머리말 현대의백내장치료는예방가능한실명을막는수준에서벗어나시력자체의개선뿐만아니라시각기능의질적인호전을기대하는수준에까지이르렀다. 특히, 백내장수술은최근들어기술적으로비약적인발전을이루어특별한위험인자가없는한안전하고효과적인치료방법으로평가받고있다. 최근국내에서뿐만아니라전세계적으로각각의

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1 백내장진단및치료지침 대한안과학회 1

2 머리말 현대의백내장치료는예방가능한실명을막는수준에서벗어나시력자체의개선뿐만아니라시각기능의질적인호전을기대하는수준에까지이르렀다. 특히, 백내장수술은최근들어기술적으로비약적인발전을이루어특별한위험인자가없는한안전하고효과적인치료방법으로평가받고있다. 최근국내에서뿐만아니라전세계적으로각각의질병에대한표준화된진료권고안을제시하고자하는노력들이이루어지고있다. 물론환자개개인의치료방법은담당의료진의지식과경험을바탕으로환자가지닌여러가지특성을고려하여결정하여야하는것이타당하나, 해당질병의일반적인병태생리및치료방법상의공통적인특성등을감안하면대표적으로참고할만한표준화된진료지침을제시하는것은해당질병의진단및치료의발전과이에대한신뢰에큰도움이될것으로기대된다. 이에안과영역에서도진단및수술적치료의비중이높은백내장질환에대해서표준화된진료권고안을제시하여여러의료진및환자들에게참고가되고자한다. 이번백내장진단및치료지침수립을위해헌신적인노력을다하신여러안과선생님들께감사드리며보완과새로운권고안개발에더욱노력하여지속적으로백내장환자의진료에보탬이되길기대해본다. 2

3 I. 백내장의이해 유병률및발병률 2. 위험인자 II. 백내장의진단 진단방법 2. 백내장의분류 III. 백내장의치료 비수술적치료 비수술적치료방법 1.2 약물치료 2. 수술적치료 수술의적응증 2.2수술에대한환자설명및동의서작성 2.3수술전문진사항 2.4수술시주의를요하는경우 2.5인공수정체선택 2.6수술도구및기구준비 2.7수술감염및염증에대한예방조치 2.8마취제및진정제의사용 3. 수술과정 수술방법 3.2의료진을대상의수술관련교육 3.3수술집도직전확인사항 4. 수술후과정 수술후관리 4.2수술결과에대한평가방법및검사 4.3주요합병증 5. 소아백내장수술 수술전검사 5.2인공수정체의결정 5.3수술에서의고려사항 3

4 5.4 합병증 6. 사회경제학적고려사항 백내장수술의비용효과성과지속적인발전 4

5 I. 백내장의이해 1. 유병률및발병률 백내장은전세계적으로예방가능한실명원인중가장큰부분을차지하고있는단일질환이다. 1-4 한국에서는신경환등이 1991~1992년에충북중원과경북문경지역에서 30년이상거주한 40세이상의성인 587명을대상으로백내장유병률을조사하였다.1 연구결과, 산간지역인중원에서는 32.8%, 농촌지역인문경에서는 43.5% 의유병률을보였고, 각각에서의연령에따른유병률은 60세가넘으면서현저히증가하여 60대에 33.3% 와 50.3%, 70대에 84.4% 와 87.1% 의유병률을보였다. 1995년에실시한경남창녕의백내장유병률조사에서는직업별로농부에서다른직업군에비해핵백내장이유의하게많았으며, 남자가 32.3% 를차지하고여자가 67.7% 를차지해남자에비해여자에서 2배이상백내장유병률이높다고보고되었다 위험인자 여러인자들이관련되어발생에관여하는것으로알려져있다. 연령, 성별 ( 여성 > 남성 ), 근시, 전신질환 ( 당뇨병, 분만횟수, 폐경기호르몬의사용, 대량설사 ), 환경요인 ( 알코올섭취, 일광노출, 자외선, 흡연, 교육수준 ), 영양과약물 ( 스테로이드, 산화제와항산화제, 높은신체질량지수등 ) 을꼽을수있다

6 II. 백내장의진단 1. 진단방법 1.1 문진 여타질환과마찬가지로백내장진단에있어가장기본적인것은문진이다. 환자가호소하는주증상에따라대부분의감별진단이이루어진다. 백내장의가장중요한증상은시력저하이나수정체혼탁의위치와부위에따라서자각증상이개인마다다르며눈부심, 대조민감도저하로야간운전의불편감, 근시, 단안복시, 색각감퇴, 경우에따라서는시야감소등의증상을호소하므로이에대해자세히문진해야한다. 또한전신질환에대해문진하여이와관련된백내장인지파악할수있다. 1.2 시력측정시력검사는안과검사중기본적인검사이며, 진단및예후에있어중요한지표가된다. 진단시이용되는시력검사표로스넬렌시력표 (Snellen chart) 나한천석시력표, ETDRS (Bailey-Lovie Early Treatment of Diabetic Retinopathy Study) 시력표등이있다. 벽걸이형태의시력표가많이사용되어왔으나, 프로젝터나모니터를이용한시력표도개발되어사용되고있다. 시력표는주로고대조상태에서검사가시행되나대비감도를측정하여시기능을평가하기도한다. ETDRS의경우알파벳으로제작되어있어우리나라에서범용으로사용하는데어려움이있어최근에는국제표준 (ISO 8596) 인기하학적변화방식을따르고대수시력표 (LogMAR) 방식으로제작한진용한시력표가사용되기도한다. 6

7 1.3 안과검사백내장진단시전반적인안과검사가필요하다. 세극등현미경검사는대부분의백내장을진단할수있는기본적인검사로시력검사결과와함께고려하여수술시기나방법을결정할수있다. 보통은산동하지않아도진단할수있으나산동시혼탁정도나섬모체소대의상태, 안저등을더정밀하게검사할수있다. 세극등현미경검사소견으로백내장종류와중증도를분류할수있으며그방법에는 Lens Opacities Classification System I, II, III (LOCS I, II, III), Wilmer system, Oxford system, Wisconsin system, World Health Organization system 등이있다..12 Wilmer식분류법은핵혼탁을주로분류한것으로 4가지표준사진과시력을기준으로핵혼탁의정도를 4단계로구분한다 동반안과질환의검사백내장진단시다른안과적질환이동반되지않았는지여부를검사하는것은백내장수술후예후예측에있어중요하다. 이러한검사로는안압검사, 굴절검사, 각막곡률측정, 안저검사, 초음파검사, 외안근검사등을시행할수있다.. 안압은녹내장과관련된검사로안압상승이있다면원인을찾아야한다. 안저검사를통해시신경, 황반부및주변부망막, 유리체상태를파악할수있다. 안저검사가불가능한백내장의경우초음파검사로망막박리나유리체혼탁등을관찰할수있다. 외안근검사를통해약시의가능성, 수술후복시의가능성등을확인할수있다. 1.5 전신질환검사전신질환과관련하여백내장이나타날수있는데대표적으로당뇨병, 아토피성피부염이나탈모, 어린선같은피부질환, 부갑상선기능저하증, 갑상선기능저하증, 영양장애, 연소성류마티스관절염등이있다. 백내장과관련된유전질환에는알포트증후군, 골형성부전증, 파브리병, 윌름종양, 마르팡증후군, 신경섬유종증 2형, 다운증후군, 파타우증후군, 터너증후군, 에드워드증후군, 윌슨병등이있다. 이러한전신질환이나유전질환이의심된다면검사가가능한경우같이하거나불가능한경우상급병원에의뢰할수있다. 1.6 수술시기의결정이나계획을위한검사 7

8 인공수정체의선택을위해서각막곡률측정, 초음파안축장검사등이시행되며, 환자에따라서각막내피의상태를평가하려면경면현미경검사를시행하는것이도움이된다. 각막지형도검사, 샤임플러그검사, 웨이브프론트수차계검사, 광간섭단층촬영 (optical coherence tomography (OCT)), 형광안저촬영, 시야검사, 다양한초음파검사, 시유발전위검사, 망막전위도검사, 눈물배출계검사등이필요할수있다. 8

9 2. 백내장의분류 2.1 발생위치에따른분류백내장은기본적으로수정체의위치에따라서피질, 핵, 후낭하혼탁의 3가지종류가순수형으로분류되며, 여기에혼합형이추가된다. 더세부적으로는혼탁의색조, 형상정도등에따라서분류된다. 수정체혼탁의정도를객관적으로기술하기위한방법중 LOCS (Lens Opacities Classification System) III 가가장널리이용된다. LOCS III 분류법은미국 National Eye Institute가주도하여만든분류법이며수정체를피질, 핵, 수정체후낭의 3부분을나누고피질과후낭하혼탁을 5단계로나누었으며표준사진을보고분류한다. 핵은혼탁과색조에따라서각기 6단계로나누어서등급을매긴다 발생연령이나원인에따른분류백내장에서가장주요한원인은노화로인한백내장의발생이다. 노화는직접적으수정체혼탁과연관이있으며, 수정체혼탁그자체역시노화때문에진행이가속화된다. 한편노화외의다른주요한백내장의원인으로는각종안과수술, 녹내장, 포도막염, 당뇨병, 근긴장성이영양증, 아토피피부염, 어린선, 산화스트레스, 자외선, 방사선등이알려져있어이러한각각의원인에따라백내장을분류하기도한다. 선천대사이상이나유전질환등에의한어린연령의백내장은연소성백내장, 그리고노화에의한백내장은노인성백내장으로분류하기도한다. III. 백내장의관리및치료 1. 비수술적관리 9

10 1.1 비수술적방법 시력개선을위해안경처방이효과적인경우가있고, 눈부심을감소시키기위해서유색안경이나모자를사용할수있다.3 백내장의원인과증상에대한교육을하는것도도움이될수있다.2-4,14,15 또한금연, 체질량지수 (body mass index) 조절, 자외선차단등이도움이될수있다. 1.2 약물방법 백내장의진행을억제시킬수있는약물로는항산화성분의점안액, 요오드화칼륨 성분의점안액등이사용되고있으며, 수술이우선고려되지않는경우에사용할수 있다. 2. 수술적치료 2.1 수술의적응증 (1) 수술이필요한환자 시력장애로생활에지장을받는사람으로서, 시력또는시각기능저하가백내장에의한것임을확인할수있는경우에백내장수술을고려할수있다.4 시력또는시각기능저하가수술시기에대한보편적인임상적판단기준이다. 하지만최근에는시력또는시각기능저하만으로수술시기를결정하기보다는환자와상담해적절한수술시기를결정하는것이일반적이다. 각환자들의기능적시력요구정도, 환경그리고다른위험성등의다양한면을고려하여수술시기를결정해야한다. 전방내유리체탈출과안압상승을동반한외상성백내장, 수정체로인한녹내장, 약시가우려되는유아의편측성백내장, 백내장으로인해시신경과망막의관찰이어려운환자의경우등에서수술이 필요하다.16,17 10

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12 (2) 수술시기를늦추는것에대한견해 백내장이심하지않고시력저하에불만이없으면서백내장으로인한합병증이발생할가능성이적은환자들은수술을연기하고정기적인검사를할수있다. 그러나, 시력저하가심한환자에게서낙상, 골절, 자동차사고의발생확률이증가하는것으로알려져있다.19성숙혹은과숙백내장을방치할경우수술의난이도가상승하고수술후회복속도가늦거나수정체유발포도막염, 수정체성녹내장과같은관련합병증확률이증가할수있다. 만약더진행될경우백내장이유리체강내로탈구되어유리체절제술까지시행해야할수도있으므로, 적절한수술시기의결정이중요하다. 2.2 수술에대한환자설명및동의서작성 환자또는환자의보호자는백내장수술로인한이득과위험에대해설명을듣고수술로인해감수해야하는위험, 비용, 불편에비해기대되는이득이더크다고판단될경우에수술을결정하도록한다. 환자또는환자의보호자는수술의적응증, 마취방법, 수술의방법, 수술후관리, 수술후발생가능한합병증등에대한설명을듣고수술동의서를작성하게한다.17, 수술전문진사항 안질환및수술의과거력, 전신질환, 현재투약중인약물, 약물부작용기왕력등위험 요인들을확인한다.19 (1) 기본적인건강상태와기왕력및전신검사 병력확인과정에서특별한기왕력등이발견되거나의심되는경우필요한전신검사를 추가로시행할수있다. 마취방법및수술방법의특성상전신검사가필요한경우도 있다.17,31 12

13 (2) 환자의협조도 치매나폐쇄공포증등신경정신과적질환및청각장애, 언어장애등신체적상태를 평가한다.32,33 (3) 사용중인약물 마취혹은수술과정에영향을끼칠수있는약물사용여부를확인함으로써합병증의가능성을일부낮출수있다. 마취시혹은수술중출혈가능성을평가하기위하여, 항응고제및항혈소판제의사용여부를확인하는것이좋다. 또, 탐슐로신 (tamsulosin) 과같은알파 1 길항제 (alpha 1-agonist) 는홍채긴장완화증후군 (Intraoperative Floppy Iris Syndrome, IFIS) 을유발할가능성이높기때문에투여여부확인이도움이된다 수술시주의를요하는경우 안구자체의구조적인이상이동반된경우나다른안과질환이동반된경우수술에주의해야한다. 전신질환이동반된환자에서백내장수술을진행할경우동반된질환의특성과환자의전신상태를고려해야한다.41. (1) 녹내장을동반하는환자 일반적으로백내장수술자체는안압을약간낮추는효과를보인다 그러나녹내장이있는환자에서백내장수술후안압이상승할가능성이높을것으로예측되거나시력저하를동반한백내장과녹내장수술이필요할경우에는백내장과녹내장수술을동시에시행하는것을고려할수있다.46,47 13

14 (2) 각막이식이필요한환자 각막이식과백내장수술을동시에시행하는이유는, 각막이식후백내장이더빨리진행할수있고백내장수술로이식한각막이손상을받을수있기때문이다. 동시수술의장점은, 두가지수술을한번에진행함으로써얻게되는시간적경제적이점과환자의번거로움을줄일수있다는점이다. 그리고, 술후시력회복이더빠를수있다그러나, 각막이식후의각막곡률을정확히알수없기때문에인공수정체도수계산이부정확하다는단점도있다. 따라서각막이식을먼저하여안정된다음백내장수술을하는것을선호하는술자들도있다.48 (3) 포도막염을동반하는환자 포도막염이있는경우에백내장수술이가능하기는하나, 염증이가라앉았거나혹은염증이최대한조절된상태에서수술을하는것이바람직하다.. 그러나백내장으로인해발생한포도막염의경우백내장수술이포도막염의치료이므로염증이조절되지않은상태에서도수술을시행해야한다. 만성포도막염의경우수술전후추가적인점안혹은경구스테로이드제의사용을고려한다. 치료는포도막염의중증도와합병증의정도에따라개별적으로접근해야한다. 또한수술전부터홍채후유착, 동공막, 동공연의섬유화반흔등이있을경우에는적절한수술기법을적용하여야한다. 49,50 (4) 연령관련황반변성을동반하는환자 백내장수술이후연령관련황반변성 (Age-related macular degeneration, AMD) 이악화될 위험성은낮다.51,52 그러나, 연령관련황반변성이있는환자는잠재시력이낮을수있고 51 따라서환자의술전기대치를낮추고이에대한충분한설명이필요하다. 14

15 (5) 각막내피질환이동반된경우또는각막내피세포밀도가낮을경우 각막내피질환이있거나내피세포밀도가낮을경우수술중시야가좋지않고수술후각막부종이발생또는악화될수있으며53 위수정체수포각막병증 (pseudophakic bullous keratopathy) 으로진행할수도있다.54,55 진행된백내장의경우수술중내피손상의위험이증가하므로백내장이너무과도하게진행하기전에수술하는것이권장된다. 백내장수술시점탄물질을적절히사용하고56술후고삼투압제제를점안하는것이도움이될수있다. 그리고백내장수술과동시또는이후에전층각막이식혹은내피각막이식을시행하는방법도고려해볼수있다.57 (6) 당뇨병을동반하는환자 당뇨에의한당뇨망막병증은백내장수술이후에더심해질수있다 백내장이심할경우당뇨망막병증의평가가어려울수있다. 잠재시력이낮을수있고따라서백내장수술결정시주의가필요하다. 하지만추후당뇨망막병증의치료에필요한시야확보를위하여대부분백내장수술을먼저시행한다. 당뇨환자는낭포황반부종 (CME, cystoid macular edema) 이발생할확률이높으며, 만약황반부종과백내장이함께발병하는경우에는백내장의정도에따라수술전에황반부종을치료하고, 이후에백내장수술을하는것이권유된다.53 (7) 거짓비늘증후군을동반하는환자 거짓비늘증후군 (pseudoexfoliation syndrome) 환자에서는동공의크기가작고섬모체소대가약하며전방의깊이가얕아수술이어렵기때문에합병증의가능성이크고수술후에도이차적인녹내장의발병위험이높은편이다.62때로는환자의눈상태에따른수술기법의수정이필요할수있다

16 (8) 유리체망막수술과백내장수술을함께진행하는경우 백내장수술과유리체수술을동시에하는방법도가능하다. 유리체출혈, 당뇨망막병증, 망막앞막, 황반원공, 망막박리등의다양한종류의유리체질환을동반하는경우에, 백내장 수술을동시에시행하는것을고려할수있다 동시수술시발생할수있는단점으로는수술시간이길어질수있고, 유리체절제술시 백내장창상이벌어질수있으며, 수술도중에축동이될수있고, 인공수정체중심이탈 등의합병증이발생할수있다.69 실리콘인공수정체는유리체절제술중실리콘기름을사용할경우실리콘기름이 인공수정체에침착되어수술시야가나빠질수있으므로, 실리콘기름주입술이예상되는 유리체절제술시인공수정체선택에있어서주의가필요하다. 65 (9) 각막굴절교정수술력이있는환자 라식또는라섹과같은각막을절삭하는굴절교정수술을받은경우, 인공수정체도수를정확하게계산하기가어렵고정확도가떨어진다.70-72인공수정체도수를계산하기위해서는수술전검사자료를확인하고이용하는것이도움이된다. 술전자료가없는경우를위한다양한방법이고안되어있으며최신의방법에대해서는저널이나교과서등을참조할수 있다.73,74 (10) 한눈실명된환자에서의백내장수술 한눈실명환자에서의백내장수술적응증은양안환자의수술적응증과동일하다. 하지만 이러한환자에서는수술경과가나쁘면양안실명이될수있으므로, 신중한접근이 요구된다.75 16

17 (11) 두번째눈에대한백내장수술 한쪽눈이백내장수술을받은이후, 다른쪽눈의백내장수술을받는경우는환자의양안시에도움이되는것으로입증된바있다 이때두번째눈의백내장수술적응증은, 첫번째눈의적응증과동일하다.76한편, 두번째눈의수술시기는환자의시각적요구및선호, 두번째눈의시력등, 여러요소에따라고려된다.81,82 (12) 양쪽눈을동시에백내장수술하는경우 전신마취가필요한경우등의특수한경우에양안동시수술법을선별적으로시행할수 있다.79 수술할때는한쪽눈이끝나면반대쪽눈은완전히다른환자의눈을시술하는 것처럼모든기구들을새것으로준비하여수술하는것이권장된다.84 (13) 안구에접근이어려운환자 움푹꺼져있는안구 (deep-set eyes) 는접근이어렵다. 따라서수술시야확보의어려움, 각공막윤부접근의어려움, 관류액이차는문제, 절개창화상등이발생할수있다.69 이에대한해결책으로는측두부절개 (temporal incision), 머리기울이기, 배수심지 (drainage wick) 등의방법이있다.85 (14) 갈색핵백내장환자 갈색핵백내장 (dense, brunescent cataract) 의수술은일반백내장의수술에비해수술이 어렵고, 시간이오래걸릴수있다. 또한후낭파열, 각막이나홍채의물리적 17

18 부상 ( 온도에의한것포함 ) 과같은합병증이발생할가능성이높으므로주의해야한다.86 (15) 고도원시및소안구증환자 인공수정체도수계산의정확도가떨어지므로다양한안구의생체계측결과를참고하는것이좋다. 원시의경우, 홍채탈출이나손상의가능성이높아진다.87-90술후인공수정체도수가술전예측치와차이가커예측의정확도가떨어질수있고술후적절한굴절교정치를위하여인공수정체를 2개넣어야하는경우도있다. 수술후의굴절이상으로환자가불편해할경우, 인공수정체교환술의가능성도염두에두어야한다.91 소안구증환자는홍채, 각막등에발생할수있는손상을고려해야한다. 또한이러한환자의경우, 인공수정체도수계산이상대적으로부정확하다.118 (16) 고도근시환자 인공수정체도수계산의정확도가떨어지므로다양한안구의생체계측결과를참고하는것이좋다. 91 고도근시환자의경우안구가안와에서차지하는부피가크고, 공막이얇기때문에구후마취시공막천공가능성을염두하고주의를기울여야한다.92,93 또한전방의깊이가더깊고, 섬모체소대와유리체의지지가약하기때문에수술중에수정체낭의앞뒤움직임이증가할수있어주의를요한다.94 술후인공수정체도수가술전예측치와차이가크고환자가불편해할경우, 인공수정체교환술의가능성도염두에두어야한다. 95 황반부위축, 근시성맥락막혈관신생및망막박리의가능성도상대적으로높으므로96-99수술전후망막에대한검사가필요하다. (17) 약시환자 18

19 잠재시력이낮으므로환자의술전기대치를낮추고이에대한충분한설명이필요하다.100 (18) 전립선비대증약복용환자 수술중홍채이완증후군 (IFIS, Intraoperative floppy iris syndrome) 이발생할확률이높다.101,102술전에전립선약중알파길항제인탐슐로신, (tamsulosin 등 ) 을복용한환자에서는약제를중단하여도홍채이완증후군발생을완전히막을수없어수술중축동, 홍채탈출, 홍채펄럭임 (billowing) 이각각혹은동시에발생할수있다.103동공확장이잘되지않으므로, 수술중전방에산동제를주입하거나, 동공확대용도구의사용이필요할수있다.95 (19) 소동공환자 수정체파열의위험성이더높으므로, 술중전방에산동제를주입하거나, 동공확대용 도구의사용이필요할수있다 (20) 홍채후유착환자 홍채후유착 (posterior synechiae) 이있는경우에는술중축동, 수술후지속되는염증, 홍채 출혈등이발생할수있다. 홍채를넓히는도구를사용하고, 수술후스테로이드를충분히 사용하는것이도움이된다.104 (21) 공막돌륭술을받은환자 19

20 공막돌륭술을받은경우에는안축장의증가, 결막하상처등의문제가있다. 망막박리재발의위험성이있다고알려져있으나, 이에대한명확한증거는없다.105,106 (22) 미숙아망막병증을동반하는환자 수술중축동, 견인망막박리, 섬모체소대의약화등의문제가있으며, 시력의예후가좋지 않을수있다.107 (23) 과숙백내장 수술을하지않으면수정체관련녹내장이나포도막염이발생할수있어반드시수술이필요한경우로수정체전낭이잘보이지않아수정체낭원형절개가어려우므로수정체낭염색이도움이될수있다. 과숙백내장에서수정체팽대 (lens intumescence) 가동반되어방사상전낭파열 (radial capsulorrhexis tear) 과후낭파열 (posterior capsular rent) 등이될가능성이높다 (24) 섬모체소대이완증또는섬모체소대손상이있는환자 섬모체소대이완증또는섬모체소대손상 (Zonule laxity or dehiscence) 이있는경우에는수정체떨림, 유리체탈출, 수정체낭파열, 수정체낭의수축등이발생할수있다. 경우에따라수정체낭확장고리 (capsular tension ring) 등의다양한기구를사용하는것이도움이된다 수정체낭을유지하기가어려운경우수정체낭째로백내장을제거하여야하고인공수정체를공막이나홍채에고정하여야하며, 유리체절제술이필요할수있다. (25) 망막앞막을동반하는환자 20

21 망막앞막 (Epiretinal membrane) 이동반되어있는경우에는잠재시력의감소와수술후중심망막부종이동반된낭포황반부종 (Cystoid macular edema, CME) 등이생길수있으있으므로때로는동시수술을고려하기도한다.,.116 (26) 후극백내장환자 후극백내장 (posterior polar cataract) 환자는후극부후낭이약하거나손상을받았을 가능성이있다. 따라서후낭파열의가능성이높은편이다.117 (27) 유리체절제술력이있는환자 유리체절제술을받았던환자는결막의반흔, 술중전방의깊이변동 (fluctuation), 수술중 축동, 핵백내장의진행, 약한수정체낭과섬모체소대등의위험을동반한다 (28) 얕은전방의환자 전방이얕은환자에서는백내장수술시홍채의손상, 홍채탈출, 술후각막부종등이 발생할가능성이더높다.104 (29) 신체적, 정신적장애가있는환자 운동장애가있거나수술침대에서누운자세를취하거나유지하기어려운환자의경우 수술을실시하는데주의를요한다. 환자의협조가어려운경우전신마취가필요할수 있다 인공수정체선택 (1) 인공수정체도수계산을위한생체계측검사 21

22 안축장 (axial length) 과각막곡률의측정이필요하다. 여러방법이있으나, 각방법별로 장단점이있으며특별히선호되거나월등한정확성을보인다고거론된방법은없다.123 광학적생체계측 (optical biometry) 은검사자에의한영향이없는편으로비교적일정한생체계측치를얻을수있어초음파검사법 (ultrasonography) 보다정확하다는장점이 있다..124 (2) 인공수정체도수계산방법 인공수정체도수계산에사용되는식에는Hoffer Q, Holladay, SRK II/T, Haigis, Holladay 2, Olsen 등여러종류가있다 안축장이 22~26 mm 사이의일반적인경우에는각도수계산공식간의정확성은큰차이를보이지않으나안축장이평균치보다큰경우에는 SRK T의정확성이좀더높고안축장이짧은경우에는 Hoffer Q, Holladay의정확성이좀더높다고알려져있다. (3) 각막굴절수술 (Refractive surgery) 을받은환자의인공수정체도수계산 이전에시력교정술을받은경우에는인공수정체의도수를정확하게계산하는것이어렵다. 통상적인방법으로계산하여얻은값이아닌, 이값을조정한값에근거하여인공수정체의도수를선택해야하며도수를계산할수있는여러가지방법이있다. 시력교정술받기이전의각막곡률, 굴절검사결과와현성굴절검사결과의차이로인공수정체의도수를결정할수있지만 (historical method) 아직까지가장정확한방법에대하여합의된바는없다 (4) 인공수정체의종류별특장점 22

23 비구면인공수정체는눈의구면수차를줄이며대비감도를향상시키는효과가있다. 난시교정인공수정체, 조절인공수정체, 다초점인공수정체도있는데, 이러한종류의특수한 인공수정체를삽입하는것은환자의삶의질향상을목표로한다.122 (5) 인공수정체선택에영향을주는요인 인공수정체의고정방법 ( 예. 수정체낭고정, 섬모체고랑고정, 공막고정등 ), 가격, 재질, 크기 140, 모양, 절개크기, 삽입방법 , 지지부 (146, 선택가능한기능 ), 환자의선호도등에 영향을받는다.147 (6) 다초점인공수정체 (Multifocal IOL) 의주의사항 다초점인공수정체를삽입한경우안경에대한의존도를낮춰삶의질을향상시키는 장점이있다. 반면, 광시증등다양한종류의시력증상을유발할가능성도있으며, 이로 인하여아주드물게는인공수정체교환술이필요할수있다.148 (7) 조절인공수정체의주의사항 안경에대한의존도를낮춰삶의질을향상시키는유효성에대한보고들이있지만 충분한조절력에대해서는아직논란이있다 수술도구및기구준비 백내장수술시에는일반적인안과용수술도구및백내장수술용추가도구들이필요하다. 예를들어, 개검기 (speculum), 주사기, 주사바늘, 집게 (forcep), 가위 (scissor), 주걱 (spatula), 지침기 (needle holder), 미세수술용칼, 낭절개도 (cystotome), 낭집게 (capsule forcep), chopper 등이필요하며수술장비로는수술침대, 수술현미경, 초음파유화기및부속품등이필요하다. 그밖에도서로다른특성을가진 23

24 다양한종류의점탄물질 (ophthalmic viscosurgical devices, OVD) 이개발되어있으며각막내피세포결핍, 얕은전방, 팽창성백내장, 소동공과같은특수한상황에맞는점탄물질을선택하여사용하는것이좋다. 섬모체소대가약할때에는수정체낭확장고리 (capsular tension ring) 사용을고려할수있다. 이것은수술중섬모체소대가분리되는것과같은합병증을줄이므로, 수술후인공수정체의중심잡기 (centration) 에도움을줄수있다. 섬모체소대의손상이더심한경우에는다양한도구 (capsular retractors, modified capsular tension ring, capsular tension segment) 를사용할수있다. 환자안구의특성을비롯한다른합병증의요소가있는경우에는, 상황에맞게추가적인도구가사용될수있다 수술감염및염증에대한예방조치 (1) 감염예방 (i) 술전처치 수술후감염예방을위한술전처치에는술전항생제의사용이가장대표적이다 (ii) Draping 전후의조치환자의안구주위의세균총이대부분의수술후감염의원인으로알려져있다. 그러므로백내장수술후감염예방법에는술전항생제사용, 5% 포비돈요오드용액결막낭세척, 5% 포비돈요오드용액안구주위피부소독, 조심스러운무균드랩, 의방법이있다. 155 (iii) 수술종류전후관리수술중사용하는관류용액에항생제를첨가, 수술종료시점에전방내항생제주입, 결막하항생제주사, 그리고수술후항생제점안등의방법이있으며술자에따라선택적으로사용된다

25 (iii) 항생제의사용포도상구균종은수술후감염성안내염의원인균으로가장흔히발견된다. 이포도상구균종이흔히사용되는항생제에대한내성이증가하고있다는점은오늘날걱정스런부분이다. 점안항생제의사용으로안구내치료농도에다다를수있지만, 수술후안구내높은항생제농도를유지하는것의중요성이점점강화되는추세인것을고려할때전신항생제의사용이도움이될것으로생각된다. 수술마지막에전방내에항생제를주입하는것이안내염을예방하는데효과가있다는보고도있다 (2) 염증의치료 (i) 스테로이드요법스테로이드안약은보통수술당일부터시작해서 3~4주에걸쳐서줄여간다. 전신적인면역억제를필요로하는포도막염환자의경우에는경구스테로이드제제등이도움이될수있다. 추가스테로이드혹은항염증제의선택은포도막염의종류, 정도, 그리고전신부작용등의위험에따라맞춤형으로접근하여야할것이다. 전신스테로이드를사용해야하는환자들은추적관찰을더자주하는것이도움이될수있다.49,50 (ii) 비스테로이드성항염증점안제 (NSAID) 수술전후에낭포황반부종 (cystoid macular edema, CME) 을예방하기위한 NSAIDs를사용하는것에대하여, 일부연구에서 NSAID 사용으로술후황반부종이감소하여이러한치료법의근거를제공하며, 술후통증의경감을목적으로NSAID를사용할수도있다. 하지만, 현재이러한치료법으로인하여최종시력결과에유의한 25

26 차이가발생한다는내용은아직까지확립된바가없다.159 수술후점안제로사용하는 항생제, 스테로이드, NSAID 는의사들마다다양한편이다 마취제및진정제의사용 사용할수있는마취의방법에는전신마취또는국소마취 ( 예. 점안 / 구주변 / 구후 ) 로 다양하다 환자와수술진등의선호도를고려하여마취방법을선택한다.162 (1) 국소마취 국소마취에는구후마취, 구주변마취, 테논낭하마취, 점안마취, 전방내마취등이있다. 165 (2) 진정마취 진정제는국소마취한환자중일부에게투여될수있다. 진정제는불안감을조절하기 위해서사용할수있다.166 진정제를투여하는경우에는만일의경우를대비하여정맥 경로를확보해놓는것이권유된다.167, 168 (3) 전신마취 환자의지적능력, 임상적상태 ( 심각한몸의떨림등 ), 정서적상태 ( 공황, 불안장애등 ) 를 근거로하여, 필요한환자에게는 MAC (Monitored Anesthesia Care) 혹은전신마취를 한다. 163, 수술과정 3.1 수술방법 26

27 (1) 수술의종류수술의상황에맞추어, 낭외적출술이나낭내적출술중선택하여사용할수있다. 오늘날백내장제거시에선호되는방법은초음파유화술에의한낭외적출법이다. 낭외적출술 (extracapsular cataract extraction, ECCE) 과초음파유화술을비교한연구에서초음파유화술그룹이수술 1년후에합병증이더적었고, 시력이더좋아졌으며, 후낭혼탁의발생도적었다. 그외에펨토초레이저를이용하여각막절개, 전낭절개, 수정체핵조각내기등을시행할수있다.169,170 (2) 이상적인수술의지향점수술로인해유발되는난시를최소화하거나기존의각막난시를감소시키는안전하고누출이없는절개, 모든수정체물질을철저히제거하는수술175 그리고각막내피, 홍채, 기타안구조직에대한외상을최소화하는것을목표로한다. 일반적으로소절개수술법이선호된다 의료진대상수술관련교육 안전한수술을하기위하여의료진과수련의등에대한교육, 적합한수술장비의준비가 요구된다. 또한수술장면을비디오로녹화하여수술이후에검토하는방법도있다.178, 수술집도직전확인사항 원래계획했던수술안을확인하여야하며, 인공수정체의확인등이필요하다 수술후과정 4.1 수술후관리 술자는수술후흔하게합병증이발생할수있는시기와시기능이안정화되는시기 때까지일정간격을두고환자를추적관리하여야한다. 환자에게발생가능한 27

28 합병증의징후나증상, 눈보호, 가능한활동범위, 투약, 필요한관찰시기, 응급상황발생시조치가능한방법등에대해서설명하여야한다. 감염이나염증같은수술후합병증을예방하기위하여점안항생제와항염증제안약을사용하여야한다. 점안안약의투약법및최초내원시점은각술자의선택이며, 눈의상태에따라서후속방문을결정해야한다. 다만, 기능적으로단안, 술중합병증발생, 수술후조기합병증의위험군 ( 고안압등 ) 인경우의후속방문은일반적인경우보다더빈번할수있다 수술결과에대한평가방법및검사 결과에대한평가는수술후안약의사용법, 새로이발생한증상, 시력에대한주관적인평가를포함하는그간의경과, 시기능의측정 ( 시력, 필요시는핀홀시력이나굴절교정 ), 안압측정, 세극등현미경검사, 환자나보호자교육과추후관리계획을포함한다. 술후시력호전이기대보다못할경우, 안과의사는원인파악을위해추가적인검사를시행할수있다 주요합병증 (1) 후낭혼탁 후낭혼탁은백내장수술에서흔히발생할수있으며시기능감소를일으킬수있다. 후낭혼탁의원인은잔존하는낭내수정체상피세포의증식등이다.188 레이저후낭절개술은이를치료하는효과적인치료법이다.189 적응증으로는시기와상관없이주관적인시력의질적또는양적저하의원인이되는후낭의혼탁이다. 다초점인공수정체를삽입받은경우에는좀더조기에후낭절개술이실시될수있는데, 이는저대비감도나빛번짐등의상황에서후낭혼탁으로인한시기능의장해정도가매우크기때문이다. 레이저후낭절개술의합병증은안압상승, 망막박리, 인공수정체손상, 그리고인공수정체의탈구등이다 합병증이아닌불편감으로는비문증이있다. 28

29 (2) 절개관련합병증 절개관련다양한합병증이발생할수있다. 홍채의탈출을비롯하여, 절개부위의유리체와관련한낭포황반부종, 안내염, 망막박리의위험이있다. 194 수술시절개부위가너무작거나크면문제가발생할수있다. 수술후절개부위의누출의우려에대해봉합이나안대를고려해볼수있다. 봉합은수술후난시를유발할수있고그정도는봉합의위치와강도에좌우된다 (3) 홍채를포함한포도막관련합병증 홍채탈출은홍채긴장저하증후군 (intraoperative floppy iris syndrome, IFIS) 또는절개창이상, 홍채에대한외상때문일수있다. 홍채외상은홍채해리, 전방출혈, 홍채투과조명결손, 동공산대, 불규칙무긴장동공등을초래할수있다. 홍채괄약근 (sphincter) 의괴사가안내염, 독성전방증후군, 또는과도한안압상승의결과로발생할수있다. 맥락막상강출혈의발생은대절개백내장수술과연관이있는데특히, 근시, 녹내장, 당뇨, 죽상경화성혈관질환, 그리고고혈압이있는경우는위험이높다.197,198 발생율에대하여발표된증거들은아직부족한상태로, 와파린과같은항응고제가맥락막출혈의위험을의미있게증가시키지는않는다.199 수술중에맥락막상강출혈을의심할수있는징후로는통증, 적반사의사라짐, 안압상승, 전방의얕아짐, 그리고홍채탈출이다.200맥락막상강출혈은대부분시력을위협하는중대한합병증을유발하기때문에빠른진단과절개창막음을통하여합병증을줄이는노력이필요하다.200,201 (4) 안내염 절개의크기와형태 ( 투명각막또는공막절개등 ) 가안내염 (endophthalmitis) 을유발하는가능한인자로받아들여져왔으나, 몇몇논문들은투명각막절개와안내염간의의미있는연관성을찾지못하였다 만일안내염이의심된다면상급의료기관으로전원하거나, 전방이나후방에서천자하여미생물검사를하고, 유리체강내항생제주사를하여야 29

30 한다. 안내염유리체절제연구 (Endophthalmitis Vitrectomy Study, EVS) 에서는안전수동 이상의시력에서는유리체천자및유리체강내항생제주사를권유하였고, 광각이하의 시력에서는유리체절제술과항생제주사로더잘치료되었다고하였다.202, 205 (5) 후낭파열및섬모체소대파열 후낭파열의위험인자는노령, 남자, 녹내장, 당뇨망막병증, 갈색또는성숙백내장, 수술전안저관찰이불가능한경우, 거짓비늘증후군, 소동공, 긴안축장, 알파길항제, 외상의과거력, 그리고똑바로눕지못하는환자등이다.206,207수술중의위험인자로는약한섬모체소대, 전낭염색의필요, 축동, 그리고협조가안되는환자등이있다.207 그러나, 후낭과섬모체소대의합병증은위의알려진위험인자가없는경우에도일어날수있다. (6) 수술후수정체조각의잔존 유리체소실과수정체조각들의후방탈구가생긴다면앞유리체절제술과적절한크기와모양의인공수정체를안정되게삽입하는것이바람직하다. 트리암시놀론주사가남은유리체를가시화하는데도움이된다.208상황에따라서는무수정체상태로수술을마치고추후이차수술을통한인공수정체의삽입을고려할수도있다.202남은수정체조각이잔존하는경우에는안압상승, 염증과같은합병증에대하여신중히관찰하여야하며, 남은경우는크기, 개수등에따라수술후유리체절제술을고려해보아야한다 (7) 망막박리및분리 백내장수술후망막박리의위험인자는긴안축장, 후낭파열, 젊은나이, 남자, 격자변성, 섬모체소대해리, 반대안의망막박리, 그리고수술후후유리체박리등이며, 이러한 위험인자가없는경우에도발생할수있다

31 (8) 낭포황반부종 낭포황반부종 (Cystoid Macular Edema) 은수술후염증과연관되어있기때문에점안항염증약물이예방및치료제로이용되고있다. 급성과만성낭포황반부종에비스테로이드성항염증제단독또는스테로이드와의복합요법이점안스테로이드단독요법보다예방과치료에더효과적이라는증거가있다 유리체강내항혈관형성인자가사용되기도한다. (9) 안압상승 안압의상승은수술초반에나타날수있는현상으로서, 일반적으로심각한부작용을일으키지는않는다. 하지만통증을유발할수도있고, 일부환자의경우시신경손상또는혈관폐쇄로이어질수있다. 수술후잔류점탄물질이안압상승의원인이될수있다.234점안스테로이드는스테로이드반응자에게안압상승을유발할수있는데특히, 젊은나이, 고도근시, 녹내장환자에게는더위험성이높다.235,236 점안스테로이드를투약중인경우는안압상승이없는지추적관찰하는것이좋다.235 (10) 녹내장 초기의합병증으로서의폐쇄각녹내장은동공차단에의해발생할수있다. 어떤형태의인공수정체에서도녹내장발생은가능하다. 하지만전방인공수정체에서후방인공수정체에비해서더빈발하게발생한다. 만일안압상승과전체적으로얕은전방이보인다면악성녹내장을의심해보아야한다. 백내장수술은수술후안압을감소시키기도하지만가끔은반대로안압이상승하여녹내장이발생할수있으며, 치료는약물요법, 레이저치료, 수술요법등이있다 (11) 상피안내증식 31

32 상피안내증식 (epithelial downgrowth) 은세극등현미경검사로진단할수있다. 증식이 홍채까지확장된다면, 수술적제거가필요할수있으며, 시력예후는불량하다.259 (12) 인공수정체제거 인공수정체와관련된합병증은드물게나타나는데, 인공수정체의디자인과재료에따라 다양하게나타난다. 인공수정체를제거하는원인은탈구나중심이탈, 빛번짐, 수정체 도수이상, 그리고인공수정체혼탁등이다.260, (13) 안검하수 술후발생가능한안검하수는대개는일시적이지만지속되면수술적치료가필요할수있다. 원인으로는안검부종, 안검혈종, 마취근독성, 개검기나고삐실걸기의사용등이다. 일반적으로협조적인환자들에게서, 점안마취제가주사마취제보다신경, 근육그리고안검의문제를감소시킬수있어선호될수있다.275 (14) 복시 백내장수술후복시가나타나면, 며칠안에사라지는것이일반적이다. 그러나만약 이러한증상이사라지지않고지속되면복시에대한추가적인검사나수술적교정이 필요할수있다.276 (15) 전방출혈 술후전방출혈은절개창에서의출혈이안구내로들어가는경우가가장흔하며, 이로 인하여술후시력이떨어지고, 염증이유발되며수정체낭의혼탁이가속화된다. 32

33 또한, 혈전을형성하여동공의움직임을방해하거나홍채후유착을유발하기도하며 안압을상승시킬수있어수술에의한전방출혈을경험한환자는안압검사를하는것이 필요하다. 277,278 (16) 각막합병증 각막부종을비롯한다양한질환을포함한다. 전방내기구에의해데스메막의파열이나박리가발생할수있다.279작은박리는재위치시키거나전방내공기방울주입으로교정이된다. 각막내피세포는기계적인손상이나장시간의초음파에너지사용에취약하다. 삼투압이상이나독성자극물질, 약물등에의해서도손상될수있다.280,281 지속적인안압상승도내피세포를손상시켜각막부종을심화시킬수있다. (17) 신경안과합병증 앞허혈성시신경병증 (Anterior Ischemic Optic Neuropathy) 과같은시신경손상은드문부작용이다. 중추신경계독성, 양안복시, 외상성시신경병증, 허혈성시신경병증등이포함된다. 구후마취후에드물게발생가능하며, 주사가지주막하공간으로들어가서뇌간으로퍼지게되면가능한일이다.282 (18) 독성전안부증후군 (Toxic Anterior Segment Syndrome, TASS) 독성전안부증후군은드물게발생하며, 대부분항염증제에잘반응하지만영구적인안내손상이생길수도있다. 감염성원인이의심될만한충분한증거가있다면전방과유리체에서배양검사를실시하여감염이아닌지확실히해야하며, 항생제치료를시작해야한다.283 원인은다양하지만증명하기는힘든경우가많다. 균의내독소, 화학적세척제, 기구세척을위한용액, 투명각막절개를통한연고의유입, 잔여점탄물질의변성, 부적당한삼투압과산도의용액, 그리고인공수정체광택물질이 33

34 원인으로지목된다. 항생제농도의희석오류로인한고농도의항생제전방유입도 원인으로알려져있다.284 (19) 수술로인한난시 수술로인한난시는소절개와신중한절개디자인과절개위치로최소화할수있다. 보고에따르면, 투명각막절개의경우절개창의넓이가 mm인경우는약 디옵터의난시가유발된다고알려져있다. 이를응용하여, 수술후난시를최소화하기위해각막의가파른축에절개창을만들기도한다 소아백내장수술 5.1 수술전검사 (1) 외래방문및수술전평가 소아백내장의경우, 수술전검사는보통첫번째내원과별도로진행된다. 검사의목적은시각적으로중대한백내장을진단, 백내장이시각증상의원인인가와다른동반된안병인이없는가를확인, 환자부모에게위험도를이해시키고수술을진행여부를결정, 전신마취의위험요소를확인그리고수술계획을세우기위함이다.287 (2) 시각장애의평가및진단 환아의시력에대한이력, 근거리및원거리에서의시력을검사, 양안시기능과약시등의 가능성을확인해야한다. 자세한가족력과부모에대하여서도산동후수정체검사를 시행해야한다.289 (3) 수술계획 34

35 소아백내장환자는백내장수술후에도흔히약시로인한저시력이발생하는경우가많다. 정상적인시력발달을위해생후수개월이내에가급적조기수술이권장된다.290 성인백내장수술과달리소아에대한수술법의종류에는수정체제거, 수정체흡입과인공수정체삽입, 후낭절개를추가, 앞유리체절제를추가, 후낭에인공수정체광학부확보를추가하는방법이있다. 동공차단을예방하기위해서적당한앞유리체절제를시행할수있다. 앞유리체의절제는현대화된자동유리체절제기가이용되고추후이차인공수정체를삽입할경우에는충분한수정체낭의지지를남겨두어야한다. 렌즈흡입과인공수정체삽입만을할경우는후낭혼탁이잘발생하지않고레이저후낭절개술은통상각성상태에서협조가가능한 8세이상환아에서시행할수있다 인공수정체의결정 (1) 렌즈도수및크기 나이가어릴수록원시의약시효과가더크기때문에시기적절한안경, 콘택트렌즈교정이필요하다. 수정체낭크기보다너무크지않은인공수정체를삽입하는것이중요하며, 소수성아크릴접힘형인공수정체가작은수정체낭에삽입하기에충분하다. 실제로전체직경이 12.5 mm인뻣뻣한인공수정체는직경 9 mm인수정체낭에안전하게삽입할수있다.296,297 수술시기가빠를수록수술후더많은근시화가진행될수있음을고려해야하며, 인공수정체삽입을하지않은환아의경우 2세전후에인공수정체삽입술을고려할수있다 수술에서의고려사항 (1) 절개의크기 소아의경우에는절개창은봉합하는것을원칙으로한다. 가는흡수성봉합사가장기간의 수술유발난시변화를감소시키는것으로보고되었다.299,300 (2) 수정체흡인 35

36 소아수정체에대하여초음파유화술은거의필요치않고수정체흡인이면충분하다. 양손수술법이전방의과도한움직임을줄여줄수있어추천된다. (3) 후낭의관리 6세이하에서후낭을남겨두는경우, 100% 후낭혼탁이발생하는것으로보고되었다. 그러므로후낭절제술이인공수정체삽입전이나후에필요하다. 6세이하에서후낭절제가이루어지지않는다면수술전에미리부모에게추후후낭혼탁발생시이차시술이필요할수있다고설명해야한다.293, 합병증 무수정체, 인공수정체녹내장은소아백내장수술의가장흔한합병증이다 수술받은 모든환아들은정기적인녹내장여부에대한검사를받아야한다. 가능하다면수술시에 각막의가로직경을재고우각검사를시행하여우각의이상이없는지확인해야한다 사회경제학적고려사항 6.1 백내장수술의비용효과성과지속적인발전 백내장수술은장비, 재료, 수술기법등모든측면에있어서빠르게발전해왔으며현대의학에서가장성공적인수술중하나이다. 또한백내장수술은환자의삶의질의비약적인향상에기여한다는점을고려할때, 경제학적인관점에서도매우비용 효과적이다 따라서만약충분한과학기술과보건정책의뒷받침이있다면백내장진료의지속적인발전이가능할것이며보다높은수준의의료서비스를제공할수있을것으로기대되는바이다. 36

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