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1 대한안과학회지 2018 년제 59 권제 5 호 J Korean Ophthalmol Soc 2018;59(5): ISSN (Print) ISSN (Online) Original Article 당일라식, 라섹수술과기존수술법의수술후결과비교 Comparison of Postoperative Results of One Day Laser-assisted in-situ Keratomileusis, Laser-assisted Sub-epithelial Keratectomy Surgery, and Conventional Surgery 김욱겸 류익희 이인식 김희선 김정섭 김진국 Wook Kyum Kim, MD, Ik Hee Ryu, MD, In Sik Lee, MD, Hee Sun Kim, MD, Jung Sub Kim, MD, Jin Kuk Kim, MD 비앤빛강남밝은세상안과의원 B&VIIt Eye Center, Seoul, Korea Purpose: To evaluate the postoperative results of one day laser-assisted in-situ keratomileusis (LASIK) or laser-assisted sub-epithelial keratectomy (LASEK) procedures, which were performed on the same day as preoperative examinations, including fundus examinations after dilating the pupil. Methods: This study included 226 LASIK patients (226 eyes) and 201 LASEK patients (201 eyes) who underwent surgery with Visumax and EX500 from January to December in We divided the patients into two groups. The one-day surgery group (one-day group) underwent surgery on the same day as preoperative examinations, including dilated fundus examinations. The scheduled surgery group (scheduled group) underwent surgery on the scheduled day after the preoperative examinations. In the one-day group, the surgery was usually performed 2 5 hours after instillation of the pupil dilating eye drops. Results: Among LASIK patients, the one-day group included 109 patients and the scheduled group included 117 patients. The postoperative myopic errors were 0.06 ± 0.37 diopters (D) and 0.07 ± 0.36 D, respectively (p = 0.91). The postoperative astigmatism was ± 0.24 D and ± 0.24 D, respectively (p = 0.77). The postoperative uncorrected visual acuity was ± 0.03 logmar and ± 0.03 logmar, respectively (p = 0.13). Among LASEK patients, the one-day group included 107 patients and the scheduled group included 94 patients. The postoperative myopic error was 0.18 ± 0.52 D and 0.22 ± 0.54 D, respectively (p = 0.95). The postoperative astigmatism was ± 0.30 D and ± 0.29 D, respectively (p = 0.14). The postoperative uncorrected visual acuity was ± 0.03 logmar and ± 0.03 logmar, respectively (p = 0.33). Conclusions: The postoperative results of the one-day LASIK and LASEK patients, whose surgery was performed on the same day as the preoperative examinations, were not significantly different from those using the conventional method. J Korean Ophthalmol Soc 2018;59(5): Keywords: Eye tracking, Laser-assisted in-situ keratomileusis (LASIK), Laser-assisted sub-epithelial keratectomy (LASEK), One day operation, Pupil Received: Revised: Accepted: Address reprint requests to Wook Kyum Kim, MD B&VIIt Eye Center, #411 Seocho-daero, Seocho-gu, Seoul 06615, Korea Tel: , Fax: kiki0306@hanmail.net * Conflicts of Interest: The authors have no conflicts to disclose. 라식, 라섹은근시난시를교정하는레이저각막굴절교정술로서수술의안정성과유효성이이미입증된수술이다. 1,2 라식, 라섹수술전에는망막상태를확인하기위하여산동후망막검사를하는경우가많으며 3-7 산동제점안후동공이완전히회복되기까지 4-6시간정도가소요된다. 8 비점조사 (flying spot beam) 방식의엑시머레이저는수술시 c2018 The Korean Ophthalmological Society This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 410

2 - 김욱겸외 : 당일라식, 라섹수술의결과 - 정확한안구추적장치의작동이필수적이다. 동공이커져있는상태는안구추적과수술후시력에부정적영향을미칠수있으므로수술전검사를시행한당일에라식, 라섹수술을하는경우는드물었다 그러나최근에는시간적여유가없는분들을대상으로검사와수술을같은날에시행하는당일라식, 라섹수술이많아지고있다. 당일수술은환자와병원모두의편리성으로인하여앞으로도더욱증가할것으로예상되며, 최근증가하고있는스마일 (small incision lenticule extraction, SMILE) 은수술중안구추적장치가필요하지않기때문에당일수술의비율을더욱증가시킬것으로생각된다 수술전주변부망막을검사하는방법으로는산동후망막을검사하는방법과산동을하지않고망막을검사하는방법이있다. 산동을하지않는검사방법으로옵토맵 (Optomap, Optos plc, Dunfermline, UK) 과같은광각안저촬영장비를이용하는방법이있다. 5,6,19 옵토맵은아직국내에널리보급되지못하여대부분의경우에는산동후망막검사를수술전에시행한다. 수술전망막검사에서망막박리의위험인자로알려진격자변성이발견되는빈도는 6-10% 정도이다. 3-5 라식후발생하는망막박리의빈도는 % 로낮은편이지만발생하게되면심각한시력장애를유발할수있다. 4,7,20 산동제로는부교감신경길항제와교감신경작용제가있으며, 각각홍채수축근과홍채산대근에작용하여동공을확장시키고, 빛에대한동공반응을억제한다. 수술전망막검사를위해서미드린피 (Mydrin P, Santen pharmaceutical Co, Osaka, Japan) 가흔히사용되고있으며, 주성분은트로피카마이드 0.5% 와페닐에프린 0.5% 이다. 트로피카마이드는부교감신경길항제로서 30분후에최대효과가나타나서동공이완전히회복되기까지 2-6시간이소요된다. 페닐에프린은교감신경작용제로서 20분후에최대효과가나타나서회복까지는 2-3시간이걸린다. 8 안구추적장치는눈의움직임을감지하여빠른시간에레이저의조사위치를조정함으로써수술중눈움직임에의한저교정, 부정난시, 중심이탈 (decentered) 의발생을줄인다. 9,21 안구추적장치는원리에따라동공모양을인식하는방식과홍채의패턴을인식하는방식으로나눌수있다. 11,13,21-23 라식, 라섹중안구추적장치가올바르게작동되기위해서는동공의크기와모양이정상적이어야한다. 24,25 동공의크기가변화되면동공중심의위치도움직이게되는데 26 동공의크기가커지면동공중심이귀쪽으로이동하고동공이작아지면동공중심이코쪽으로이동하는경향을보인다. 27 동공중심과각막정점의거리를나타내는카파각이크거나수술중카파각이많이변화하는경우에는 수술후시력저하와고위수차가유발될가능성이높다. 26 당일라식, 라섹수술은산동제점안후동공이완전히회복되지않은상태에서수술을진행하는것으로서이러한동공상태가술후결과에어떤영향을미치는지에대해서는아직까지보고된바가없었다. 이에본연구는비쥬맥스펨토초레이저 (Visumax TM Femtosecond Laser, Zeiss, Oberkochen, Germany) 와 EX500 (Allegretto EX500 Laser; Alcon, Fort Worth, TX, USA) 레이저를사용하여라식, 라섹수술을받은환자를대상으로당일수술방법과기존수술방법의결과를비교해보고자하였다. 대상과방법 본연구는 2016년 1월부터동년 12월까지본원에서라식을받은 226명 (226안) 과라섹을받은 201명 (201안) 을대상으로하였으며수술전후의의무기록을후향적으로분석하였다. 인증된연구윤리심의위원회 (institutional review board, IRB) 의심의를거쳐연구계획을승인 ( 승인번호 P ) 받았다. 모든환자는비쥬맥스펨토초레이저 (Zeiss) 와 EX500 레이저 (Alcon) 를사용하여수술을진행하였으며 EX500 레이저 (Alcon) 는 Food and Drug Administration (FDA) 승인을받은엑시머레이저장비이다. 22,23,28,29 굴절수술이외의안과수술병력이있는환자, 망막질환, 백내장, 시신경질환, 약시가있는환자, 동공모양에이상이있는환자, 한눈보기 (monovision) 수술을받은환자, 수술중각막콜라겐교차결합술을시행한환자, 비쥬맥스 (Zeiss) 와 EX500 (Alcon) 이외의장비로수술한환자들은연구대상에서제외하였다. 라식, 라섹수술방법라식수술은비쥬맥스펨토초레이저 (Visumax TM Femtosecond Laser) 를사용하여두께 100 µm, 직경 8.0 mm, 경첩의위치는상측으로하여각막절편을만들었으며, 각막절제는 EX500 레이저 (Alcon) 를사용하였다. 술후 0.5% 목시플록사신 (Vigamox, Alcon, Fort Worth, TX, USA) 과 0.1% 플루오로메토론 (Flumetholon 0.1%, Santen pharmaceutical Co., Osaka, Japan) 을첫 1주간하루 4회사용하고, 다음 1주간하루 2회사용하였다. 라섹수술은 Amoil 브러쉬 (Amoils epithelial scrubber, Innovative excimer solution, Inc., Toronto, Canada) 를이용하여각막상피를제거한후 EX500 레이저 (Alcon) 를사용하여각막절제술을시행하였다. 레이저조사후 0.02% mitomycin C를면봉에묻혀절제부위에 10-20초간바른뒤차가운평형염류용액으로 20초간각막표면과결막낭을충 411

3 - 대한안과학회지 2018 년제 59 권제 5 호 - 분히세척하였다. 그후치료용콘택트렌즈를착용시키고항생제안약을점안하였다. 수술당일부터 0.5% 레보플록사신 (Cravit, Santen pharmaceutical Co., Osaka, Japan) 을 3시간마다사용하였으며, 술후 3-5일째치료용콘택트렌즈를제거한후, 하루 4회 1주간더사용하였다. 0.1% 플루오로메토론은치료용콘택트렌즈를제거한후사용하였으며 1 주간은 3시간마다사용하고, 그후 1달간하루 4번씩사용하였으며점차사용빈도를줄여술후약 4개월간사용하였다. 당일수술환자의수술가능여부결정방법본연구에포함된당일수술군환자들은당일라식, 라섹수술방법을자원하는환자들이었다. 이들은수술전검사결과가수술에적합하지못할경우에는당일수술이불가할수있음을사전에안내받고이에동의하였다. 당일수술환자들은오전에내원하여전안부상태와동공모양을세극등현미경으로확인한후술전검사들을진행하였다. 주변부망막검사를위하여미드린피 (Mydrin P) 를점안하였으며동공이충분히산동된후간접검안경 (indirect ophthalmoscopy) 을사용하여주변부망막검사를시행하였다. 각막염, 결막염, 안검염, 심한안구건조증, 망막변성이있는경우에는치료를먼저한후수술을받도록안내하였다. 당일수술환자의동공크기와모양확인방법산동제점안후 30분정도에망막검사를시행하였으며, 수술전에동공크기와빛에대한반응을확인하였다. 펜라이트로동공을비추어동공이작아지는반응을보일경우에수술실에입장하도록하였으며동공반응이전혀없는경우에는더기다리게하였다. 빛에동공이반응하는것은산동제의효과가사라지고있으며수술중레이저의조명을밝게함으로써동공크기를더줄일수있는상태라고판단했다. 수술직전세극등현미경으로전안부및동공크기와모양을한번더확인한후수술을진행하였으며, 모든대상환자에서수술중안구추적장치가정상적으로작동하였다. EX500 레이저의안구추적방식과레이저조사중심수동조정 EX500 레이저 (Alcon) 의안구추적장치는적외선카메라를사용하여동공의경계를인식하여안구의움직임을파악한다. 28,29 안구의움직임을빠른시간에감지하고변화된위치의정도를계산하여레이저조사위치를조정함으로써수술중정확한각막절삭을가능하게한다. EX500 (Alcon) 의안구추적장치의이미지처리속도 (sampling rate) 는 1,000 Hz (1분에 1,000회 ) 이고레이저반응시간 (response time, latency) 은약 2-3 msec이다. 29 EX500 레이저 (Alcon) 의안구추적장치는동공크기가 2.0 mm에서 8.0 mm까지에서작동한다. 28 EX500 레이저 (Alcon) 는동공중심이기본적으로조사중심 (reference point) 이지만, 레이저조사중심을동공중심에서각막정점을옮길수있는기능을제공한다. 이러한오프셋 (offset) 조정기능은두가지방식으로사용이가능한데펜타캠의검사이미지를불러와서자동으로오프셋을조정하는방법과술자가제1 퍼킨지반사점 (the first Purkinje reflex) 을확인하여오프셋을수동으로조정하는방법이있다. 29 오프셋을수동으로조정하는기능은 EX500 레이저 (Alcon) 에서제공하는 4가지레이저조사방식중각막지형도가이드방식 (topography guided laser ablation) 과웨이브프론트가이드방식 (wavefront guided laser ablation) 에서는사용할수없고, 22,23 웨이브프론트옵티마이즈방식 (wavefront optimized laser ablation) 과커스텀큐 (custom Q) 방식에서만사용가능하다. 28,29 본연구에서는당일수술군과계획수술군모두에서커스텀큐 (custom Q) 방식으로수술하였으며, 모든경우에서수술중오프셋을수동으로조정하였다. 당일라식, 라섹수술의결과를알아보기위하여당일수술군과계획수술군의수술전후의근시, 난시, 시력을비교하였으며, 당일수술여부외에술전검사방법과수술과정은두군에서모두동일하게진행되었다. 계획수술군에서검사후 3개월이상경과하여수술을받게된경우에는굴절이상의변화를확인하기위하여수술직전에굴절검사를한번더추가하였다. 라식, 라섹은수술방법뿐아니라술후회복기간의차이가많으므로라식을받은환자와라섹을받은환자를나누어분석하였다. 라식을받은환자는술후 1개월경에측정한값을분석에사용하였으며, 라섹을받은환자는술후 6 개월경에측정한값을사용하여분석하였다. 1,30 모든환자에서우안의값만을분석에사용하였다. 통계적검정은 SPSS 18.0 프로그램 (IBM Corp., Armonk, NY, USA) 을이용하였으며독립 t-test를이용하여두군의평균값을비교하였고, p값이 0.05 미만을통계학적으로유의하다고정의하였다. 결과 라식을받은환자는모두 226명이었으며이중당일수술군은 109명이었고계획수술군은 117명이었다. 두군에서술전근시, 난시, 교정시력, 동공크기, 각막두께는차이가없었다 (Table 1). 412

4 - 김욱겸외 : 당일라식, 라섹수술의결과 - Table 1. Comparison of preoperative characteristics between the one day operation group and scheduled operation group who underwent laser-assisted in-situ keratomileusis (226 patients) Characteristics One day operation group Scheduled operation group p-value Number of patients (n) Age (years) 27.9 ± ± Gender (male:female) 38:71 46:71 Preoperative myopia (diopters) ± ± Preoperative astigmatism (diopters) ± ± Preoperative BCVA (logmar) ± ± Preoperative scotopic pupil diameter (mm) 6.6 ± ± Preoperative IOP (mmhg) 15.8 ± ± Preoperative CCT (μm) ± ± BCVA = best corrected visual acuity; IOP = intraocular pressure; CCT= central cornea thickness. Table 2. Postoperative 1 month results of the one day operation group and scheduled operation group who underwent laser-assisted in-situ keratomileusis (226 patients) One day operation group Scheduled operation group p-value Number of patients (n) UCVA at postoperative 1 months (logmar) ± ± Postoperative myopia (diopters) 0.06 ± ± Postoperative astigmatism (diopters) ± ± Postoperative spherical equivalent (diopters) ± ± UCVA = uncorrected visual acuity. A B Figure 1. Comparison of postoperative uncorrected visual acuity between the same day operation group and scheduled operation group. Postoperative visual acuity after laser-assisted in-situ keratomileusis of 226 patients (A) and postoperative visual acuity after laser-assisted sub-epithelial keratectomy of 201 patients (B). Table 3. Efficacy indices (postoperative UDVA/preoperative CDVA) of both groups One day operation group Scheduled operation group p-value LASIK 1.05 ± ± LASEK 1.10 ± ± UDVA = uncorrected distance visual acuity; CDVA = corrected distance visual acuity; LASIK = laser-assisted in-situ keratomileusis; LASEK = laser-assisted sub-epithelial keratectomy. 라식후 1개월경에검사한굴절이상은당일수술군과계획수술군에서근시는각각 0.06 ± 0.37디옵터, 0.07 ± 0.36 디옵터였고 (p=0.91), 난시는각각 ± 0.24디옵터, ± 0.24디옵터였으며 (p=0.77), 나안시력은각각 ± 0.03 logmar, ± 0.03 logmar로두군에서차이가없었 다 (p=0.13) (Table 2). 라식후 1개월의나안시력이 0.8 이상인환자의비율은두군모두에서 100% 였으며, 시력이 1.0 이상인경우는당일수술군에서 87% (109명중 95명 ), 계획수술군에서 88% (117명중 103명 ) 였다 (Fig. 1). 라식의효용성지수는당일수술군에서술후 1개월에 413

5 - 대한안과학회지 2018 년제 59 권제 5 호 - A B Figure 2. Refractive outcomes of the one day operation and scheduled operation group. The spherical equivalent refraction of one day laser-assisted in-situ keratomileusis (LASIK) group and scheduled LASIK group at postoperative 1 month (A). The spherical equivalent refraction of one day laser-assisted sub-epithelial keratectomy (LASEK) group and scheduled LASEK group at postoperative 6 months (B). A B C D Figure 3. Predictability of spherical equivalent correction of the one day operation and scheduled operation group. The results of the one day laser-assisted in-situ keratomileusis (LASIK) group (A) and scheduled LASIK group (B) at postoperative 1 month. The results of one day laser-assisted sub-epithelial keratectomy (LASEK) group (C) and scheduled LASEK group (D) at postoperative 6 months. 414

6 - 김욱겸외 : 당일라식, 라섹수술의결과 - A B Figure 4. Postoperative refractive astigmatism distribution. Astigmatism after the one day laser-assisted in-situ keratomileusis (LASIK) group and scheduled LASIK group at postoperative 1 month (A), and astigmatism after the one day laser-assisted sub-epithelial keratectomy (LASEK) group and scheduled LASEK group at postoperative 6 months (B). Table 4. Comparison of preoperative characteristics between the one day operation group and scheduled operation group who underwent laser-assisted sub-epithelial keratectomy (201 patients) Characteristics One day operation group Scheduled operation group p-value Number of patients (n) Age (years) 25.2 ± ± Gender (male:female) 38:69 28:66 Preoperative myopia (diopters) ± ± Preoperative astigmatism (diopters) ± ± Preoperative BCVA (logmar) ± ± Preoperative scotopic pupil diameter (mm) 6.7 ± ± Preoperative IOP (mmhg) 15.6 ± ± Preoperative CCT (μm) ± ± BCVA = best corrected visual acuity; IOP = intraocular pressure; CCT= central cornea thickness. Table 5. Postoperative 6 months results of the one day operation group and scheduled operation group who underwent laser-assisted in-situ keratomileusis (201 patients) One day operation group Scheduled operation group p-value Number of patients (n) UCVA at postoperative 6 months (logmar) ± ± Postoperative myopia (diopters) 0.18 ± ± Postoperative astigmatism (diopters) ± ± Postoperative spherical equivalent (diopters) ± ± UCVA = uncorrected visual acuity ± 0.09, 계획수술군에서 1.07 ± 0.08로두군간의차이가없었다 (p=0.30) (Table 3). 라식후 1개월의구면대응치는당일수술군에서 88% 에서 ±0.5D 이내, 98% 에서 ±1.0D 이내에있었으며, 계획수술군에서는 89% 에서 ±0.5D, 99% 에서 ±1.0D 이내에있었고 (Fig. 2), 결정계수 (R 2 ) 는당일수술군에서 , 계획수술군에서 였다 (Fig. 3). 라식후 1개월의난시는당일수술군에서 89% 에서 0.5D 이내, 99% 에서 1.0D 이내였고, 계획수술군에서 는 87% 에서 0.5D 이내, 100% 에서 1.0D 이내에있었다 (Fig. 4). 라섹을받은환자는모두 201명이었으며이중당일수술군은 107명이었고계획수술군은 94명이었다. 두군에서술전근시, 난시, 교정시력, 동공크기, 각막두께는차이가없었다 (Table 4). 라섹후 6개월경에검사한굴절이상은당일수술군과계획수술군에서근시는각각 0.18 ± 0.52디옵터, 0.22 ±

7 - 대한안과학회지 2018 년제 59 권제 5 호 - 디옵터였고 (p=0.95), 난시는각각 ± 0.30디옵터 ± 0.29디옵터였으며 (p=0.14), 나안시력은각각 ± 0.03 logmar, ± 0.03 logmar로두군에서차이가없었다 (p=0.33) (Table 5). 라섹후나안시력이 0.8 이상인환자의비율은두군모두에서 100% 였으며, 시력이 1.0 이상인경우는당일수술군에서 90% (107명중 96명 ), 계획수술군에서 91% (94명중 86명 ) 였다 (Fig. 1). 라섹의효용성지수는당일수술군에서술후 6개월에 1.10 ± 0.09, 계획수술군에서 1.08 ± 0.08로두군간의차이가없었다 (p=0.33) (Table 3). 라섹후 6개월의구면대응치는당일수술군에서 79% 에서 ±0.5D 이내, 97% 에서 ±1.0D 이내에있었으며, 계획수술군에서는 79% 에서 ±0.5D, 94% 에서 ±1.0D 이내에있었고 (Fig. 2), 결정계수 (R 2 ) 는당일수술군에서 , 계획수술군에서 이었다 (Fig. 3). 라섹후 6개월의난시는당일수술군에서 72% 에서 0.5D 이내, 98% 에서 1.0D 이내였고, 계획수술군에서는 84% 에서 0.5D 이내, 97% 에서 1.0D 이내에있었다 (Fig. 4). 고찰 라식, 라섹수술전망막검사에서주변부망막질환은약 2% 에서발견되며 6,7 라식후망막박리의빈도는 % 로보고되었다. 4,6 라식후망막박리의빈도는술전망막변성이있었던경우에서망막변성이없었던경우보다높으므로 7 수술전에망막변성여부를확인하기위한망막검사는꼭필요하다. 5,21 술전에발견된망막변성을예방적레이저광응고술로치료하면망막박리의발생빈도를낮출수있다고한다. 6 당일라식, 라섹은산동검사후동공이조금커진상태에서수술이진행되며, 이러한상태가술후결과에미치는영향은아직까지보고된적이없었다. 본연구는 EX500 레이저 (Alcon) 로당일라식, 라섹수술을받은환자들의수술후결과가기존수술방법과비교하였을때차이가없음을보여준다. 라식후 1개월의근시, 난시및시력은두군에서차이가없었으며, 라섹후 6개월의근시, 난시및시력도두군에서차이를보이지않았다. 본연구는당일수술시동공의상태가수술후결과에유의한영향을미치지않는다는것을보여준다. 이러한결과를올바로해석하기위해서는본연구에포함된환자들의수술시동공상태와사용된 EX500 레이저 (Alcon) 의안구추적장치에대한이해가필요하다. 당일수술환자들은산동제를점안한후약 30분후망막검사를시행하였으며, 산동제점안 2-5시간후에수술을진행하였다. 당일수술환자들의산동제점안후수술시점까지의시간이동일하 지않았으며이는환자마다검사와상담에소요되는시간이달랐고, 수술대기시간이있었으며, 유전성각막질환의검사결과를확인한후수술을진행했기때문이었다. 그래서당일수술군에는산동제점안후수술시점까지의시간이짧아서동공이큰상태에서수술받은환자와산동제점안후시간이길어서동공이거의회복된상태에서수술받은환자가모두포함되었다. 이러한점은본연구가실제이루어지는당일수술의결과를잘반영해줄것으로생각된다. 안구추적장치는작동원리에따라홍채의패턴을인식하는방식과동공의모양을인식하는방식으로나뉘며 13,21-23 홍채의패턴을인식하는방식은안구의수평, 수직움직임외에도회선을보정할수있는장점이있다. 11,12,14,15,25,31-33 그러나홍채의패턴을인식하는방식은홍채의모양과각막의투명도와동공의크기에더많은영향을받는다. 24,25 실제로홍채인식방식의안구추적장치를사용한라식수술에서절편을만드는중발생한전방의공기방울 24 과불투명기포층 (opaque bubble layer, OBL) 으로인해안구추적장치가제대로작동되지못했다는보고들이있다. 25 이에비하여동공모양을인식하는방식은대부분의상황에서안구추적장치가정상적으로작동하며 28,29 동공의크기에도영향을적게받을가능성이높은방식이다. EX500 (Alcon) 과같이동공모양을인식하는방식의안구추적장치를사용할때에도산동된상태에서는동공중심의위치가평소와달라져레이저조사에영향을줄수있다는우려가있을수있다. 그러나본연구의대상이된환자들에서는 EX500 레이저 (Alcon) 의수동으로오프셋을조정하는방법을사용하여수술을하였기때문에, 동공의모양이비록평소와다르더라도레이저조사에는영향을주지않았을것으로생각된다. 29 EX500 레이저 (Alcon) 를사용하더라도웨이브프론트가이드방식이나토포가이드방식은수동오프셋조정기능을사용할수없으므로당일수술시본연구와는다른결과를보일수있음을유의하여야할것이다. 이상에서살펴본바와같이 EX500 레이저 (Alcon) 의안구추적장치의특성과레이저조사중심의수동조정방법은동공이완전히회복되지않은상태에서진행한당일라식, 라섹수술의결과가기존방식과차이가없는것으로나타난중요한이유가되었을것으로생각된다. 그러므로본연구의결과를안구추적장치방식이다른모든레이저에일반적으로적용할수없을것으로생각되며레이저장비별당일수술의결과에대해서는추가적인연구가필요할것이다. EX500 (Alcon) 과같이동공중심을인식하는방식의안 416

8 - 김욱겸외 : 당일라식, 라섹수술의결과 - 구추적장치는안구의회선과상하방향인 Z축의안구의움직임을보정해주지못하는단점이있다. 이를보완하기위하여 EX500 (Alcon) 은뉴로트랙 (neuro track) 이라는기능을사용하여안구의회선을예방하고, 수술중 Z축방향의이동이있으면거리유지광선 (distance diode beam) 을사용하여수동으로보정해주어야한다. 22,23,29 EX500 (Alcon) 은알레그레토 Eye-Q 400의최신버전으로서안구추적장치의속도가 1,000 Hz로빨라지고반응속도는 2-3 ms로짧아져술후중심이탈 (decenter) 이 Eye-Q보다적어졌다. 29 본연구는두군에서사용된수술장비와방법을동일하게하여당일수술여부의영향을알아보고자하였다. 본연구의한계점으로는당일수술의결과를술후근시, 난시와시력으로만비교하였다는점이다. 술후고위수차를비교하기위한파면분석검사, 시력의질을비교하기위한 optical quality analysis system (OQAS) 검사, 중심이탈정도를비교하기위한각막지형도검사가포함된추가연구가앞으로필요할것으로생각된다. 29 결론적으로 EX500 레이저 (Alcon) 를사용한당일라식, 라섹수술은산동검사후완전히회복되지않은동공상태에서도술후결과가기존수술방법과비교하여차이가없었다. 본연구의결과는당일수술을희망하는환자와이를담당한술자가모두안심하고수술을진행할수있는근거가될수있을것으로생각된다. REFERENCES 1) O'Brart DP, Shalchi Z, Mcdonald RJ, et al. Twenty-year follow-up of a randomized prospective clinical trial of excimer laser photorefractive keratectomy. Am J Ophthalmol 2014;158: e1. 2) Sandoval HP, Donnenfeld ED, Kohnen T, et al. Modern laser in situ keratomileusis outcomes. J Cataract Refract Surg 2016;42: ) Lam DS, Fan DS, Chan WM, et al. Prevalence and characteristics of peripheral retinal degeneration in Chinese adults with high myopia: a cross-sectional prevalence survey. Optom Vis Sci 2005; 82: ) Arevalo JF. Retinal complications after laser-assisted in situ keratomileusis (LASIK). Curr Opin Ophthalmol 2004;15: ) Lewis H. Peripheral retinal degenerations and the risk of retinal detachment. Am J Ophthalmol 2003;136: ) Lin SC, Tseng SH. Prophylactic laser photocoagulation for retinal breaks before laser in situ keratomileusis. J Refract Surg 2003; 19: ) Lin J, Xie X, Du X, et al. Incidence of vitreoretinal pathologic conditions in myopic eyes after laser in situ keratomileusis. Zhonghua Yan Ke Za Zhi 2002;38: ) Wright KW, Strube YNJ. Pediatric Ophthalmology and Strabismus, 3rd ed. New York: Oxford University Press, 2012; 92. 9) Lee YC. Active eye-tracking improves LASIK results. J Refract Surg 2007;23: ) Mosquera SA, Arbelaez MC. Use of a six-dimensional eye-tracker in corneal laser refractive surgery with the Schwind Amaris Maris TotalTech laser. J Refract Surg 2011;27: ) Meidani A, Tzavara C. Comparison of efficacy, safety, and predictability of laser in situ keratomileusis using two laser suites. Clin Ophthalmol 2016;10: ) Waring GO 3rd. One-kilohertz eye tracker and active intraoperative torsion detection in the NIDEK CXIII and Quest excimer lasers. J Refract Surg 2009;25(10 Suppl):S ) Pajic B, Cvejic Z, Mijatovic Z, et al. Excimer laser surgery: biometrical iris eye recognition with cyclorotational control eye tracker system. Sensors (Basel) 2017;17. pii:e ) Ciccio AE, Durrie DS, Stahl JE, Schwendeman F. Ocular cyclotorsion during customized laser ablation. J Refract Surg 2005; 21:S ) Chang J. Cyclotorsion during laser in situ keratomileusis. J Cataract Refract Surg 2008;34: ) Reinstein DZ, Gobbe M, Gobbe L, et al. Optical zone centration accuracy using corneal fixation-based SMILE compared to eye tracker-based femtosecond laser-assisted LASIK for myopia. J Refract Surg 2015;31: ) Piñero DP, Teus MA. Clinical outcomes of small-incision lenticule extraction and femtosecond laser assisted wavefront-guided laserin situ keratomileusis. J Cataract Refract Surg 2016;42: ) Chan C, Lawless M, Sutton G, et al. Small incision lenticule extraction (SMILE) in Clin Exp Optom 2016;99: ) Nagiel A, Lalane RA, Sadda SR, Schwartz SD. Ultra-widefield fundus imaging: A review of clinical applications and future trends. Retina 2016;36: ) Wilkes SR, Beard CN, Kurland LT, et al. The incidence of retinal detachment in Rochester, Minnesota, Am J Ophthalmol 1982;94: ) Ghosh S, Couper TA, Lamoureux E, et al. Evaluation of iris recognition system for wavefront-guided laser in situ keratomileusis for myopic astigmatism. J Cataract Refract Surg 2008;34: ) Motwani M. The use of WaveLight(R) Contoura to create a uniform cornea: the LYRA Protocol. Part 2: the consequences of treating astigmatism on an incorrect axis via excimer laser. Clin Ophthalmol 2017;11: ) Kanellopoulos AJ. Topography-modified refraction (TMR): adjustment of treated cylinder amount and axis to the topography versus standard clinical refraction in myopic topography-guided LASIK. Clin Ophthalmol 2016;10: ecollection ) Utine CA, Altunsoy M, Basar D. Visante anterior segment OCT in a patient with ga sbubbles in the anterior chamber after femtosecond laser corneal flap formation. Int Ophthalmol 2010;30: ) Gimeno FL, Chan CM, Li L, et al. Comparison of eye-tracking success in laser in situ keratomileusis after flap creation with 2 femtosecond laser models. J Cataract Refract Surg 2011;37: ) de Ortueta D, Arba-Mosquera S. Laser in situ keratomileusis for high hyperopia with corneal vertex centration and asymmetric offset. Eur J Ophthalmol 2017;27: ) Narváez J, Brucks M, Zimmerman G, et al. Intraoperative cyclorotation and pupil centroid shift during LASIK and PRK. J Refract Surg 2012;28: ) Motwani M, Pei R. Treatment of moderate-to-high hyperopia with the WaveLight Allegretto 400 and EX500 excimer laser systems. Clin Ophthalmol 2017;11: ) Kanellopoulos AJ, Asimellis G. LASIK ablation centration: an ob- 417

9 - 대한안과학회지 2018 년제 59 권제 5 호 - jective digitized assessment and comparison between two generations of an excimer laser. J Refract Surg 2015;31: ) Kim WK, Cho EY, Kim HS, Kim JK. The incidence of increased intraocular pressure when using 0.1% fluorometholone after photorefractive keratectomy. J Korean Ophthalmol Soc 2015;56: ) Chen X, Stojanovic A, Stojanovic F, et al. Effect of limbal marking prior to laser ablation on the magnitude of cyclotorsional error. J Refract Surg 2012;28: ) Shajari M, Bühren J, Kohnen T. Dynamic torsional misalignment of eyes during laser in-situ keratomileusis. Graefes Arch Clin Exp Ophthalmol 2016;254: ) Febbraro JL, Koch DD, Khan HN, et al. Detection of static cyclotorsion and compensation for dynamic cyclotorsion in laser in situ keratomileusis. J Cataract Refract Surg 2010;36: = 국문초록 = 당일라식, 라섹수술과기존수술법의수술후결과비교 목적 : 산동검사를포함한술전검사를받은당일에수술을진행한당일라식, 라섹수술법의수술후결과를알아보고자하였다. 대상과방법 : 2016 년 1 월부터동년 12 월까지본원에서비쥬맥스와 EX500 레이저로라식수술을받은환자 226 명 (226 안 ) 과라섹수술을받은환자 201 명 (201 안 ) 을대상으로하였다. 검사와수술을같은날에진행한당일수술군과검사후다른날에수술을진행한계획수술군의술후근시, 난시및시력을비교분석하였다. 결과 : 라식수술을받은환자중당일수술군은 109 명, 계획수술군은 117 명이었으며, 술후근시는각각 0.06 ± 0.37 디옵터, 0.07 ± 0.36 디옵터였고 (p=0.91) 난시는각각 ± 0.24 디옵터, ± 0.24 디옵터였으며 (p=0.77) 시력은각각 ± 0.03 logmar, ± 0.03 logmar 였다 (p=0.13). 라섹수술을받은환자중당일수술군은 107 명, 계획수술군은 94 명이었으며, 술후근시는각각 0.18 ± 0.52 디옵터, 0.22 ± 0.54 디옵터였고 (p=0.95) 난시는각각 ± 0.30 디옵터, ± 0.29 디옵터였으며 (p=0.14) 시력은각각 ± 0.03 logmar, ± 0.03 logmar 였다 (p=0.33). 결론 : 산동제를점안하고수술전검사를받은날에시행한당일라식, 라섹수술법은기존수술법에비하여술후근시, 난시및시력에서유의한차이를보이지않았다. < 대한안과학회지 2018;59(5): > 418

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<30362D31302D313628B1E8C1F8B1B92DB1E8BFEDB0E E687770> 대한안과학회지 2013 년제 54 권제 2 호 J Korean Ophthalmol Soc 2013;54(2):224-230 pissn: 0378-6471 eissn: 2092-9374 http://dx.doi.org/10.3341/jkos.2013.54.2.224 아마리스레이저를이용한굴절수술후연령에따른재교정빈도분석 김욱겸 1,2 양훈 1 조은영 1 김희선 1