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要約 目的:眼部帯状疱疹に全眼筋麻痺を合併した1例の報告。
症例:45歳,男性。右三叉神経第一枝領域の帯状疱疹による右前頭部皮疹を発症し,近医内科でビダラビンの点滴治療を受けた。1週間後に右眼瞼下垂が生じ,近医眼科と脳神経外科を受診した。右眼球運動障害も認めたため頭部MRI検査を受けたが,異常はなかった。その2週後に右眼虹彩炎も発症し,眼瞼腫脹,眼球運動障害も持続するため当科へ紹介となった。初診時視力は右(0.2),左(1.2),右前頭部の皮疹,右眼瞼腫脹,眼瞼下垂,瞳孔散大,角膜後面沈着物および虹彩炎を認めた。右眼球運動は外転以外の全方向で制限されていた。さらに2週間後には,右眼の上下内転制限に加え,外転制限も進行してきたため頭部MRIを再度施行したところ,右海綿静脈洞部から眼窩先端部にかけて造影増強効果ならびに外眼筋の軽度腫脹を認め,さらに同側の三叉神経脊髄路核の位置に相当する延髄から上位頸髄にかけての部位に連続性の高信号も認められた。そのため,アシクロビル点滴追加とステロイドパルス療法を施行し,治療1か月後には右視力は(0.9)に,右眼瞼下垂と眼球運動障害も改善した。
結論:本症例の全眼筋麻痺は,海綿静脈洞部における三叉神経から動眼神経および外転神経への炎症波及が主な原因であると考えられた。
Abstract Purpose:To report a case of herpes zoster ophthalmicus with total ophthalmoplegia.
Case:A 45-year-old male developed vesicular cutaneous eruption in the region of the right trigeminal nerve that followed varicella zoster virus infection, and vidarabine was administrated at nearby medical clinic. One week later, he showed blepharoptosis and ocular motility disorder of the right eye. Cranial magnetic resonance imaging(MRI)showed no remarkable findings. Two weeks later, he developed iritis in the right eye and referred to us. His best corrected visual acuity was 0.2 in the right eye and 1.2 in the left vesicular cutaneous eruption, blepharoptosis, and restricted ocular motility in all directions except abduction were observed. Slit-lamp microscopy showed dilation of pupil, keratic precipitates, and iritis in the right eye. Two weeks later, he developed right abducent palsy. MRI showed gadolinium enhancement from the right cavernous sinus to orbital apex, swelling of extraocular muscles, and continuous long high-signal lesion corresponding to the right spinal trigeminal nucleus and tract, extending from the medulla oblongata to the first cervical segment of the spinal cord. He was treated with intravenous acyclovir and corticosteroid. His corrected visual acuity improved to 0.9, as well as improved ocular motility and blepharoptosis one month later.
Conclusion:In this case, total opthalmoplegia could be due to inflammation in the cavernous sinus area which interfered trigeminal, oculomotor and abducens nerves.
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