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1 대한안과학회지제 49 권제 7 호 2008 J Korean Ophthalmol Soc 49(7): , 2008 DOI : /jkos 간헐외사시의술후재발및재수술의요인분석 노준호 백혜정 가천의과학대학교안과학교실 목적 : 간헐외사시의술후재발에관계하는인자와, 그중특히재수술에이르게하는요인을알아보고자하였다. 대상과방법 : 간헐외사시로양안외직근후전술을시행받고 1 년이상추적관찰이가능했던 285 명의의무기록을후향적으로분석하였다. 술후 1 년째경과관찰시일차안위에서의사시각이 10PD 이내인경우를성공이라정의하고, 술후 3 개월까지 10PD 이내였으나술후 1 년째 10PD 이상의외편위를보일때를재발군, 10PD 이상의내편위를보일때를과교정군으로정의하여, 재발군을술후 1 년에성공군과비교하여재발에관련된요인을살펴보았다. 이때특히재발군중과도한외편위로재수술까지시행받은군의양상을관찰하여재발후재수술에이르게하는요인을알아보았다. 결과 : 술후 1 일사시각이 10~20PD 이내로과교정되었을때술후재발률이유의하게낮았고 (p<.05), 이때수술연령, 술전사시각, 입체시등은재발과관계가없었다. 재발군중재수술을시행했던군은단순히재발한채추가수술이필요하지않았던군에비해술전입체시가 400 초이상인경우가많았고 (p<.05), 술후 1 일째사시각은재수술여부와는상관관계가없었다. 결론 : 간헐외사시수술후재발은술후 1 일째의사시각이관여하였지만, 재발군중재수술에이르렀던경우는술후 1 일째의사시각과무관하게술전입체시가관여하였다. 따라서간헐외사시수술후, 특히재수술여부의예측에있어서는수술을통한운동기능의조정보다술전감각기능의좋고나쁨이더중요한요인으로생각된다. < 한안지 49(7): , 2008> 내사시가많은서양과달리일본, 중국을포함한아시아권에서는외사시가더많은것으로알려져있고, 국내보고에서도외사시가내사시에비해 2 배이상많으며특히간헐외사시는외사시의과반수이상을차지하는가장흔한형태로알려져있다. 1-5 간헐외사시의치료목적은양안단일시의유지및개선과시기능의정상화에있으며치료는수술적, 비수술적요법으로나눌수있는데대개는수술적요법이주가되고굴절이상교정, 프리즘안경처방, 교대차폐, 오목렌즈사용등의비수술적요법은술전후에보조적으로사용되고있다. 6 간헐외사시의수술성공률은 40~86.5% 로연구자마다큰차이를보여술후경과를정확히예측하기가 < 접수일 : 2007 년 3 월 7 일, 심사통과일 : 2008 년 4 월 10 일 > 통신저자 : 백혜정인천시남동구구월동 1198 가천의과학대학교안과 Tel: , 3364, Fax: hjpaik@gilhospital.com * 본논문의요지는 2006 년제 96 회대한안과학회추계학술대회에서구연으로발표되었음. 어렵지만, 7-14 일반적으로술후경과는외편위 (exotropic drift) 로진행하고그중일부에서재발하는것으로알려져있다. 15 수술경과에영향을미치는요인으로는술후경과관찰기간, 술전후사시각, 입체시, 약시, 하사근기능항진, 수술방법, 외사시유형등다양한요인들이국내외에보고되고있지만아직이에대해서는논란의여지가많다. 이에저자들은간헐외사시술후재발군을대상으로재발에영향을미치는요인을분석하고그중특히외편위도가심해재수술을시행한재수술군을분석하여재수술에영향을미치는요인에대해서알아보고자하였다. 대상과방법 2001 년 7 월부터 2005 년 7 월까지본원에서간헐외사시로진단받고양안외직근후전술을시행받았던환자중술후 1 년이상경과관찰이가능하였던총 285 명의환자를대상으로의무기록을후향적으로분석하였다. 수술은단일술자에의해이루어졌으며재발요인으로고려하였던것은진단및수술연령, 술전사시각및술후 1 일째사시각, 약시, 입체시, 하사근기능항진동반유무였다. 술후경과는이전논문을토대로술후

2 노준호외 : 간헐외사시술후재발, 재수술요인분석 년에일차안위에서의사시각이 10PD 이내인경우를성공이라정의하고, 술후 3 개월까지 10PD 이내로성공상태를유지하였으나술후 1 년경과시 10PD 이상외편위된경우를재발군, 10PD 이상내편위된경우를과교정군으로정의하였다. 또한재발군중 20PD 이상의외편위로수술을시행받은경우를재수술군으로, 비록재발하였지만추가수술이필요하지않았던경우는단순재발군으로정의하고두군을비교하여, 특히재발후재수술에이르게하는요인을알아보았다. 1% cyclogyl 과 0.5% atropine 으로조절마비굴절검사를시행하여최대교정시력을측정하였고, 사시각은굴절이상을교정한뒤협조가가능한경우조절시표를이용하여 5 m 원거리와 33 cm 근거리에서교대가림검사로측정하였고, 협조가불가능한경우히르쉬버그검사나크림스키검사로측정하였다. 원거리사시각측정시에는상, 하, 좌, 우모두에서사시각을측정하였고양안운동검사를시행하여외안근기능항진및기능저하를확인하였으며입체시는티트무스입체시검사를통해측정하였다 수술은수술방법에따른변수를통제하기위해모든대상에서양안외직근후전술로제한하였고 Parks 가제안한양을기준으로하되술자의경험에따른수술량의조정을인정하였다. 특히본연구에서는하사근기능항진유무를평가할수있었던 265 명중 73 명, 28% 에서간헐외사시에하사근기능항진이동반되었으나그정도가심하지않아추가적인하사근교정술이필요하지않았다. 또한하사근후전술이나절제술같은수술적교정을요하는경우는처음부터대상에서제외하였다. 각각의요인들과재발및재수술과의상관관계에대한통계분석은 SPSS 12.0 의 Chi-square test 및 Fisher exact test 를사용하였다. 결 과 총 285 명의환자중남자 139 명 (48.8%), 여자 146 명 (51.2%) 으로남녀간의성비는비슷하였고평균연령은 7.4 세였다. 전체 285 명중성공군 233 명 (81.9%), 재발군 42 명 (14.6%), 과교정군 10 명 (3.5%) 이었고재발군은다시재수술군 13 명 (30.9%) 과단순재발군 29 명 (69.1%) 으로나뉘었다. 약시동반유무를확인할수있었던 265 명중재발군은 40 명으로그중 4 명 (10%) 이약시였고성공군은 225 명중 19 명 (8.4%) 만이약시를동반하여통계적으로의미있는차이를보이지않았다. 하사근기능항진유무를확인할수있었던 261 명중에서는재발군 42 명중 14 명 (33.3%), 성공군 219 명중 59 명 (26.9%) 이 각각하사근기능항진을동반하였고역시두군간에유의한차이가없었다. 입체시의정도는티트무스검사상 400 초미만의입체시를보인경우가성공군 136 명 (69.8%), 재발군 22 명 (57.9%) 인반면, 400 초이상의좋지못한입체시를보인경우가성공군 59 명 (30.2%), 재발군 16 명 (42.1%) 으로두군간에차이를보였으나통계적으로유의하지는않았다 (Table 1). 수술연령및진단에서수술까지의기간도재발군과성공군에서큰차이를보이지않았고, 술전사시각또한재발군과성공군모두대부분 20~39PD 사이에분포하여두군간에차이가없었다 (Table 2). 수술 1 일째사시각분포는재발군에서 10PD 이하로내편위된경우가 25 명 (59.5%) 으로가장많았던반면, 성공군에서는 10~20PD 이하로내편위된경우가 158 명 (67.8%) 으로가장많아두군간에유의한차이를보였고 (p<.05), 따라서술후 1 일째사시각이재발과관계가있음을알수있었다 (Table 3). 재수술군과단순재발군에대해서도같은방식으로상관관계를분석하였는데이중오직술전입체시만이재수술에관여하였다 (Table 4). 즉, 재수술군에서는단순재발군에비해술전입체시가 400 초이상으로불량한경우가많았고 (p<.05)(table 5), 다른요인들은재수술여부와무관하였으며특히재발에관여하였던술후 1 일째사시각과재수술여부도상관관계가없었다. Table 1. Distribution of stereopsis in Recurrence and Success groups Stereopsis (sec) Recurrence (N=38) Success(N=195) < (57.9) 136 (69.8) 400~ (28.9) 39 (20.0) (13.2) 20 (10.2) (P>0.05) Table 2. Distribution of preoperative deviation angle in Recurrence and Success groups Alignment (Δ) Recurrence (N=42) Success (N=233) 10~19 2 (4.8) 9 (3.8) 20~29 18 (42.9) 123 (52.7) 30~39 14 (33.3) 86 (36.9) 40~49 6 (14.3) 11 (4.7) 50 2 (4.8) 4 (1.9) (P>0.05) 1115

3 대한안과학회지제 49 권제 7 호 2008 년 Table 3. Distribution of deviation angle on the first postoperative day one in Recurrence and Success groups Alignment (Δ) Recurrence (N=42) Success (N=233) 10~20 ET* 15 (35.7) 158 (67.8) Ortho~10 ET 25 (59.5) 70 (30.0) XT 2 (4.8) 5 (2.2) * ET=Esotropia; XT=Exotropia. (P<0.05) Table 4. Correlationship between Recurrence (no operation) and Reoperation groups according to factors Factor P-value Age (Operation) Period (Diagnosis~Operation) Stereopsis 0.041* Amblyopia IOOA Alignment (Preoperative) Alignment (POD#1) (*P<0.05) Table 5. Distribution of stereopsis in Reoperation and Observation (recurrence but no operation) groups Stereopsis (sec) Reoperation (N=13) Observation (N=29) <400 4 (30.8) 21 (72.4) 400~ (46.2) 5 (17.2) (23.1) 3 (10.4) (P<0.05) 고 찰 수술적으로치료받지않은간헐외사시의자연경과에대해서는항상외사시로의진행을주장한 von Noorden and Campos 23, Jampolsky 24 와불변을주장한 Fletcher 25, Hiles et al 26, Romanchuk et al 27 의의견이대립하고있다. 반면간헐외사시의수술후경과에대해서는 Mark 28 가술후경과의의외성, 비예측성을주장하기도하였으나일반적으로는외편위 (exotropic drift) 되고그중일부에서재발하는것으로알려져있다. 15 술후재발에관여한는요인에대해많은연구가있었는데, Ruttum 29 은술전사시각, 원 근거리사시각차이, 수술시나이, 굴절력등다양한요인이관여한다고주장하였고, Keenan and Willshaw 30 은술후초기의과교정도를, Stoller et al 31 은외사시의간헐성만이유의한영향을주었다고주장하였으며최근에 Gezer et al 32 은술전편위도, 굴절이상과재발과의 연관성을주장하였다. 특히수술직후과교정도가재발과상관관계가있을것이라는많은연구가있었는데, Rabb and Parks 33, Knapp 34 은수술직후약 11~20PD, Scott et al 15 은 4~14PD 의과교정이좋은결과를얻을수있다고하였고국내에서도이와유사한보고가다수있었다. 14,35-37 본연구에서도술후 1 일째 10~20PD 의과교정도를보였던군에서술후 1 년째재발률이유의하게낮음을확인할수있었다. 이는수술직후과교정이복시를유발하고억제를제거하며융합능력을자극하여안구위치의장기적안정성을획득하기때문으로생각된다. 38 하지만 von Noorden 23 은수술직후일정량의과교정을의도적으로만드는것은우연일뿐이라고하였고, Cooper 39 의연구에서도과교정의예측도가 37% 에불과하였다. 수술연령과재발과의관계를살펴보면, 본연구의결과와같이상관관계가없다는입장과 9,35,40 4 세이하에서수술성공률이높다는입장, 7,33 4 세이후의수술이바람직하다는입장이있다. 23 특히시력발달이미약한 4 세이전의소아에서술후과교정은입체시기능저하, 양안시기능소실과내사시로의이차적지각적응을가져올수있다는보고도있으며, 40 성인에서는과교정이복시를유발하므로 15PD 이내로부족교정해야한다는연구결과도있다. 39 따라서재발과의상관여부를떠나, 수술연령은술후과교정시에중요하게고려되어야요인으로생각된다. 내사시에서안구위치의수술적교정이술후입체시기능을향상시킨다고알려진것처럼간헐외사시에서도과교정을통한술후안구위치의변화는양안시기능의회복및입체시의부분적향상을가져올수있을것으로보인다. 42 또술후향상된입체시는안구위치의장기적안정성획득에영항을주는양성적인되먹임효과를유발하는것으로생각된다. 본연구에서술전좋은입체시의정도는성공군, 재발군, 재수술군의순서였는데, 그중재발군과성공군에서는입체시의차이가통계적으로유의하지않았지만, 재수술군은단순재발군에비해유의하게불량한술전입체시를나타내었다. 이는술전입체시가나쁠경우수술을통해술후입체시가부분적으로향상됨에도불구하고, 안구위치의장기적안정성에차이를유발할수있음을보여준다. 감각기능에따른간헐외사시수술결과에대한 Yeo et al 43 의연구에서는, 비록표본이적고추적기간이짧아통계적으로유의하지는않았지만감각기능이불량한경우수술성공률이낮은것으로조사되었는데, 이는억제가없고정상망막대응을가진환자들이술후에이상망막대응을가진환자들에비해융합능력과입체시 1116

4 노준호외 : 간헐외사시술후재발, 재수술요인분석 기능이더발달하여이로인해양안에안정성을획득하는것으로설명하고있다. 이와달리 Beneish and Flanders 44 은술전입체시가불량한경우술후성공률이높았다고하여본연구와상반되는보고를하였다. 그외에도재발및재수술과관련하여진단연령이나유병기간, 하사근기능항진, 약시동반여부가고려되었으나본연구에따르면큰상관관계가없는것으로보인다. 본연구의수술성공률은 81.9% 로이전연구결과와비슷하거나다소높은수치를보이는데수술성공의정의와수술방법에따른차이, 술후경과관찰기간이증가할수록외편위경향이증가하는점등을고려하였을때의미있는차이로보이지않는다. 또수술방법이술후결과에영향을준다는입장과차이가없다는상반된입장이존재하므로본연구에서는수술방법의차이에따른변수를막기위해양안외직근후전술로제한하였다. 결론적으로간헐외사시의재발여부에는술후 1 일째사시각이관여하였지만, 재발군중과도한외편위로재수술에이르렀던경우에는술후 1 일째의사시각과무관하게 400 초이상의불량한술전입체시가관여하였다. 따라서간헐외사시수술후, 특히재수술여부의예측에있어서는술후 1 일째사시각과같은운동기능의조정보다술전입체시와같은감각기능의좋고나쁨이더중요할것으로생각된다. 이를위해술자는굴절이상교정, 교대차폐, 마이너스렌즈착용등의보조적인비수술적요법을시행하여감각기능의유지및개선에힘써야하며만약술전입체시가불량하다면보호자에게재수술가능성과장기적인경과관찰의필요성에대해사전에충분히설명하는것이필요할것으로생각된다. 참고문헌 1) Friedmann L, Biedner B, David R, Sachs U. Screening for refractive errors, strabismus and other ocular anomalies from ages 6 months to 3 years. J Pediatr Ophthalmol Strabismus 1977;17: ) Friedmann Z, Neumann E, Hyams SW, Peleg B. Ophthalmic screening of 38,000 children, age 1 to 2 1/2 years, in child welfare clinics. J Pediatr Ophthalmol Strabismus 1980;17: ) Preslan MW, Novak A. Baltimore vision screening project. Ophthalmology 1996;103: ) Nam SH, Kim CH, Park SH, Shin HH. A vision screening in the preschool children. J Korean Ophthalmol Soc 1990;31: ) Yu YS, Kim SM, Kwon JY, et al. Preschool vision screening in Korea; Preliminary study. J Korean Ophthalmol Soc 1991; 32: ) Park JY, Sohn HY, Cho YA. Is the non surgical treatment effective on intermittent exotropia in children school-age? J Korean Ophthalmol Soc 1995;36: ) Pratt-Johnson JA, Barlow JM, Tillson G. Early surgery in intermittent exotropia. Am J Ophthalmol 1977;84: ) Hardesty HH, Boynton JR, Keenan JP. Treatment of intermittent exotropia. Arch Ophthalmol 1978;96: ) Richard JM, Parks MM. Intermittent exotropia. Surgical results in different age groups. Ophthalmology 1983;90: ) Kushner BJ. Selective surgery for intermittent exotropia based on distant/near differences. Arch Ophthalmol 1998;16: ) Ing MR, Nishimura J, Okino L. Outcome study of bilateral lateral rectus recession for intermittent exotropia in children. Ophthalmic Surg Lasers 1999;30: ) Chang BL. Operative results in exotropia. J Korean Ophthalmol Soc 1983;37: ) Kim MM, Cho ST. Long term surgical results of intermittent exotropia. J Korean Ophthalmol Soc 1994;35: ) Ko KW, Min BM. Factors related to surgical results of intermittent exotropia. J Korean Ophthalmol Soc 1996;37: ) Scott WE, Keech RV, Marsh A. The postoperative results and stability of exodeviations. Arch Ophthalmol 1978;96: ) Kim HY, Lee SY, Lee YC. The usefulness of Titmus test and distance stereoacuity using B-VAT in intermittent exotropes. J Korean Ophthalmol Soc 2004;45: ) Lee SY. Comparison of distance and near stereoacuity in normal and intermittent exotropic children. J Korean Ophthalmol Soc 2001;42: ) Hong SW, Park SC. Stereoacutiy of normal subjects assessed by Frisby Davis distance stereotest. J Korean Ophthalmol Soc 2006;47: ) Suh WJ, Lee UK, Kim MM. Change of postoperative distance steroacuity in intermittent exotropic patients. J Korean Ophthalmol Soc 2000;41: ) Roh YB, Kim CM, Oum BS, Lee JS. Distance stereoacuity in children with intermittent exotropia using B-VAT II video acuity tester. J Korean Ophthalmol Soc 1998;39: ) Burian HM, Spivey BE. The surgical management of exodeviations. Am J Ophthalmol 1965;59: ) Baker JD, Davies GT. Monofixational intermittent exotropia. Arch Ophthalmol 1979;97: ) von Noorden GK, Campos EC. Exodeviation. In : Binocular vision and ocular motility: therapy and management of strabismus, 6th ed. St Louis: CV Mosby, 2002; chap ) Jampolsky A. Characteristics of suppression in strabismus. Arch Ophthalmol 1955;54: ) Burian HM. Transactions of the New Orleans Academy of Ophthalmology, Symposium on Strabismus. St Louis: Mosby, 1971; ) Hiles DA, Davies GT, Costenbader FD. Long-term observations on unoperated intermittent exotropia. Arch Ophthalmol 1968;80: 1117

5 대한안과학회지제 49 권제 7 호 2008 년 ) Romanchuk KG, Dotchin SA, Zurevinsky J. The natural history of surgically untreated intermittent exotropia-looking into the distant future. J AAPOS 2006;10: ) Ruttum MS. Initial versus subsequent postoperative motor alignment in intermittent exotropia. J AAPOS 1997;1: ) Scott AB, Marsh AJ, Jampolsky A. Quantitative guidelines for exotropia surgery. Invest Ophthalmol Vis Sci 1975;14: ) Keenan JM, Willshaw HE. The outcome of strabismus surgery in childhood exotropia. Eye 1994;8: ) Stoller SH, Simon JW, Lininger LL. Bilateral rectus recession for exotropia. A survival analysis. J Pediatr Ophthalmol Strabismus 1994;31: ) Gezer A, Sezen F, Nasri N, Gözüm N. Factors influencing the outcome of strabismus surgery in patient with exotropia. J AAPOS 2004;8: ) Rabb EL, Parks MM. Recession of the lateral recti. Early and late postoperative alignments. Arch Ophthalmol 1969;82: ) Knapp P. Helveston EM, Jampolsky A, et al. Transections of the New Orleans Academy of Ophthalmology. Symposium on Strabismus. St Louis: C.V. Mosby, 1971; ) Hur J, Won IG. Surgical results of 79 cases of intermittent exotropia in children. J Korean Ophthalmol Soc 1990;31: ) Choi DG, Kim PS. The surgical outcome of intermittent exotropia and the prognostic factors. J Korean Ophthalmol Soc 1998;39: ) Lee JY, Choi DG. The clinical analysis of recurrence after surgical correction of intermittent exotropia. J Korean Ophthalmol Soc 2002;43: ) Tarsman W, Jeger EA. Duane s Clinical Ophthalmology. Philadelphia: Harper & Row, 1991: ) Cooper EL. Purposeful overcorrection in exotropia. In: Kanger S, Giessen, eds. International strabismus symposium. 1966; ) Haik GM. Transections of the New Orleans Academy of Ophthalmology. Strabismus. St Louis: C.V. Mosby, 1962;1962: ) Schlossman A, Muchnick RS, Stern K. The surgical management of intermittent exotropia in adult. Ophthalmology 1983;90: ) Birch EE, Stager DR Sr, Berry P, Leffler J. Stereopsis and long term stability of alignment in esotropia. J AAPOS 2004;8 : ) Yeo SI, Kim SY, Hwang WS, Kong SM. Surgical results according to sensory function tests in intermittent exotropia. J Korean Ophthalmol Soc 1999;40: ) Beneish R, Flanders M. The role of stereopsis and early postoperative alignment in long-term surgical results of intermittent exotropia. Can J Ophthalmol 1994;29:

6 노준호외 : 간헐외사시술후재발, 재수술요인분석 =ABSTRACT= Clinical Study on Factors Associated with Recurrence and Reoperation in Intermittent Exotropia Joon Ho Roh, M.D., Hae Jung Paik, M.D., Ph.D. Department of Ophthalmology, Gachon University, Gil Medical Center, Incheon, Korea Purpose: The purpose of this study is to analyze factors associated with recurrence and reoperation in intermittent exotropia. Methods: The medical records of 285 patients who had undergone the bilateral lateral recti recessions for intermittent exotropia with at least 1 year of postoperative follow-up were reviewed retrospectively. Surgical success was defined as a final deviation less than 10PD, overcorrection more than 10PD and recurrence less than 10PD at postoperative 3 months but recurring later, so being exodeviated more than 10PD in primary gaze at postoperative 1 year. Reoperation was performed when the eye was excessively exodeviated with follow-up, requiring surgical revision clinically. We investigated factors associated with recurrence, comparing recurrence group to success group, and also investigated factors associated with reoperation, comparing reoperation group to recurrence group. Results: Alignment at postoperative 1 day was proved to be significant factor influencing on recurrence. The age at the time of operation, preoperative alignment, stereopsis, etc were not associated with recurrence. Also, stereopsis was associated with reoperation, but there were no relationship between reoperation and other factors. Conclusions: Alignment at postoperative 1 day was related to recurrence and poor stereopsis ( 400 sec) was associated with reoperation. Therefore, sensory function, such as stereopsis should be considered more important than motor control when considering reoperation. J Korean Ophthalmol Soc 49(7): , 2008 Key Words: Intermittent exotropia, Recurrence, Reoperation Address reprint requests to Hae Jung Paik, M.D., Ph.D. Department of Ophthalmology, Gachon University, Gil Medical Center #1198, Kuwol-dong, Namdong-gu, Incheon , Korea Tel: , 3364, Fax: , hjpaik@gilhospital.com 1119

(백혜정-송현재) hwp

(백혜정-송현재) hwp 대한안과학회지 2010 년제 51 권제 7 호 J Korean Ophthalmol Soc 2010;51(7):992-997 pissn: 0378-6471 eissn: 2092-9374 DOI : 10.3341/jkos.2010.51.7.992 = 증례보고 = 주시안을가진간헐외사시의편위안증량비대칭외직근후전술 송현재 백혜정 가천의과학대학교안과학교실 목적 : 주시안을가진간헐외사시의일차수술로편위안증량비대칭외직근후전술의결과를양안대칭외직근후전술과비교하고자하였다.