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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 다층속말림내경계막절편술을이용한크기가큰황반원공의치료 The Treatment of Large Macular Holes Using a Multi-layered Inverted Internal Limiting Membrane Flap Technique 송동훈 염명인 박정민 Dong Hun Song, MD, Myeong In Yeom, MD, Jung Min Park, MD, PhD 메리놀병원안과 Department of Ophthalmology, Maryknoll Medical Center, Busan, Korea Purpose: To describe a multi-layered inverted internal limiting membrane (ILM) flap technique and to evaluate the surgical outcomes of this surgery in patients with macular holes > 800 μm in base diameter. Methods: The medical records of patients who received a multi-layered ILM flap technique were retrospectively studied and patients with macular holes > 800 μm were included in the analyses. Best-corrected visual acuity (BCVA) before and after surgery, preoperative hole size, hole base size, vertical size, and hole closure after surgery were checked using spectral domain optical coherence tomography. Pars plana vitrectomy was performed and the ILM was stained using indocyanine green and peeled with the base attached at the hole margin. The ILM flap was inverted over the macular hole with 2~3 layers, and gas injection was performed. Results: The mean age of 12 patients was 65.2 ± 12.3 years. The mean BCVA (logmar) was 1.27 ± The mean hole size was ± μm, the mean vertical size was ± 80.9 μm, and the mean hole base size was 1,182.8 ± μm. The mean follow-up period was ± days. Nine macular holes were closed after surgery but three macular holes were not closed. The postoperative mean BCVA (logmar) was 0.21 ± Eight eyes showed visual improvement while three eyes did not show visual improvement after macular hole surgery. Conclusions: The macular hole was closed successfully and the visual acuity improved after the multi-layered, inverted ILM flap technique. The multi-layered, inverted ILM flap technique is therefore considered the treatment of choice for large macular holes. J Korean Ophthalmol Soc 2018;59(5): Keywords: Inverted internal limiting membrane (ILM) flap technique, Large macular hole, Macular hole, Macular hole surgery, Multi-layered 황반원공은안구내의유리체가중심와부위를견인함으로써중심와부위의전층망막결손과그주변의낭포성변 Received: Revised: Accepted: Address reprint requests to Jung Min Park, MD, PhD Department of Ophthalmology, Maryknoll Medical Center, #121 Junggu-ro, Jung-gu, Busan 48972, Korea Tel: , Fax: Pjm1438@hanmail.net * Conflicts of Interest: The authors have no conflicts to disclose. 화를일으켜중심시력의저하를발생시키는질환으로원공발생후섬유아세포가증식하고근섬유모세포는수축하여결과적으로서서히원공의크기가증가하게된다. 1-3 황반원공의치료는내경계막제거술이라는수술적치료를시행함으로써성공률은약 80-90% 에이른다. 4 하지만 Gass가분류한황반원공의단계 3과 4에해당되는크기가큰황반원공환자에서는수술후원공의폐쇄율이다른환자에비해상대적으로낮은것으로알려져있다. 5 Michalewska는크기가 400 μm 이상인큰황반원공에서내경계막을원공의경계면까지만벗긴후이벗겨낸내경 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. 428

- 송동훈외 : 다층속말림내경계막절편술 - 계막을앞뒤로뒤집어서원공을덮는방법 (inverted internal limiting membrane [ILM] flap technique) 으로원공폐쇄에높은성공률을보인다고처음으로보고하였다. 6-9 이후에도 Figure 1.

2 - 송동훈외 : 다층속말림내경계막절편술 - 계막을앞뒤로뒤집어서원공을덮는방법 (inverted internal limiting membrane [ILM] flap technique) 으로원공폐쇄에높은성공률을보인다고처음으로보고하였다. 6-9 이후에도 Figure 1. Parameter of macular hole on optical coherence tomography. The macular hole diameters measured at the level of retinal pigment epithelium (BD), at the minimum extent of the hole (HD). The height of the hole (HT) was also measured. HT = height; HD = hole diameter; BD = base diameter. Khodani et al 10 이같은술기를통해기저직경의크기가 1,000 μm 이상의황반원공에서성공적인원공의폐쇄를보여주었다. 이술기는벗겨낸내경계막이원공의경계에부착이유지되어야하는데, 일반적인방식의내경계막제거술보다술기가어렵고, 내경계막절편 (flap) 으로원공을덮는과정에서절편이원공의경계에서완전히떨어지게되면계획된수술술기를시행할수없게된다. 특히기존의한층 (single-layered) 의절편으로만원공을덮어주는방식에서는내경계막절편의일부분이원공의경계면에서떨어진상태로술기를시행하기때문에이러한상황이더욱빈번히발생할수있다. 본연구에서는기존의전형적인방식의 inverted ILM flap technique을변형하여벗겨진내경계막을여러층 (multi-layered) 으로원공에덮어주는술기를소개하고, 기저직경 (base diameter, BD) 의크기가 800 μm 이상인황반 A B C D Figure 2. Schematic drawing showing multi-layered inverted internal limiting membrane (ILM) flap technique. (A) After performing a 23-gauge 3-port pars plana vitrectomy. (B) Indocyanine green (0.1% solution) is applied around the macular hole (MH). (C) The ILM is peeled off in a circular fashion around the MH. The ILM is not removed completely but left attached to the edge of the MH. (D) The ILM flap is flipped by inverting it using the intraocular forceps to cover the whole MH layer upon layer and gently massaged to make it flattened. Supplementary perfluorocarbon liquids is applied on top of the multi-layered inverted ILM flap as ballast before air-fluid exchange is performed. 429

3 - 대한안과학회지 2018 년제 59 권제 5 호 - 원공환자에서그수술결과를알아보고자하였다. 대상과방법 2015년 3월부터 2017년 3월까지본원에서다층속말림내경계막절편술 (multi-layered inverted ILM flap technique) 을실시한환자를대상으로차트리뷰를통한후향적연구를실시하였다. 다층속말림내경계막절편술을받은환자중안저검사및빛간섭단층촬영을통하여중심와부위의감각신경망막전층결손이확인된환자에서수술전시력, 굴절값을조사하였으며빛간섭단층촬영영상으로원공의최소직경 (hole diameter, HD), 기저직경 (BD), 최대높이 (height, HT) 를측정하였고기저직경의크기가 800 μm 이상인환자를대상으로포함하였다 (Fig. 1). 시력은한석천 3미터시력표로측정후 logarithm of the minimum angle of resolution (logmar) 으로변환하여계산하였으며굴절값은구면대응치 (spherical equivalent) 로환산하였다. 수술은 1인의술자에의하여이루어졌으며, 백내장이있는경우황반원공수술과함께백내장수술을실시하였다. 황반원공의수술방법은우선 3개의모양체평면부공막창을통한표준 3-ports 유리체절제술을시행하였다. 뒷유리체박리를일으킨다음유리체를제거하였고망막전막이있는경우망막전막을제거하였으며, 0.05% 인도시아닌그린을이용하여내경계막절편술을시행하였다. 내경계막절편술에서는내경계막 (ILM) 을원공경계면 360 전방향에서 disc diameter (DD) 바깥부터벗기고가장안쪽에서원형으로원공경계면과내경계막 (ILM) 이부착된상태에서벗겨낸내경계막을앞뒤로뒤집어서 (inverted) 2-3층 (multi-layered) 으로원공부위에덮어이식후 perfluorocarbon liquid를이용해이식된부위를눌러주었다 (Fig. 2). 이후액채공기교환술을시행하고 perfluoropropane (C 3F 8) 이나 sulfur hexafluoride (SF 6) 를이용하여안내가스충전술을시행하였으며수술후환자들은얼굴하향자세를유지하도록하였다. 수술후에는빛간섭단층촬영으로중심와의해부학적모양과시세포층의회복을조사하였고감각신경층의결손없는경우를제1형폐쇄 (type 1 closure), 감각신경층의결손이있는경우를제2형폐쇄 (type 2 closure) 로분류하였다. 11,12 빛간섭단층촬영영상은스펙트럼영역빛간섭단층촬영장비 (Cirrus HD-OCT, Carl zeiss Meditec, Dulin, CA, USA) 를사용하여분석하였다. 수술후매방문시마다최대교정시력을측정하였으며, 비접촉렌즈를이용한정밀안저검사빛간섭단층촬영을시행하였다. 경과관찰은환자의상태에따라주기적으로시행하였고검사자의판단에따라방문시기를조절하였으며마지막방문시환자의상태를분석에이용하였다. 본연구는헬싱키선언을준수하였고본원윤리위원회의승인을받아진행하였다. 통계분석은 SPSS for Windows software version 22.0 (IBM Corp., Armonk, NY, USA) 을이용하여 p-value가 0.05 미만인경우를통계적으로유의한것으로판정하였다. 결과 대상환자 12안모두한국인이었으며 8안은여자, 4안은남자였다. 12안의평균나이는 65.2 ± 12.3세였다. 수술전 Table 1. Characteristics of patients Case Sex Age Refractive Hole diameter Base diameter Hole height Laterality (years) error (D, SE) (μm) (μm) (μm) Other ocular disorder 1 F 70 OS , Cataract 2 F 61 OD Cataract 3 F 73 OD Cataract 4 F 79 OS , Pseudophakia 5 F 49 OD Pseudophakia 6 F 75 OS , ERM, pseudophakia 7 M 55 OS , RRD (SO tamponade), ERM, pseudophakia 8 M 38 OS , RRD (s/p buckling), cataract, high myopia 9 M 67 OD Cataract 10 F 68 OD , Cataract, ERM 11 M 77 OS , Pseudophakia 12 F 70 OS , Cataract SE = spherical equivalent; F= female; M = male; OD = oculus dexter; OS = oculus sinister; ERM = epiretinal membrane; RRD = rhegmatogenous retinal detachment; SO = silicone oil; s/p = status post. 430

4 - 송동훈외 : 다층속말림내경계막절편술 - Table 2. Result of multi-layered inverted inverted internal limiting membrane flap technique Case number Follow up Baseline visual acuity Postoperative visual acuity (days) (logmar) (logmar) Type of closure Type 1 closure * Type 1 closure Type 1 closure Non-closure Type 2 closure Type 1 closure Type 1 closure Type 1 closure Type 1 closure Non-closure Non-closure Type 1 closure * Type 1 closure: Closed without foveal neurosensory retinal defect; Type 2 closure: Closed with foveal neurosensory retinal defect. Table 3. Result of the relation between hole size and hole closure Result N Base diameter (μm) Hole diameter (μm) Mean Standard deviation Mean Standard deviation Closure Non-closure Between 2 group comparision p-value * * Mann-Whitney U-test. Figure 3. A case of full thickness macular hole in 70-year-old-female. Preoperative color fundus photography (A) and optical coherence tomography (OCT) (B) of the left eye demonstrated large macular hole (hole base: 1,436 μm). 6 days after surgery, type 1 closure of hole was detected in OCT scan image (C). There was no change in logmar vision from 1.10 to 평균교정시력 (logmar) 은 1.27 ± 0.61이었고평균구면대응굴절값은 1.13 ± 1.54 diopter였다. 원공크기는최소직경 ± μm, 기저직경은 1,182.8 ± μm, 최대높이는 ± 80.9 μm였다. 증례6, 증례7, 증례10은망막전막이동반된상태였다. 증례7, 증례8은망막박리로수술받은과거력이있는환자였다 (Table 1). 수술후평균경과관찰기간은 ± 143.3일이었다. 대상환자 12안중 9안은수술후원공이폐쇄되었고경과 관찰기간동안빛간섭단층촬영을통해중심와의해부학적구조가더욱개선됨을확인하였다. 폐쇄된중심와의모양은 9안중 8안에서는제1형폐쇄를보였으며 1안에서는제 2형폐쇄를보였다. 수술후평균교정시력 (logmar) 은 0.21 ± 0.51이었고 12안중 8안에서시력이호전되었으나 4안에서는호전이없었다. 원공이폐쇄된환자에서는 9안중 7안에서시력의호전을보였다 (Table 2). 800 μm 이상의큰황반원공에서원공의크기와술후원 431

7 days after surgery, type 1 closure of hole was detected in OCT scan image (C). logmar vision improved from 1.60 to 1.00. Figure 5. A case of full thickness macular hole in 38-year-old-male.

5 - 대한안과학회지 2018 년제 59 권제 5 호 - Figure 4. A case of full thickness macular hole in 75-year-old-female. Preoperative color fundus photography (A) and optical coherence tomography (OCT) (B) of the left eye demonstrated large macular hole (hole base: 1,304 μm). 7 days after surgery, type 1 closure of hole was detected in OCT scan image (C). logmar vision improved from 1.60 to Figure 5. A case of full thickness macular hole in 38-year-old-male. Preoperative color fundus photography (A) and optical coherence tomography (OCT) (B) of the left eye demonstrated large macular hole (hole base: 1,387 μm). 13 days after surgery, type 1 closure of hole was detected in OCT scan image (C). logmar vision improved from 1.20 to 공의폐쇄여부는통계적으로유의한관계를나타내지않았다. 원공이폐쇄된 9안의평균기저직경은 1,084.1 ± μm, 평균최소직경은 ± 68.9 μm였고폐쇄되지않은 3안의평균기저직경은 1,479.0 ± μm, 평균최소직경은 ± μm였다 (Table 3). 증례1은좌안시력저하로내원한 70세여자환자였다. 좌안최대교정시력 (logmar) 은 1.10이었다. 빛간섭단층촬영에서원공의크기는최소직경 908 μm, 기저직경 1,304 μm, 최대높이 393 μm였다. 수술후 6일째 1형폐쇄가관찰되었고최대교정시력 (logmar) 은 1.10으로변화가없었다 (Fig. 3). 증례6 은 3년전좌안백내장수술을받은인공수정체안의 75세여자환자였다. 백내장수술이후에눈이계속불편하 고침침하여내원하였다. 좌안최대교정시력 (logmar) 은 1.60이었다. 빛간섭단층촬영에서원공의크기는최소직경 686 μm, 기저직경 1,304 μm, 최대높이 395 μm였다. 수술후 7일째 1형폐쇄가관찰되었고최대교정시력 (logmar) 은 1.00으로호전되었다 (Fig. 4). 증례8은양안외상성망막박리로타병원에서공막돌륭술을받고본원에서경과관찰중발생한좌안변시증으로내원한고도근시를가진 38세남자환자였다. 최대교정시력 (logmar) 은 1.20으로측정되었고안저검사와빛간섭단층촬영에서최소직경 610 μm, 기저직경 1,387 μm, 최대높이 498 μm인황반원공이진단되었다. 수술후 13일째 1 형폐쇄가관찰되었고최대교정시력 (logmar) 은 0.70으로 432

2 months after surgery, type 1 closure of hole was detected in OCT scan image (C). logmar vision improved from 0.80 to 0.70. Figure 7. A case of full thickness macular hole in 70-year-old-female.

6 - 송동훈외 : 다층속말림내경계막절편술 - Figure 6. A case of full thickness macular hole in 67-year-old-male. Preoperative color fundus photography (A) and optical coherence tomography (OCT) (B) of the right eye demonstrated large macular hole (hole base: 962 μm). 2 months after surgery, type 1 closure of hole was detected in OCT scan image (C). logmar vision improved from 0.80 to Figure 7. A case of full thickness macular hole in 70-year-old-female. Preoperative color fundus photography (A) and optical coherence tomography (OCT) (B) of the right eye demonstrated large macular hole (hole base: 1,071 μm). 14 days after surgery, type 1 closure of hole was detected in OCT scan image (C). logmar vision improved from 0.80 to 호전되었다 (Fig. 5). 증례9는건강검진상발견된우안시력저하로내원한 67 세남자환자였다. 우안최대교정시력 (logmar) 은 0.80으로측정되었고안저검사와빛간섭단층촬영에서최소직경 661 μm, 기저직경 962 μm, 최대높이 475 μm인황반원공이진단되었다. 백내장수술과함께평면부유리체절제술, 내경계막절편술, 가스주입술을시행하였다. 수술후 1개월째촬영한빛간섭단층촬영에서는원공폐쇄가관찰되지않았지만최대교정시력 (logmar) 은 0.70으로다소호전되었다. 수술후 2개월째 1형원공폐쇄가관찰되었으며최대교정시력도 0.2로더호전되었다 (Fig. 6). 증례12는시력검사중우연히발견된좌안시력저하로 내원한 70세여자환자였다. 좌안최대교정시력 (logmar) 은 1.00이었다. 빛간섭단층촬영에서원공의크기는최소직경 612 μm, 기저직경 1,071 μm, 최대높이 409 μm였다. 수술후 14일째 1형폐쇄가관찰되었고최대교정시력 (logmar) 은 1.00으로변화가없었다 (Fig. 7). 고찰 황반원공의치료로서내경계막제거술이시행된이후로특발성황반원공에서수술시행후약 90% 의해부학적성공률과술후시력개선효과를얻을수있게되었다. 13,14 하지만 Gass가분류한황반원공의 3, 4 단계인큰황반원공 433

7 - 대한안과학회지 2018 년제 59 권제 5 호 - 에서는원공의폐쇄가상대적으로어렵다고보고된적도있다. 15 Morizane et al 16 은황반원공환자에서내경계막제거술을시행한후해부학적으로원공의폐쇄에실패한환자에서이차적으로내경계막자가이식술을실시한적이있다. 이수술은환자에게남아있는내경계막을떼어낸뒤이것을원공속으로이식하는방법으로일반적인내경계막제거술과동일하게내경계막을일정한크기로벗겨내면되므로술식이비교적간단하지만떼어낸절편을원공안으로이식하는과정에서원공의바닥면부위의망막색소상피층에물리적인손상이일어날수있다는단점이있다. 최근에는고도근시에동반된크기가큰황반원공환자에서속말림내경계막절편술 (inverted ILM flap technique) 로좋은수술결과가보고된바있다. 7-9 이식된내경계막절편이원공을폐쇄하는원리는내경계막절편에포함된뮬러세포 (Muller cell) 가조직의괴사와관련된생장인자 (growth factor) 를활성화시켜신경아교세포의분열과증식을촉진하고또한그자체로서세포증식의뼈대로작용하여원공의폐쇄를촉진시킨다고알려져있다. 6 기존에알려진방식의속말림내경계막절편술은내경계막을완전히떼어내지않고원공의한쪽경계면과절편이부착된상태로내경계막절편을원공안에이식하는데, 내경계막을벗기면서내경계막절편이원공의경계면에서떨어지게되면원공을덮을수없기때문에원공의경계에서는내경계막이완전히떨어지지않게조심하여야하며, 덮은절편이원공면에서미끄러져이탈되는등술기를시행함에있어여러어려움이있다. 본연구에서저자는전형적인속말림내경계막절편술방법을대신해내경계막을원공경계면 360 전방향에서 DD 바깥부터벗기고가장안쪽의원공경계면과내경계막이부착된상태에서내경계막을접어 2-3겹으로원공면에덮어주었다. 이러한방법이주는가장큰장점은 2-3 겹으로포개어진절편에서한절편의원공면과다른절편의유리체면사이의맞물림효과로각각의절편이서로강하게부착을할수있게한다. 이렇게안정적으로부착된절편들은기존방식의가장큰난관이라할수있는액채공기교환술과정에서발생하는절편의이탈을예방할수있다. 고도근시환자에서황반원공이발생한경우일반환자에비해내경계막이얇고약한경우가많기때문에일반적인경우보다절편을만들기힘들다. 고도근시환자인증례8의경우내경계막을벗겨내는과정에서한쪽방향에서만벗겨낸절편으로는기저직경 1,387 μm인원공을모두덮기에부족하였지만여러방향에서절편을만들어원공을덮었기때문에크기가큰황반원공을충분히덮을수있었고수술 후제1형원공폐쇄를보였다. 또한다층속말림내경계막절편술에서는여러겹의절편으로원공의덮어줌으로써신경감각망막, 망막상피세포그리고내경계막사이에닫힌공간을형성하게되고이러한닫힌공간안에위치한내경막절편은세포이동의뼈대로작용함으로써주변세포조직의구심성이동을도와제1 형원공폐쇄의형성을돕고술기중노출된망막색소상피세포가손상당할위험도줄어들게된다. 최근 Aurora et al 17 이소개한 Cabbage Leaf Inverted Flap ILM Peeling에서는술자가 3개의구분되는절편을만든다음이절편을포개어원공을덮어주는방법을보여주고있다. 이런경우본술기와마찬가지로큰황반원공을덮을수있는충분한크기의절편을얻을수있고절편또한비교적안정적으로원공에위치할수있게된다. 하지만절편이 360 전방향에서원공의경계면과부착된상태가아니기때문에원공내닫힌공간을형성하기힘들며본술기보다안정성이떨어지기때문에액채공기교환술과정중한절편이라도이탈될경우에는계획된술기를진행하는데어려움이있다. 본연구에서는수술대상이기저직경 800 μm 이상으로크기가큰황반원공환자임에도불구하고 12안중 9안에서원공의해부학적폐쇄를확인할수있었다. 수술후폐쇄에성공하더라도중심와의해부학적구조가정상과다른경우도있었다. 수술후중심와부위에결손없이황반원공이폐쇄되는경우를제1형폐쇄 (type 1 closure), 황반원공이폐쇄는되었지만중심와부위에결손이남아있는경우는제2형폐쇄 (type 2 closure) 로분류하였다. 11,12 한연구에의하면원공의직경이 400 μm 이상인황반원공에서는제1형폐쇄가 56% 정도라고하였다. 18 본연구에서는원공이폐쇄된 9안중 8안에서제1형폐쇄를보여해부학적으로우수한결과를보였다. Wakely et al 19 의연구에의하면황반원공의최소직경 (HD), 기저직경 (BD) 이황반원공수술의구조적그리고기능적성공에있어서중요한예후인자로작용하며특히기저직경 (BD) 이가장유용하고강력한수술성공의예측인자라고설명하고있다. 본연구에서기저직경 (BD) 과황반원공의폐쇄여부사이의상관관계는찾을수는없었지만원공이폐쇄되지않은 3안의평균기저직경 (BD) 1,479.0 ± μm로폐쇄된 9안의평균 1,084.1 ± μm보다크다는사실을알수있다. 본연구에서는 12안중 8안에서시력호전을보였지만원공폐쇄여부와시력호전사이의통계적유의관계는찾을수없었다. 원공이폐쇄된 9안중 7안에서시력의호전을보였고원공이폐쇄되지않은 3안중 1안에서시력이향상되었다 (Table 4). 황반원공의수술후시력회복에있어 434

8 - 송동훈외 : 다층속말림내경계막절편술 - Table 4. Result of the relation between hole closure and visual acuity improvement Result Visual acuity improvement Improve No improve Total Closure Non-closure p-value * * Chi-square test. 서는수술전원공의크기, 수술전원공시세포층의상태, 수술전환자의시력등다양한요소가영향을주는것으로알려져있다 본연구의경우황반원공수술과백내장수술을함께실시한증례도포함하고있어백내장수술로인한시력상승의인자를통제하지못하였다. 환자의병력상유리체절제술이나공막돌륭술같이망막박리수술을받았던환자도포함하고있는데기록에남아있지않아정확한확인은어렵지만이러한경우수술전이미환자의시세포가손상되어황반원공의수술로시력향상을기대하기힘든상태였을수도있다. 수술전증상의지속기간역시시세포손상에영향을주어술후시력에영향을미친다. 또한황반원공폐쇄이후시세포외절의재생과함께서서히느린속도로시력이회복되는경우도존재하기때문에추적기간이짧은환자에서는이러한경우를반영하지못하였을것이다. 이러한다양한요인으로원공폐쇄와시력호전사이의유의성을판단하기에는한계가있었다. 황반원공폐쇄에실패한 3안의평균나이는 74.7 ± 5.9세였으며 2명은여성, 1명은남성이었다. 3안의수술전평균최대교정시력 (logmar) 은 0.97 ± 0.49였고빛간섭단층촬영상평균최소직경 ± μm, 기저직경 1,479.0 ± μm, 최대높이 ± 71.8 μm로평균기저직경과최소직경, 최대높이가모두전체평균에비해높았다. 원공폐쇄에실패한 3안중 1안에서수술중 perfluoropropane (C 3F 8) 을주입하였고 2안에서는 sulfur hexafluoride (SF 6) 를주입하였다. 본연구는적은수의환자를대상으로시행한후향적연구로서전체대상안이총 12안으로그수가적었기때문에통계적으로유의한결과를얻기어려웠다. 또한수술후연구전마지막내원시점의차트리뷰를통해연구를진행하였기때문에여러가지술후측정값들의측정시점이모두달랐다. 술후측정시점이너무짧은경우서서히진행하는시세포외절의재생에따른시력회복을결과값에반영하기힘들기때문에수술에따른시력호전여부를판단하는데한계가있다. 본연구의또다른한계점은크기가큰황반원공의기준 으로잡은기저직경 800 μm에대한근거가부족하다는점이다. 여러다른연구에서도최소직경, 기적직경등을다양한크기의기준에따라연구를진행하였지만보편적으로받아들일수있는기준은존재하지않았다. 6,10,23-25 Mahalingam and Sambhav 24 는최소직경이 700 μm 이상인 5안을대상으로술기를실시하였다. Khodani et al 10 은기저직경의크기가 1,000 μm 이상의황반원공환자를대상으로속말림내경계막절편술을실시하였다. Lee et al 25 은최소직경 400 μm 이상의황반원공환자에서한층속말림내경계막절편술을실시하였다. 본연구에서는기저직경 (BD) 이가장유용하고강력한수술성공의예측인자라는 Wakely et al 19 의연구를참조하여기저직경을기준으로하였고그크기가 800 μm이상의전층황반원공환자를연구의대상으로포함하였다. 본연구를통해다층속말림내경계막절편술 (multi-layered inverted ILM flap technique) 에따른원공의폐쇄와시력의호전사이의유의한관계에대한결론을내릴수는없었지만수술후시력호전을기대할수있었고크기가아주큰황반원공에서이술기를통해우수한해부학적결과를얻을수있어지금까지알려진다른수술방법과더불어시도해볼만한가치가있는새롭고유용한술기라고생각된다. 또한한국인만을대상으로실시한연구로서국내황반원공환자의치료에있어본술기의효과를확인할수있었다는데그의의가있다. 향후많은환자를대상으로이술기에대한수술성공률과시력예후, 합병증등에대한연구가필요하다. 더불어본술기의적응증에있어기준이될수있는황반원공의크기에관한추가적인연구를시행하여보다명확한기준를바탕으로본술기를사용하여할것이다. REFERENCES 1) La Cour M, Friis J. Macular holes: classification, epidemiology, natural history and treatment. Acta Ophthalmol Scand 2002;80: ) Johnson RN, Gass JD. Idiopathic macular holes. Observations, stages of formation, and implications for surgical intervention. Ophthalmology 1988;95: ) Yooh HS, Brooks HL Jr, Capone A Jr, et al. Ultrastructural features of tissue removed during idiopathic macular hole surgery. Am J Ophthalmol 1996;122: ) Tatham A, Banerjee S. Face-down posturing after macular hole surgery: a meta-analysis. Br J Ophthalmol 2010;94: ) Konstantinidis A, Hero M, Nanos P, Panos GD. Efficacy of autologous platelets in macular hole surgery. Clin Ophthalmol 2013;7: ) Michalewska Z, Michalewski J, Adelman RA, Nawrocki J. Inverted internal limiting membrane flap technique for large macular holes. Ophthalmology 2010;117: ) Kuriyama S, Hayashi H, Jingami Y, et al. Efficacy of inverted internal limiting membrane flap technique for the treatment of mac- 435

9 - 대한안과학회지 2018 년제 59 권제 5 호 - ular hole in high myopia. Am J Ophthalmol 2013;156: e1. 8) Michalewska Z, Michalewski J, Dulczewska-Cichecka K, Nawrocki J. Inverted internal limiting membrane flap technique for surgical repair of myopic macular holes. Retina 2014;34: ) Shin MK, Park KH, Park SW, et al. Perfluoro-n-octane-assisted single-layered inverted internal limiting membrane flap technique for macular hole surgery. Retina 2014;34: ) Khodani M, Bansal P, Narayanan R, Chhablani J. Inverted internal limiting membrane flap technique for very large macular hole. Int J Ophthalmol 2016;9: ) Kang SW, Ahn K, Ham DI. Types of macular hole closure and their clinical implications. Br J Ophthalmol 2003;87: ) Shukla SY, Afshar AR, Kiernan DF, Hariprasad SM. Outcomes of chronic macular hole surgical repair. Indian J Ophthalmol 2014; 62: ) Tognetto D, Grandin R, Sanguinetti G, et al. Internal limiting membrane removal during macular hole surgery: results of a multicenter retrospective study. Ophthalmology 2006;113: ) Haritoglou C, Reiniger IW, Schaumberger M, et al. Five-year follow-up of macular hole surgery with peeling of the internal limiting membrane: update of a prospective study. Retina 2006;26: ) Freeman WR, Azen SP, Kim JW, et al. Vitrectomy for the treatment of full-thickness stage 3 or 4 macular holes. Results of a multicentered randomized clinical trial. The Vitrectomy for Treatment of Macular Hole Study Group. Arch Ophthalmol 1997;115: ) Morizane Y, Shiraga F, Kimura S, et al. Autologous transplantation of the internal limiting membrane for refractory macular holes. AmJ Ophthalmol 2014;157:861-9.e1. 17) Aurora A, Seth A, Sanduja N. Cabbage leaf inverted flap ILM peeling for macular hole: a novel technique. Ophthalmic Surg Lasers Imaging Retina 2017;48: ) Ip MS, Baker BJ, Duker JS, et al. Anatomical outcomes of surgery for idiopathic macular hole as determined by optical coherence tomography. Arch Ophthalmol 2002;120: ) Wakely L, Rahman R, Stephenson J. A comparison of several methods of macular hole measurement using optical coherence tomography, and their value in predicting anatomical and visual outcomes. Br J Ophthalmol 2012;96: ) Michalewska Z, Michalewski J, Cisiecki S, et al. Correlation between foveal structure and visual outcome following macular hole surgery: a spectral optical coherence tomography study. Graefes Arch Clin Exp Ophthalmol 2008;246: ) Leonard RE 2nd, Smiddy WE, Flynn HW Jr, Feuer W. Long-term visual outcomes in patients with successful macular hole surgery. Ophthalmology 1997;104: ) Kumagai K, Ogino N, Demizu S, et al. Variables that influence visual acuity after macular hole surgery. Jpn J Ophthalmol 2001; 45: ) Ullrich S, Haritoglou C, Gass C, et al. Macular hole size as a prognostic factor in macular hole surgery. Br J Ophthalmol 2002; 86: ) Mahalingam P, Sambhav K. Surgical outcomes of inverted internal limiting membrane flap technique for large macular hole. Indian J Ophthalmol 2013;61: ) Lee JJ, Lee IH, Park KH, et al. Vascular displacement in idiopathic macular hole after single-layered inverted internal limiting membrane flap surgery. Korean J Ophthalmol 2017;31: = 국문초록 = 다층속말림내경계막절편술을이용한크기가큰황반원공의치료 목적 : 다층속말림내경계막절편술의수술방법을소개하고기저직경의크기가 800 μm 이상인황반원공환자에서그수술결과를알아보고자하였다. 대상과방법 : 다층속말림내경계막절편술을시행받은황반원공환자의의무기록을후향적으로조사하여, 수술전원공기저직경의크기가 800 μm 이상인환자를연구대상으로하였다. 대상환자에서수술전후교정시력, 빛간섭단층영상에서측정한수술전원공의최소직경과기저직경, 최대높이, 술후원공폐쇄여부등을확인하였다. 수술은유리체절제술을실시한뒤인도시아닌그린으로내경계막을염색한후내경계막을원공경계면까지만박리하였다. 벗겨진내경계막을뒤집어서 2-3 겹으로원공에이식한뒤안구내에가스를충전하였다. 결과 : 12 안의평균나이는 65.2 ± 12.3 세였다. 수술전평균교정시력 (logmar) 은 1.27 ± 0.61 이었고원공크기는 ± μm, 기저부는 1,182.8 ± μm, 높이는 ± 80.9 μm 였다. 수술후평균경과관찰기간은 ± 일이었다. 9 안은수술후원공이폐쇄되었고 3 안에서는폐쇄가이루어지지않았다. 수술후평균교정시력 (logmar) 은 0.21 ± 0.51 이었고 8 안에서는시력호전이되었으나 4 안은시력호전이없었다. 결론 : 다층속말림내경계막절편술을통해안정적으로수술후원공의폐쇄와시력의호전을기대할수있었다. 크기가큰황반원공에서시행해볼만한가치가있는유용한수술술기라고생각된다. < 대한안과학회지 2018;59(5): > 436

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김범수 Analysis of Outcomes after Resection of Sarcomatous Hepatocellular Carcinoma Purpose: Sarcomatous hepatocellular carcinoma (HCC) is rare. Therefore, the clinicopathologic characteristics and prognosis