活動性TED患者における眼圧亢進症、緑内障、圧迫性神経障害

Ocular Hypertension, Glaucoma or Compressive Neuropathy in Patient with Active TED.

• Nina S Stoyanova
• Marieta I Konareva-Kostianeva
• Vesela T Mitkova-Hristova

抄録

はじめに:

高い眼圧と視野欠損を伴う甲状腺眼疾患の重症例は、診断上の課題であり、甲状腺性視神経症の除外と緑内障との鑑別診断を必要とします。

INTRODUCTION: Severe cases of thyroid eye disease with high intraocular pressure and visual field defects are a real diagnostic challenge requiring the exclusion of dysthyroid optic neuropathy and differential diagnosis with glaucoma.

AIM:

活動性甲状腺眼症（TED）、視力低下、眼圧上昇を呈した患者の症例を報告する。

AIM: To report а case of a patient with active thyroid eye disease (TED), decreased visual acuity and elevated intraocular pressure.

材料および方法:

両眼にTED、クラス2c3c4a6a（NOSPECS）、6点（CASによる）活性を有する52歳女性で、非インスリン依存性糖尿病で、最大累積投与量5750mgまでのコルチコステロイド療法を受け、タプティコム、ブリザドプト、ルクスフェンによる局所降圧療法を受けた患者を紹介します。この患者は、眼科的検査を完全に受け、眼窩のトノメトリー、外眼圧測定、コンピュータペリメトリー、光コヒーレンス断層撮影（OCT）、コンピュータ断層撮影（CT）スキャンを受けた。

MATERIALS AND METHODS: We present a 52-year-old woman with TED in both eyes, class 2c3c4a6a (NOSPECS), with 6 points (by CAS) activity, who received corticosteroid therapy to a maximum cumulative dose of 5750 mg, with non-insulin-dependent diabetes mellitus and topical antihypertensive treatment with tapticom, brizadopt, and luxfen. The patient received full ophthalmological exam, tonometry, exophthalmometry, computer perimetry, optical coherence tomography (OCT) and computed tomography (CT) scan of orbits.

結果:

以下の結果が得られました。右眼BCVA＝0.6、左眼BCVA＝0.3、TOD＝26mmHg、ТОS＝21mmHg、眼外検診。右目30mmと左目31mm、全方向の複視、瞼と結膜の浮腫と充血、瞼の後退、瞳孔反応の緩慢、正常な色覚、透明な眼球媒体、視神経円板の境界が不明瞭、緑内障性の発掘がない、静脈のねじれと拡張、糖尿病性の変化がない網膜、正常な反射を持つ黄斑。眼球外筋の肥厚、眼窩軟部組織の浮腫、視神経圧迫のCTデータ。

RESULTS: The following results were obtained: BCVA of right eye = 0.6, BCVA of left eye = 0.3; TOD = 26 mm Hg and ТОS = 21 mm Hg; exophthalmometry: 30 mm for the right eye and 31 mm for the left one; diplopia in all directions, edema and hyperemia of the eyelids and conjunctiva, eyelids retraction, sluggish pupil reactions, normal color vision, transparent ocular media, indistinct borders of the optic nerve disc, without glaucomatous excavation, tortuosity and dilation of the venules, retina - without diabetic changes, maculas - with normal reflex; CP datа for a localized inferotemporal visual field defect, CT data for thickening of all extraocular muscles, soft tissue orbital edema, and optic nerves compression.

結論:

視力の低下、視神経頭部の眼科的評価、緑内障性OCT変化の欠如、非典型的な眼周囲変化、およびCTデータから、甲状腺機能障害性視神経障害の存在が確認されました。視神経障害はTED患者の中で最も重篤な合併症であり、眼窩頂点の肥大した眼外筋や軟部組織からの視神経の圧迫および/またはその血液供給が原因で発症し、中等度から重度の眼瞼下垂がある場合には視神経の機械的緊張が原因で発症します。

CONCLUSION: Our results confirmed the presence of dysthyroid optic neuropathy based on the decreased visual acuity, ophthalmo-scopic evaluation of the optic nerve head, lack of glaucomatous OCT changes, atypical perimetric changes and the CT data. The optic neuropathy is the most severe complication in patients with TED which develops due to the compression of the optic nerve and/or its blood supply from the enlarged extraocular muscles and soft tissues in the orbital apex and due to the mechanical tension of the optic nerve in cases moderate or severe proptosis is present.

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