안와골절 이후 안와기종과 함께 악화된 외상시신경병증 1예
Traumatic Optic Neuropathy Aggravated by Orbital Emphysema after Orbital Fracture
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목적: 안와골절 환자에서 안와기종과 함께 악화된 외상시신경병증 1예를 보고하고자 한다. 증례요약: 특이병력이 없는 19세 남성이 우측 안와상연 둔상 이후 우측 안와골절로 내원하였다. 컴퓨터단층촬영검사(computed tomography, CT)에서 하내측 지주를 포함한 우측 안와 내하벽골절이 관찰되었다. 교정시력 우안 0.4, 좌안 1.0, 안압은 우안 15 mmHg, 좌안 18 mmHg이었다. 우안의 하전 및 외전장애가 관찰되었고, 상대구심동공운동장애(relative afferent pupillary defect, RAPD)는확실하지 않았다. 안저검사에서는 황반부 이측의 망막진탕 외 특이 소견은 관찰되지 않았다. 외상 12시간째 우안 시력이 빛인지로감소하였다. 명확한 RAPD와 함께 안저촬영과 optical coherence tomography에서 우안 시신경유두부종이 관찰되었고, 초기 CT에서관찰되지 않았던 안와 내 공기음영이 시신경과 인접하여 관찰되었다. 3일간 고용량 스테로이드 정맥주사 후 안와감압을 위한 우안가쪽눈구석절개술과 가쪽눈구석인대절단술을 하였으나 시력은 안전수지 이상으로 개선되지 않았다. 결론: 안와기종으로 인한 안와내압의 증가와 울혈이 기존의 외상시신경병증을 악화시킬 가능성을 인지하고, 이에 대한 주의깊은 관찰이 필요하다.
Abstract
Purpose: To report a case of traumatic optic neuropathy aggravated by orbital emphysema after an orbital fracture. Case summary: A 19-year-old man with no specific medical history was referred for a right orbital fracture caused by blunt trauma to the supraorbital rim of the right eye. Computed tomography (CT) showed a right orbital fracture involving the inferomedial wall and inferomedial strut. The corrected visual acuity was 0.4 in the right eye (RE) and 1.0 in the left and the intraocular pressure was 15 and 18 mmHg, respectively. Restriction on downgaze, abduction, and an indefinite relative afferent pupillary defect (RAPD) were observed in the RE. Fundus exam was non-specific other than commotio retinae on the temporal side of the macula in the RE. After 12 hours post trauma, the visual acuity of the RE had decreased to light perception. Definite RAPD was observed with optic disc swelling on the fundus photo and optical coherence tomography. Orbital CT showed air shadows, which were not seen on the initial evaluation, adjacent to the optic disc. We diagnosed traumatic optic neuropathy aggravated by orbital emphysema. High-dose intravenous steroid was given for 3 days. Despite a lateral canthotomy and cantholysis to decompress the right orbit, visual acuity did not improve above counting fingers. Conclusions: Increased intraorbital pressure and congestion caused by orbital emphysema may exacerbate traumatic optic neuropathy. Therefore, close observation is required.
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