시신경교차손상을 동반한 외상성 안구탈출
Traumatic Eyeball Protrusion with Optic Chiasmal Injury
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목적: 안구 둔상으로 인해 발생한 안구 탈출과 시신경 교차의 찢김손상 1예를 보고하고자 한다. 증례요약: 59세 남자가 쇠파이프에 우측 눈을 부딪혀 우안 안구통, 안구 탈출, 시력 소실을 주소로 응급실에 내원하였다. 초진 시 우안안구 탈출 및 광각무의 시력을 보였다. 동공 산대 및 광반응 소실과 누소관 열상이 있었으며, 내, 상, 하직근이 안구로부터 분리되었다. 좌안의 비정상적인 동공반응이 관찰되었고 시력은 0.7이었다. 환자는 우안 내, 상, 하직근의 일차 봉합술과 누소관 재건술을 시행 받았다. 수술 후 1일째 시야검사에서 좌안 이측반맹이 관찰되어 시행한 뇌 자기공명영상(MRI)에서 시신경교차의 손상이 발견되었다. 즉시고농도의 부신피질호르몬요법을 시행하였으나 시야가 악화되어 좌측 시신경감압요법을 시행하였다. 수술 후 2개월째 좌안 시력은 0.3이었고 시야는 안정되었다. 결론: 안구 탈출에 의한 단안 시신경 손상 시 반대안의 동공반응에 이상이 있을 경우, 시신경 시신경 교차의 손상을 고려하여 시야검사및 MRI로 빠른 진단이 필요하다. 시신경 및 시신경교차 손상이 고농도의 부신피질호르몬요법에 반응하지 않으면 시신경감압술을 고려해 볼 수 있을 것이다.
Abstract
Purpose: To report a case of eyeball protrusion with optic chiasmal injury due to eyeball trauma. Case summary: A 59-year-old male presented to the emergency room for right eyeball pain, eyeball protrusion and decreased visual acuity after collision with a metal pipe. On initial examination, the right eyeball was protruded, the patient could not perceive light, his pupil was dilated and did not respond to the light. The patient had a laceration of the lower canaliculi and the medial, superior and inferior rectus muscles were separated from the eyeball. Abnormal left pupil response was observed, and visual acuity of the left eye was 0.7. He underwent primary repair of the right medial, inferior and superior rectus muscles and reconstruction of the lower canaliculi. Because the visual field of the left eye at post-operative day 1demonstrated temporal hemianopsia, an optic chiasmal injury was revealed on brain magnetic resonance imaging (MRI). The patient underwent left optic chiasmal decompression because the visual field was aggravated despite the immediate high dose of corticosteroid therapy. At post-operative 2 months, the patient’s left visual acuity was 0.3 and the visual field was stable. Conclusions: Optic chiasmal injury should be considered and promptly diagnosed through visual field test and MRI when ipsilateral optic nerve injury with abnormal contralateral pupil response is caused by eyeball protrusion. Optic chiasmal decompression should be considered when traumatic optic nerve and chiasmal injuries do not respond to high-dose corticosteroid therapy.
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