누구접근법으로 안와내벽골절정복술 후 발생한 신경성눈꺼풀처짐
Postoperative Neurogenic Blepharoptosis after Repair of a Medial Orbital Wall Fracture Using the Transcaruncular Approach
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목적: 누구접근법으로 안와내벽골절정복술 후 발생한 신경성눈꺼풀처짐을 보고하고자 한다. 증례요약: 13세 여아가 운동을 하던 중 넘어지면서 안면을 부딪힌 후 발생한 두눈복시와 안구통증을 주소로 내원하였다. 안와전산화단 층촬영상 좌안 안와내벽의 파열골절 및 안와연부조직이 벌집뼈동굴로 탈출된 소견이 보였으며, 내직근이 골절편에 끼어 있었다. 환아 는 누구접근법으로 안와내벽골절정복술을 시행 받았고 수술은 성공적이었으나, 마취에서 깬 직후 위눈꺼풀올림근 기능소실이 동반된 중증의 위눈꺼풀처짐이 발생했다. 수술 후 부종에 의해 눈꺼풀처짐이 발생하였으리라 생각하여 경구 부신피질호르몬제제를 투여하고 경과관찰하였으나 눈꺼풀처짐은 회복되지 않았다. 다른 안구 증상이나 징후는 없었다. 약 8주간의 보존적 치료 후에도 눈꺼풀각막반사 간거리(MRD1)나 윗눈꺼풀올림근의 기능회복이 없어서 국소마취를 통한 눈꺼풀처짐 교정수술을 시행 받았다. 수술 중, 널힘줄앞지방과 연부조직은 정상적으로 보였으며, 눈꺼풀판과 위눈꺼풀올림근널힘줄 모두 정상소견이었다. 환아는 위눈꺼풀올림근 최대절제술을 시행 받았으며, 눈꺼풀처짐교정수술 2주 후 내원 시 눈꺼풀처짐은 완치되었다.
Abstract
Purpose: We report a case of neurogenic blepharoptosis after reconstruction of a medial orbital wall fracture using the transcaruncular approach. Case summary: A 13-year-old girl presented with left eyeball pain and binocular diplopia caused by trauma from falling. Orbital computerized tomography showed a blowout fracture of the left medial orbital wall, herniation of the orbital soft tissue into the ethmoid sinus, and a portion of the medial rectus muscle trapped in the fracture. The patient underwent successful reconstruction of the medial orbital wall using the transcaruncular approach. However, moderate blepharoptosis with functional loss of the levator palpebrae superioris muscle developed immediately after awaking from the anesthesia. The blepharoptosis was presumed to have developed due to postoperative edema; therefore, oral corticosteroid was prescribed. However, the blepharoptosis did not improve. No other ocular signs or symptoms were detected. Because neither the margin reflex distance (MRD1) nor the function of the levator palpebrae superioris muscle recovered after eight weeks of conservative treatment, surgical correction of blepharoptosis was performed under local anesthesia. The preaponeurotic fat, soft tissue, tarsal plate, and aponeurosis of the levator palpebrae superioris all appeared normal. The patient underwent maximal resection of the levator palpebrae superioris muscle and the blepharoptosis was alleviated two weeks after the operation.
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