Kosin Medical Journal 2015;30: KMJ Original Article Complications caused by perfluorocarbon liquid

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1 KMJ Original Article Complications caused by perfluorocarbon liquid used in pars plana vitrectomy Jae Ho Yoo 1, Ki Yup Nam 2, Seung Uk Lee 2, Ji Eun Lee 2, Sang Joon Lee 2 1 Oksan Health Subcenter, Euiseong-Gun, Korea 2 Department of Ophthalmology, College of Medicine, Kosin University, Busan, Korea 유리체망막수술시사용된과불화탄소액의안내잔류와이로인한합병증 유재호 1, 남기엽 2, 이승욱 2, 이지은 2, 이상준 2 1 의성군옥산보건지소, 2 고신대학교의과대학안과학교실 Objectives: To assess the inadvertent intraocular retention of perfluorocarbon liquid (PFCL) after vitreoretinal surgery and their complications. Methods: We retrospectively reviewed the medical records of 108 patients who underwent vitreoretinal surgeries using intraoperative PFCL (perfluoro-n-octane (C 8 F 18 ), 0.69 centistoke at 25, PERFLUORN, Alcon, USA) and the removal of PFCL through fluid-air exchange. The analysis was focused on the occurrence of intraocular retained PFCL, diagnoses,surgicalprocedures,andcomplications. Results: Retinal detachment (51 cases, 47%) was the most common surgery which used PFCL intraoperatively. Other causes were vitreous hemorrhage (24 cases, 22%), posteriorly dislocated lens (22 cases, 21%), and trauma (11 cases, 10%). Intraocular PFCL was found in a total of 9 (8.3%) eyes. PFCL bubbles remained in anterior chamber and vitreous cavity were observed in 4 cases and subretinal retained PFCL was observed in 5 cases. Three of 5 cases of subretinal PFCL exhibited in subfoveal space. Among the three subfoveal cases, macular hole developed after PFCL removal in 1 case, epiretinal membrane in the area where had been PFCL bubble. However, we observed no complications in 1 case of subfoveal PFCL that was removed by surgery. PFCL in anterior chamber and vitreous cavity were in 4 cases. Conclusions: The presence of subfoveal PFCL might affect visual and anatomic outcomes. However, subfoveal PFCL may induce visual complications, and therefore requires special attention. Key Words: complicaton, Perfluorocarbon liquid, retinal detachment, Vitrectomy 과불화탄소액은거대열공망막박리및증식성유리체망막병증, 외상망막박리, 수정체혹은인공수정체탈구등각종유리체망막질환수술시유리체대용물로사용된다. 과불화탄소액은물보다높은비중을나타내며, 광학적투명성, 낮은점도등의특성으로인해망막하액의이동, 거대망막열공의평탄화등에유용하게사용되고있다. 이러한과불화탄소액이안내수술후에잔류하게되는경우, 특히망막하로유입된과불화탄소액에의한여러합병증이보고되었다. 1~5 이는큰주변부망막절개술을시행하거나, 과불화탄소액제거를위한공기- 액체치환술시 Corresponding Author: Sang Joon Lee, Department of Ophthalmology, College of Medicine, Kosin University, 262, Gamcheon-ro Seo-gu, Busan 49267, Korea TEL: FAX: hhiatus@gmail.com Received: Revised: Accepted: Feb. 20, 2014 May 24, 2014 Jul. 9,

2 에잘일어나는것으로알려져있다. 6 망막하과불화탄소액잔류의빈도는연구에따라 0.9 ~ 11% 까지다양하게보고되고있다. 6-8 장기간과불화탄소액이망막하에잔류된경우다양한결과를유발할수있으며, 10년간경과관찰시유의한합병증이없었다는보고에서부터과불화탄소액에의한영구적중심암점까지다양한보고가알려져있다. 1 국내의경우과불화탄소액에의한안독성실험및과불화탄소액을이용한유리체망막수술의임상성적등에대한보고는있으나, 과불화탄소액의잔류증례에대한분석은없었다. 본연구는과불화탄소액이망막하유입, 유리체강내잔류한증례의진단및수술방법, 이로인한합병증발병여부등을알아보았다. 대상과방법 2004년부터 2009년동안본원에서망막박리, 유리체출혈, 유리체강내수정체이탈등으로유리체망막수술을시행하며과불화탄소액으로 perfluoro-n-octane(perfluorn, ALCON, U.S.A., perfluoro-n-octane(c8f18), 0.69 centistoke at 25 ) 을사용한환자 108 명, 108 안의병력지를후향적으로분석하였다. 성별은남자 80명 (74.1%), 여자 28명 (25.9%) 이었고, 연령분포는 22세에서 84세로평균 57.25±15.10 세였다. 추적관찰기간은 1~70 개월, 평균 21.73±17.73 개월이었 다. 수술안은우안 45안, 좌안 63안이었다 (Table 1). 모든환자는술전에교정시력측정, 안압측정, 세극등검사및안저검사를시행하였다. 수술방법은전체환자, 108안모두에서기본적으로평면부유리체절제술과과불화탄소액주입및제거술을시행하였다. 과불화탄소액주입시모든경우에끝이무딘 23 gauge 바늘을이용하여시신경유두근처에서서서히주입하였다. 열공성망막박리의경우망막하액이앞쪽의열공을통해배출되게하였고, 망막박리와망막주름이펴지도록하면서필요에따라남은견인과증식막을제거하였다. 기존의망막열공으로망막하액배출이어려운경우망막하액배출을위한망막절개술을시행하였다. 과불화탄소액주입시에는끝이무딘 23 게이지바늘을이용하여시신경유두근처에서서서히주입하였다. 과불환탄소액의제거는끝이실리콘으로된 extrusion needle 을이용하여제거하였다. 만약백내장으로인해수술시야에방해가되는경우수정체절제술을함께시행하였다. 필요에따라증식막제거술, 주변부망막절개술, 망막열공냉동응고술, 안내레이저광응고술, 공막돌륭술, 액체공기교환, 과불화탄소가스나실리콘기름충전을통한망막압박을시행하였다. 수술방법에따라안저검사가적절히이루어질수없어과불화탄소액의잔류를확인할수없는경우는대상에서제외하였다. 이들환자에서과불화탄소액의잔류유무와해부학적잔류위치, 잔류기간에따른합병증의발병여부등에 Table 1. Demographics of total patient and retained PFCL cases. Total Retained PFCL No. of surgeries 108 9(8.3%) Gender Male 80 8(10%) Female 28 1(3.6%) Age (years) Mean (S.D.) 57.25± ±18.78 Range Follow-up period (month) Time Left in (month) Mean (S.D.) 21.73± ±20.01 Range Mean (S.D.) 18.58±4.24 Range

3 Complications of heavy liquid during PPV Table 2. Cumulative Percent of Eyes with Retained Perfluorocarbon Liquid Total No. of cases (%) Retained PFCL, No.(%) Rhegmatogenous retinal detachment 45(42%) 5(11.1%) Idiopathic 39(36%) 4(10.3%) Trauma 6(6%) 1(16.7%) Vitreous and Subretinal hemorrhage 31(29%) 0(0.0%) Due to diabetic Retinopathy 22(20%) 0(0.0%) Due to Trauma 5(5%) 0(0.0%) Due to Retinal vein occlusion 2(2%) 0(0.0%) Due to Age-related macular degeneration 1(1%) 0(0.0%) Lens drop in vitreal cavity 21(19%) 3(14.3%) Tractional retinal detachment 7(6%) 1(14.3%) Suprachoroidal hemorrahge 2(2%) 0(0.0%) Choroidal detachment 2(2%) 0(0.0%) Total 108(100%) 9(8.3%) Table3. Patient Characteristics with retained PFCL Pati ent Age Gend er Diagnosis 1 78 M RRD 2 73 M 3 51 M 4 63 M Posterioly dislocated lens Posterioly dislocated lens Posterioly dislocated lens 5 20 M RRD 6 30 F RRD 7 57 F TRD, PDR 8 45 M RRD 9 52 M RRD Operation PPV, Lensectomy, SB, Gas inject PPV, Phacofragm atome PPV, Phacofragm atome PPV, Phaco c Scleral fixed IOL PPV, SB, SiO inject PPV, SB, C3F8 Gas inject PPV, SiO inject PPV, SB, FAX, EL, lensectomy, SiO inject PPV, SB, Lensectomy, SiO inject Site of PFCL Anterior chamber Anterior chamber Anterior chamber Vitreal cavity PreOP VA PostOP VA Time Left in (month) Follow up period (month) Complic ation Futher Surgery nil nil CF CF 1 18 nil nil LP HM 1 2 nil nil HM Floater nil Extrafovea CF nil nil Extrafovea CF nil nil Subfovea CF HM 3 48 Macular hole Subfovea CF nil PFCL removal Seconda ry IOL implant Subfovea CF HM ERM nil 125

4 Fig. 1. A. Anterior segment Photo shows multiple PFCL bubble in inferior anterior chamber.(red arrow) B. Postoperative retinography of case 5 showing multiple PFCL spheres in the posterior pole, extramacular.(red arrow) After 2 years, notice the reflexes caused by PFCL. The patient's visual acuity was C. Postoperative retinography shows PFCL bubble at superior side of macula.(red arrow) D.Vertical OCT section of the "C" case was shown and the intraretinal black hollow (arrow head) was PFCL subretinal bubble. 대하여알아보았다. 결과 과불화탄소액을사용한총 108안의수술중 9안에서과불화탄소액이안내에잔류되어 8.3% 의빈도를보였다. 과불화탄소액을사용한수술로, 전체 108안중열공성망막박리 45안 (41.7%), 유리체출혈 30안 (27.8%), 유리체강내수정체이탈 21안 (19.4%), 견인성망막박리 7안 (6.5%), 맥락막상강출혈 2안 (1.9%), 맥락막박리 2안 (1.9%), 망막하출혈 1안 (0.9%) 이었다 (Table 2). 과불화탄소액이잔류되었던수술적응증은열공성망막박리가 5안 (4.6%) 으로가장많았으며, 다음으로수정체후방편위 3안 (2.8%), 견인성망막박리 1안 (0.9%) 순이었다 (Table 2). 과불화탄소액이잔류된해부학적위치로분류하면전방내 3안, 유리체강내 1안, 망막하에잔류된경우가 5안이었다 (Table 3). 전방과유리체강내에잔류된 4안의경우수술의원인은수정체후방편위가 3안, 열공성망막박리수술 1안이었고, 12개월의경과관찰기간동안유의한해부학적변화가세극등검사상관찰되지않았다. 환자는과불화탄소액으로인한비문증을호소하였다. 과불환탄소액이전방내에잔류한 1례의경우열공성망막박리수술시에과불화탄소액을사용하였다 (Fig. 1A). 수정체후방편위로유리체절제술과수정체파쇄술을시행하기위해과불화탄소액을사용한 3례의경우 2안에서전방내, 1안에서유리체강내에과불화탄소액이잔류되었다. 증례 4의경우경과관찰중유리체강내에서과불화탄소액이발견되었고, 1년간의경과관찰기간동안해부학적변화는발생하지않았 126

Complications of heavy liquid during PPV Fig 2. A. Retinography shows round reflex at macular due to subfoveal PFCL and atrophic change around posterior pole due to laser treatment. B.

5 Complications of heavy liquid during PPV Fig 2. A. Retinography shows round reflex at macular due to subfoveal PFCL and atrophic change around posterior pole due to laser treatment. B. After 48 months with secondary IOL implant, retinography shows no obvious anatomy changes.(red arrow) The patients last visual acuity was C.Vertical OCT section of the "B" case was shown and subfoveal PFCL bubble was observed.(blue arrow head) D. Postoperative retinography showing yellowish glistening macula due to submacular PFCL.(red arrow) E. After 6 months, retinography shows inferiorly displaced PFCL (red arrow) and premacular gliosis and epiretinal membrane.(blue arrow head) 127

6 으나환자는비문증을호소하였다 (Table 3). 과불화탄소액이망막하로유입된경우는총 5안으로이중 2안은황반부를벗어난망막하에유입되었고, 3안은황반하로유입되었다. 이경우수술적응증은열공성망막박리가 4안으로가장많았으며, 증식성당뇨망막병증에동반된견인성망막박리가 1안이었다. 황반부를벗어난후극부망막하로유입된 2안의수술적응증은모두열공성망막박리였으며, 경과관찰기간은 2년에서 4년이었다. 경과관찰동안시력에대한영향이없었고, 90D 세극등검사와 OCT 검사상망막의변화가관찰되지않았다 (Fig. 1B, C). 과불화탄소액이황반하로유입된 3안의수술원인은열공성망막박리 2안, 증식성당뇨망막병증에동반된견인성망막박리 1안이었다. 증례 7의경우견인성망막박리로과불화탄소액을사용하였고, 술후발견된황반하과불화탄소액은 3개월뒤 2차수술시에제거하였으나, 48개월간의경과관찰기간동안과불화탄소액이있던위치에황반원공이발생하였다. 증례 8의경우열공성망막박리수술시에사용한과불화탄소액이황반하에잔류되었으나 48개월간의경과관찰기간동안유의한합병증은발생하지않았다 (Fig 2A, B.). 증례 9의경우망막박리수술시에사용한과불화탄소액이황반하로유입되었으며, 실리콘기름충전안으로복와위를취한상태에서과불화탄소액이망막하부로이동하였으나후에과불환탄소액이잔류되었던부위에망막앞막이발생하였다 (Fig 2D, E). 고찰 1987 년 Chang 등이과불화탄소의이러한성질을이용하여망막박리수술의도구로과불화탄소액의사용을권하였고, 임상에서그사용이늘어가고있다. 2 그러나일반적으로과불환탄소액사용의일차적응증으로증식성유리체망막병증으로동반한망막박리, 거대열공성망막박리, 관통상등이알려져있으나, 기존에과불환탄소액이필요한수술적응증빈도에대한임상보고는없었다. 본 연구에서는망막박리수술에서과불화탄소액이 (42%) 가장많이사용되었고, 유리체및망막하출혈, 수정체후방편위, 견인성망막박리, 맥락막상강출혈, 맥락막박리순으로사용되었다. 망막하과불화탄소액잔류의빈도는연구에따라 0.9 ~ 11% 까지다양하게보고되고있다. 6-8 본연구의경우유리체절제술후의전방, 유리체강, 망막하를포함한전체적인안내잔류빈도는 8.3% 였다. 열공성망막박리수술이후망막하에유입된경우만고려할경우총 45안중 4안 (8.8%) 에서망막하과불화탄소액유입이발견되어앞선보고들과유사한빈도를보였다. 하지만이러한잔류빈도는사용된과불환탄소액의종류및점도, 망막결손부의크기, 술후평형염액을이용한세척의정도, 수술수기등에영향을받을수있다. 8 Garica-Valenzuela 등은 120 이상의큰주변부망막절개술, 과불화탄소액의사용후제거를위한세척의유무등이유의한위험인자라고보고하였다. 6 Scott등은유리체망막수술 6개월후 perfluoro-n-octane 과 perfluoroperhydrophenanthrene 에따른망막하과불화탄소액의잔류빈도는 7.8% 와 38.3% 로후자에서높은빈도를보였다고하였다. 8 본연구에서는전수술에서 perfluoro-n-octane (C8F18) 을사용하였다. C8F18 의표면장력과비중, 점도, 굴절률이각각 14(mN/m), 1.76 (g/cm3), 0.8 (mpas), 1.27이나 C14F24 의경우 18(mN/m), 2.03 (g/cm3), 8.03(mPas), 1.33 으로차이가있다. 즉비중이상대적으로낮고, 증기압이높은 C 8 F 18 의경우 C 14 F 24 에비해제거가상대적으로쉽고, C 14 F 24 의경우굴절률이식염수나방수와비슷하여상대적으로수술후제거에어려운점이있다. 본연구에서도과불화탄소액의안내잔류로인해발생한합병증을살펴보면잔류된해부학적위치에따라망막에미치는영향이달랐다. 전방에잔류된증례는 3안이었고, 2개월까지경과관찰하였으나세극등검사상합병증이없었다. 전방으로유입된경우각막독성, 백내장, 그리고염증발생에대한보고가있으며, 4,5,9 Moreira 등은토끼실험을통해결막충혈및각막혼탁이발생할수있음 128

7 Complications of heavy liquid during PPV 을보고하였으며, 10 Alster 등은잔류된과불화탄소액에의한동공차단녹내장등도보고하고있다. 11 전방내과불화탄소액으로인한합병증발생기간의측면에서 perfluorodecaline 의경우각막내피세포와접촉후 4-13 주후부터각막부전이, 12 Wilbanks 등은과불화탄소액에의한기계적손상으로빠르면 1개월부터각막독성이발생한다고보고하였다. 13 과불화탄소액의유리체강내잔존으로인한결과도보고자에따라많은차이가있다. Rofail 등은거대열공성망막박리수술후망막압박을위해과불화탄소액을 6-50 일간사용한결과유의한합병증이없었다고하였다. 14 이와는달리 Eckardt 등은토끼유리체강내에 perfluoro-n-octane 과 perfluoropolyether 를주입하여 2개월간관찰하여, 주입 6일후부터조직학적변화가발생함을관찰하였고, 2개월후망막과망막색소상피층의손상을확인하였다. 15 본연구의 1안에서과불화탄소액이유리체강내잔류된증례의경우 1년까지경과관찰시, 비문증이발생하기는하였으나시력및해부학적결과에영향을미치는합병증은발생하지않았다. 본연구의경우 3안에서황반하로과불화탄소액이잔류되었다. 이중 1안은 3개월후 2차수술시과불화탄소액을제거하였으나경과관찰중과불화탄소액이유입된부위에황반원공이발생하였고, 1안에서는망막앞막이발생하였다. 나머지 1안의경우 48개월간유의한합병증이발생하지않았다. PFCL 이황반하에있던곳에망막앞막이발생한증례의경우인과관계를알수없다. 이와대조적으로황반부를벗어나망막하에잔류된경우 2-4년까지경과관찰시유의한합병증이발생하지않아 Garcia 등의보고와언급처럼황반부이외의망막하과불화탄소액은비교적안정된결과를보였다. 6 황반부를벗어난후극부의망막하과불화탄소액의경우장기간의경과관찰에도안정된경과를보이며, 술후시력및해부학적결과에영향을미치지않았다. 잔류한과불화탄소액의해부학적위치가환자의시력과관련이많은것으로보인다. 즉, 전방내유입된과불화탄소액의경우비교적단기간의 잔류에는안정된경과를보이므로술후에발견된경우전방천자등을통해제거하는것이적절할것이다. 망막하로유입된경우황반부를벗어난부위에잔류된경우황반하에잔류된경우에서보다비교적합병증이적고, 장기간잔류에도비교적안정된경과를보이는것으로생각된다. 하지만황반하로유입된경우다양한합병증을유발할수있음에유의해야할것이다. 황반은시력의중심이기때문에 PFCL 이잔류하면시력에대한합병증이발생하기쉬울뿐아니라, fovea 의두께가다른망막보다얇아 fovea 아래에 PFCL 이잔류하게되면쉽게황반원공이발생할것으로추측된다. 또한황반하과불화탄소액의제거후가역적시력회복및중심암점소실등의보고가있어이데대한적극적인대처가필요할것으로사료된다 REFERENCES 1. Lesnoni G, Rossi T, Gelso A. Subfoveal liquid perfluorocarbon. Retina 2004;24: Chang S, Lincoff H, Zimmerman NJ, Fuchs W. Giant retinal tears. Surgical techniques and results using perfluorocarbon liquids. Arch Ophthalmol 1989;107: Peyman GA, Schulman JA, Sullivan B. Perfluorocarbon liquids in ophthalmology. Surv Ophthalmol 1995;39: Han DP, Nanda SK, O'Brien WJ, Guy J, Murray TG, Boldt HC. Evaluation of anterior segment tolerance to short-term intravitreal perfluoron. Retina 1994;14: Tanji TM, Peyman GA, Mehta NJ, Millsap CM. Perfluoroperhydrophenanthrene (Vitreon) as a short-term vitreous substitute after complex vitreoretinal surgery. Ophthalmic surgery 1993;24: Garcia-Valenzuela E, Ito Y, Abrams GW. Risk factors for retention of subretinal perfluorocarbon liquid in vitreoretinal surgery. Retina 2004;24: Bourke RD, Simpson RN, Cooling RJ, Sparrow JR. The stability of perfluoro-n-octane during vitreoretinal procedures. Archives of ophthalmology 1996;114:

8 8. Scott IU, Murray TG, Flynn HW, Jr., Smiddy WE, Feuer WJ, Schiffman JC. Outcomes and complications associated with perfluoro-n-octane and perfluoroperhydrophenanthrene in complex retinal detachment repair. Ophthalmology 2000;107: Viebahn M, Buettner H. Perfluorophenanthrene unsuitable for postoperative retinal tamponade. Am J Ophthalmol 1994;118: Moreira H, de Queiroz JM, Jr., Liggett PE, McDonnell PJ. Corneal toxicity study of two perfluorocarbon liquids in rabbit eyes. Cornea 1992;11: Alster Y, Ben-Nun Y, Loewenstein A, Lazar M. Pupillary block glaucoma due to residual perfluoro-decalin. Ophthalmic Surg Lasers 1996;27: Aydin E, Demir HD. Perfluorodecaline residue in the anterior chamber of a patient with an intact crystalline lens: a case report. J Med Case Rep 2008;2: Wilbanks GA, Apel AJ, Jolly SS, Devenyi RG, Rootman DS. Perfluorodecalin corneal toxicity: five case reports. Cornea 1996;15: Rofail M, Lee LR. Perfluoro-n-octane as a postoperative vitreoretinal tamponade in the management of giant retinal tears. Retina 2005;25: Eckardt C, Nicolai U, Winter M, Knop E. Experimental intraocular tolerance to liquid perfluorooctane and perfluoropolyether. Retina 1991;11: Vilaplana D, Poposki V, Martinez-Palmer A, Castilla M. [Subfoveal perfluorocarbon liquid. Two new cases]. Arch Soc Esp Oftalmol 2009;84: Escalada Gutierrez F, Mateo Garcia C. [Extraction of subfoveal liquid perfluorocarbon]. Arch Soc Esp Oftalmol 2002;77: Wong TY, Ho T. Retained perfluorodecalin after retinal detachment surgery. Int Ophthalmol 1996;20:

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A 617 Special Issue Diabetic Retinopathy Won Ki Lee, M.D. Department of Ophthalmology The Catholic University of Korea College of Medicine Kangnam St. Mary s Hospital E mail : wklee@catholic.ac.kr Abstract R