眼窩骨折を伴った眼窩先端部症候群の1例

A case of orbital apex syndrome with orbital fracture

要約　目的：外傷による眼窩先端部症候群に対し治療が奏効した症例を報告する。

症例：44歳，男性。自宅で家具を製作中に脚立から転落し，床に置いてあった鉄製パイプの側面に右眼を打撲し受傷した。初診時の所見として，視力は右（0.7），左（1.2），眼圧は右18mmHg，左17mmHg，右相対的瞳孔求心路障害陽性を疑い，眼球突出度は右27mm，左22mmであった。強制開瞼下でのHess赤緑試験で右動眼神経麻痺を認めた。また，眼窩CTでは右開放型眼窩下壁および内側壁骨折，眼窩内出血を認めた。右眼窩先端部症候群と診断し，受傷後2日目に入院した。抗炎症目的に副腎皮質ステロイド（ステロイド）の点滴静注，止血目的にカルバゾクロムスルホン酸の点滴静注，眼圧下降目的にアセタゾラミドの内服を開始した。ステロイドは漸減投与し，受傷後16日目には両眼の眼球突出度が23mmで左右差が消失し，視力は右（1.0）と改善した。眼球運動も改善傾向にあったが，右眼の上転障害が残存していたため右眼窩下壁骨折によるものと判断し，受傷後31日目に右眼窩下壁骨折整復術を施行した。その後の経過は良好で，受傷後60日目に自覚複視は消失していた。

結論：外傷を契機とした眼窩先端部症候群に対して，早急な薬物加療によって，視力の回復と自覚複視の軽減を認めた。

Abstract　Purpose：We report a case of successful treatment of orbital apex syndrome due to trauma.

Case：The patient was a 44-year-old man. While making furniture at home, he fell from a stepladder and bruised his right eye on the side of an iron pipe lying on the floor. At the time of initial examination, his visual acuity was 0.7 in the right eye（OD）and 1.2 in the left eye（OS）, and intraocular pressure was 18 mmHg OD and 17 mmHg OS. Relative afferent pupillary defect（RAPD）was suspected and ocular protrusion was 27 mm OD and 22 mm OS. Hess red-green test under forced eyelid opening showed right oculomotor nerve palsy. In addition, orbital CT showed right open inferior and medial orbital wall fractures and intraorbital hemorrhage. The patient was diagnosed with right orbital apex syndrome and was admitted to the hospital on the second day after injury. Intravenous adrenal corticosteroids（steroids）were administrated for anti-inflammatory purposes, intravenous carbazochrome sulfonate for hemostasis, and oral acetazolamide for intraocular pressure lowering. Steroids decreased administered gradually, and on the 16th day after the injury, the difference between the right and left eye protrusion disappeared, and the corrected visual acuity improved to the right 1.0. His eye movements also gradually improved, but he still had an abduction disorder of the right eye, which was most probably caused by the fracture of the right infraorbital wall. Right infraorbital wall fracture repair was performed on the 31st day after the injury. The subsequent course was good, and subjective diplopia disappeared on the 60th day after the injury.

Conclusion：Prompt medical treatment of trauma-induced orbital apex syndrome resulted in recovery of visual acuity and reduction of subjective diplopia.