治療青光眼可以有更好的選擇--
微脈衝睫狀肌雷射熱治療
(MicroPulse Cyclophotocoagulation-MPCPC)
青光眼(Glaucoma)會讓視力漸漸地損傷並且無聲無息，一種使視神經永久損傷的眼疾，又譬喻是『視覺偷竊者』(圖一)。其實任何人都有可能得到青光眼，但是60歲以上、家族史中有罹患過青光眼、糖尿病或高血壓的患者，是最大的好發族群。然而青光眼與高血壓或糖尿病一樣，它無法完全「根治」，是眼科中的慢性疾病，需要終生進行治療與定期追蹤，但患者若能確實接受治療，則可以生活得跟一般人無異，然而我們的視神經一但遭破壞就無法再生，因此控制好眼壓，盡量減少視神經的持續受損為治療青光眼的最高原則。
圖一:青光眼末期，可見視神經幾乎100%凹陷，且呈白色外觀
微脈衝睫狀肌雷射熱治療
(MPCPC):
是一種新型的非侵入性青光眼治療，能在不影響本身視力及眼球的結構下，經由雷射治療來減少製造眼內房水、增加眼內房水的排出，雷射治療過程更是比傳統青光眼手術快速、也較少引起患者不適且恢復更快、效果更佳(圖二)。相較傳統青光眼手術，更是大幅降低了副作用，如結膜水泡產生(圖三)、異物感、眼球表面疾患、眼睛手術後睜不開、大小眼、角膜病變、白內障、視網膜剝離及黃斑部水腫(圖四)…等病變。
圖二:雷射微脈衝睫狀肌熱治療(MPCPC)
圖三:傳統標準青光眼手術後所造成的結膜水泡
圖四:黃斑部水腫，視力會下降。
◎實際案例: 張先生是一位約莫30歲的年輕人，患有開放性青光眼疾病已將近五年，看過各大醫院及各知名眼科專科診所，之後經友人介紹後來到本診所，眼壓長年一直介於35-45mmHg左右，已使用四種青光眼藥水但控制效果仍有限。雖然視力及視野檢查並未在青光眼的影響下明顯惡化，但眼壓高居不下仍易使視神經繼續受到損傷。在蕭醫師評估及建議之下，認為張先生尚年輕，不願意見到他因青光眼手術所造成長期接續性的問題，可以嘗試新型療法並避免傳統手術容易造成的副作用，張先生思考後也願意自費接受了這樣的治療。雷射熱治療當天的眼壓仍高於45mmHg，在接受雷射熱治療5天後再複診，眼壓已降至22mmHg，張先生表示能接受也很滿意這樣的雷射熱治療療法；覺得眼球真的有比較輕鬆舒服，不像治療前一樣時常脹痛不適且因為眼壓降不下來而感到擔心，並直接預約下次的雷射熱治療。
目前此療法仍屬於自費療程，尚無健保給付，一次費用約30000元，如有點青光眼藥水仍控制效果不佳者，可藉由專業醫師評估後提供個別性的諮詢及建議。
參考資料:
Ophthalmology
Glaucoma 2019;2:167-171 ©2019 by the American Academy of Ophthalmology.
Cornea considerations in glaucoma surgery
Preeya Gupta, MD, Durham, North Carolina, shared some
information on important cornea considerations in glaucoma, highlighting both
ocular surface disease and the corneal endothelium.
Glaucoma management causes dry eye and ocular surface disease
(OSD), she said. Both medications and surgery can disrupt the surface.
OSD has a real impact in glaucoma management, she said, and
has significant impact on vision quality and visual function. It can also
negatively impact drop compliance.
Dr. Gupta highlighted several modern therapies that may
reduce OSD, including preservative-free glaucoma medications, SLT, and MIGS as
a standalone procedure or combined with cataract surgery. Future options could
include a drug delivery implant.
The corneal endothelium is another consideration, Dr. Gupta
said. The purpose of the endothelium is to keep the cornea clear, she said, but
it does not regenerate, and many things can damage it (including glaucoma
surgery). For endothelium surveillance, Dr. Gupta mentioned pachymetry, slit
lamp examination, and specular microscopy all as viable options. Monitoring
endothelial cell count is important, particularly in those post-glaucoma
surgery who may be at risk for endothelial cell loss, but there is currently no
firm consensus on the use of endothelial cell count monitoring, Dr. Gupta said.
With new technologies, ophthalmologists will want to determine how to best
follow these patients, she said
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