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1 대한안과학회지 2014 년제 55 권제 4 호 J Korean Ophthalmol Soc 2014;55(4): pissn: eissn: Case Report 당뇨망막병증환자에서의망막지혈증 Lipemia Retinalis in a Patient with Diabetic Retinopathy 최성원 김유철 Sung Won Choi, MD, Yu Cheol Kim, MD 계명대학교의과대학동산의료원안과학교실 Department of Ophthalmology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea Purpose: To report a case of lipemia retinalis in a patient with diabetes. Case summary: 27-year-old female with type 2 diabetes visited our clinic with visual disturbance in her left eye while being followed up from a pars plana vitrectomy in her right eye for proliferative diabetic retinopathy. On fundus examination of both eyes, the retinal vessels were creamy white and the retinal veins were undistinguishable from the retinal arteries. The serum triglyceride level was 2,676 mg/dl. The patient was asymptomatic except for visual impairment due to vitreous hemorrhage in her left eye. The patient was diagnosed with lipemia retinalis and chylomicronemia syndrome. fter controlling the triglyceride level, funduscopic findings in the both eyes were improved. However, the visual acuity in her right eye remained unchanged. Conclusions: Lipemia retinalis can be a sign of a systemic condition although it may not affect visual acuity. Fundus examination may be a useful tool in the early diagnosis of hyperlipidemia. J Korean Ophthalmol Soc 2014;55(4): Key Words: Chylomicronemia syndrome, Lipemia retinalis, Triglyceride 망막지혈증은혈중중성지방 ( 트리글라세라이드 ) 수치가 2,000 mg/dl 이상이될때나타나는드문안저소견이다. 혈장의중성지방수치가증가되면혈액이우유빛을나타내게되어큰망막혈관은오렌지색을나타내며동맥과정맥의구분이어려워진다. 안저검사에서이러한망막혈관의변화와더불어망막은연어색 (salmon color) 을나타내며심할경우크림 (creamy appearance) 처럼보이기도한다. runzell and Received: Revised: ccepted: ddress reprint requests to Yu Cheol Kim, MD Department of Ophthalmology, Keimyung University Dongsan Medical Center, #56 Dalseong-ro, Jung-gu, Daegu , Korea Tel: , Fax: eyedr@dsmc.or.kr * This study was presented as a poster at the 109th nnual Meeting of the Korean Ophthalmological Society ierman 1 의연구에따르면안저소견은중성지방의혈중농도에따라변화를보이며중성지방수치의증가로인하여망막지혈증의소견을보이더라도중성지방수치가회복이되면안저소견역시원상태로회복이된다고알려졌다. Lipid Research Program prevalence study에따르면고중성지방혈증은인구 10,000명당 1.79명의유병률을나타내며 2 인슐린저항성당뇨와같은대사장애질환의경우에더빈번하게발생한다고알려졌다. 3 저자들은당뇨환자에서혈중중성지방수치증가로인한망막지혈증증례가있어이를보고하고자한다. 증례보고 증식당뇨망막병증으로경과관찰중인 27세여자환자가좌안의시력저하를주소로내원하였다. 환자는 20세에 2형당뇨로진단받았고 5년후본원에서증식당뇨망막병증으로진단받았으며우안은황반부를포함한망막앞출혈이있어 c2014 The Korean Ophthalmological Society This is an Open ccess article distributed under the terms of the Creative Commons ttribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 623

- 대한안과학회지 2014 년제 55 권제 4 호 - Figure 1. () Fundus photograph shows preretinal hemorrhage involving the macula. () Fundus photograph after pars plana vitrectomy. 유리체절제술을시행받았다 (Fig. 1). 내원시좌안시력은 0.

2 - 대한안과학회지 2014 년제 55 권제 4 호 - Figure 1. () Fundus photograph shows preretinal hemorrhage involving the macula. () Fundus photograph after pars plana vitrectomy. 유리체절제술을시행받았다 (Fig. 1). 내원시좌안시력은 0.1, 안압은 18 mmhg로 3개월전검사시의 0.5보다저하되어있었고우안시력은 0.6, 안압은 16 mmhg 로차이가없었다. 안저검사에서양안의망막혈관은오렌지색을띠고있었고, 좌안에는지질 (lipid) 로추정되는노란색의삼출물이포함된유리체출혈및망막전출혈이동반되어있었다 (Fig. 2, C). 빛간섭단층촬영 (Spectral OCT/SLO; OTI, Ophthalmic Technology, Toronto, Ontario, Canada) 에서황반부종이나심한경성삼출물의소견은관찰되지않았고형광안저혈관조영검사 (FF450 plus fundus camera, Carl Zeiss Inc., Germany) 에서는변화된혈관이확장 (dilation) 되어있고사행 (tortuosity) 이관찰되었으나누출이나충만지연등의소견은확인되지않았다 (Fig. 2). 환자의과거력에서당조절이잘이루어지지않았던것과망막혈관의이상소견으로보아망막지혈증을의심하고혈액검사를시행하였다. 혈액검사결과, 공복혈당수치는 313 mg/dl, 혈중중성지방은 2,676 mg/dl, 당화혈색소는 13.9%, HDL-콜레스테롤 68.5 mg/dl, LDL-콜레스테롤 mg/dl 로측정되었고, 원심분리후의혈장은혼탁한흰색을띠고있었다 (Fig. 3). 증식당뇨망막병증과망막지혈증으로진단하고좌안유리체절제술을시행하고혈중중성지방수치가조절이되지않을경우급성췌장염이나혈액점성의증가로인한심혈관계질환도발생할수있기때문에식이조절과내과치료를병행하였다. 7일간의입원치료후공복혈당수치는 113 mg/dl, 혈중중성지방수치는 mg/dl 으로호전되었고원심분리후의혈장도과거에비해맑아진소견을보였다 (Fig. 3). 망막소견도치료전과비교하여망막혈관의동, 정맥의구별이가능할정도로호전을보였으나 (Fig. 2D), 우안의시력은 0.6으로안저소견의호전에따른시력변화는 없었고좌안은수술후출혈이제거되어 0.2로시력이호전되었다 (Fig. 2E). 고찰 혈중의중성지방수치는 200 mg/dl 이하가정상이지만조절되지않는당뇨환자와비만, 알코올중독, 신부전, 간기능저하, 갑상선기능저하와같은대사장애가있는경우고중성지방혈증의발생빈도는증가하며에스트로젠과같은호르몬제나베타차단제같은약물에의해서도유발이가능하다. 4 이같은경우는이차적으로혈중의중성지방수치를올리는원인들로알려졌으며가족성고중성지방혈증같은유전적인원인으로도가능하다. 5 망막지혈증은혈중의중성지방수치가 2,000-2,500 mg/dl 이상으로증가시발현될수있는망막혈관의이상소견으로망막혈관이우유빛 (creamy-white) 으로변하는것을관찰할수있다. 6 망막과망막혈관의색변화는적혈구들이얇게분포되어있는주변부망막에서부터먼저관찰되고혈중중성지방수치가증가될수록후극부까지변화가미치게되지만직접적으로시력에는영향을미치지는않으며 7 혈중중성지방수치가정상화되면망막소견도회복된다고알려졌다. Lu et al 8 의연구에따르면고중성지방혈증에서망막지혈증소견을보일때시력에는영향을미치지않지만전기생리학적검사를시행한결과, 간상세포와원추세포의 a-, b- 파장의진폭이정상치보다감소되어있는것을확인할수있었고중성지방수치의회복시에는전기생리학적검사에서도회복을보인다고하였다. 망막지혈증이동반된고중성지방혈증을가진환자의치료는혈중의중성지방수치정도에따라시행되며내과적약물과식이조절및금식을병행하여혈중 624

tomography before (,, C) and after (D, E) resolution of

() Retinal vessels are orange-colored and arterioles and

() Fluorescein angiogram (left) shows tortuous and dilated

Optical coherence tomography (right) reveals normal retinal

(C) Vitreous hemorrhage and preretinal hemorrhage with

3 - 최성원 김유철 : 망막지혈증 - D C E Figure 2. Fundus photography, fluorescein angiogram and optical coherence tomography before (,, C) and after (D, E) resolution of elevated triglyceride. () Retinal vessels are orange-colored and arterioles and venules are indistinguishable. () Fluorescein angiogram (left) shows tortuous and dilated large retinal vessels without leakage. Optical coherence tomography (right) reveals normal retinal thickness with foveal depression. (C) Vitreous hemorrhage and preretinal hemorrhage with suspected lipid materials were seen. (D, E) In both eyes retinal vessels have recovered their own colors. 중성지방 수치를 500 mg/dl 이하로 낮추는 것을 목표로 한 9 다. 환자의 경우 당화혈색소는 13.9%, 공복 혈당 수치 313 mg/dl로 조절되지 않는 당뇨병을 가진 환자로 망막 혈관의 이상 소견을 보여 망막지혈증 의심하에 혈액검사를 시행하 625

- 대한안과학회지 2014 년제 55 권제 4 호 - Figure 3. () blood specimen was lipemic with a triglyceride concentration of 2,676 mg/dl. () The blood specimen with a triglyceride concentration of 425.

6으로유지되며변화는없었던것으로보아망막지혈증이시력에는영향을미치지않는다는것을확인할수있었고빛간섭단층촬영과형광안저혈관조영검사에서도혈관의확장과뒤틀림 (tortuosity) 외에일반적인당뇨망막병증의소견과크게다르지않아안저소견에서혈관의변화외의다른안과검사의영상에는영향이없음을보여주었다.

4 - 대한안과학회지 2014 년제 55 권제 4 호 - Figure 3. () blood specimen was lipemic with a triglyceride concentration of 2,676 mg/dl. () The blood specimen with a triglyceride concentration of mg/dl was less lipemic than (). 여혈중중성지방수치가 2,676 mg/dl 으로측정되면서유미지립혈증증후군에의한망막지혈증으로진단할수있었다. 우안은중성지방수치의변화에따른안저소견의변화는있었지만시력은 0.6으로유지되며변화는없었던것으로보아망막지혈증이시력에는영향을미치지않는다는것을확인할수있었고빛간섭단층촬영과형광안저혈관조영검사에서도혈관의확장과뒤틀림 (tortuosity) 외에일반적인당뇨망막병증의소견과크게다르지않아안저소견에서혈관의변화외의다른안과검사의영상에는영향이없음을보여주었다. 좌안은기존의망막지혈증증례에서볼수없었던유리체출혈이있었던경우로망막지혈증에서유리체강내에출혈이있을경우지질이출혈과함께관찰될수있음을알수있었다. 저자들은조절되지않는당뇨병환자에서안저소견의변화가고중성지방혈증을진단할수있는좋은진단적방법이될수있기에이를보고하는바이다. REFERENCES 1) runzell JD, ierman EL. Chylomicronemia syndrome. Interaction of genetic and acquired hypertriglyceridemia. Med Clin North m 1982;66: ) Citkowitz E. Hypertriglyceridemia. Emedicine Online. Updated November overview. 3) Mostaza JM, Vega GL, Snell P, Grundy SM. bnormal metabolism of free fatty acids in hypertriglyceridaemic men: apparent insulin resistance of adipose tissue. J Intern Med 1998;243: ) Yuan G, l-shali KZ, Hegele R. Hypertriglyceridemia: its etiology, effects and treatment. CMJ 2007;176: ) Fredrickson DS, Levy RI, Lees RS. Fat transport in lipoproteinsdan integrated approach to mechanisms and disorders. N Engl J Med 1967;276: ) Vinger PF, Sachs. Ocular manifestations of hyperlipoproteinemia. m J Ophthalmol 1970;70: ) Gopal L, Sunder KS, Rao SK, et al. Hyperlipidemia in a poorlycontrolled diabetic presenting with lipemic aqueous and lipemia retinalis. Retina 2004;24: ) Lu CK, Chen SJ, Niu DM, et al. Electrophysiological Changes in lipaemia retinalis. m J Ophthalmol 2005;139: ) Leaf D. Chylomicronemia and the chylomicronemia syndrome: a practical approach to management. m J Med 2008;121:

5 - 최성원 김유철 : 망막지혈증 - = 국문초록 = 당뇨망막병증환자에서의망막지혈증 목적 : 조절되지않는당뇨와동반된망막지혈증의증례를보고하고자한다. 증례요약 : 2 형당뇨병으로진단후증식당뇨망막병증으로우안유리체절제술을받고경과관찰중이던 27 세여자환자가좌안의시력저하를주소로내원하였다. 안저검사에서양안망막혈관은우유빛 (creamy-white) 양상을보이며동맥과정맥이구분되지않았고중성지방 ( 트리글라세라이드 ) 수치가 2,676 mg/dl 로측정되었다. 좌안은유리체출혈로인한시력저하가있었으나, 우안은시력저하가없었으며, 환자는유미지립혈증증후군에의한망막지혈증진단하에입원하였고, 좌안유리체절제술을시행하였다. 식이조절과항고지혈증제치료를병행한후중성지방수치는 425 mg/dl 로호전되었고양안안저소견도호전되었으나, 우안시력은 0.6 으로치료전과차이가없었다. 결론 : 안저검사에서보이는망막지혈증은직접적으로시력을저하시키지는않지만, 고중성지방혈증을의심할수있는좋은진단적소견으로생각된다. < 대한안과학회지 2014;55(4): > 627

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A 617 Special Issue Diabetic Retinopathy Won Ki Lee, M.D. Department of Ophthalmology The Catholic University of Korea College of Medicine Kangnam St. Mary s Hospital E mail : wklee@catholic.ac.kr Abstract R