眼窩膿瘍を合併した急性涙囊炎の1例

A case of acute dacryocystitis associated with orbital abscess

要約　背景：急性涙囊炎では眼窩隔膜より前方の蜂窩織炎を伴うことが多く，眼窩内へと炎症が波及することは非常に稀である。しかしいったん眼窩内へと炎症が波及すると膿瘍を形成することも多く，通常の涙囊炎より治療に難渋する。今回筆者らは，眼窩膿瘍を合併した急性涙囊炎の1例を経験したので報告する。

症例：患者は90歳，女性。1週間前にベッドから転落して以降，発赤を伴うが疼痛のない左眼瞼腫脹を自覚するようになり，しばらくは増悪，軽快を繰り返していたが，開瞼困難となり当院を受診した。全方向に左眼球運動障害，左眼球運動時痛を認め，左矯正視力0.3，左眼圧3mmHgであった。CTでは眼窩内方，筋円錐外に低吸収域，等吸収域の混在した占拠性病変を認め，眼球は圧排され変形し，耳側前方への偏位を認めた。抗菌薬投与を開始し，翌日には結膜円蓋部鼻側より多量の排膿を認めた。同部位を切開して，さらに排膿を行った。眼瞼腫脹は徐々に軽快し，7日後には眼窩膿瘍はほぼ消失し，眼球運動障害は改善し，左矯正視力も0.6と改善を認めた。

結論：涙囊炎に合併して眼窩膿瘍を認めた場合，早期にドレナージの検討をする必要があり，抗菌薬の投与のみでは改善せずに不可逆的な視力障害をきたした報告も散見される。本症例では，結膜円蓋部鼻側からの排膿で良好な経過を得ることができた。

Abstract　Background and purpose：Acute dacryocystitis is often associated with cellulitis anterior to the orbital septum, and the inflammation rarely spreads into the orbit. However, once the inflammation has spread into the orbit, it often forms an abscess, which is more difficult to treat than ordinary dacryocystitis. Herein, We report a case of acute dacryocystitis complicated by an orbital abscess.

Case：A 90-year-old woman visited our hospital, compaining of swelling of the left eyelid, with redness but no pain after falling out of bed a week ago. Subsequently, the left eyelid swelling repeatedly worsened and lessened for a because she had difficulty opening her eyelid, she came to our hospital. She had left eye movement disorder in all directions, pain during left eye movement, left visual acuity of 0.3, and left intraocular pressure of 3 mmHg. A computed tomography showed an occupying lesion with mixed hypoabsorption and isoabsorption areas in the medial orbit and extramuscular cone, and the eyeball was deformed and deflected anteriorly to the ear. We started her on antimicrobial therapy, and the next day, we observed a large amount of purulent discharge from the nasal side of the fornical conjunctiva. We made an incision in the same area and, the purulent discharge was drained. The eyelid swelling gradually decreased and the orbital abscess almost disappeared after 7 days. Her eye movement disorder was ameliorated, and her left visual acuity improved to 0.6.

Conclusion：There are many reports of orbital abscesses associated with dacryocystitis that require early drainage and, are associated with irreversible visual impairment showing no improvement with only antimicrobial therapy. In this case, drainage from the nasal side of the fornical conjunctiva was successful.