한방안이비인후피부과학회지제 31 권제 2 호 (2018 년 5 월 ) J Korean Med Ophthalmol Otolaryngol Dermatol 2018;31(2):152-151 pissn 1738-6640 eissn 2234-4020 http://www.ood.or.kr http://dx.doi.org/10.6114/jkood.2018.31.2.152 Case Report / 증례당뇨망막병증성유리체출혈환자치험 1 례보고 이득주 이마음 권강 서형식부산대학교한방병원안이비인후피부과 A Case Report of Diabetic Retinopathy Vitreous Hemorrhage Deuk-Joo Lee Ma-Eum Lee Kang Kwon Hyung-Sik Seo Dept. of Ophthalmology, Otolaryngology and Dermatology, Pusan National University Korean Medicine Hospital Abstract Objectives : The aim of this study is to report the effect of Korean medicine treatment on diabetic retinopathy vitreous hemorrhage. Methods : A 66-year-old female who had diabetes for over 20 years showed vitreous hemorrhage of Grade 4 at initial visit. For about 2 months, acupuncture, moxibustion and herbal medicine treatment were performed. Prognosis was confirmed by funduscopic examination, automatic refractive examination and visual acuity test. Results : In the fundus photographs, we can observe the recovery of turbidity in Grade 4, which decreases to Grade 1, and the result of refraction in the right eye and visual acuity that was not measured when the turbidity is severe. Conclusions : This study was a case of a patient with diabetic retinopathy vitreous hemorrhage complaining of decreased visual acuity. Patients were given herbal medication, acupuncture and moxibustion. Through the funduscopic examination, the treatment effect on the absorption of vitreous hemorrhage was confirmed. Key words : Diabetic retinopathy; Vitreous hemorrhage; funduscopic examination c 2018 the Society of Korean Medicine Ophthalmology & Otolaryngology & Dermatology This is an Open Access journal distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/license/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 152
이득주외 3 인 : 당뇨망막병증성유리체출혈환자치험 1 례보고 Ⅰ. 서론 유리체출혈 (vitreous hemorrhage) 은망막, 맥락막, 섬모체의혈관조직에서생긴출혈이유리체로번져나온것으로외상, 망막의여러출혈질환, 당뇨망막병증, 혈액질환, 거미막밑출혈등이원인이된다. 유리체출혈의정도에따라시력장애없는비문증부터완전시력상실등시력장애정도도달라진다. 유리체는혈관이없으므로적혈구는느리게흡수되며망막박리가없으면출혈이자연적으로흡수되도록기다린다. 최근에는 1-2개월뒤에도출혈이호전되지않으면유리체절제술을시행하는경향이있다 1). 目盲은外眼을관찰하면이상이없지만시력이점차적또는급격히떨어져심한경우보이지않게되는눈병을말하며, 서양의학의시망막박리, 급성시신경염, 안저출혈성병변등과유사하다 2). 본증례에서다루는유리체출혈은眼盲의血灌瞳神內障에해당하는질환이다. 眼昏또는眼盲질환에대한한의학관련논문은보고된바가있으나수가적으며유리체출혈에대한증례는 1편 3) 으로증례보고가미흡한실정이다. 유리체출혈은망막박리를동반하지않으면보존적치료로접근할수있는질환으로비록 1례의증례이나유리체출혈환자에한의학치료를적용하여호전반응을얻었기에이를보고하는바이다. 이를통해한의계에안과치료의적용범위가넓어지기를기대한다. Ⅱ. 증례 1. 환자명 : 문 OO, 66 세, 여자 Corresponding author : Hyung-sik Seo, Pusan National University Korean Medicine Hospital, 20, Geumo-ro, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Korea. (Tel : 055-360-5630, E-mail : aran99@pusan.ac.kr) Recieved 2018/4/6 Revised 2018/5/3 Accepted 2018/5/10 2. 주소증 visual disturbance 3. 현병력상기환자 2017년 12월 29일경우측시력저하호소하여당일본원내원. 안저검사상우안유리체출혈진단. 2018년 1월 2일타대학병원안과내원. 시력안전지수 ( 우안 )/0.1( 좌안 ), 안압 (mmhg) 18( 우안 )/21( 좌안 ) 이였으며우안유리체출혈진단받고유리체절제술권유받았으나환자분한방치료원하여수술거부후 2018년 1월 8일부터본원에서외래치료시작함. 4. 과거력및가족력 1) 당뇨 : 1987년진단후당뇨약복약중. 1 당뇨병성괴저 : 2015년 7월족부좌측 5지, 중족골절단. 2016년 6월반신욕으로인한화상으로족부우측 1지, 좌측 1지피부이식술시행. 2 좌안당뇨망막병증성유리체출혈 : 2016년 3월좌안시력감소, 유리체절제술시행. 3 양안증식당뇨망막병증 : 2014년경범망막광응고술시행. 2) 고혈압 : 2016년진단후혈압약복약중. 3) 양안백내장 : 2006년경인공수정체삽입술시행. 5. 가족력부, 모 당뇨. 6. 치료방법 2018년 1월 8일부터 3월 2일까지주 2-3회외래치료 ( 총 20회 ) 시행. 1) 침치료 0.25 40mm의 1회용호침으로우측안구주위혈睛明, 四白, 球后, 太陽, 攒竹, 陽白, 絲竹空에자침하였으며 20분간유침. 153
한방안이비인후피부과학회지제 31 권제 2 호 (2018 년 5 월 ) 2) 뜸치료 양측陽白穴 (GB14) 에 2 회간접애주구시행. 3) 한약치료 반하백출천마탕 ( 산제 ) 과육미지황환병용투약. 환자분육미지황환복용후소화불편감호소하여투약중지. 치료종료시까지반하백출천마탕 ( 산제 ) 은지속적으로복용하였음. 1 반하백출천마탕 ( 단미엑스산혼합제, 주 ) 한국신약 ) 1포 (3.65g) 1일 3회식후 30분에 53일투약 (Table 1). 2 육미지황환 ( 주 ) 한국신약 ) 1포 (20환) 1일 3회식후 30분에 34일투약 (Table 2). Table 1. Composition of Banhabaegchoolcheonma-tang Extract Herbal name Scientific name Dose(g) 黃柏 Phellodendri Cortex 0.25 黃芪 Astragali Radix 0.63 乾薑 Zingiberis Rhizoma 0.38 人蔘 Ginseng Radix 0.63 茯苓 Poria(Hoelen) 0.63 澤瀉 Rhizoma Alismatis 0.63 白朮 Atractylodis Rhizoma Alba 1.25 蒼朮 Rhizoma Atractylodis Japonicae 0.63 神麯 Massa Medicata Fermentata 1.25 半夏 Rhizoma Pinelliae 1.88 麥芽 Hordei Fructus Germiniatus 1.88 陳皮 Citri Pericarpium 1.88 生薑 Zingiberis Rhizoma Recens 0.83 Table 2. Composition of Yukmijiwhang-Whan Herbal name Scientific name Dose(g) 熟地黃 Rehmanniae Radix preparata 0.64 山茱萸 Corni Fructus 0.32 山藥 Dioscoreae Rhizoma 0.32 牧丹皮 Moutan Cortex Radicis 0.24 澤瀉 Alismatis Rhizoma 0.24 茯苓 Poria(Hoelen) 0.24 4) 양약치료 1 고혈압관련약물 : ASTRIX 100 mg 1Cap, NORVASC 10mg 1Tab, Rovatitan 10/160mg 1Tab 1일 1회아침식후 30분복약. 2 당뇨관련약물 : DEXID 300 mg 1Tab, JARDIANCE 25mg 1Tab 1일 1회아침식후 30 분복약. HUMALOG MIX 50 300UNIT/3 ml 36UNIT 1Sy/day 피하주입. 7. 이학적검사치료전 후안저촬영기 (TRC-NW8, Topcon corporation), 자동각막굴절검사기 (Auto Kerato Refractometer KR-8900) 를이용하여측정. 시력검사, 안저사진으로유리체출혈의정도 4) (Table 3) 를비교. 8. 경과안저촬영은외래치료동안총 3번 2017년 12월 29일 (Fig. 1), 2018년 2월 8일 (Fig. 2), 2018년 3월 2 일 (Fig. 3) 에이루어졌으며굴절검사및시력검사는총 2번 (2018년 1월 2일, 2018년 3월 6일 ) 시행함. 안저사진에서 Grade 4에해당하던유리체출혈이 Grade 1로감소하는혼탁도의회복 (Table 3, Fig. 4) 을관찰할수있으며혼탁이심했을때측정이되지않았던우안의굴절검사결과가이전의상태로회복됨 (Table 4). III. 고찰당뇨병치료법발전으로인해당뇨병환자의수명이연장됨으로서그로인한합병증의빈도도증가하였다. 당뇨망막병증은망막의미세순환장애로발생하는데주로후극부의망막모세혈관이쉽게침범되며, 비관류부위는망막의중간주변부에주로발생한다. 당뇨망막병증은혈관신생유무에따라비증식당뇨망 154
이득주외 3 인 : 당뇨망막병증성유리체출혈환자치험 1 례보고 Fig. 1. (A, B) Fundus photographs show vitreous hemorrhage in right eye. (Rt/Lt) December 29 th, 2017. Fig. 2. (C, D) Fundus photographs (Rt/Lt) Feburary 8 th, 2018. Fig. 3. (E, F) Fundus photographs (Rt/Lt) March 2 th, 2018. Fig. 4. (A, C, E) Progress of absorption of vitreous hemorrhage in right eye. 155
한방안이비인후피부과학회지제 31 권제 2 호 (2018 년 5 월 ) Table 3. The Vitreous Hemorrhage Density Grading Scale Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 No blood present in the vitreous, the entire retina is visible. Some hemorrhage present, which obscures between a total of 1 to 5 clock hours of retina. Laser photocoagulation (PRP) can be successfully performed. Hemorrhage obscures between a total of 5 to 10 clock hours of central and/or peripheral retina, or a large hemorrhage is located posterior to the equator, with varying clock hours of anterior retina visible. Laser is feasible, but a full PRP can not be placed. A red reflex is present, with no retinal detail seen posterior to the equator, precluding any photocoagulation. Dense vitreous hemorrhage with no red reflex present. Table 4. Refraction Test, Visual Acuity Test Value Refraction test visual acuity test 2017. 12. 19.* +0.87 0.75 56/ +1.50 1.00 100 0.4/0.1 2018. 1. 2. N/T/ +0.75 0.00 180 finger count/0.1 2018. 3. 6. +0.87 1.25 65/ +1.37 0.37 160 0.4/0.1 *Test results before vitreous hemorrhage, OD/OS Record in order of SPH CYL AX, OD/OS 막병증과증식당뇨망막병증으로분류된다 1). 비증식당뇨망막병증에서는모세혈관혈관벽이부분적으로약화, 원형확장되어발생하는미세혈관류와망막출혈, 면화반, 염주정맥, 망막내미세혈관이상등이발생한다. 이시기를지나시신경유두부위나망막의내측표면위로비정상적인신생혈관이형성되면증식당뇨망막병증으로진단한다. 증식당뇨망막병증은신생혈관과증식성섬유혈관막의발생으로유리체출혈이나견인성망막박리또는신생혈관녹내장등의합병증으로실명까지이를수있는만성질환이다 5). 증식당뇨망막병증에서망막미세혈관폐색은국소적인저관류를만들며이로인해발생한허혈은망막색소상피, 내피세포에서혈관내피세포성장인자의생성을증가시킨다. 이러한혈관내피세포성장인자는망막의모세혈관을확장시키며, 미세혈관류를만든다 6). 또한, 망막혈관의투과성이비정상적으로증가됨에따라혈관외누출이생기고, 이로인해당뇨황반부종 (diabetic macular edema) 이발생 한다. 황반부종으로인한시력저하는비교적점진적으로발생하고중등도의시력저하를유발하는데비하여, 신생혈관으로인한출혈이나견인망막박리등의합병증이발생할경우에는중증의시력저하가급격히발생하게된다 7). 당뇨망막병증에대한치료는즉시수술을필요로하는경우와수술이선택적인경우로나눌수있다. 황반부를침범한견인망막박리, 신생혈관녹내장, 앞유리체섬유혈관증식은수술하지않으면실명하게된다. 반면범망막광응고치료가되어있는눈에서유리체출혈이나중심와를침범하지않은망막앞출혈은수술전상당히기다리더라도잠재적인시력은대개변화가없다 8). 유리체출혈로인한시력장애가발생하였을때일반적으로 3-6개월정도자연적인흡수를기다려보았다가유리체절제술을시행하는것이일반적이나 9-11), 유리체출혈로인하여발생한녹내장이약물로조절되지않을때, 망막박리가동반된증거가나타날때, 반대편눈의시력상태가불량할때, 환자본인 156
이득주외 3 인 : 당뇨망막병증성유리체출혈환자치험 1 례보고 의시력회복욕구가클때조기수술의적응증이된다 12). 유리체출혈은출혈정도에따라 Grade 0~4로분류되며 4) (Table 3) 한의학적으로출혈량이경미한경우 云霧移睛, 다량인경우 暴盲 에해당되며, 治法으로 急則治其標 의원칙을따르며止血을먼저행하며出血이안정화된후에活血化瘀위주의치료를한다. 보존적치료가유효하지않거나망막박리의소견이보이면유리체절제술을고려한다 13). 증식당뇨망막병증에서유리체절제술의주요목표는유리체와혈관이발달한섬유혈관막을망막으로부터제거하는것이다. 증식당뇨망막병증의합병증이발생하였을때시행하는유리체절제술은유리체출혈과증식망막전막을제거하고황반을재유착시키며동시에유리체피질을제거하고, 허혈성변화가있으면안내광응고술을시행하여망막신생혈관을퇴행시켜안구내해부학적구조를안정적으로유지해장기적으로시력회복상태를지속시키는것이주목적이다 14). 증식당뇨망막병증의경우유리체절제술후유리체출혈, 홍채신생혈관, 안압상승, 각막이상, 망막박리, 백내장등의합병증이발생할수있다. 증식당뇨망막병증으로유리체절제술을받은후생길수있는합병증들중가장처치곤란한것으로알려져있는신생혈관녹내장은대개유리체절제술후 6개월이내에발생하고수술후지속적인망막박리가있을때잘생기며유수정체안보다는무수정체안이나인공수정체안에서잘발생한다고알려져있다 15-16). 본증례의환자는당뇨로 20년이상지속적으로약을복용및피하주입한분으로, 증식당뇨망막병증으로인한유리체출혈로볼수있다. 처방은 中西醫臨床眼科學 玻璃體出血부분에수록되어있는변증시치氣滯血瘀 ( 血府逐瘀湯 ), 虛火上炎 ( 知柏地黃丸 ), 脾不統血 ( 歸脾湯 ), 痰濁瘀阻 ( 滌痰湯合桃紅四物湯 ) 를고려할수있는데 13), 환자가頭重感을같이호소하여痰濁瘀阻라진단하고化痰시키는半夏白朮天麻湯 ( 보험산제 ) 을처방하였다. 또한, 당뇨망막병증성유리체출혈은중의안과학에서 消渴內障 에속하며한의학적消渴이당뇨와동일한병이라연결하기는어려우나渴而多飮, 消穀善飢, 渴而尿數有膏油등의증상이당뇨증상과유사하며, 消渴이오래되면나타나는風痺, 腦疽, 背瘡, 中滿, 鼓脹, 雙目失明등과같은消渴轉變證은당뇨병으로인한합병증과일치하는부분이많아유사한질환으로생각할수있다 17). 消渴轉變證의眼病 ( 雀目, 內障 ) 에대한病理는黃帝內經부터明淸對까지역대의가의정리를살펴보면火熱혹은腎虛로말미암은虛熱로보았다 18). 陰이虧損하여虛火의上炎으로발생하는병증을치료하는대표적인방제로육미지황환을들수있으며, 최근한의학, 중의학의실험연구결과항당뇨효능, 면역증강, 혈당및중성지방감소에효과가있음이확인되었다. 따라서본증례환자에게도외래진료동안반하백출천마탕에육미지황환을합방하여투약하였다 19-20). 침치료는우측안구주위혈睛明, 四白, 球后, 太陽, 攒竹, 陽白, 絲竹空에 20분간유침하였고 21), 陽白穴에간접애주구를 2회시행하였다. 한국유리체망막질환에대한진료및치료에대한최근경향이라는주제로한국망막학회회원 273명에게이등 22) 이설문조사에서증식성당뇨망막병증으로범망막광응고술을받은환자에서망막박리나유의한견인을동반하지않은심한유리체출혈이발생한경우 49% 에서일정기간관찰후유리체절제술이나레이저치료를시행한다고답하였으며즉시유리체절제술을시행한다는의견이 14% 였다. 상기환자의경우에도병원에서즉시유리체절제술을권유받았으나유리체출혈로인한다른동반질환이없었고수술에대한부작용의위험으로저자는환자의동의를얻어한의학적치료를시행하였다. 내원시유리체출혈로안저검사상안저의구조물을분별할수없을정도로혼탁이심하였으며 (Vitreous hemorrhage Grade 4), 이로인해시력안전지수 /0.1, 자동굴절검사가측정되지않는등시력저하도동반되었으나치료 2개월후안저검사상에서혼탁의감소 (Vitreous hemorrhage 157
한방안이비인후피부과학회지제 31 권제 2 호 (2018 년 5 월 ) Grade 1) 를확인할수있었고시력과자동굴절검사측정값도이전값 (0.4/0.1) 으로회복되었다. 다만, 본증례는 1례로서부족한부분이있으며안저검사상유리체출혈소견을확인할수있었으나, 형광안저혈관조영검사로미세동맥류, 주변혈관신생및혈관의누출소견을추가적으로확인하지못한점이본연구의미진한부분이라하겠다. 그러나안저촬영기기를이용한기기적망진으로유리체출혈을진단하고환자의경과관찰을하였으며, 투약이용이하고비용이저렴하며장복할수있는한방제제약을활용하여만족한치료결과를얻은점에서의의가있다. 본증례를통해비록환자가심한유리체출혈로유리체절제술을권유받았다고하더라도망막박리나유의한견인을동반하지않는경우라면한의학적치료와진단기기를활용한경과관찰이필요할것으로사료된다. 추후안과질환에대한연구및증례보고가확대되기를기대한다. Ⅳ. 결론본연구는시력저하를호소하는당뇨망막병증성유리체출혈환자 1례에대해치료한치험례이다. 환자에게한약제투약, 안구주위혈침치료, 간접구를시행한결과유리체출혈의흡수에치료효과가있음을안저검사및시력검사를통해확인할수있었다. 윤리적승인본증례보고의연구대상자에게사진및진료기록의학술적이용에대해사전동의를받았음. References 1. Kim HS, Kim HM, Sung GJ, Yoo YS. Ophthalmology. Seoul:ilchokak, Inc. 2014:262. 2. Kim KU, Park HK, Park JH, Jang HU. A study of treatment and differentiation of syndromes on optic disease in Huang Di Nei Jing. The Journal of Korean society of meridian diagnosis. 2005;3:104-19. 3. Jung JH, Kwon K, Seo HS. Clinical Study on one Patient with Vitreous Hemorrhage Caused by Diabetic Retinopathy. J Korean Med Ophthalmol Otolaryngol Dermatol. 2004;17(2):112-9. 4. Lieberman RM, Gow JA, Grillone LR. Development and implementation of vitreous hemorrhage grading scale. Retin Physician. 2006;3:S1-8. 5. Moss SE, Klein R, Klein BE. The 14-year incidence of visual loss in a diabetic population. Ophthalmology. 1998;105:998-1003. 6. Spaide RF, Fisher YL. Intravitreal bevacizumab (avastin) treatment of proliferative diabetic retinopathy complicated by vitreous hemorrhage. Retina. 2006;26: 275-8. 7. Song JH. Prevention and management of diabetic retinopathy. J Korean Med Assoc. 2014;57(6):525-34. 8. Oum BS, Lee JE. Vitreoretinal surgery: principles and practice. Gyeonggi:naewaehaksool, Inc. 2013:241. 9. Butner RW, McPherson AR. Spontaneous vitreous hemorrhage. Ann Ophthalmol. 1982;14: 268-70. 10. Ziemianski MC, McMeel JW, Franks EP. Natural history of vitreous hemorrhage in diabetic reti nopathy. Ophthalmology. 1980; 87:306-12. 158
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