裂孔原性網膜剝離との鑑別が困難であったVogt-小柳-原田病の1例

A case of Vogt-Koyanagi-Harada disease that was difficult to differentiate from rhegmatogenous retinal detachment

要約　目的：Vogt-小柳-原田病（VKH）は漿液性網膜剝離を生じるが，後極部から網膜剝離が生じて，その後に周辺部に拡大するケースが多い。今回，片眼の網膜周辺部から網膜剝離が生じて拡大したために，裂孔原性網膜剝離（RRD）との鑑別が困難であったVKHの1例を報告する。

症例：64歳，女性。X年6月に頭痛を自覚した。その3日後から右眼の充血，その後，飛蚊症と視力低下を自覚して近医を受診した。右眼のぶどう膜炎と下鼻側に限局性の網膜剝離を指摘され，精査加療目的に大阪医科薬科大学眼科に紹介受診となった。初診時，右眼は視力（0.4）で，2＋の前房内炎症細胞と，ほぼ全周に虹彩後癒着を認め，下鼻側に限局性の網膜剝離を認めた。その後，下鼻側から下耳側へと網膜剝離が拡大し，黄斑部に及んだため，同年7月に硝子体・白内障同時手術を施行した。術中は下方網膜の赤道部付近に網膜裂孔を認めた。術後4日目に僚眼（左眼）に角膜後面沈着物，1＋の前房内炎症が出現した。左眼もステロイド点眼を開始し，その後に虹彩炎は消退した。一方，右眼網膜はいったん復位したが，術後18日目に両眼に漿液性網膜剝離が出現した。VKHと診断してステロイドパルス療法を行い，その後プレドニゾロン内服に切り替えた。現在はプレドニゾロン内服を漸減中である。

結論：VKHにRRDを併発した報告は散見される。前房内炎症を伴う遷延化したRRDが，手術を行ったあとに偶然VKHを生じたのか，あるいは，まず片眼にVKHの漿液性網膜剝離が生じ，網膜裂孔を併発してRRDが拡大したのかについての鑑別は困難であった。

Abstract　Purpose：Vogt-Koyanagi-Harada disease（VKH）is characterized by serous retinal detachment that typically originates. Here we report a case of VKH that was initially challenging to distinguish from rhegmatogenous retinal detachment（RRD）, which originated and progressed from the peripheral retina of one eye.

Case：A 64-year-old woman experienced headaches in June of 2022. Three days later, she noted hyperemia in her right eye, followed by floaters and decreased vision. She visited a local doctor who diagnosed uvetis and localized retinal detachment on the inferior nasal side. She was referred to our department. An initial examination revealed a corrected visual acuity of 0.4 in her right eye, 2＋ cells in the anterior chamber, posterior synechiae encircling the iris, and focal retinal detachment on the inferior nasal side. Subsequently, the detachment progressed from the inferior nasal to the inferior temporal side, involving the detached macula. In July 2022, she underwent simultaneous vitreous and cataract surgery, which revealed a retinal tear. On the fourth postoperative day, keratic precipitates and 1＋ cells in the anterior chamber appeared in her left eye. Steroid eye drops resolved the iritis in her left eye. Despite temporarily attaching the retina of the right eye, serous retinal detachment manifested in both eyes on the 18th postoperative day. She was diagnosed with VKH and underwent steroid pulse therapy. She is currently undergoing tapering of oral steroids.

Conclusion：While VKH accompanied by RRD has been reported, our case presented challenges in their differentiation. Her symptoms initially resembled prolonged RRD with inflammation. Furthermore, it remains uncertain whether the VKH developed coincidentally postoperatively or it first occurred in one eye, subsequently causing the retinal tear to progress from serous detachment to RRD.