臨床眼科71巻1号

2017年01月発行

特集 眼疾患の一次予防と二次予防—眼疾患はどこまで予防可能か？

加齢黄斑変性の一次予防と二次予防

著者： 安川力¹

所属機関： ¹名古屋市立大学大学院医学研究科視覚科学

ページ範囲：P.34 - P.42

文献概要

はじめに

　加齢黄斑変性（age-related macular degeneration：AMD）は，滲出型と萎縮型があり，滲出型AMDはわが国に多く，黄斑部に脈絡膜新生血管が発生し，視力低下，変視症，中心暗点などの自覚症状を認め，放置すると多くの症例で数か月のうちに不可逆的な視力障害に至る^1〜3）。一方，萎縮型AMDは欧米に多く，視細胞，網膜色素上皮（retinal pigment epithelium：RPE），脈絡膜毛細血管が揃って地図状に萎縮し，数年かけて徐々に拡大し，黄斑部に萎縮が及ぶとやはり視力低下に至る。萎縮型に対してはいまだ良い治療法はないが，滲出型に関しては，2004年に光線力学的療法（photodynamic therapy：PDT）が^4），2008年以降に血管内皮増殖因子（vascular endothelial growth factor：VEGF）阻害薬の硝子体内注射が承認され^5〜8），特にVEGF阻害薬の登場により，AMDの視力予後は大きく改善した。

　早期発見・早期治療（二次予防）は後遺障害を残さず，視力予後を向上させるために重要な治療の大原則である。二次予防の観点からは，予防的（proactive）に治療を行うべきところであるが，数年にわたって治療を要する症例も多く，高額医療費，注射手技や薬剤に関連する合併症の問題，頻回の通院による患者の精神的，肉体的，経済的負担が問題であるばかりでなく，結局のところ視力低下に至る症例も少なくない^9〜13）。

　したがって，AMD診療において，「（抗VEGF療法などの）良い治療法が出ました！」と患者に説明して，治療に積極的になるように患者に仕向け，製薬企業の販売促進に踊らされて，予防的（proactive）投与をやみくもに続ける方針は，非常に行き当たりばったりで，AMDという疾患の本質が見えていない。AMDは両眼発症する症例が20〜40％程度であり，仮に片眼が生涯発症しないならば，AMD発症眼が末期の病態となったとしても，自動車の普通免許は取得できるし，生活に困ることにはならないので，何としても健常眼を発症させないこと（一次予防）が最重要である。そのためには，日常診療において，患者に（一次）予防の大切さを十分に説明して，予防意識を高めてもらう必要がある。医師と患者が，AMD治療の難しさと予防の大切さに関して共通の意識をもつことで，たとえAMD発症眼が視力低下に至っても良好な信頼関係を保ち，患者の不安の軽減にもつながる。

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