汎網膜光凝固後で交感性眼炎の診断が困難であった1例

A case of sympathetic ophthalmia, which was difficult to diagnose after panretinal photocoagulation

要約　目的：汎網膜光凝固（PRP）後で交感性眼炎の診断が困難であった1例を経験したので報告する。

症例：患者は61歳，女性。全身既往歴として糖尿病，高血圧症があり，過去に両眼の糖尿病網膜症や白内障に対して手術を受けたことがあった。左眼の視力低下を自覚し近医を受診した。糖尿病黄斑浮腫と診断され，ステロイドテノン囊下注射を施行ののち経過観察とされていたが，左視力が（0.8）から（0.15）と低下したため当科を紹介受診した。

所見：初診時視力は右0.1（0.15），左0.2（0.2）で，左眼は前眼部に軽度の炎症細胞を認めた。眼底は，両眼全周性にPRP後の凝固斑を認めた。蛍光眼底造影検査では，両眼ともに早期相では蛍光漏出を認めず，後期相では蛍光漏出は認めたが，そのほかに有意な所見はなかった。光干渉断層計（OCT）検査では両眼に漿液性網膜剝離，網膜下フィブリン，脈絡膜肥厚を認めた。追加の問診で頭痛，耳鳴りを自覚していることがわかり，髄液検査では細胞増多を認めた。内眼手術歴があるため，交感性眼炎と診断し，ステロイドパルス療法を行った。治療開始後39日目の時点で左視力は（0.2）から（0.9）まで改善し，OCT検査では漿液性網膜剝離などの所見は認めなかった。

結論：PRP後であるため交感性眼炎の診断に苦慮した。PRPによる凝固斑が過剰凝固し，網膜光凝固による所見がマスクされていたためであると考えるが，これまでにPRP後で交感性眼炎の診断に苦慮した報告はなかった。

Abstract　Purpose：To report a case of sympathetic ophthalmia, which was difficult to diagnose after panretinal photocoagulation（PRP）.

Case：A 61-year-old female patient had a medical history of diabetes mellitus and hypertension. She had previously undergone surgery for diabetic retinopathy and cataracts in both eyes. Experiencing vision loss in her left eye, she sought consultation with her local doctor. She was diagnosed with diabetic macular edema and received triamcinolone sub-tenon injections for follow-up observation but was referred to our department because her left eye visual acuity had decreased from（0.8）to（0.15）. In our hospital, initial visual acuity was 0.1（0.15）in the right eye and 0.2（n. c.）in the left eye, with mild inflammatory cells in the anterior segment of the left eye. The fundus showed post-PRP coagulation plaques in both eyes. Fluorescence fundus angiography（HRA）showed no significant findings and no fluorescence leakage in all phases. Optical coherence tomography（OCT）examination showed serous retinal detachment, subretinal fibrin, and choroidal thickening in both eyes. An additional interview revealed that the patient experienced headache and tinnitus, and a CSF examination showed hypercellularity. As the patient had a history of internal ophthalmic surgery, a diagnosis of sympathetic ophthalmia was made and steroid pulse therapy was administered. At 39 days after the start of treatment, visual acuity in the left eye had improved to（0.9）and OCT examination showed no serous retinal detachment or other findings.

Conclusions：The difficulty in diagnosing case of sympathetic ophthalmia was likely due to post-PRP, as the coagulation spots induced by PRP were possibly over-coagulated, masking the findings of retinal photocoagulation.