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1 대한안과학회지 2016 년제 57 권제 3 호 J Korean Ophthalmol Soc 2016;57(3): ISSN (Print) ISSN (Online) Original Article 회절성이중다초점인공수정체와회절성삼중다초점인공수정체의임상결과비교 Comparison of the Visual Outcomes after Cataract Surgery with Implantation of a Bifocal and Trifocal Diffractive Intraocular Lens 유성 김용일 하상원 이광자 이규원 박영정 Sung Yu, MD, Yong Il Kim, MD, Sang Won Ha, MD, Gwang Ja Lee, MD, Kyoo Won Lee, MD, PhD, Young Jeung Park, MD, PhD 제일안과병원 Cheil Eye Hospital, Daegu, Korea Purpose: To evaluate and compare visual outcomes and optical quality after implantation of a bifocal (Acrysof ReSTOR SN6AD1) or trifocal (AT LISA tri 839MP) diffractive intraocular lens (IOL). Methods: Fifty-one eyes of 43 patients undergoing cataract surgery were enrolled and assigned to one of two groups: the trifocal group, comprising 24 eyes implanted with the trifocal diffractive IOL (AT LISA tri 839MP), and the bifocal group, comprising 27 eyes implanted with the bifocal diffractive IOL (Acrysof ReSTOR SN6AD1). Visual acuity (distant, intermediate, and near vision) and refractive postoperative outcomes were evaluated at one and three months postoperatively. Measurements of optical quality (using OQAS II ), contrast sensitivity (using CGT-2000 ), automated visual field examination, and evaluation of defocus curve were performed three months postoperatively. Results: No statistically significant differences between the two groups were found in three-month postoperative distant and near (40 cm) visual acuities and optical quality. However, intermediate (63 cm, 80 cm, and 100 cm) visual acuities were significantly better in the trifocal group. Distant contrast sensitivity (5 m) under mesopic conditions was significantly better with the bifocal lens, whereas near contrast sensitivity (30 cm) under mesopic and scotopic conditions was significantly better with trifocal lens. There was no statistical difference between the groups under photopic conditions. In the defocus curve, the visual acuity was significantly better at intermediate distance in the trifocal group. Conclusions: Trifocal diffractive IOLs provide significantly better intermediate vision than bifocal IOLs, with equivalent postoperative levels of distant and near vision and ocular optical quality. Further, they provide better near contrast sensitivity under scotopic condition compared to diffractive bifocal IOLs. J Korean Ophthalmol Soc 2016;57(3): Keywords: Bifocal, Cataract, Diffractive, Multifocal intraocular lens, Trifocal 최근백내장수술은다초점인공수정체삽입으로백내장 Received: Revised: Accepted: Address reprint requests to Young Jeung Park, MD, PhD Cheil Eye Hospital, #1 Ayang-ro, Dong-gu, Daegu 41196, Korea Tel: , Fax: eyepark9@naver.com 수술후환자들이안경없이일상생활을할수있게하였고다양한취미활동을할수있게하여삶의질을향상시키고있다. 이러한다초점인공수정체는회절이나굴절의광학적원리를바탕으로만들어지고디자인의특성에따라서술후시력과시기능에영향을준다. 회절성다초점인공수정체는 Huygens-Fresnel principle을기초로만들어진것으로, 회절에의해서빛에너지의일부를소실하지만근거리 c2016 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. 405

2 - 대한안과학회지 2016 년제 57 권제 3 호 - 와원거리에두개의초점을가지게된다. 1 국내외여러연구에서회절성다초점인공수정체는수술후원거리와근거리시력이우수하다고알려져있다. 2-4 그러나지금까지많이사용된회절성이중다초점인공수정체는원거리와근거리에만정확한초점이맞아서중간거리시력이부족하여술후안경의필요성이요구되며특히젊은연령대의백내장수술환자는컴퓨터사용등의중간거리시력요구가많아기존의이중다초점인공수정체로모든거리에서안경을벗을수없는문제점이부각되고있다. 5,6 최근에 2개의회절을합쳐서 3개의초점이만들어지는삼중다초점인공수정체가개발되어임상에사용되고있다. 7 이러한회절성삼중다초점인공수정체는원거리및근거리뿐만아니라중간거리시력까지우수하다는연구가발표되고있다 국내에서도회절성삼중다초점인공수정체인 AT LISA tri 839MP (Carl Zeiss Meditiec AG, Jena, Germany) 가도입되어사용되고있다. 지금까지여러종류의다초점인공수정체간의술후시력과시기능에대한비교연구는많이있으나, 11,12 다초점인공수정체의이중초점과삼중초점의차이에따라서시력이나시기능차이에대한연구는충분하지않다. 그래서저자들은회절성다초점인공수정체중널리사용되는이중다초점인공수정체인 Acrysof ReSTOR SN6AD1 (Alcon Laboratories Inc., Fort Worth, TX, USA) 과최근국내에도입되어사용되는삼중다초점인공수정체인 AT LISA tri 839MP를삽입한환자를대상으로수술후시력과다양한광학적시기능을비교해보고자한다. 대상과방법 받을환자는수술전다초점인공수정체의장단점및발생가능한합병증에대해서충분한설명을듣고동의하였다. 모든대상환자는백내장수술전에세극등검사, 나안원거리시력, 안압측정, 자동굴절각막곡률계, 안저검사, 스펙트럼빛간섭단층촬영 (Spectralis OCT, Heidelberg Engineering, Heidelberg, Germany) 을시행하였다. 인공수정체도수는 IOL Master (Carl Zeiss Meditiec AG, Jena, Germany) 와 A-scan (ECHOSCAN US-3000, NIDEK, Aichi, Japan) 을이용하여측정한안축장을사용하였고, 인공수정체도수는 Sanders-Retzlaff-Kraff/Theoretical (SRK/T) 공식에서정시안 (0.0D) 에가까운도수로결정하였다. 다초점인공수정체 AT LISA tri 839MP는 single piece, 비구면인공수정체로친수성아크릴재질에소수성아크릴표면으로만들어져있고, 광학부크기가 6.0 mm이며전체길이는 11.0 mm 의 plate 지지부를가진다. 전면광학부중심 4.34 mm는삼중초점, 바깥쪽 mm는이중초점을갖고입사광선의 50% 는원거리, 20% 는중간거리, 30% 는근거리에초점이모이도록디자인되어있다. 근거리시력을위하여 +3.33D, 중간거리시력을위하여 +1.66D의덧댐굴절력을가진회절성삼중다초점인공수정체이다 (Fig. 1). Acrysof ReSTOR SN6AD1은대칭형양면볼록한 single piece로청색광차단기능을가진소수성아크릴재질 (hydrophobic acrylic material) 이고, 전면비구면인공수정체로 6.0 mm 광학부크기에전체길이가 13.0 mm의 C-loop형지지부디자인이다. 전면중심부 3.6 mm에 9개의아포다이즈드회절 (apodized diffractie) 로 +3.0D의덧댐굴 대상환자 2014년 8월부터 2015년 2월까지본원에서한명의술자 (Y.J. Park) 에의해백내장초음파유화술시행후 3개월이상추적관찰이가능했던환자를대상으로 AT LISA tri 839MP를삽입한 20명 24안과 Acrysof ReSTOR SN6AD1 을삽입한 23명 27안을대상으로의무기록을후향적으로조사하였다. 대상자는술후굴절력차이에의한시기능과시력차이를최소화하기위해서, 술후 3개월째나안원거리시력이 0.1 logmar 미만, 현성굴절검사상구면렌즈대응치가 ±0.5 diopter (D) 이내, 굴절난시가 0.5D 이하, 스펙트럼빛간섭단층촬영에서시신경유두와황반부에특이소견이없는환자를대상으로하였다. 각막지형도상불규칙각막난시, 술후시력에영향을줄수있는각막질환이나망막질환, 녹내장, 외상력, 염증이있는환자는대상에서제외하였고또한술중합병증이생긴경우도제외하였다. 수술 Figure 1. AT LISA tri 839MP (left, adapted from Sheppard et al 10 ), Acrysof ReSTOR SN6AD1 (right, adapted from Davison and Simpson 1 ). 406

3 - 유성외 : 회절성다초점인공수정체비교 - 절력을가지는회절성이중다초점인공수정체로동공이커질수록원거리시력이잘보이도록디자인되어있다. 3.0 mm 동공에서빛에너지는원거리에 58.9%, 근거리에 25.5% 분포된다 (Fig. 1). 수술수술은침공마취 (Pinpoint anesthesia) 를이용하였고이측에 2.8 mm 의미세투명각막절개후전낭원형절개의크기는 5.0 mm 내외로하여 Infinity Vision System (Alcon Laboratories Inc., Irvine, CA, USA) 을이용하여초음파유화술을시행한후인공수정체를후낭에삽입하였다. 관류및흡인을시행하여남은점탐물질을제거하였다. 모든대상환자는수술중전낭원형절개의합병증, 후낭파열및수정체중심이탈등의합병증은발생하지않았다. 술후검사두군에서술후 1, 3개월에자동굴절검사기를이용하여굴절력을측정하고, 나안원거리시력, 나안중간거리 63 cm, 80 cm 및 100 cm 시력, 나안근거리 40 cm 시력, 최대교정원거리시력을명소시 (photopic condition, 100 cd/m 2 ) 상태에서측정하였다. 원거리시력은 5 m 한천석시력표를이용하여측정하였고, Logarithmic Visual Acuity Chart-ETDRS 2000 Series Chart 2 (precision Vision, LaSalle, IL, USA) 를이용하여 40 cm에서근거리시력을, Colenbrander Mixed Contrast Card Set (precision Vision, LaSalle, IL, USA) 를이용하여 63 cm, 80 cm 및 100 cm에서중간거리시력을측정하였다. 술후 3개월에시력의질을평가하기위해서 Optical Quality Analysis System II (OQAS II, Visiometrics S.L., Castelldefels, Spain) 를이용하여 objective scatter index (OSI), modulation transfer function (MTF) cut-off value, Strehl ratio, VA100, VA20, VA9를측정하였다. 시야검사는 Humphrey field analyzer (Carl Zeiss Meditec, Dublin, CA, USA) 를이용한 24-2 Swedish Interactive Thresholding Algorithm (SITA)-fast 검사상의 mean deviation (MD), pattern standard deviation (PSD), Fovea threshold를두군간에비교하였다. 대비감도는술후 3개월에자동대비감도눈부심측정기인 Contrast glare tester 2000 (CGT 2000, Takagi, Seiko, Japan) 을사용하여원거리 5 m 및근거리 30 cm에서명소시 (photopic), 박명시 (mesopic), 암소시 (scoptopic) 상태에서눈부심 (glare) 유무에따라 14개의대비감도정도를 6.3, 4.0, 2.5, 1.6, 1.0, 0.7 cycle/degree마다측정하였다. 초점심도 (defocusing curve) 는명소시 (photopic condition, 100 cd/m 2 ) 상태에서한천석시력표를이용하였고, 원거리에서시력을완전교정한상태에서 -4.5D에서 +2.0D까지, 0.5D 단위의구면렌즈를교체하며시력을측정하였고, 그결과값을이용하여초점심도 (defocusing curve) 를얻었다. 술후 3개월째산동상태에서세극등검사로인공수정체의낭내이탈이나후발성백내장유무를조사하였다. 통계통계학적분석은 PAWS 18.0 version (SPSS Inc., Chicago, IL, USA) 을이용하였으며독립표본 t-test를이용하여두군간의차이를비교하였고 p<0.05인경우통계적으로유의한것으로간주하였다. 결과 AT LISA tri 839MP 삽입군은 20명 (24안) 이고 Acrysof ReSTOR SN6AD1 삽입군은 23명 (27안) 으로두군의평 Table 1. Patient demographics Intraocular lens type AT LISA tri 839MP Acrysof ReSTOR SN6AD1 p-value * Number of eyes (patients) 24 (20) 27 (23) OD:OS 14:10 16:11 Sex (male:female) 16:4 16: Age (years) 49.5 ± ± S.E. (D) 0.39 ± ± UCDVA (log MAR) 0.58 ± ± Axial length (mm) ± ± Corneal power (D) ± ± Anterior chamber depth (mm) 3.47 ± ± Intraocular lens power (D) ± ± Values are presented as mean ± SD unless otherwise indicated. OD = oculus dexter; OS = oculus sinister; S.E. = spherical equivalent; D = diopter; UCDVA = uncorrected distance visual acuity; log MAR = logarithm of the minimum angle of resolution. * Independent student t-test. 407

4 - 대한안과학회지 2016 년제 57 권제 3 호 - Table 2. Visual acuity and spherical equivalent at postoperative 1 month and 3 months 1 month 3 months AT LISA tri Acrysof ReSTOR p-value * AT LISA tri Acrysof ReSTOR 839MP SN6AD1 839MP SN6AD1 p-value * S.E. (D) ± ± ± ± BCDVA (log MAR) 0.00 ± ± ± ± UCDVA (log MAR) 0.02 ± ± ± ± UNVA (log MAR) 0.10 ± ± ± ± UIVA63 (log MAR) 0.19 ± ± ± ± * UIVA80 (log MAR) 0.07 ± ± 0.09 <0.001 * 0.06 ± ± 0.11 <0.001 * UIVA100 (log MAR) 0.11 ± ± 0.21 <0.001 * 0.11 ± ± 0.10 <0.001 * Values are presented as mean ± SD unless otherwise indicated. S.E. = spherical equivalent; D = diopter; BCDVA = best corrected distance visual acuity; log MAR = logarithm of the minimum angle of resolution; UCDVA = uncorrected distance visual acuity; UNVA = uncorrected near visual acuity at 40 cm distance; UIVA63 = uncorrected intermediate visual acuity at 63 cm distance; UIVA80 = uncorrected intermediate visual acuity at 80 cm distance; UIVA100 = uncorrected intermediate visual acuity at 100 cm distance. * Independent student t-test. Table 3. Optical quality parameters measured by optical quality analysis system II (OQAS II ) at postoperative 3 months Intraocular lens type AT LISA tri 839MP Acrysof ReSTOR SN6AD1 p-value * OSI 1.28 ± ± MTF cut-off value (cpd) ± ± Strehl ratio 0.37 ± ± VA ± ± VA ± ± VA ± ± Values are presented as mean ± SD unless otherwise indicated. OSI = objective scatter index; MTF = modulation transfer function; VA100 = optical quality of the eye for 100% contrast conditions; VA20 = optical quality of the eye for 20% contrast conditions; VA9 = optical quality of the eye for 9% contrast conditions. * Independent student t-test. 균나이와술전평균나안시력은각각 49.5 ± 6.7세, 0.58 ± 0.79 (logmar) 와 52.4 ± 9.3세, 0.38 ± 0.77 (logmar) 이었다. 사용된인공수정체도수는 AT LISA tri 839MP 삽입군과 Acrysof ReSTOR SN6AD1 삽입군에서각각평균 ± 2.72D와 ± 2.41D였다 (Table 1). 술후, 1개월, 3개월째측정한평균나안원거리 5 m 시력, 평균나안근거리 40 cm 시력은두군에서차이가없었다. 그러나평균나안중간거리 80 cm 및 100 cm 시력은 Acrysof ReSTOR SN6AD1 삽입군에비해 AT LISA tri 839MP 삽입군이각각의경과관찰시기에서통계적으로의미있게높게측정되었다 (p<0.01). 술후 3개월째나안원거리시력, 근거리시력, 중간거리 63 cm, 80 cm, 100 cm 시력은 AT LISA tri 839MP 삽입군 /Acrysof ReSTOR SN6AD1 삽입군에서각각 0.01 ± 0.07/0.02 ± 0.08, 0.09 ± 0.07/0.07 ± 0.10, 0.17 ± 0.11/0.24 ± 0.12, 0.06 ± 0.13/0.29 ± 0.11, 0.11 ± 0.13/0.29 ± 0.10 (logmar) 이었다 (Table 2). 술후자동굴절검사에서구면렌즈대응치는 AT LISA tri 839MP 삽입군 /Acrysof ReSTOR SN6AD1 삽입군에서 1 개월째 ± 0.35D/-0.19 ± 0.27D, 3개월째 ± 0.36D/-0.03 ± 0.26D로측정되어두군에서통계적으로의미있는차이가없었다 (Table 2). 술후 3개월째 OQAS II 를이용하여측정한시기능검사상 AT LISA tri 839MP 삽입군 /Acrysof ReSTOR SN6AD1 삽입군에서 OSI 1.28 ± 0.65/1.16 ± 0.40, MTF cutoff value ± 10.74/40.71 ± 8.75, Strehl ratio 0.37 ± 0.54/0.26 ± 0.10으로두군에서차이가없었다. 그리고대비감도에따른시력 VA100, VA20, VA9도두군에서차이가없었다 (Table 3). Humphrey field analyzer 를이용한 24-2 SITA-fast 시야검사상의 MD는 AT LISA tri 839MP 삽입군 /Acrysof ReSTOR SN6AD1 삽입군에서 ± 1.10/-1.72 ± 1.08, PSD는 1.46 ± 0.23/1.54 ± 0.32, Fovea threshold는 ± 2.01/33.76 ± 2.59로두군간통계적으로유의한차이를보이지않았다 (Table 4). CGT 2000 을이용한대비감도검사상, 원거리 (5 m) 에서는명소시와암소시에서 glare on 및 off 상태에서두군간유의한차이를보이지않았으나, 박명시 glare off 상태에서 Acrysof ReSTOR SN6AD1이대비감도가좋은것으로나타났다 (Visual angle of test target 각각 6.3, 4, 2.5, 1.6 degree 408

257 PSD 1.46 ± 0.23 1.54 ± 0.32 0.366 Fovea threshold 34.60 ± 2.01 33.76 ± 2.59 0.240 Values are presented as mean ± SD unless otherwise indicated.

5 - 유성외 : 회절성다초점인공수정체비교 - Table 4. Visual field parameters measured by Humphrey field analyzer : SITA-Fast at postoperative 3 months Intraocular lens type AT LISA tri 839MP Acrysof ReSTOR SN6AD1 p-value * MD ± ± PSD 1.46 ± ± Fovea threshold ± ± Values are presented as mean ± SD unless otherwise indicated. SITA = Swedish Interactive Thresholding Algorithm; MD = mean deviation; PSD = pattern standard deviation. * Independent student t-test. A B Figure 2. Contrast sensitivity test by CGT (A) Contrast sensitivity at 5 m, (B) contrast sensitivity at 30 cm. Superior column tested when glare off, inferior column tested when glare on. deg = degree. * p < Figure 3. Visual acuity at various defocus levels. The values are a mean of log MAR visual acuity. * p < 에서 p=0.019, p=0.044, p=0.010, p=0.003). 근거리 (30 cm) 에서는 glare on의모든조건과 glare off 시명소시에서는두군에서차이가없었으나박명시 (Visual angle of test target 각각 2.5, 1.6, 1 degree에서 p=0.020, p=0.005, p=0.020) 및암 소시 (Visual angle of test target 각각 2.5, 1.6, 1, 0.64 degree 에서 p=0.004, p<0.001, p=0.036, p=0.030) 에서 AT LISA tri 839MP 의대비감도가유의하게더좋은결과를 보였다 (Fig. 2). 초점심도는 AT LISA tri 839MP 삽입군에서 Acrysof ReSTOR SN6AD1 삽입군에비해 +1.5D, +1.0D, -1.0D, -1.5D, -3.0D, -3.5D에서더나은시력결과를나타냈다 (p=0.002, p<0.001, p=0.012, p<0.001, p=0.008, p=0.024) (Fig. 3). 술후 3개월째산동검사하여인공수정체의위치를확인한결과대상안모두에서인공수정체는낭내에잘고정되어중심이탈이없었고, 시력에영향을주는후발성백내장등의합병증은없었다. 고찰 백내장수술에서다초점인공수정체의삽입은시력의기능적향상과안경을착용하지않고일상생활을원하는환자가늘어나면서증가하고있다. 지금까지개발된회절성다초점인공수정체는원거리와근거리에서우수한시력결과를보였다. 2-4,13 하지만대부분회절성이중다초점인공수정체는중간거리시력 ( 컴퓨터작업등 ) 이만족스럽지못 409

6 - 대한안과학회지 2016 년제 57 권제 3 호 - 하다는연구가발표되고있다. 5,6 이러한미흡한중간거리시력에대한보완으로초점심도가넓은회전비축대칭굴절형다초점인공수정체에대한적용이나이중초점인공수정체에서덧댐굴절력을낮추어서중간거리시력을보완하려는연구가임상에서적용되고있다. 14,15 본연구는지금까지널리사용되는회절성이중다초점인공수정체 Acrysof ReSTOR SN6AD1과회절성삼중다초점인공수정체 AT LISA tri 839MP의수술후시각적및광학적임상결과를비교하였다. 본연구에서대상안은모두술후 3 개월째현성굴절검사상구면렌즈대응치가 ±0.5D 이내로정확하게굴절이상이교정되었으며굴절난시가 0.5D 이하인경우를대상으로하여대상환자간에술후굴절력에의한시력차이를최소화하여다초점인공수정체자체의특징에따른시력과시기능의차이를알아보고자하였다. 본연구에서수술후 3개월째원거리시력과근거리시력은 AT LISA tri 839MP 삽입군과 Acrysof ReSTOR SN6AD1 삽입군에서유의한차이가없었으나, 중간거리 63 cm, 80 cm, 100 cm 시력은각각 0.17 ± 0.11/0.24 ± 0.12, 0.06 ± 0.13/0.29 ± 0.11, 0.11 ± 0.13/0.29 ± 0.10 (logmar) 으로모두 AT LISA tri 839MP에서유의하게우수한시력을보였다. Marques and Ferreira 16 는두가지종류의회절성삼중다초점인공수정체인 Finevision Micro F (Micro AY, PhysIOL, Liège, Belgium)/AT LISA tri 839MP에서중간거리 80 cm에서시력이 0.09 ± 0.13/0.14 ± 0.09 (logmar) 로저자들의결과처럼회절성삼중다초점인공수정체는충분한중간거리시력을보고하고있다. Mojzis et al 17 의연구에서는회절성이중다초점인공수정체인 AT LISA 801 삽입군과회절성삼중다초점인공수정체인 AT LISA tri 839MP 삽입군에서원거리시력은나안과교정모두유의한차이가없었으나, 근거리및중간거리시력은삼중초점군에서우수한시력을보고하고있다. 이처럼회절성삼중다초점인공수정체는원거리와근거리시력이우수하면서도중간거리에해당하는덧댐굴절력이중간거리시력을보완해서모든거리에서우수한시력을보이는것으로생각된다. 최근에는회절성이나굴절성이중다초점인공수정체에서덧댐굴절력을양안에다르게하는방법, 즉한눈은근거리, 다른눈은중간거리시력에맞는덧댐굴절력을더한다초점인공수정체를삽입하는임상연구가진행되고있다. 향후모든거리에서시력을잘보이기위해서양안의삼중초점다초점인공수정체를삽입하는것과각각의눈에덧댐굴절력이다른이중초점다초점인공수정체를삽입하는것중어떤방법이더생리적으로효과적인가에대한추가적연구가필요할것으로생각된다. OQAS II 는다이오드레이저의근적외선 (near-infrared light; 780 nm) 을이용한 double-pass system으로시력의질을평가할수있다. 이장비의임상에서는백내장정도의객관적평가, 백내장술후, 굴절수술후그리고눈물막의변화에따른시력의질평가등다양한부분에적용되고있다. 18,19 Saad et al 20 은 OQAS II 로측정한정상인에서 30대미만은 OSI는 0.47 ± 0.11, MTF cut-off ± 3.93 cpd, Strehl ratio 0.23 ± 0.02이고 40대이상은 OSI는 1.73 ± 0.26, MTF cut-off ± 3.89 cpd, Strehl ratio 0.15 ± 0.002로보고하면서연령이증가할수록시력의질이떨어짐을보고하였다. 저자들의연구에서술후 3개월째 OQAS II 검사상 AT LISA tri 839MP 삽입군과 Acrysof ReSTOR SN6AD1 삽입군에서각각평균 OSI는 1.28 ± 0.65, 1.16 ± 0.40, MTF cut-off value는각각 ± cpd, ± 8.75 cpd였으며, Strehl ratio는각각 0.37 ± 0.54, 0.26 ± 0.10, VA 100은각각 1.42 ± 0.36, 1.36 ± 0.29로두군간유의한차이를보이지않았다. 이는 Kim et al 14 이술후 3 개월째 OQAS II 검사상 ReSTOR 삽입군과 Lentis Mplus 삽입군에서각각평균 OSI는 1.07 ± 0.40, 0.88 ± 0.39, MTF cutoff는 ± 8.07 cpd, ± 8.66 cpd, Strehl ratio는 0.25 ± 0.07, 0.18 ± 0.05로보고한것과비슷한결과이며 Saad et al 20 이보고한 40대이상의정상인보다우수한시력의질을보였다. Aychoua et al 21 은다초점인공수정체에대한자동시야검사에대한연구에서유수정체안, 단초점인공수정체안과다초점인공수정체안으로나누어시야검사결과를비교했을 MD 값이유수정체안과단초점인공수정체안은차이가없었으나유수정체안과다초점인공수정체안에서 MD 값은통계적으로유의하게 2.40 db 감소함을보고하면서이는다초점인공수정체구조에의해서 MD 값이감소한다고보고하였다. Farid et al 22 은단초점인공수정체와다초점인공수정체간 MD가 db와 db로통계학적으로유의하게다초점인공수정체가감소하며이는 6개월이지나고검사해도여전히차이가나서이러한 MD의감소는신경적응에의해서개선되지않음을발표하였다. 본연구에서는 MD는 AT LISA tri 839MP 군이 -1.95, Acrysof ReSTOR SN6AD1 군이 -1.72였으며, PSD는각각 1.46, 1.54, fovea fhreshold는각각 34.60, 33.7로두군간유의한차이를보이지않아서두다초점인공수정체의디자인에따라서는자동시야검사의검사결과에영향을주지않는것을알수있었다. 향후국내에서도단초점인공수정체와자동시야검사결과의비교연구가필요할것으로생각되며기존에발표된연구결과로녹내장이나황반변성등시신경에이상이있는질환에서는다초점인공수정체를삽입하지않는것이좋을것으로생각된다. 410

7 - 유성외 : 회절성다초점인공수정체비교 - 다초점인공수정체에서입사광선이분산되어 2개이상의초점을만들기때문에대비감도가감소하는것은광학구조상피할수없는일이다. 여러연구들에서다초점인공수정체삽입후명소시대비감도를평가하였으며, 정상범위내에있을지라도유의하게단초점에비해서저하된대비감도를보이고 23,24 이것은다초점인공수정체삽입후불만족의주요원인으로보고하고있다. 25 이러한빛에너지의감소는박명시에더욱대비감도저하를야기할수있을것으로생각된다. 본연구에서대비감도검사상, 원거리에서는명소시및암소시에서두군간유의한차이를보이지않았으나, 박명시 glare off 상태에서 Acrysof ReSTOR SN6AD1 이대비감도가좋은것으로나타났다. 이는인공수정체의디자인상 glare off 상태에서동공크기가 3.6 mm 이상으로증가할경우원거리시력이잘보이게디자인한아포다이즈회절의특성이반영된것으로생각된다. 26 또한박명시 glare off 상태에서 AT LISA tri 839MP의근거리에서대비감도가전반적으로좋았는데, 이는동공크기와상관없이전체광학영역이회절성을갖는 AT LISA tri 839MP 디자인에의한것으로해석할수있다. 이러한다초점인공수정체의디자인에따라서대비감도의차이는향후다초점인공수정체를고려할때환자들의생활패턴을고려하여적절한다초점인공수정체를선택해줄수있는자료로활용될수있으리라생각된다. Mojzis et al 17 은회절성이중다초점인공수정체와회절성삼중다초점인공수정체에서대비감도에서차이가없었는데이두다초점인공수정체는동공크기에상관없이광학부전체가회절이있게디자인된것이저자들의결과와차이나는원인으로생각된다. 본연구에서도초점심도는 AT LISA tri 839MP 삽입군에서 Acrysof ReSTOR SN6AD1 삽입군에비해 +1.5D, +1D, -1D, -1.5D, -3D, -3.5D에서더나은시력결과를나타냈고기존의다른삼중다초점인공수정체의초점심도에대한연구들과마찬가지로중간거리시력에대한초점심도가이중다초점인공수정체보다우수하게나타났다. 10,17 이는 Mojzis et al 17 의 defocus curve에서도이중다초점회절성인공수정체 AT LISA 801 삽입군과삼중다초점회절성인공수정체 AT LISA tri 839MP의비교연구에서삼중초점군이 -0.50~-1.50D의중간거리시력에서우수한초점심도를보인것과일치하는소견이다. 본연구는대상안이적고, 술후시력이우수한환자만을대상으로하여두회절성다초점인공수정체를비교한결과로모든환자의결과로해석하기는어렵고, 술후환자의만족도를반영하지못하여실제의시기능의차이가환자의일상생활만족도와관계가있는지를조사하지못한점, 그리고단기간의시력과인공수정체의안전성을평가한한계 가있다. 그리고비교가된인공수정체가청색광차단기능이있는인공수정체를사용함으로써대비감도에영향을줄수있는점을배제하지못했다. 그래서향후더많은환자를대상으로연구가필요하며인공수정체의특성이동일한군에서삼중다초점과이중다초점인공수정체의시기능차이에대한연구와장기간의임상결과에대한추가연구가필요할것으로생각된다. 하지만본연구는위의한계점에도불구하고국내외에서이중과삼중의회절성다초점인공수정체간의임상결과를비교한드문연구이고, 다양한시기능검사의비교로회절성다초점인공수정체의시기능결과를알아보는자료로활용할수있는의의가있다. 또한백내장과같이노안을교정하기위해서다초점인공수정체를고려할때환자의요구에맞춘인공수정체를선정할때참고자료가되리라생각된다. 결론적으로백내장수술후회절성삼중다초점인공수정체 AT LISA tri 839MP는기존의회절성이중다초점인공수정체 Acrysof ReSTOR SN6AD1과원거리, 근거리시력및시기능은동일하면서중간거리시력이우수한결과를보여백내장과노안을고려한수술에사용될유용한다초점인공수정체로생각된다. REFERENCES 1) Davison JA, Simpson MJ. History and development of the apodized diffractive intraocular lens. J Cataract Refract Surg 2006; 32: ) Alfonso JF, Fernández-Vega L, Baamonde MB, Montés-Micó R. Prospective visual evaluation of apodized diffractive intraocular lenses. J Cataract Refract Surg 2007;33: ) de Vries NE, Webers CA, Montés-Micó R, et al. Long-term follow-up of a multifocal apodized diffractive intraocular lens after cataract surgery. J Cataract Refract Surg 2008;34: ) Park YL, Hwang GY, Joo CK. Comparative study of clinical outcomes between 2 types of multifocal aspheric intraocular lenses. J Korean Ophthalmol Soc 2013;54: ) Blaylock JF, Si Z, Vickers C. Visual and refractive status at different focal distances after implantation of the ReSTOR multifocal intraocular lens. J Cataract Refract Surg 2006;32: ) Alfonso JF, Fernández-Vega L, Puchades C, Montés-Micó R. Intermediate visual function with different multifocal intraocular lens models. J Cataract Refract Surg 2010;36: ) Voskresenskaya A, Pozdeyeva N, Pashtaev N, et al. Initial results of trifocal diffractive IOL implantation. Graefes Arch Clin Exp Ophthalmol 2010;248: ) Gatinel D, Pagnoulle C, Houbrechts Y, Gobin L. Design and qualification of a diffractive trifocal optical profile for intraocular lenses. J Cataract Refract Surg 2011;37: ) Cochener B, Vryghem J, Rozot P, et al. Visual and refractive outcomes after implantation of a fully diffractive trifocal lens. Clin Ophthalmol 2012;6: ) Sheppard AL, Shah S, Bhatt U, et al. Visual outcomes and sub- 411

8 - 대한안과학회지 2016 년제 57 권제 3 호 - jective experience after bilateral implantation of a new diffractive trifocal intraocular lens. J Cataract Refract Surg 2013;39: ) Alfonso JF, Puchades C, Fernández-Vega L, et al. Contrast sensitivity comparison between AcrySof ReSTOR and Acri.LISA aspheric intraocular lenses. J Refract Surg 2010;26: ) Alfonso JF, Fernández-Vega L, Blázquez JI, Montés-Micó R. Visual function comparison of 2 aspheric multifocal intraocular lenses. J Cataract Refract Surg 2012;38: ) Kim SM, Kim CH, Chung ES, Chung TY. Visual outcome and patient satisfaction after implantation of multifocal IOLs: threemonth follow-up results. J Korean Ophthalmol Soc 2012;53: ) Kim JH, Kim EJ, Kim YI, et al. Comparison of clinical outcomes between diffractive and refractive multifocal intraocular lens with same near added. J Korean Ophthalmol Soc 2015;56: ) Kretz FT, Gerl M, Gerl R, et al. Clinical evaluation of a new pupil independent diffractive multifocal intraocular lens with a D near addition: a European multicentre study. Br J Ophthalmol 2015;May: pii: bjophthalmol [Epub ahead of print] 16) Marques EF, Ferreira TB. Comparison of visual outcomes of 2 diffractive trifocal intraocular lenses. J Cataract Refract Surg 2015; 41: ) Mojzis P, Kukuckova L, Majerova K, et al. Comparative analysis of the visual performance after cataract surgery with implantation of a bifocal or trifocal diffractive IOL. J Refract Surg 2014;30: ) Cabot F, Saad A, McAlinden C, et al. Objective assessment of crystalline lens opacity level by measuring ocular light scattering with a double-pass system. Am J Ophthalmol 2013;155:629-35, 635.e ) Lee K, Ahn JM, Kim EK, Kim TI. Comparison of optical quality parameters and ocular aberrations after wavefront-guided laser in-situ keratomileusis versus wavefront-guided laser epithelial keratomileusis for myopia. Graefes Arch Clin Exp Ophthalmol 2013; 251: ) Saad A, Saab M, Gatinel D. Repeatability of measurements with a double-pass system. J Cataract Refract Surg 2010;36: ) Aychoua N, Junoy Montolio FG, Jansonius NM. Influence of multifocal intraocular lenses on standard automated perimetry test results. JAMA Ophthalmol 2013;131: ) Farid M, Chak G, Garg S, Steinert RF. Reduction in mean deviation values in automated perimetry in eyes with multifocal compared to monofocal intraocular lens implants. Am J Ophthalmol 2014;158: e1. 23) Lee JM, Seo KY, Kim EK. Comparison of optical aberrations and contrast sensitivity between monofocal and multifocal intraocular lens. J Korean Ophthalmol Soc 2002;43: ) Yoon JU, Chung JL, Hong JP, et al. Comparison of wavefront analysis and visual function between monofocal and multifocal aspheric intraocular lenses. J Korean Ophthalmol Soc 2009;50: ) Kamiya K, Hayashi K, Shimizu K, et al. Multifocal intraocular lens explantation: a case series of 50 eyes. Am J Ophthalmol 2014;158: e1. 26) Alfonso JF, Fernández-Vega L, Baamonde MB, Montés-Micó R. Correlation of pupil size with visual acuity and contrast sensitivity after implantation of an apodized diffractive intraocular lens. J Cataract Refract Surg 2007;33: = 국문초록 = 회절성이중다초점인공수정체와회절성삼중다초점인공수정체의임상결과비교 목적 : 회절성이중다초점인공수정체 (Acrysof ReSTOR SN6AD1) 와회절성삼중다초점인공수정체 (AT LISA tri 839MP) 의단기간시각적및광학적임상결과를비교하고자한다. 대상과방법 : 백내장수술을시행받은 43 명 51 안을대상으로, 24 안은회절성삼중다초점인공수정체 (AT LISA tri 839MP), 27 안은회절성이중다초점인공수정체 (Acrysof ReSTOR SN6AD1) 를삽입하였다. 술후 1 개월, 3 개월째근거리, 중간거리, 원거리시력및굴절값을측정하였고, 술후 3 개월째 OQAS II 를이용한시력의질, CGT-2000 을이용한대비감도검사, 자동시야검사, 초점심도를측정하여두군에서비교하였다. 결과 : 술후 3 개월째두군에서원거리및근거리시력과광학질은차이가없었으나중간거리 (63 cm, 80 cm, 100 cm) 에서시력은삼중다초점군이통계적으로유의하게좋았다. 대비감도는명소시에서는두군에차이가없었으나박명시에서는원거리 (5 m) 에서이중다초점군이, 암소시및박명시에서는근거리 (30 cm) 에서삼중다초점군이유의하게높게측정되었다. 초점심도검사상삼중다초점군이중간거리에서더깊은초점심도를보였다. 결론 : 회절성삼중다초점인공수정체는이중다초점인공수정체와비교하여원거리와근거리의시력및광학질은동일하면서중간거리시력은더잘보이며야간근거리대비감도가높았다. < 대한안과학회지 2016;57(3): > 412

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<31312D30392D313928B9DABFB5C1A42DB1E8C1F6C7F E687770> 대한안과학회지 2015 년제 56 권제 6 호 J Korean Ophthalmol Soc 2015;56(6):875-884 ISSN 0378-6471 (Print) ISSN 2092-9374 (Online) http://dx.doi.org/10.3341/jkos.2015.56.6.875 Original Article 덧댐굴절력이같은회절성과굴절성다초점인공수정체의임상결과비교