難治性角膜潰瘍による角膜穿孔に強膜移植術が有効であった1例

Scleral transplantation for corneal perforation due to keratitis

要約　目的：難治性角膜潰瘍に対して複数回の手術を含む治療に抵抗し角膜穿孔を生じるも，強膜移植後に瘢痕治癒し眼球摘出を免れた1例を経験したので報告する。

症例：症例はハードコンタクトレンズ誤装用の71歳，男性。近医で右角膜潰瘍と診断され抗菌薬を処方されるも改善なく，順天堂大学医学部附属静岡病院眼科へ紹介され初診となった。初診時視力は手動弁（矯正不能）で，結膜充血，角膜潰瘍，前房蓄膿を認めた。培養検査結果は陰性も後の塗抹検鏡で糸状菌が検出され抗真菌薬治療を開始。経過観察中に角膜菲薄化と角膜穿孔を生じたため結膜被覆術を3回，表層角膜移植術を1回施行した。縫合離開と角膜融解を繰り返したため，強膜移植術を施行したところ瘢痕治癒した。術後約2年目の視力は手動弁（矯正不能）を維持している。

結論：難治性角膜潰瘍による角膜菲薄化・角膜穿孔に対し，結膜被覆術や表層角膜移植術による治療に抵抗した場合，それらに代わる術式として強膜移植術も選択肢の1つになりうる。

Abstract　Purpose：We report a case of a 71-year-old man who had a history of hard contact lens misuse and presented with a refractory corneal ulcer. Despite multiple surgeries and treatment resistance, the patient developed corneal perforation. However, scar healing occurred after penetrating keratoplasty, and enucleation was avoided.

Case presentation：The patient was a 71-year-old male who had misused hard contact lenses. He was initially diagnosed with a right corneal ulcer by a local physician, for which he was prescribed antibiotics；however, as no improvement was seen, he was referred to our department as a new patient. At the initial visit, his visual acuity was hand motion（uncorrectable）；further he presented with conjunctival congestion, a corneal ulcer, anterior chamber purulence, and corneal perforation. Although initial culture results were negative, fungal filaments were later detected in a smear examination, leading to the initiation of antifungal therapy. During the course of observation in which patient developed corneal thinning and perforation；this led to the performance of three separate conjunctival surgeries and one superficial corneal transplantation. Repeated suture dehiscence and corneal melting, led to the performance of penetrating keratoplasty as penetrating keratoplasty was performed as an alternative procedure, resulting in successful scar healing. At the two-year postoperative follow-up, the patient maintained a visual acuity of hand motion（uncorrectable）.

Conclusion：When treatment with conjunctival flap surgery or superficial corneal transplantation is met with resistance in cases of refractory corneal ulcer with corneal thinning and perforation, penetrating keratoplasty may be considered as a viable treatment option. This case illustrates that penetrating keratoplasty can lead to scar healing in such challenging cases and prevent the need for enucleation.