망막대동맥류에 동반된 내경계막하출혈의 수술적 제거 후 발생한 황반하 재출혈
The Recurrent Submacular Hemorrhage after Removal of Sub-Internal Limiting Membrane Hemorrhage with Retinal Arterial Macroaneurysm
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목적: 망막대동맥류에 동반된 내경계막하출혈을 제거한 후 황반하재출혈이 발생한 예를 경험하여 보고하고자 한다. 증례요약: 75세 여자가 3주 전부터 발생한 좌안 시력저하를 주소로 내원하였다. 최대교정시력은 우안 0.7, 좌안 0.03이었고 안압은 우안이 10 mmHg, 좌안이 12 mmHg이었다. 안저검사에서 황반부의 망막앞출혈, 망막하출혈과 하비측혈관궁에 망막대동맥류가 관찰되 었고, 유리체절제술을 시행하였다. 내경계막을 인도시아닌그린염색약으로 염색하고 벗기고 내경계막하출혈을 제거하였다. 수술 3일 후 수술 1, 2일에 관찰되지 않았던 저안압(4 mmHg)에 의한 맥락막주름이 관찰되었으나 공막절개창으로의 누출은 관찰되지 않았다. 수술 후 8일째 황반부를 침범하는 재출혈이 발생하여 유리체강 내 과불화프로판가스를 주입하고 고개를 숙인 자세를 유지하였다. 수 술 후 4개월째 황반부를 침범한 출혈은 완전히 소실되었고 망막대동맥류도 백색섬유조직으로 변하였으며, 최대교정시력은 0.3이었다. 결론: 망막대동맥류에 의해 발생한 황반부 내경계막하출혈을 제거하였을 때 드물지만 황반하출혈이 재발할 수 있으며, 특히 저안압이 동반된 경우 재출혈의 가능성이 있으므로 유의해야 하겠다.
Abstract
Purpose: To report a case of a recurrent macular hemorrhage that developed after surgical removal of the internal limiting membrane (ILM) for subintimal hemorrhage due to retinal macroaneurysm. Case Summary: A 75-year-old female was admitted to the hospital complaining of decreased vision in the left eye which had started 3 weeks previously. The best corrected visual acuity (BCVA) of the right and left eye was 0.7 and 0.03, respectively. The intraocular pressure (IOP) of the right and left eye was 10 mm Hg and 12 mm Hg, respectively. On the fundus examination, macular preretinal and subretinal hemorrhage was observed and a diagnosis of retinal arterial macroaneurym of the inferonasal major artery was made. Vitrectomy was performed. After indocyanine green dye staining, the sub-ILM hemorrhage was treated with removal of the ILM. At postoperative day 3, the annular chorioretinal folds were observed due to the hypotony (4 mm Hg). However, the absence of leakage was confirmed through the sclerotomy site. At postoperative day 8, recurrent submacular hemorrhage occurred and the hemorrhage was observed to have spread after intravitreal C3F8 gas injection and when the patient was placed in the prone position. At postoperative 4 months, the hemorrhage that had invaded the macular area was completely resolved. The BCVA was 0.3, respectively. Conclusions: When removing a sub-ILM hemorrhage due to retinal macroaneurysm, recurrent hemorrhage can occur especially in a patient with ocular hypotony, as in the present case report. Physicians should be aware of this possibility and the proper treatment the condition requires.
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