대한안과학회지 2019 년제 60 권제 1 호 J Korean Ophthalmol Soc 2019;60(1):69-74 ISSN 0378-6471 (Print) ISSN 2092-9374 (Online) https://doi.org/10.3341/jkos.2019.60.1.69 Case Report 안와연조직염및안와농양의수술적치료후진단된급성눈물주머니염 1 예 A Case of Acute Dacryocystitis Diagnosed after Surgical Treatment of Orbital Cellulitis and Orbital Abscess 허민구 윤종명 곽미선 Min Gu Huh, MD, Jong Myung Yun, MD, Mi Seon Kwak, MD 대구파티마병원안과 Department of Ophthalmology, Daegu Fatima Hospital, Daegu, Korea Purpose: We report a case of acute dacryocystitis diagnosed with abscess and rupture of lacrimal sac and fistula to posterior orbit during the operation. Case summary: A 71-year-old woman visited our clinic with edema and pain in the eyelid from three days ago. For past four months, there was viscous of the left eye and tears. The patient had severe conjunctival chemosis and hyperemia, compared with the left eyelid edema and redness. Orbital CT scan showed orbital cellulitis, which was followed by systemic antibiotics and steroid therapy. On the 4th day of therapy, orbital abscess formation was observed in orbit MRI and surgical drainage was planned. During surgery, we found rupture of the posterior part of lacrimal sac and fistula to posterior orbit. Pseudomonas aeruginosa was identified in the bacterial cultures, and after the administration of appropriate antibiotics, the disease showed improved progress, and then additional dacryocystorhinostomy was performed. Conclusions: In our case, acute dacryocystitis rarely spread in orbit, which may lead to delayed diagnosis, orbital cellulitis and abscess, resulting in serious complications of vision threat. So, we think that it is necessary to consider surgical treatment more actively in the stage of chronic dacryocysitis. J Korean Ophthalmol Soc 2019;60(1):69-74 Keywords: Dacryocystitis, Orbital abscess, Orbital cellulitis 안와연조직염은안와조직내의급성염증으로시력을위협하는감염성경과를초래할수있다. 1 안와와부비동의해부학적구조의인접성으로인해주위부비동의염증으로부터파급되는것이대부분이나, 눈물주머니염이심해져 Received: 2018. 5. 17. Revised: 2018. 6. 28. Accepted: 2018. 12. 23. Address reprint requests to Mi Seon Kwak, MD Daegu Fatima Hospital, #99 Ayangro, Dong-gu, Daegu 41199, Korea Tel: 82-53-940-7140, Fax: 82-53-954-7417 E-mail: mskwak66@hotmail.com * Conflicts of Interest: The authors have no conflicts to disclose. 안와뒤쪽으로전파되어안와연조직염과안와농양을형성하는경우는드문것으로알려져있다. 급성눈물주머니염의주된합병증으로는감염이아래눈꺼풀조직으로퍼져안와사이막앞연조직염이발생할수있으며, 심한경우눈물주머니농양으로피부에샛길을형성할수있으나안와로의전파는드물다. 2-4 이미국내에서눈물주머니염에의한안와농양에대해한차례보고된바가있지만, 5 본증례에서는기존증례와달리안와사이막앞연조직염 (preseptal cellulitis) 증상은경미하면서안와연조직염 (orbital cellulitis) 이주된증상으로, 염증의기원인눈물주머니염을의심하는데어려움이있었다. c2019 The Korean Ophthalmological Society This is an Open Access article 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. 69
- 대한안과학회지 2019 년제 60 권제 1 호 - 또한일차적치료로전신적항생제및스테로이드치료를시도하였으나경과가호전되지않고악화되었으며, 결국안와농양이합병되어수술로안와농양을배액하면서눈물주머니의농양및뒤쪽부분의파열과함께안와뒤쪽으로형성된샛길을확인하였기에보고하고자한다. 증례보고 71세여자환자가 4개월전부터좌안의점성분비물, 눈물흘림증상을주소로타안과에내원하여진료후안약점안을지속하다 3일전부터눈꺼풀의부종과통증이발생하여본원응급실경유하여본원안과에의뢰되었다. 과거력상 7년전부터고혈압과당뇨로약을복용하고있었으며, 이외에다른기저질환은없었다. 본원에내원시최대교정시력은우안 0.8, 좌안 0.6, 안압은우안 15 mmhg, 좌안 22 mmhg 로측정되었다. 왼쪽눈꺼풀의부종과발적이관찰되었으며, 결막의심한부종과충혈이관찰되었고 (Fig. 1A), 안구운동은전방향으로제한이있었다 (Fig. 1B). 동공대광반사는정상으로관찰되었으며, 좌안세극등검사상각막과전방에는 특이소견이없었고, 안저검사에서도특이소견은없었다. 초진시시행한전신혈액검사에서백혈구수가 14,580/mm 3 로증가, C 반응성단백수치 (c-reactive protein) 가 5.70 mg/dl 로증가된이외에특이소견은없었으며, 뇨검사및흉부촬영에서도특이이상소견이나타나지않았다. 안와전산화단층촬영상좌안이우안에비해돌출되어있었고, 좌안안와의아래안쪽으로저음영의조직들이안구를위가쪽으로밀고있는소견이관찰되었으며벌집굴부위에염증으로의심되는저음영의액체저류소견도동반되었다 (Fig. 2A). 눈물주머니오목부위근처에는급성눈물주머니염을의심할만한뚜렷한소견이보이지않았다 (Fig. 2B). 코곁굴염에대해이비인후과에협진의뢰하였고, 비내시경검사상벌집굴염및뒤벌집굴폴립 (posterior ethmoidal polyp) 이관찰되었다. 좌안안와연조직염진단하에전신항생제및스테로이드치료를계획하였고, Aztreonam (Mezactam, Crystal Life Science, Seoul, Korea) 1 g 하루 2회정맥주사, Ceftriaxone sodium (Ceftriaxone, Hawon Pharm Co., Ltd., Seoul, Korea) 1 g 하루 2회정맥주사, Methylprednisolone (Methysol, Alvogen Korea, Seoul, Korea) 500 mg 하루 1회정맥주사를점안항 A B Figure 1. Initial photograph and gaze of extraocular movement. Clinical photograph shows lid swelling, proptosis, conjunctival chemosis, and hyperemia (A). Initial examination shows limitation of movement in all directions in the left eye (B). 70
- 허민구외 : 눈물주머니염에의한안와연조직염 - 생제로 Gatifloxacin (Gatiflo, Taejoon Pharm Co., Ltd., Seoul, Korea) 하루 4회점안, Ofloxacin (Ocuflox, Samil. Co., Ltd., Seoul, Korea) 하루 1회점안, 점안소염제로 Fluorometholone (Flumetholone, Santen Pharm Co., Ltd., Seoul, Korea) 하루 4회점안을병행투여하였다. 입원 3일째, 내원당시시행한혈액및소변세균배양검사결과특이소견이관찰되지않았고, 기존치료를유지하였으나안구주위통증을지속적으로호소하였고, 눈꺼풀부종과발적, 결막부종과충혈이더심해졌다. 입원 4일째안와자기공명영상촬영을시행하였고, 좌안안구후부쪽에 1.7 cm 크기의농양이관찰되어 (Fig. 2C) 수술적배농술을계획하였다. 입원 5일째전신마취하에이비인후과와합동수술을시행하였으며먼저이비인후과에서코곁굴염에대해비내시경적벌집굴절제술을시행하고, 안와농양의배액을위해종이판 (lamina papyracea) 에천자를시도하였으나실패하 였다. 이어서본과에서눈물언덕가쪽결막을절개하여안와의내측부위로접근하였으며눈물주머니농양과안와농양을배액한뒤세균배양검사를시행하였고, 눈물주머니뒤쪽부분의파열과함께눈물주머니에서뒤눈물주머니오목능선뒤쪽깊은안와로샛길이형성되어있는것을관찰할수있었다. 농성분비물의완전한배액을확인한뒤절개한결막을봉합하고수술을마쳤다 (Fig. 3). 수술후 2일째확인된세균배양검사상그람음성균인 Pseudomonas aeruginosa가자랐으며, 항생제감수성검사결과에따라전신정맥항생제를교체투여하였다. 수술후시행한안와전산화단층촬영결과로왼쪽안와아래안쪽의염증변화로생각되는저음영부분들이많이감소하였고, 눈꺼풀의부종, 안구돌출, 결막의부종이호전되어수술후 5일째퇴원하였으며, 수술후 1개월뒤눈물주머니코안연결술을시행하였다. 이후 2개월뒤경과관찰에서눈꺼풀의 A B C Figure 2. Computed tomography (CT) image and magnetic resonance imaging (MRI) of the patient. Initial orbital CT scan shows low density lesion (arrow) at inferomedial aspect and the left eyeball was protruded by the lesion (A). There was no obvious evidence of inflammation near the fossa of lacrimal sac (B). Orbital enhanced fat-saturated T1-weighted MRI, four days after systemic antibiotics and steroid therapy, shows orbital abscess formation (arrow) in intraconal space (C). A B C Figure 3. Surgical procedures of the abscess drainage. Through an incision between the caruncle and plica semilunaris, soft tissue dissection is performed. Abscess drainage was done (A). Ruptured lacrimal sac (circle) and abscess (arrow) was found (B). The fistula from lacrimal sac to orbit was found using lacrimal probe (circle) (C). 71
- 대한안과학회지 2019 년제 60 권제 1 호 - 부종, 안구돌출, 결막의부종이완전히호전된양상을보였으며 (Fig. 4A), 컴퓨터단층촬영에서도염증성병변의호전이관찰되었다 (Fig. 4B). 고찰 안와연조직염은안와사이막을침범하여안와뒤쪽에서연조직의염증을보인다는점에서안와사이막앞연조직염과구별된다. 흔하지는않지만안와연조직염에서는심각한시력저하, 시신경병증, 뇌수막염, 해면정맥굴혈전, 뇌내농양형성등의합병증을동반할수있어안와사이막앞연조직염과의구별이중요하다. 6 안와연조직염의임상증상으로는안구돌출, 안구운동장애, 시력저하, 결막부종, 안통등이있으며, 특히안구운동장애, 안구돌출, 시력저하는안와뒤쪽의연조직염증을시사하는특이한징후이다. 7 본증례에서도앞서언급한징후들이관찰되어안와연조직염으로진단하고입원치료를시행하였다. 일단안와연조직염으로진단되면즉각적인입원및항생제정맥주사치료가필요하다. 가장흔한원인균인포도상구균, 연쇄상구균및혐기성균에대한광범위항생제또는지역성및항생제감수성의경향에따라경험적항생제를사용하기도한다. 6 수술적치료는안와의국소농양이나골막하농양, 부비동염이동반될때고려한다. 본증례에서는안와연조직염에대해초기치료로광범위적인정맥항생제주사를시도하였으나, 시력저하및눈꺼풀부종과안구돌출등의경과가악화되고추가영상소견에서안와농양의형성이확인되어수술적배농술을시행하였다. 세균배양검사상그람음성균인녹농균 (Pseudomonas aeruginosa) 이자랐으며, 항생제감수성검사에서기존약제에는저항성이있었으나, piperacillin/tazobactam에반응하는것으로나 타났다. Pseudomonas aeruginosa는모든항생제에내성을가질수있는잠재적위험이있는균이며, 최근몇년간다제내성균이급격히증가하고있다. 8 본증례의경우처럼초기치료로광범위정맥항생제를즉각사용했음에도불구하고경과가악화된것은항생제저항성을가진균주로인해치료에잘반응하지않았을가능성이있어보인다. 그러므로경험적광범위항생제의초기치료가중요하나, 치료에잘반응하지않을경우에는신속히판단하여적절한항생제변경이필요하다고생각된다. Chen et al 9 은안와연조직염의치료로항생제치료만시행한환자군과스테로이드를병용하여치료한환자군을비교하여보고하였으며, 스테로이드를병용한환자군에서질병이진행되지않고입원기간이단축되었음을보고하였다. 또한안와염증이잠재적으로시력을위협하는결과를가져올수있는상태에서는즉각적인치료가필수적이다. 10,11 내원당시눈꺼풀부종, 안구돌출이심한상태였고, 평소보다시력저하가있으면서안압도높았기때문에항생제치료와병행하여스테로이드를사용하는것이염증을억제하고조절하는데에효과가있을것으로생각하였다. 감염증에서의스테로이드사용은면역억제에대한우려로논쟁의여지가있지만본증례의경우입원후첫 3일만스테로이드를투여하였으며, 경과가악화된원인이스테로이드사용으로인한면역억제효과라기보다는치료를시작한시점에이미농양형성이시작되어약제에잘반응하지않았을것으로생각되며앞서언급한항생제저항성균주도경과악화에기여하였을것이라고생각된다. 내원당시안와컴퓨터단층촬영에서눈물샘오목주위에눈물주머니염을의심할만한뚜렷한소견이관찰되지않아눈물주머니염으로인한안와연조직염을추정하기에어려 A B Figure 4. Follow-up photograph and orbital computed tomography (CT). Clinical photograph, three months after abscess drainage, shows remarkable improvement of the lid swelling, proptosis and conjunctival chemosis (A). Orbital CT scan, three months after abscess drainage, shows marked decrease of the previous low density lesion (B). 72
- 허민구외 : 눈물주머니염에의한안와연조직염 - 움이있었다. 일반적으로눈물주머니염이안구뒤로전파되어합병증을일으키는경우는드물다고알려져있는데이는안와사이막의기시부가뒤눈물오목능선에서시작해안구뒤로전파를막고안쪽눈구석인대의뒤갈래 (posterior limb of medial canthal ligament) 와안와사이막앞눈둘레근및눈꺼풀판앞눈둘레근의심층갈래 (deep head of preseptal orbicularis and pretarsal orbicularis) 가장벽역할을하기때문이다. 그러나 Kikkawa et al 3 은눈물주머니염이반복되면눈물주머니의벽과뒤쪽의경계성구조물들이약화되어염증이안구뒤로쉽게전파될수있다고설명하였다. 본증례의수술과정에서눈물주머니뒷부분의파열이관찰되었는데, 이미여러차례의눈물주머니염이반복되어구조물이약화되었을것으로생각된다. Maheshwari et al 12 은급성눈물주머니염에서기인한안와연조직염및안와농양환자 6명의증례를보고하였으며, 그중 2명은안와뒤쪽까지농양이전파되어시력소실및안저검사상맥락막망막의주름이관찰되었으며, 4명은원추외공간에국한된농양이형성되어전신적항생제및스테로이드치료와더불어수술적농양배액술을모두시행하였다. Martins et al 13 은이전에보고되었던눈물주머니염에서기인한안와연조직염환자 14명의증례를검토하였고, 8명의증례에서원추내안와농양, 4명의증례에서원추외안와농양의형성이관찰되었으며, 2명의증례에서안와농양이형성되지않은미만성안와연조직염의소견을보여눈물주머니염으로인해꽤높은빈도로안와농양이형성된다는것을알수있었다. 눈물주머니염의합병증으로안와로의전파는드문것으로알려져있지만, 이처럼여러증례가보고되었고심한경우에는안와농양이형성될수있으며, 외과적배액이필수적이다. 본증례의경우급성의눈꺼풀부종과통증을주소로내원하였고, 안와전산화단층촬영소견과안구돌출, 안구운동장애, 시력저하등의징후를통해안와연조직염의진단하에초기치료로광범위정맥항생제및스테로이드주사를시작하였다. 그러나치료에도불구하고점차악화되는경과를보여안와자기공명영상촬영으로안구후부에형성된안와농양을확인하여결국수술적배농술을시행하였고, 눈물길세척과눈물길더듬자를이용하여눈물주머니뒷부분의파열과함께뒤쪽안와로형성된샛길을확인할수있었다. 눈물주머니염을일으키는원인균으로는 Staphylococcus와 Streptococcus의균주가높은빈도로알려져있고드물게그람음성균이나곰팡이균도원인균이될수있으나, 14 본증례에서는농양을배액하여세균배양한결과 Pseudomonas aeruginosa가동정되어적절한항생제를투여해완전한호 전의경과를보였고이후추가적으로눈물주머니코안연결술을시행하였다. 눈물주머니염에서기인한안와연조직염의증례는드물지만문진시병력이나증상의확인이간과되지않아야할것이다. 통상급성눈물주머니염이앞쪽으로진행하여안와사이막앞연조직염, 눈물주머니농양, 피부샛길과같은전형적인증상을유발하는경우와는달리본증례처럼드물게안와쪽으로진행하는경우에는진단이늦어지고안와연조직염및안와농양이합병되어시력위협의중대한합병증이발생할수있어만성눈물주머니염의단계에서보다적극적으로수술적치료를고려하는것이필요하다고생각된다. REFERENCES 1) Connell B, Kamal Z, McNabb AA. Fulminant orbital cellulitis with complete loss of vision. Clin Exp Ophthalmol 2001;29:260-1. 1) 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. 3) Kikkawa DO, Heinz GW, Martin RT, et al. Orbital cellulitis and abscess secondary to dacryocystitis. Arch Ophthalmol 2002;120: 1096-9. 4) Ataullah S, Sloan B. Acute dacryocystitis presenting as an orbital abscess. Clin Experiment Ophthalmol 2002;30:44-6. 5) Choi YJ, Choi WC, Yang SW, Choi Y. A case of orbital abscess secondary to dacryocystitis. J Korean Ophthalmol Soc 2005;46: 156-63. 6) Lee SM, Yen MT. Management of preseptal and orbital cellulitis. Saudi J Opthalmol 2011;25:21-9. 7) Weakley DR. Orbital cellulitis complicating strabismus surgery: a case report and review of the literature. Ann Ophthalmol 1991; 23:454-7. 8) Bassetti M, Vena A, Croxatto A, et al. How to manage pseudomonas aeruginosa infections. Drugs Context 2018;7:212527. 9) Chen L, Silverman N, Wu A, et al. Intravenous steroids with antibiotics for children with orbital cellulitis. Ophthalmic Plast Reconstr Surg 2018;34:205-8. 10) Goytia VK, Giannoni CM, Edwards MS. Intraorbital and intracranial extension of sinusitis: comparative morbidity. J Pediatr 2011;158:486-91. 11) Patt BS, Manning SC. Blindness resulting from orbital complications of sinusitis. Otolaryngol Head Neck Surg 1991;104:789-95. 12) Maheshwari R, Maheshwari S, Shah T. Acute dacryocystitis causing orbital cellulitis and abscess. Orbit 2009;28:196-9. 13) Martins MC, Ricardo JR, Akaishi P, et al. Orbital abscess secondary to acute dacryocystitis: case report. Arq Bras Oftalmol 2008; 71:576-8. 14) Coden DJ, Hornblass A, Haas BD. Clinical bacteriology of dacryocystitis in adults. Ophthalmic Plast Reconstr Surg 1993;2:125-31. 73
- 대한안과학회지 2019 년제 60 권제 1 호 - = 국문초록 = 안와연조직염및안와농양의수술적치료후진단된급성눈물주머니염 1 예 목적 : 안와연조직염을치료하던중경과악화및안와농양이합병되어수술중발견된눈물주머니의농양및파열과뒤쪽안와로형성된샛길을확인하고급성눈물주머니염을진단하였기에보고하고자한다. 증례요약 : 71 세여자환자가 3 일전부터발생한눈꺼풀의부종과통증을주소로내원하였다. 좌안눈꺼풀부종과발적에비해심한결막부종및충혈소견을보였으며, 안와전산화단층촬영상안와연조직염소견이관찰되어전신항생제및스테로이드치료를하였으나경과가악화되었다. 치료 4 일째안와자기공명영상촬영에서안와농양이관찰되어수술적배농술을계획하였고, 수술중눈물주머니의농양과눈물주머니뒷부분의파열및안와로형성된샛길을확인하였다. 세균배양검사상녹농균이동정되어적절한항생제투여후호전되었으며, 이후눈물주머니코안연결술을시행하였다. 결론 : 본증례와같이급성눈물주머니염이드물게안와쪽으로진행하는경우에는진단이늦어지고안와연조직염및안와농양이합병되어시력위협의중대한합병증이발생할수있으므로만성눈물주머니염단계에서보다적극적으로수술적치료를고려하는것이필요하다고생각된다. < 대한안과학회지 2019;60(1):69-74> 허민구 / Min Gu Huh 대구파티마병원안과 Department of Ophthalmology, Daegu Fatima Hospital 74