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1 대한안과학회지 2017 년제 58 권제 5 호 J Korean Ophthalmol Soc 2017;58(5): ISSN (Print) ISSN (Online) Case Report 자발적맥락막상강출혈에의한급성폐쇄각녹내장 1 예 A Case of Acute Angle-closure Glaucoma Secondary to Spontaneous Suprachoroidal Hemorrhage 윤동희 김홍균 신재필 김인택 김대우 Dong Hee Yoon, MD, Hong Kyun Kim, MD, PhD, Jae Pil Shin, MD, PhD, In Taek Kim, MD, PhD, Dai Woo Kim, MD 경북대학교의학전문대학원안과학교실 Department of Ophthalmology, Kyungpook National University School of Medicine, Daegu, Korea Purpose: To report a case of acute angle-closure glaucoma secondary to spontaneous suprachoroidal hemorrhage in a hemodialysis patient. Case summary: A 71-year-old man visited our clinic after 3 days of vision loss and ocular pain in the right eye. He had been treated with hemodialysis using heparin due to diabetic nephropathy. Visual acuity (VA) was hand motion in the right eye and 0.2 in the left eye. The intraocular pressure (IOP) was 58 mmhg in the right eye and 15 mmhg in the left eye. Gonioscopic examination revealed a closed angle in the right eye. Fundus examination of the right eye showed a massive hemorrhagic retinal detachment and ultrasound sonography revealed a dome-shaped retinal detachment with suprachoroidal hemorrhage in the right eye. The patient was treated with topical aqueous suppressants and cycloplegics. After two weeks of medical treatment, VA in the right eye was still hand motion and IOP was 8 mmhg. Gonioscopic examination showed a wide-open angle in the right eye. During the two-month observation period, VA in the right eye did not recover, however there was no sign of IOP elevation or symptoms of ocular pain. Conclusions: Spontaneous suprachoroidal hemorrhage can occur in patients who receive hemodialysis with heparin. This spontaneous suprachoroidal hemorrhage can be subsequently accompanied by acute angle-closure glaucoma. Spontaneous decrease of suprachoroidal hemorrhage, loss of angle-closure, and decline of IOP can be expected by treating with topical aqueous suppressants and cycloplegics. J Korean Ophthalmol Soc 2017;58(5): Keywords: Acute angle-closure glaucoma, Hemodialysis, Suprachoroidal hemorrhage 자발적맥락막상강출혈은드물게일어나는증상이며갑작스러운시력소실과함께여러합병증을일으키며예후가좋지않은것으로알려져있다. 1 그중맥락막상강출혈에의 Received: Revised: Accepted: Address reprint requests to Dai Woo Kim, MD Department of Ophthalmology, Kyungpook National University Hospital, #130 Dongdeok-ro, Jung-gu, Daegu 41944, Korea Tel: , Fax: proector97@gmail.com 한급성폐쇄각녹내장은드물게발생하고거대출혈성망막박리또는맥락막박리가수정체와홍채를앞으로전위시킴으로써시력소실과안통을유발하게된다. 자발적맥락막상강출혈의원인은고령 2, 항응고제의사용 3, 당뇨 3, 고혈압 4, 만성신부전 5 등의전신질환으로알려져있다. 저자들은당뇨신장병증으로헤파린을투여하며투석하는환자에서발생한맥락막상강출혈에의한급성폐쇄각녹내장을경험하였고안압강하제및조절마비제점안을통해자연스러운맥락막상강출혈의감소, 폐쇄각의소실, 이로 c2017 The Korean Ophthalmological Society This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 611

내원당시우안최대교정시력안전수동, 좌안최대교정시력 0.2로측정되었고, 골드만압평안압우안 58 mmhg, 좌안 15 mmhg로측정되었다. 양안 4.0 mm/2.0 mm로비대칭동공소견을보이며우안동공고정상태였다. 전안부검사상우안각막부종, 얕은전방깊이를보였고 (Fig. 1) 좌안은특이소견이없 A B C D Figure 2.

2 - 대한안과학회지 2017 년제 58 권제 5 호 - 인한안압감소를경험하였기에이를보고하고자한다. 증례보고 Figure 1. Anterior segment photograph after acute angle-closure attack. Slit lamp photograph shows a shallow anterior chamber in the right eye. 3년전당뇨망막병증을진단받고양안범망막성광응고술시행후자의적으로치료를중단하였으며, 당뇨신장병증으로헤파린 25,000 U 투여하며투석하고있는 71세남자환자로, 내원 3일전부터우안비문증및우안시력저하, 내원당일악화된우안의통증으로내원하였다. 내원당시우안최대교정시력안전수동, 좌안최대교정시력 0.2로측정되었고, 골드만압평안압우안 58 mmhg, 좌안 15 mmhg로측정되었다. 양안 4.0 mm/2.0 mm로비대칭동공소견을보이며우안동공고정상태였다. 전안부검사상우안각막부종, 얕은전방깊이를보였고 (Fig. 1) 좌안은특이소견이없 A B C D Figure 2. Changes of massive hemorrhagic retinal detachment in the right eye. (A) Fundus photography shows massive hemorrhagic retinal detachment in the right eye before treatment. (B) Ultrasound sonography of the right eye reveals a dome-shaped choroidal detachment with hypo-echogenous content in addition to hemorrhagic retinal detachment before treatment. (C, D) Fundus photography and ultrasound sonography show vitreous hemorrhage in the right eye two weeks after instillation of topical aqueous suppressants and cycloplegics. 612

3 - 윤동희외 : 맥락막상강출혈에의한폐쇄각녹내장 - 었으며전방각경검사상우안전방각 B15S였고안저검사와안초음파검사상우안녹내장성시신경변화및우안 6시에서 10시방향까지맥락막상강출혈을동반한망막박리소견을보였다 (Fig. 2A, B). 내원당일안압하강제, 조절마비제점안치료를시작하였고 3일뒤우안안압은 32 mmhg 였으며출혈성망막박리정도는증가한소견을보였다. 안압하강제와조절마비제치료를계속유지하며 14일후경과관찰시, 우안최대교정시력안전수동, 좌안최대교정시력 0.2, 골드만압평안압우안 8 mmhg, 좌안 16 mmhg로측정되었다. 전안부검사상우안각막부종소견이감소하였고, 전방깊이는좌안과같은깊이로회복되었으며, 안저검사상우안거대출혈성망막박리는감소하였지만새롭게발생한유리체출혈소견이관찰되었다 (Fig. 2C, D). 정기적으로 2개월간안압강하제및조절마비제점안을차례로중지하며경과관찰하였고우안시력회복없이우안유리체출혈과출혈성망막박리소견이있으나양안안압 mmhg 로정상범위유지되며환자의안통없이전반적으로안정된상태로유지되었다. 고찰 자발적맥락막상강출혈에관여하는요소는다음과같이기전에따라분류할수있다. 5 첫번째로동맥경화 5 나고혈압 4, 당뇨, 고령 6, 고도근시 7 인사람들은손상되기쉬운맥락막과후섬모체혈관구조를가지고있기때문에이러한구조가자발적맥락막상강출혈을일으킬수있다. 두번째로발살바법 (Valsalva maneuver) 8 을시행하거나조절되지않는고혈압환자 9 에서안압이올라갈수있고이러한기계적인힘에의해혈관이손상되어자발적맥락막상강출혈이발생할수있다. 10 마지막으로혈액질환이나항응고제, 항혈소판약제를사용하는환자는지혈이잘되지않아모든망막층의미세출혈부터거대출혈까지다양한증상을야기시킬수있다. 또한맥락막상강출혈은저안압으로인하여괴사된단후모양체혹은장후모양체동맥의개별분지가파열되어생기거나저안압이맥락막삼출을야기하여단후모양체동맥혹은장후모양체동맥을긴장후파열시켜발생한다고알려져있다. 11 Beyer et al 12 은토끼실험을통하여저안압에의해맥락막모세혈관층의충혈이일어나고후극부맥락막상강의출혈소견을보이며다음으로맥락막과모양체혈관들의신장및파열로인해모양체기저부의혈관들로부터출혈이발생하는것을설명하였다. 이러한저안압증은수술중이나수술후에비교적많이발생하는합병증이나, 장기간혈액투석을하는경우도발생할수있다. 혈액투석전후의안압변화정도에대해서는보고마다 차이가있다. 혈액투석전후에유의한안압의변화가없다는보고가있는가하면, 혈중삼투압감소와안압상승의연관성을보고한연구도있으며, 13 체액의과도한제거로안압이감소한다는보고도있다. 14,15 Tokuyama et al 14 은혈액투석시혈중에서수분은급격하게감소하는데비해혈중삼투압은거의일정하게유지되어혈중교질삼투압은증가하고이결과안구내수분이혈액안구장벽을통해방수에서혈중으로이동해안압이감소한다고하였다. 또한헤파린을사용하며혈액투석을하는환자에게서결막출혈, 전방내출혈, 망막출혈등안과적출혈합병증의빈도가높다는보고가있다. 16,17 이러한여러가지연구결과들을토대로, 장기간의혈액투석으로인한저안압, 헤파린으로인한출혈성경향, 71세의고령, 고혈압, 당뇨와같이맥락막과후섬모체의혈관손상을유발할수있는기저질환등이원인이되어자발적맥락막상강출혈이발생하였을것이라추정하였다. 자발적맥락막상강출혈로인한합병증으로이차적으로급성폐쇄각녹내장이발생할수있다. 이는거대하게박리된맥락막과망막에의하여수정체와홍채가앞쪽으로갑작스럽게이동되면서앞방각이좁아지며발생한다. 18 안초음파 19 와빛간섭단층촬영 20 은후포도막과맥락막을볼수있어자발적맥락막상강출혈에의한폐쇄각녹내장을진단하는데도움을줄수있다. 이에대한치료로는안압하강제, 조절마비제점안과같은내과적치료와홍채절개술, 앞방세척술을포함한수술적치료가있다. 수정체와각막이닿은경우나각막부종이있는경우, 진행하는폐쇄각녹내장의경우공막절개술또는유리체절제술을시행하거나조절되지않는통증이지속될때는안구적출술을시행할수있다. 안구뒤쪽의알코올주사법및섬모체냉동요법과같은치료도시도해볼수있다. 18 이러한치료에도불구하고, 자발적맥락막상강출혈에의한폐쇄각녹내장의시력예후는좋지않다. 맥락막상강출혈로인해이미망막구조가파괴되었고, 장시간의안압상승으로인하여안구내허혈성변화가발생하기때문이다. 21 그동안자발적맥락막상강출혈에의한폐쇄각녹내장에서내과적치료는거의효과가없는것으로보고되었다. 21 하지만본증례에서는수술적치료없이안압하강제및조절마비제의점안만으로통증의호전과전방각검사상개방각소견을보였으며안압도정상범위로유지되었다. 이는시간이지남에따라맥락막상강출혈이흡수되고유리체출혈로진행되어수정체와홍채가원위치로돌아와폐쇄각녹내장이완화되었기때문이다. 맥락막상강출혈이유리체출혈로진행된기전은반외신생혈관막 (extrachoroidal neovascular membrane) 의혈관이파열된것에서기인하였을것으로추 613

4 - 대한안과학회지 2017 년제 58 권제 5 호 - 정된다. 22 결론적으로본증례처럼항응고제를복용하지않지만헤파린을투여하여투석하는환자에서자발적맥락막상강출혈이발생할수있으며, 이로인해이차적으로급성폐쇄각녹내장이동반될수있다. 내과와의협진을통해헤파린의과다한사용을방지하고적절한농도를유지하게하여이러한합병증의발생위험을낮추도록노력하여야하며, 합병증이발생할경우안압강하제및조절마비제점안을통해자연스러운맥락막상강출혈의감소, 폐쇄각의소실, 안압감소를기대할수있다. 고령이며전신질환을가지고있는환자를진료할때에는발생할수있는합병증에대해항상인지하여야하며자발적맥락막상강출혈에의한급성폐쇄각녹내장발생시공막절개술, 안구적출술같은수술적치료만을고려하지않고안압하강제및조절마비제점안과같은내과적치료를우선적으로고려해볼필요가있을것으로생각된다. REFERENCES 1) Lakhanpal V. Experimental and clinical observations on massive suprachoroidal hemorrhage. Trans Am Ophthalmol Soc 1993;91: ) Ophir A, Pikkel J, Groisman G. Spontaneous expulsive suprachoroidal hemorrhage. Cornea 2001;20: ) Nguyen HN, Nork TM. Massive spontaneous suprachoroidal hemorrhage in a young woman with cystic fibrosis and diabetes mellitus on anticoagulants. Retin Cases Brief Rep 2012;6: ) el Baba F, Jarrett WH 2nd, Harbin TS Jr, et al. Massive hemorrhage complicating age-related macular degeneration. Clinicopathologic correlation and role of anticoagulants. Ophthalmology 1986;93: ) Yang SS, Fu AD, McDonald HR, et al. Massive spontaneous choroidal hemorrhage. Retina 2003;23: ) Klein R, Myers CE, Lee KE, et al. Small drusen and age-related macular degeneration: The Beaver Dam Eye Study. J Clin Med 2015;4: ) Chak M, Williamson TH. Spontaneous suprachoroidal haemorrhage associated with high myopia and aspirin. Eye (Lond) 2003; 17: ) Hammam T, Madhavan C. Spontaneous suprachoroidal haemorrhage following a valsalva manoeuvre. Eye (Lond) 2003;17: ) Fukuchi T, Suda K, Matsuda H, et al. Secondary acute angle closure with spontaneous suprachoroidal hemorrhage suspected by ultrasound biomicroscopic examination. Jpn J Ophthalmol 2009;53: ) Pollack AL, McDonald HR, Ai E, et al. Massive suprachoroidal hemorrhage during pars plana vitrectomy associated with Valsalva maneuver. Am J Ophthalmol 2001;132: ) Maumenee AE, Schwartz MF. Acute intraoperative choroidal effusion. Am J Ophthalmol 1985;100: ) Beyer CF, Peyman GA, Hill JM. Expulsive choroidal hemorrhage in rabbits. A histopathologic study. Arch Ophthalmol 1989;107: ) Tovbin D, Belfair N, Shapira S, et al. High postdialysis urea rebound can predict intradialytic increase in intraocular pressure in dialysis patients with lowered intradialytic hemoconcentration. Nephron 2002;90: ) Tokuyama T, Ikeda T, Sato K. Effect of plasma colloid osmotic pressure on intraocular pressure during haemodialysis. Br J Ophthalmol 1998;82: ) Kang YS, Hwang YH, Kim JS, Lee JH. The effect of hemodialysis on intraocular pressure, retinal nerve fiber layer thickness and corneal thickness. J Korean Ophthalmol Soc 2012;53: ) Lohr JW, Schwab SJ. Minimizing hemorrhagic complications in dialysis patients. J Am Soc Nephrol 1991;2: ) Slusher MM, Hamilton RW. Letter: Spontaneous hyphema during hemodialysis. N Engl J Med 1975;293: ) Alexandrakis G, Chaudhry NA, Liggett PE, Weitzman M. Spontaneous suprachoroidal hemorrhage in age-related macular degeneration presenting as angle-closure glaucoma. Retina 1998; 18: ) Chu TG, Green RL. Suprachoroidal hemorrhage. Surv Ophthalmol 1999;43: ) Knopp EA, Chynn KY. Spontaneous expulsive choroidal hemorrhage: CT findings. AJNR Am J Neuroradiol 1990;11: ) Chen SN, Ho CL, Ho JD, et al. Acute angle-closure glaucoma resulting from spontaneous hemorrhagic retinal detachment in age-related macular degeneration: case reports and literature review. Jpn J Ophthalmol 2001;45: ) Tilanus MA, Vaandrager W, Cuypers MH, et al. Relationship between anticoagulant medication and massive intraocular hemorrhage in age-related macular degeneration. Graefes Arch Clin Exp Ophthalmol 2000;238:

5 - 윤동희외 : 맥락막상강출혈에의한폐쇄각녹내장 - = 국문초록 = 자발적맥락막상강출혈에의한급성폐쇄각녹내장 1 예 목적 : 당뇨신장병증으로헤파린을투여하며투석하는환자에서맥락막상강출혈에의한급성폐쇄각녹내장을경험하여이를보고하고자한다. 증례요약 : 71 세남자환자로당뇨에의한만성신장병증으로헤파린을투여하며투석하고있는상태로내원 3 일전부터발생한우안시력저하, 통증을주소로내원하였다. 내원당시우안최대교정시력안전수동, 좌안최대교정시력 0.2 로측정되었고우안안압 58 mmhg, 좌안안압 15 mmhg 로측정되었다. 우안의전방각경검사상폐쇄각소견이관찰되었고, 안저검사상거대한출혈성망막박리를보였으며, 안초음파검사상맥락막상강출혈을동반한망막박리소견을보였다. 우안에방수생성억제제및조절마비제를점안하기시작하였고경과관찰 2 주째, 우안최대교정시력안전수동, 안압 8 mmhg 로측정되었으며전방각경검사상개방각소견을보였다. 2 개월간의경과관찰기간동안우안시력회복은보이지않았으나, 안압상승소견이나이와관련한통증등의증상은보이지않았다. 결론 : 항응고제를복용하지않지만헤파린을이용하여투석하는환자에게서자발적맥락막상강출혈이발생할수있으며, 이로인해이차적으로급성폐쇄각녹내장이동반될수있다. 방수생성억제제및조절마비제점안치료를통해자연스러운맥락막상강출혈의감소, 폐쇄각의소실, 이로인한안압감소를기대할수있다. < 대한안과학회지 2017;58(5): > 615

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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