검안및콘택트렌즈학회지 2019 년제 18 권제 3 호 Ann Optom Contact Lens 2019;18(3):91-95 ISSN 2384-0919 (Print) ISSN 2384-0927 (Online) Case Report 급성눈물주머니염에합병된안와연조직염및안와농양 Orbital Cellulitis and Orbital Abscess Secondary to Acute Dacryocystitis 박영명 1 이태은 1,2,3 유인천 1,2,3 조남천 1,2,3 안민 1,2,3 Young Myoung Park, MD 1, Tae Eun Lee, MD, PhD 1,2,3, In Cheon You, MD, PhD 1,2,3, Nam Chun Cho, MD, PhD 1,2,3, Min Ahn, MD, PhD 1,2,3 전북대학교의과대학안과학교실 1, 전북대학교임상의학연구소 2, 전북대학교병원의생명연구원 3 Department of Ophthalmology, Chonbuk National University Medical School 1, Jeonju, Korea Research Institute of Clinical Medicine of Chonbuk National University 2, Jeonju, Korea Biomedical Research Institute of Chonbuk National University Hospital 3, Jeonju, Korea Purpose: To report a case of orbital cellulitis and orbital abscess secondary to acute dacryocystitis. Case summary: A 56-year-old man with eyelid swelling on the left eye hit by a car door was diagnosed with orbital cellulitis at a local clinic and was treated with oral antibiotics for days. However, the symptoms got worse and the patient was referred for assessment. The patient had severe eyelid and conjunctival swelling on the left eye with decreased visual acuity with proptosis. We obtained a contrast-enhanced computed tomography (CT) scan, which demonstrated dacryocystitis with orbital cellulitis, sinusitis of left maxillary and ethmoid sinus. Endoscopic endonasal dacryocystorhinostomy and functional endoscopic sinus surgery at the ear, nose, and throat department was done to treat the patient. The day after the operation, eyelid swelling and proptosis were better than the previous day. But the next day, symptoms got worse so we obtained a follow-up contrast-enhanced CT scan, which demonstrated increased soft tissue attenuation medially medial rectus muscle. These findings in the CT scan were thought of as orbital abscess, so surgical incision and drainage was done. After the operation, pain, eyelid and conjunctival swelling were decreased and the best-corrected visual acuity of the left eye was recovered to 1.2. Conclusions: In adults, orbital cellulitis is mostly caused by sinusitis, but we should consider that it could be caused by acute dacryocystitis. Ann Optom Contact Lens 2019;18(3):91-95 Key Words: Acute dacryocystitis; Dacryocystorhinostomy; Oribital abscess; Orbital cellulitis 눈물주머니염은코눈물관폐쇄가주된원인이며, 눈물이고이게되고여기에세균성감염이합병되는경우발생한다. 눈물주머니는해부학적으로안와사이막 (orbital septum) 앞쪽에위치하기때문에급성눈물주머니염이발생하면안와사이막앞연조직염 (preseptal cellulitis) 을초래하는경우는흔 Received: 2019. 6. 10. Revised: 2019. 7. 23. Accepted: 2019. 9. 3. Address reprint requests to Min Ahn, MD, PhD Department of Ophthalmology, Chonbuk National University Hospital, #20 Geonji-ro, Deokjin-gu, Jeonju 54907, Korea Tel: 82-63-250-1965, Fax: 82-63-250-1960 E-mail: ahnmin@jbnu.ac.kr 히있으나, 1,2 뒤눈물주머니오목능선 (posterior lacrimal crest) 뒤쪽으로전파되어안와연조직염 (orbital cellulitis) 이나안와농양 (orbital abscess) 을보이는경우는드물다. 3,4 안구뒤로염증이파급되면백혈구증가, 체온상승과같은전신감염징후와함께눈꺼풀부종, 결막부종, 안구돌출, 복시, 안구운동의제한, 시력감소및시력상실등을유발할수있다. 1 저자는시력저하를보이는안와연조직염환자에서전산화단층촬영상급성눈물주머니염의소견과급성부비동염소견을보여내시경적눈물주머니코안연결술과기능내시경부비동수술을실시한후합병된안와농양에의해증상이악화된환자를경험하였기에보고하는바이다. Copyright 2019, The Korean Optometry Society The Korean Contact Lens Study Society Annals of Optometry and Contact Lens is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 91
- 검안및콘택트렌즈학회지 2019 년제 18 권제 3 호 - 증 례 56세남자환자가차문에부딪힌뒤발생한왼쪽눈의눈꺼풀부종을주증상으로본원에내원하였다. 좌측눈꺼풀의심한부종, 피부의발적, 결막의중증도의부종과충혈소견을보였으며, 하안검비측의부종은특이적이지않았으며, 안구의돌출로눈꺼풀을벌리기어려운상태였다 (Fig. 1). 식은땀, 오한등의전신증상을동반하고있었고특이안과적과거력및질환력은없었다. 내원당시측정한시력은우안나안시력 0.2, 교정시력 1.2였으며, 왼쪽눈나안시력 0.1, 교정시력 0.3이었다. 안압은우안 23 mmhg, 좌안 49 mmhg로왼쪽눈안압상승소견을보이고있었다. 전안부검사상각막과전방에는특이소견이없었으며, 왼쪽눈상대적구심성동공장애검사에서부정증상을보이고있었다. 왼쪽눈망막은눈꺼풀부종으로관찰이어려운상태였다. 완전혈구계산에서백혈구수가 17,300/mm 3, 절대호중구수는 15,160/mm 3 로증가되었으며, 전신감염에의한염증 Figure 1. Photograph taken on his first visit shows severe lid swelling and redness. The patient was not able to open his left eye. 상태를추정할수있는적혈구침강계수와고민감도 C-반응성단백은각각 25 mm/hr, 105.18 mg/l로증가되어있었다. 안와전산화단층촬영상왼쪽눈의급성눈물주머니염, 안와연조직염그리고좌측상악동, 사골동의급만성부비동염의소견을보이고있었다 (Fig. 2). 상기소견에대해내시경적눈물주머니코안연결술을시행하였으며, 부비동염에대해이비인후과와협력수술하였다. 수술은전신마취와기관삽관하에시행하였으며, 감압을위해가쪽의눈구석절개술실시후이비인후과에서기능내시경부비동수술을시행하였다. 고식적인방법의내시경적눈물주머니코안연결술을시행하였다. 눈물주머니의삼출물에서배양검사를실시하였고수술중눈물주머니주변조직에서농성분비물이지속적으로배액되었다 (Fig. 3). 주변조직에대한변연절제술및항생제를이용한세척후, 실리콘관을삽입한후수술을마무리했다. 수술후경험적으로 vancomycin 1 g 하루 2회정맥투여로전신항생제요법을시행하였으며, 수술후 2일뒤부터그람양성균과음성균에모두효과가있는 ceftazidime 2 g 하루 3회정맥투여로변경하여투여하였다. 수술 1일뒤에증상이호전되는양상을보였으나, 수술 2일뒤좌안의통증을호소하였으며, 눈꺼풀부종, 발적및안구돌출이악화되는양상을보여병변에대한확인을위해전산화단층촬영을재실시하였으며, 검사상내직근의내측에연부조직음염이증가된양상을보였으며 (Fig. 3), 합병된안와농양에의한소견으로생각되어수술적절개배농술을실시하였다. 왼쪽눈상안검및하안검을내측으로절개하여농양을절개배농하고항생제를이용한세척을실시하였다. 절개부위에배액판을거치한뒤절개부분을봉합하지않고수술을마무리하였다. 눈물주머니의절제생검표본에대한조직병리학적검사상 Actinomycosis가동정되 A B C D Figure 2. Initial orbital enhanced computed tomography scan (axial view) shows well-circumscribed round lesion centered on the lacrimal fossa with central low attenuation and peripheral enhancement (arrow) (A). Coronal view shows swollen lacrimal sac bordered laterally by enhancing muscle and soft tissue. Left eyeball was deviated by the lesion (B). Another well-circumscribed oval shape lesion with central heterogenous attenuation and peripheral enhancement (arrowhead) (C). Maxillary sinus filled with homogenous peripheral mucosal thickening and calcified lesion (D). 92
- 박영명외 : 눈물주머니염에속발한안와농양 - 었으며, 농양의배양검사상 Streptococcus constellatus가동정되어항생제감수성검사를실시하였다. 항생제감수성검사상기존에사용중인항생제에감수성을보이고있어전신항생제요법을유지하며치료하였다. 절개배농술후 2일동안 methylprednisolone 125 mg을하루에한번정맥주사하였으며, 이후에는경구 prednisolone 30 mg을유지하였다. 절개배농술배농술후 4일뒤삼출물감소및증상의개선 소견을보여배액판을제거후피부봉합하였다 (Fig. 4). 퇴원전시행한전산화단층촬영에서좌측눈물주머니와안와내부의농양은소실되었으며, 주변조직의부종과음영증가소견도현저하게감소되어있었다. 퇴원시눈꺼풀부종, 결막부종, 통증등의임상증상이호전되었으며, 왼쪽눈나안시력은 0.5, 최대교정시력은 1.2까지회복되어입원후 22일째에퇴원하였다. A B C D Figure 3. Pus drained through the incision site of left lacrimal sac during the dacryocystorhinostomy (A). Follow-up photograph 2 days after operation shows more severe eyelid swelling and redness than initial photograph (B). Follow-up orbital computed tomography scan (axial view) 2 days after dacryocystorhinostomy shows the markedly decreased previous low attenuation lesion in lacrimal sac but increased soft tissue attenuation and heterogeneous mass like attenuation bordered laterally medial rectus muscle pressed eyeball (C). Coronal view shows more deviated left eyeball (D). A B Figure 4. Follow-up photograph 1 day after surgical incision and drainage (A). Photograph before discharge shows decreased eyelid and conjunctival swelling (B). 93
- 검안및콘택트렌즈학회지 2019 년제 18 권제 3 호 - 고찰 안와연조직염혹은안와농양은다양한질환에의한유발될수있으나, 5 주변기관이나조직의염증이파급되어이차적으로발생하는경우가많으며, 1 소아에서는사골동염이가장흔한원인으로알려져있다. 5 부비동염, 6 눈꺼풀피부나 7 결막의감염, 외상으로이물이들어간경우나 8 안와벽골절 1 등이원인이될수있으며, 드물게는구강, 치아의 9 문제혹은안와내삽입된인공물이나 10 백내장수술 11 등의수술적처치후에도발생할수있다. 여러가지원인중에서부비동염이주된원인으로알려져있으며, Birch-Hirschfeld 12 에의하면안와감염의 60% 가부비동염에의해발생하는것으로보고하였다. 안와는해부학적으로주변의구조물인비강, 부비동, 두개강으로부터얇은뼈에의해구조적으로구분되고, 여기에는신경혈관이나코눈물관이지나가기위한정상적인구멍이나틈새가존재하고있다. 1 감염은정상적인해부학적인구조를통해주변조직에서안와로전파되며, 급성부비동염의경우염증성삼출물이형성되어부비동의압력이증가하면뼈주위혈관공급의장애로괴사가일어나구조적인장벽이파괴되어안와로의감염이더쉽게발생할수있다. 1 눈물주머니염은주로안와사이막앞연조직염을유발하고안구뒤로의전파는드물게발생하는데, 이는안와사이막이뒤눈물주머니오목능선에서시작하기때문에안구뒤로의전파를막고안쪽눈구석인대와앞눈꺼풀판, 눈둘레근일부가중요한구조적장벽역할을하기때문이다. 1 반복적인눈물주머니염은눈물주머니주변의구조물들을약화시키므로염증의안구뒤전파가쉽게될수있다. 13 눈물주머니염의원인균으로그람양성균포도알균속과포도상구균속이가장흔하며, 그외에도드물게그람음성균, 곰팡이균등이있을수있다. 14 안와주위감염의임상증상으로눈꺼풀부종, 눈꺼풀발적, 결막부종, 안구운동의장애, 안구돌출, 시력저하등이있을수있으며, 전신적으로는발열, 구토, 섬망, 혼수, 발작과같은증상이나고온을동반한빈맥이나타나기도한다. 15 임상증상과초음파, 전산화단층촬영, 자기공명영상등의영상검사의결과를통합적으로고려하여진단에도움을얻고치료방향을결정하게된다. 치료는안와사이막앞연조직염과안와연조직염의경우전신적인항생제치료를우선으로실시하며, 골막하농양과안와농양에서는수술적치료가효과적인것으로알려져있다. 본증례의경우외상후발생한눈꺼풀부종과통증, 시력저하를주소로내원하여실시한전산화단층촬영에서급성눈물주머니염과주변조직에염증성변화를보이는연 부조직음영이증가되어안와연조직염의소견을보이고있었다. 사골동및상악동의부비동염은내부석회화소견을일부동반한급만성의상태로주변구조물의손상은없었다. 상기소견을통해급만성부비동염, 급성눈물주머니염에합병된안와연조직염으로진단할수있었고감염이안구뒤로전파되어발생한것으로생각할수있었다. 상기증례의환자는전산화단층촬영에서눈물주머니염의소견과부비동염의소견이동반되어있어부비동염에합병된안와연조직염의가능성을배제할수는없었다. 내시경적눈물주머니코안연결술을실시하였으며, 수술후 2일째증상악화소견을보여서실시한조영증강전산화단층촬영에서안와농양의소견을보여수술적절개배액술을추가로실시한후호전되었다. 급성눈물주머니염에합병되어안와연조직염과안와농양이동시에발생할수있으며, 이러한경우시력저하및시력상실등을유발할수있다. 안와연조직염의주된원인은부비동염이나상기사례와같이급성눈물주머니염에합병되어발생할수있으며, 안와농양으로진행할경우적시적인피부경유눈물주머니코안연결술을시행하고동시에안와농양절개술을시행하는것이효과적일수있다. 때문에임상증상및영상의학적검사를통한빠른진단과이에맞는적절한수술적처치가환자의예후에중요할수있을것이다. REFERENCES 1) Choi YJ, Choi WC, Yang SW, Choi YK. A case of orbital abscess secondary to dacryocystitis. J Korean Ophthalmol Soc 2005;46: 156-63. 2) Ataullah S, Sloan B. Acute dacryocystitis presenting as an orbital abscess. Clin Exp Ophthalmol 2002;30:44-6. 3) Ferguson MP, McNab AA. Current treatment and outcome in orbital cellulitis. Aust N Z J Ophthalmol 1999;27:375-9. 4) Mauriello JA Jr, Wasserman BA. Acute dacryocystitis: an unusual cause of life-threatening orbital intraconal abscess with frozen globe. Ophthalmic Plast Reconstr Surg 1996;12:294-5. 5) Reddy SC, Sharma HS, Mazidah AS, et al. Orbital abscess due to acute ethmoiditis in a neonate. Int J Pediatr Otorhinolaryngol 1999;49:81-6. 6) Pond F, Berkowitz RG. Superolateral subperiosteal orbital abscess complicating sinusitis in a child. Int J Pediatr Otorhinolaryngol 1999;48:255-8. 7) Mahasin Z, Saleem M, Quick CA. Multiple bilateral orbital abscesses secondary to nasal furunculosis. Int J Pediatr Otorhinolaryngol 2001;58:167-71. 8) Philip J, Sylvester K. Post-traumatic orbital cellulitis. Br J Oral Maxillofac Surg 2010;48:326. 9) Bizakis JG, Papadakis CE, Prassopoulos P, et al. Transantral evacuation of an orbital abscess following a molar tooth extraction. Am 94
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