涙小管炎による周辺角膜穿孔に対して涙道内視鏡と表層角膜移植を行った1例

A case of peripheral corneal perforation due to canaliculitis treated with dacryoendoscopy and lamellar keratoplasty

要約　目的：慢性涙囊炎や涙小管炎などの涙道感染に角膜穿孔を合併することがある。今回筆者らは，涙小管炎に合併した周辺角膜穿孔に対し，表層角膜移植術と，涙道内視鏡を使用した菌石の排出を並行して行った症例を経験したので報告する。

症例：84歳，女性。数年前から左眼の眼脂が続いていた。前医で左眼白内障に対して水晶体再建術を受けた2か月後，起床時に左視力低下および流涙を自覚した。左角膜穿孔を指摘され当院を紹介受診した。矯正視力は右1.2，左0.3で，両眼の点状表層角膜症，左眼の膿性眼脂，下眼瞼内反症，下涙点腫脹，左角膜鼻下方周辺部の穿孔と虹彩嵌頓を認めた。血液検査では抗SS-A抗体陽性，MMP-3高値だった。CTで涙小管部に腫瘤状の高吸収域を認めた。涙道内視鏡を行ったところ，下涙小管の著明な拡張と多量の膿を認めた。涙道チューブ挿入と下眼瞼内反症手術を行った。入院のうえ，治療用コンタクトレンズ装用と抗菌薬点眼・点滴を行った。翌日，角膜穿孔部が拡大して前房が消失したため，表層角膜移植術を施行した。術中に下涙点を切開したところ多量の菌石が排出された。以降も菌石の排出を繰り返し，涙小管炎は治癒した。眼内炎などの合併症は生じなかった。左視力は0.9まで改善した。

結論：本症例は自己免疫素因，ドライアイ，下眼瞼内反症が背景にあり，涙小管炎による角膜穿孔を生じたと思われた。多量の眼脂があったが，涙小管炎の治療と並行して早期に角膜表層移植術を行い，治癒させることができた。

Abstract　Purpose：Lacrimal duct infections, such as chronic dacryocystitis and canaliculitis, can sometimes lead to corneal perforation. We report a case of peripheral corneal perforation associated with canaliculitis that was successfully treated with lamellar keratoplasty and endoscopic removal of lacrimal concretions.

Case：An 84-year-old woman had been suffering from persistent eye discharge of her left eye for several years. Two months after undergoing cataract surgery with intraocular lens implantation by a previous ophthalmologist, she noticed decreased visual acuity and epiphora in her left eye upon waking. She was referred to our hospital with a diagnosis of left corneal perforation. Examination revealed best-corrected visual acuity of 1.2 in the right eye and 0.3 in the left eye. Ocular findings included bilateral punctate superficial keratopathy, purulent discharge in the left eye, lower eyelid entropion, swelling of the left lower punctum, and peripheral corneal perforation with iris prolapse in the inferonasal quadrant of the left eye. Blood tests showed positive anti-SS-A antibodies and elevated MMP-3 levels. Computed tomography revealed a mass-like hyperdense lesion in the canalicular region. Dacryoendoscopy showed marked dilatation of the lower canaliculus and a significant amount of pus. We performed lacrimal duct intubation and entropion surgery for the lower eyelid. During hospitalization, the patient was treated with therapeutic contact lenses, topical antibiotics, and intravenous antibiotics. The following day, the corneal perforation worsened, resulting in the loss of the anterior chamber, necessitating lamellar keratoplasty. During surgery, incision of the lower punctum led to the discharge of a large volume of lacrimal concretions. Repeated removal of lacrimal concretions was performed, and the canaliculitis resolved. No complications, such as endophthalmitis, occurred, and the patient's left visual acuity improved to 0.9.

Conclusion：This case of corneal perforation due to canaliculitis was influenced by underlying factors such as autoimmune elements, dry eye, and lower eyelid entropion. Early lamellar keratoplasty combined with canaliculitis treatment resulted in a favorable outcome.