悪性緑内障に対するYAGレーザー前部硝子体膜切開後に脈絡膜出血をきたした1例

A case of choroidal hemorrhage after YAG laser anterior vitreous membrane incision for malignant glaucoma

要約　目的：悪性緑内障レーザー治療翌日に脈絡膜出血を認めた症例を経験した報告。

症例：53歳，女性。全身性エリテマトーデスによるループス腎炎で人工透析中。2021年11月X−3日に右眼のステロイド緑内障に対して近医で線維柱帯切除術を施行，X日に右眼痛と視力低下を自覚して和歌山県立医科大学附属病院を夜間に救急受診。右眼の浅前房と高眼圧（68mmHg）であり，悪性緑内障を認めた。アトロピン点眼とYAGレーザー前部硝子体膜切開施行により眼圧は下降（34mmHg）した。X＋1日，前房の深化と眼圧の正常化（12mmHg）は認めたが，脈絡膜出血を認めた。X＋2日以降，低眼圧（4〜7mmHg）が持続したためX＋14日目に強膜弁縫合術を施行したところ，眼圧の上昇（20mmHg台）により脈絡膜出血は改善したが，硝子体出血を認めたため，X＋66日に経強膜的脈絡膜出血排出と硝子体手術を施行した。術後眼圧は高眼圧（30mmHg台）が持続したため，X＋85日に線維柱帯切除術を行い，以後合併症なく，矯正視力は0.4，眼圧は12〜14mmHgで経過した。

結論：夜間の時間外救急では十分に全身状態を把握できないこともあり，腎機能廃絶患者では眼圧降下薬の全身投与が行いにくい状況もある。そのため，悪性緑内障に対する外科的治療前後の圧較差が大きくなる可能性があり，治療後の脈絡膜出血に注意して慎重な経過観察を行う必要がある。

Abstract　Purpose：We report a case of choroidal hemorrhage that occurred on the day following malignant glaucoma laser treatment.

Case：A 53-year-old female with lupus nephritis due to systemic lupus erythematosus, receiving hemodialysis. In November 2021（day X−3）, she underwent trabeculectomy for steroid-induced glaucoma in her right eye at a local ophthalmology clinic. On day X, she presented to Wakayama Medical University Hospital's emergency department during the night with complaints of right eye pain and decreased vision. Examination revealed a shallow anterior chamber and elevated intraocular pressure（IOP）of 68 mmHg, consistent with malignant glaucoma. Atropine eye drops and a YAG laser anterior hyaloidotomy were performed, resulting in an IOP reduction to 34 mmHg. On day X＋1, deepening of the anterior chamber and normalization of IOP（12 mmHg）were observed, but choroidal hemorrhage was detected. Due to sustained low IOP（4-7 mmHg）from X＋2 days onwards, scleral flap revision was performed on day X＋14, which ameliorated choroidal hemorrhage but revealed vitreous hemorrhage. On day X＋66, transscleral choroidal effusion drainage and vitrectomy were performed. As IOP remained elevated（in the 20 mmHg range）following surgery, trabeculectomy was undertaken on day X＋85. Subsequently, the patient had an uneven recovery, achieving a corrected visual acuity of 0.4 and maintaining IOP within 12-14 mmHg.

Conclusion：Emergency presentations during nighttime hours may limit the comprehensive assessment of a patient's systemic status. In individuals with end-stage renal disease, administering systemic hypotensive medications may be challenging. Therefore, it is crucial to remain vigilant for significant IOP discrepancies before and after surgical intervention for malignant glaucoma. Close monitoring for postoperative choroidal hemorrhage is imperative, given the potential for abrupt changes in IOP.