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第7回 「眼科救急」

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聖路加国際病院救命救急センター
救急ジェネラルカンファレンス第7回「眼科救急」
当科を回っている研修医が作成しております。このスライドは文献をもとに作成しておりますが、あくまで一個人の見解であり, 病院全体の方針や意見を反映するものではありません。臨床現場へのそのままの応用は厳に慎んでください。また、スライドをお読みの方が患者・患者関係者の場合は、本内容の利用の際には必ず主治医にご相談ください。なにかご不明な点がございましたら、コメントください。

Publicado en: Salud y medicina
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第7回 「眼科救急」

  1. 1. 救急ジェネラルカンファレンス第7回 聖路加国際病院 救命救急センター Last updated Feb.29.2016 Ver. 2.0眼科救急
  2. 2. 本⽇のお話 1.  眼科救急の疫学 2.  ⾮外傷性の眼科救急疾患 –  極めて緊急 (数分以内の介⼊) –  緊急 (数時間以内の介⼊) –  準緊急 (数⽇以内の介⼊) 3.  眼外傷 –  眼球外傷 –  眼周囲外傷 2
  3. 3. 眼科救急の疫学 鈴⽊ et al. (2011) ⽇職災医誌,59:27─31
  4. 4. ⾮外傷性の眼疾患 4
  5. 5. “緊急度”で ⼤きく3つに分類 極めて緊急 –  数分以内の介⼊ 緊急 –  数時間以内の介⼊ 準緊急 –  数⽇以内の介⼊ 5 1 2 3 眼化学外傷 網膜中⼼静脈閉塞症 急性緑内障発作 ⾓膜びらん 網膜剥離 眼窩吹き抜け⾻折 ⾮外傷性の眼科救急疾患
  6. 6. 6 極めて緊急な眼科疾患 (数分以内の介⼊を要する) 1 Images courtesy of Medscape 眼化学外傷 網膜中⼼動脈閉塞症
  7. 7. 眼化学外傷 左眼に酸性物質がかかった⼀例 ①極めて緊急な眼科疾患
  8. 8. 眼化学外傷 酸性/アルカリ性物質による⾓膜障害 – アルカリ性の⽅が重症 (組織浸透が⾼い) 8 症状 「塩酸が眼に! 」「すぐに洗ったが痛い」 –  眼痛, 充⾎, 流涙, 視⼒低下 診断 フルオレセイン染⾊ –  禁忌は 眼球穿孔, 破裂, ソフトコンタクト ①極めて緊急な眼科疾患
  9. 9. 管理 l  Immediate copious but gentle irrigation using sterile water, saline, or Ringer’s solution. NEVER use acidic solutions to neutralize alkalis or vice-versa. Can use ベノキシール®(local anesthetic)before washing. l  Measure pH before and after irrigation; continue irrigation until pH is neutralized (7.0 to 7.4). Wait 5 to 10 minutes after irrigation is stopped to allow the dilutant to be absorbed. l  Remove any chemical particulate matter from surface of eye and evert lids to sweep fornices with sterile cotton swab. l  Topical lubrication with preservative-free artificial tears up to q1h and oitment qhs. l  Topical broad-spectrum antibiotic (gatifloxacin or moxifloxacin tid to qid). l  Topical cycloplegic (cyclopentolate 1%, scopolamine 0.25%, or atropine 1% bid to qid depending on severity). l  For more severe damage, consider topical steroids. l  Consider oral doxycycline 100 mg po bid (collagenase inhibitor). l  May require treatment of increased IOP. l  In severe cases, surgery may be required. ⽣⾷で洗浄 + 緊急で眼科紹介 –  ウロペーパーでpHが中性になるまで 眼化学外傷 ①極めて緊急な眼科疾患
  10. 10. 網膜中⼼動脈閉塞症 疼痛なく突然左⽬が全く視えなくなった ①極めて緊急な眼科疾患
  11. 11. 症状 •  突然,⾼度の視⼒低下, ⽚眼性 •  痛み(-)充⾎(-)その他の症候なし May have history of amaurosis fugax (fleeting episodes of visual loss), prior CVA, or TIAs. 診断 Cherry red spot –  PITFALL:発症2時間以内は正常かわずかな混濁 網膜中⼼動脈閉塞症 ①極めて緊急な眼科疾患 網膜中⼼動脈閉塞により,突然無痛性の 失明または視野⽋損が起こる.
  12. 12. 対応 疑ったら眼球マッサージ –  close eyes, massage eye –  禁忌は ⽩内障・緑内障術後 tPA静注が有効かもしれない –  症状発現から4.5時間以内のtPA静注で 視⼒回復率が有意に上昇した. Schrag M et al, JAMA Neurol, 2015 鑑別 視神経炎(1.0→0.3) vs CRAO(1.0→0) 網膜中⼼動脈閉塞症 ①極めて緊急な眼科疾患
  13. 13. 対応 疑ったら眼球マッサージ l  Treatment is controversial owing to poor prognosis and questionable benefit of treatment. l  Goal: to move emboli distally to restore proximal retinal blood flow. Most maneuvers are aimed at rapid lowering of IOP. l  Treat immediately before starting workup (if patient presents within 24 hours of visual loss), best hope is to treat within 90 minutes. l  Digital ocular massage (眼球マッサージ):眼を閉じてもらい, 交互に眼を ⼩刻みに押さえる。禁忌:⽩内障・緑内障術後 l  Systemic acetazolamide (Diamox 500 mg IV or po). l  Topical ocular hypotensive drops: β-blocker (timolol 0.5% 1 gtt q15min x 2, repeat as necessary). l  Other treatment modalities (ophthalmologist) include: l  Anterior chamber paracentesis l  Consider admission to hospital for carbogen treatment (95% oxygen-5% CO2 for 10 minutes q2h for 24-48 hrs) to attempt to increase oxygenation and induce vasodilation 網膜中⼼動脈閉塞症 ①極めて緊急な眼科疾患
  14. 14. 1 4Images courtesy of Medscape 急性緑内障発作 緊急な眼科疾患2 (数時間以内の対応を要する)
  15. 15. 1 5 急性緑内障発作 ②緊急な眼科疾患
  16. 16. 隅⾓の閉塞による急激な眼圧上昇発作 1 6 症状 「昨⽇の夜から, 右眼が⾒えにくい」 「頭が痛い, 吐いてる 」 –  眼圧上昇し, 眼痛, 頭痛, 吐気・嘔吐 –  ⾓膜浮腫で, 視⼒低下 –  充⾎(⽑様充⾎) 診断 対向反射↓ 眼圧↑ 急性緑内障発作 ②緊急な眼科疾患
  17. 17. 対応 初期治療 + 緊急で眼科紹介 –  浸透圧利尿薬点滴, 縮瞳薬点眼の頻回点眼 –  例)D-マンニトール1瓶点滴, 2%ピロカルピン塩酸塩点眼液 15分ごと •  閉塞性が⾒つけられる •  眼の真横に当てる •  ⼩児や認知症患者にも使⽤可能 急性緑内障発作 ②緊急な眼科疾患 iCare tonometer ペンライト法
  18. 18. 1 8Images courtesy of Medscape 準緊急な眼科疾患 (数⽇以内の対応を要する) 3 ⾓膜びらん 網膜剥離 眼窩吹き抜け⾻折
  19. 19. ⾓膜びらん ③準緊急な眼科疾患
  20. 20. 症状 「眼を擦った, ぶつけた」 「痛い」 –  鋭い痛み, 羞明, 異物感, 流涙, 瞬き時不快感 診断 フルオレセイン染⾊後, スリットランプ –  眼瞼を翻転させ, 異物がないかを確認 (特に線状のびらんを伴う時) ⾓膜びらん ③準緊急な眼科疾患
  21. 21. 対応 ① 破傷⾵トキソイド ② 眼帯 → 現在は推奨されていない ⾓膜びらん ③準緊急な眼科疾患
  22. 22. 対応 ③ 抗⽣剤 –  An ointment is preferred to drops as it acts a lubricant. Choices include erythromycin or sulfacetamide ointment 4 times daily for 3-5 days. –  Patients who wear contact lenses are at risk of pseudomonal infection and should receive antibiotics (e.g. ciprofloxacin, gentamicin, or ofloxacin) accordingly. The patient should be advised to not use contact lenses until the abrasion has healed and the patient has been reevaluated by an ophthalmologist. ⾓膜びらん ③準緊急な眼科疾患
  23. 23. 網膜剥離 ③準緊急な眼科疾患
  24. 24. 網膜裂孔部から網膜がめくれた疾患 2 4 症状 60歳代に多い –  ⿊いものが⾒えた = ⾶蚊症 –  網膜裂孔 → ⾶蚊症増加・出現 –  網膜剥離 → 視野⽋損 → 視⼒低下 検査 眼球エコーで検出 –  With the eyelids closed, a generous amount of conducting gel is applied to the lid. For patient comfort and to facilitate clean-up, a transparent dressing (or Tegaderm) can be placed on the lid before applying gel. The probe is then placed gently perpendicular to the orbit while fanning cephalad to caudad. 網膜剥離 ③準緊急な眼科疾患
  25. 25. 2 5 対応 網膜裂孔の段階で発⾒したい! –  ⾶蚊症が増えていたら, 早めに眼科紹介 網膜剥離 ③準緊急な眼科疾患
  26. 26. Normal eye Retinal detachment Ultrasound Village website 眼球エコ−
  27. 27. 眼球エコ− l Shinar et al, J Emerg Med, 2011 •  Emergency practitioners achieved a 97% sensitivity (95% confidence interval [CI] 82-100%) and 92% specificity (95% CI 82-97%) on 92 examinations •  Disc edema and vitreous hemorrhage accounted for false positives, and a subacute retinal detachment accounted for the only false negative. l Schott et al, J Emerg Med, 2013 •  Posterior vitreous detachment(後部硝⼦体剥離) can be incorrectly diagnosed as retinal detachment RD(左) ゲインを変えても 波打つ厚い膜が消失しない PVD(右) No treatment recommended.
  28. 28. 眼球エコ−応⽤編 Dislocated lens (e.g. due to trauma) Suspected ocular foreign body
  29. 29. 眼球エコ−応⽤編 視神経鞘径(ONSD)の拡⼤からICP頭蓋内圧亢進を推定 •  If the optic nerve sheath is >5mm at a point 3mm behind the globe, then there is increased ICP Acad Emerg Med April 2003, Vol.10, No.4
  30. 30. 眼窩吹き抜け⾻折 ③準緊急な眼科疾患
  31. 31. 鈍的外傷などで起きる眼窩部の⾻折 – 眼窩下壁に多い 症状 複視, 眼球陥凹, 下眼瞼⽪膚の知覚↓(V2) 診断 眼球運動検査:上転障害 CT冠状断:下壁⾻折, (内壁⾻折) 眼窩吹き抜け⾻折 ③準緊急な眼科疾患
  32. 32. 3 2 対応 翌⽇眼科紹介. ただし, ⼩児は緊急の場合あり! –  the bone can return to its original position –  下直筋が挟まる、壊死などによって眼球運動 障害が残ってしまう 眼窩吹き抜け⾻折 ③準緊急な眼科疾患
  33. 33. 外傷性の眼疾患 3 3
  34. 34. 眼外傷 開放性眼外傷 – 眼球破裂 – 眼球穿孔 ⾮開放性眼外傷 – 眼球打撲 – 眼球の全層でない傷 眼周囲外傷 – 外傷性視神経症 – 眼瞼裂傷 異物 –  ⾓膜異物 –  結膜異物 –  眼内異物
  35. 35. 眼球破裂 開放性眼外傷
  36. 36. 3 6 症状 視⼒低下(光覚弁があるかないか) 眼痛, 充⾎ 診断 眼瞼腫脹/出⾎, 結膜腫脹/出⾎ – 概ね診察困難!CT撮像! 対応 緊急で眼科紹介! 眼球破裂 開放性眼外傷
  37. 37. 眼球穿孔 開放性眼外傷
  38. 38. 物理的に⾓膜・強膜が切れた状態 3 8 症状 「ガラス⽚が直撃」「⽬が痛い」 「⾒えにくい」 –  視⼒低下, 眼痛, 充⾎ 診断 外傷性⽩内障, 眼内異物, 細菌性眼内炎合併症 ⾓膜/強膜/結膜裂傷, 創部から虹彩脱出 対応 緊急で眼科紹介! 眼球穿孔 開放性眼外傷
  39. 39. 眼球打撲 ⾮開放性眼外傷
  40. 40. 眼球に外⼒が加わったため 眼内組織の脆弱な部分(虹彩の付け根など)が断裂 4 0 診断 眼部:前房出⾎, 虹彩断裂 眼底:外傷性網膜剥離, 硝⼦体出⾎ 対応 緊急で眼科紹介! 眼球打撲 ⾮開放性眼外傷
  41. 41. 外傷性視神経症 眼周囲外傷
  42. 42. 眉⽑外則部の打撲により視神経管が障害 4 2 症状 急激な⾼度の視⼒低下 診断 Swinging light test (in slightly darkened room ↔︎ dilated pupils) –  RAPD (relative afferent pupillary defect) 陽性 –  通称 Marcus-Gunn pupil 陽性 外傷性視神経症 眼周囲外傷
  43. 43. RAPD, Marcus-Gunn pupil relative afferent pupillary defect 紹介先は地域の中核病院 → steroid pulse, 視神経管開放術 may be necessary
  44. 44. 眼瞼裂傷 眼周囲外傷
  45. 45. 物理的に眼瞼が切れた状態 4 5 治療 創部の縫合(7-0くらいの細さ) 診断 涙⼩管断裂に注意! (特に⽝咬傷) –  涙⼩管をつなげないと永続的な流涙症に… 眼瞼裂傷 眼周囲外傷
  46. 46. 受傷数⽇してから 受診することもある 4 6 症状 鉄⽚, ⽊⽚などで ⽬の違和感, 眼痛, 流涙 対応 点眼⿇酔(ベノキシール®)をして異物除去 –  眼科医でも深く刺さっている異物は難しく, 2回に分けることもある –  受傷後すぐでない限り, 綿棒で こすってとるのは難しい –  slit lamp microscope がないと 異物除去は眼科医でも⼤変難しい ⾓膜異物 異物
  47. 47. 上眼瞼の眼瞼溝に 異物があることが多い 症状 ⽬の違和感, 眼痛, 流涙, 充⾎ 対応 上眼瞼の翻転:下の⽅を⾒てもらう –  できれば点眼⿇酔を使わずに結膜異物除去 –  異物が取れなければ眼科紹介 結膜異物 異物
  48. 48. 鉄⽚が最多 4 8 症状 ⾼度の視⼒低下 (⼿動弁程度) 診断 前眼部:穿孔創 (⾓膜に多い) 単純X線、CT:異物の確認 –  異物は⾦属の可能性が⾼くMRI禁忌 対応 緊急で眼科紹介! ⽬を触らない・⽬に⼒を⼊れない 眼内異物 異物
  49. 49. 外傷性眼緊急のPearls 1.  Do no harm: do not cause iatrogenic injury by failing to protect an open-globe injury with an eyeshield. If you suspect an open-globe injury, stop the physical examination immediately and protect the eye with an eyeshield. 2.  Always check IOP unless you suspect an open-globe injury. 3.  The management of IOFBs represented over 56% of ocular-related malpractice claims. 4.  Get the most experienced person for the eyelid or canalicular lacerations, and remember that the repair can be delayed for 24 to 48 hours. 5.  Dog bites to the eye result in a high incidence of canalicular injuries. 6.  Do not contaminate a penetrating injury by administering nonsterile eyedrops. 7.  Avoid use of eye patches in corneal abrasions less than 10 mm. 8.  Always include an assessment of optic nerve function by using the swinging flashlight test when treating a patient with an ophthalmologic complaint. 9.  Use topical NSAIDs in order to minimize the need for systemic pain medications and their associated complications. 10.  Consider admission for patients with a hyphema > 50%, since these patients are at significantly greater risk for complications. 4 9Evidence-based medicine (www.ebmedicine.net)
  50. 50. おまけ 救急医も簡単に眼底が⾒えるようになるかも? •  Portable Eye Examination Kit (PEEK) (www.peekvision.org)
  51. 51. 参考⽂献 Papers l  鈴⽊ 誠⼀, 恩⽥ 秀寿, 植⽥ 俊彦, ⼩出 良平 (2011). 昭和⼤学眼科における 2007 年眼科救急統計, ⽇職災医誌; 59:27─31. l  Shinar Z, Chan L, Orlinsky M (2011). Use of ocular ultrasound for the evaluation of retinal detachment. J Emerg Med; 40(1):53-7. Websites l  CareNeTV: http://carenetv.carenet.com l  Medscape: http://reference.medscape.com/features/slideshow/acute-ocular-emergencies) l  Ultrasound Village: www.ultrasoundvillage.com l  University of Iowa EyeRounds Online Atlas of Ophthalmology: www.eyerounds.org Books l  Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual, 6th edition. l  Kaiser PK, Friedman NJ. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology, 4th edition.

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