MH progressed to stage Ⅳ and visual acuity decreased to 0.15, and vitrectomy surgery was performed with inverted internal limiting membrane（ILM）technique＋20％ SF6 gas replacement. Since this case was MH with TDS, the operational method of ILM inverted flap technique was selected, and the area of ILM peeling was limited to upper side of macula, and the flap was inverted onto the lower side（posterior staphyloma）. On postoperative day 9, closure of the macular hole was confirmed by OCT. Corrected visual acuity improved to 0.4 at 2 months postoperatively.

Conclusion：In idiopathic MH associated with TDS, the upper-to-lower inverted internal limiting membrane flap technique may be effective in the closure of macular hole.