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要約 目的:片側顔面痙攣に対しA型ボツリヌス毒素(BTX-A)注射を施行した際,誤って角膜水晶体を穿通し,硝子体腔へBTX-Aが注入された可能性のある症例の報告。
症例:71歳の女性が近医内科で左片側顔面痙攣に対しBTX-A注射を施行された。注射直後より左眼の霧視を自覚し,同内科より当院を紹介され受診した。初診時視力は左(0.8),眼圧は16mmHgであった。角膜穿孔創,前囊亀裂,前囊下混濁白内障を認め,眼底は透見困難であった。前眼部光干渉断層計でも角膜穿孔創と前囊亀裂が確認され,BTX-A注射針による外傷性白内障と判断し,水晶体再建術を施行した。超音波水晶体乳化吸引術中,後囊破損および破損部直下の硝子体腔に浮遊する白色の硝子体混濁を認めた。BTX-A注射針が水晶体を貫通し硝子体腔まで穿孔し,さらに薬液が注入された可能性があると判断し,同時に硝子体切除術も施行した。術中網膜に裂傷は認めなかった。術後矯正視力は(1.2)まで改善し,術後の網膜電図においても異常所見はなかった。
結論:眼瞼痙攣や片側顔面痙攣に対するA型ボツリヌス毒素の眼瞼注射は,眼科医以外の医師によって施行される場合があるが,施行方法を誤ると重篤な合併症を引き起こす可能性がある。安全で確実な手技習得の必要性や,眼球穿孔の危険性について啓発していく必要がある。
Abstract Purpose:To report a case of inadvertent intraocular injection of botulinum toxin A(BTX-A)into the vitreous cavity for hemifacial spasm resulting in corneal and lens perforation.
Case:A 71-year-old female underwent BTX-A injections for left hemifacial spasm at a private internal medical clinic and developed ocular perforation. Corrected visual acuity was 0.8 in the left eye. Slit-lamp examination revealed a corneal perforation tear, an anterior capsule crack, and anterior subcapsular cataract in her left eye. Dilated fundus examination could not be performed due to poor transparency. Anterior segment optical coherence tomography(OCT)showed a corneal perforation wound and an anterior capsule crack. Diagnosis of globe perforation and traumatic cataract was made. She underwent phacoemulsification and aspiration for the traumatic cataract caused by BTX-A injection needle to the left eye. Posterior capsule rapture and vitreous opacity floating underneath the rupture area in the vitreous cavity were observed. Pars plana vitrectomy was performed simultaneously. No retinal tear was observed during vitrectomy. In 2 more days, vision in her right eye returned to1.2. Electroretinogram showed intact function in her left eye.
Conclusion:BTX-A injections often have been performed by non-ophthalmologists. This could cause significant complications without appropriate procedure. Intraocular injection of BTX-A was well tolerated, although the needle penetration itself could cause corneal and lens perforation that would need intervention. Appropriate training and procedure may avoid such incidences.
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