Journal of Retina 2018;3(2): ORIGINAL ARTICLE pissn eissn 습성나이관련황반변성에서 5 회주사시시력이 0.1

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1 Journal of Retina 2018;3(2):64-70 ORIGINAL ARTICLE pissn eissn 습성나이관련황반변성에서 5 회주사시시력이 0.1 이하였던환자들의 1 년추적결과 Long-Term Visual Outcomes in Patients with Neovascular AMD Who Exhibited Visual Acuity of 0.1 or Worse at 5th Injection 태기선 1, 김종우 2, 김철구 2, 이동원 2, 김재휘 2 Kee Sun Tae 1, Jong Woo Kim 2, Chul Gu Kim 2, Dong Won Lee 2, Jae Hui Kim 2 1 태안과, 2 건양대학교의과대학김안과병원안과 1 Dr. Tae Eye Clinic, Seoul, Korea 2 Department of Ophthalmology, Kim s Eye Hospital, Konyang University College of Medicine, Seoul, Korea Purpose: To evaluate one-year follow-up outcomes of patients with neovascular age-related macular degeneration (AMD) who exhibited best-corrected visual acuity (BCVA) of 0.1 or worse at the 5th anti-vascular endothelial growth factor (VEGF) injection. The factors associated with visual prognosis were additionally investigated. Methods: This retrospective study included 21 eyes (21 patients) diagnosed with neovascular AMD exhibiting BCVA of 0.1 or worse (0.1:13 eyes, worse than 0.1:8 eyes) at the 5th anti-vegf (VEGF) injection. The timing of the 5th injection was identified. In addition, factors associated with 0.1 or better BCVA at 12 months after the 5th injection were investigated Results: The timing of the 5th injection was a mean 9.1 ± 3.2 months after diagnosis. The mean logarithm of minimal angle of resolution BCVA at the 5th injection and at 12 months after was 1.14 ± 0.20 and 1.21 ± 0.40, respectively. At 12 months after the 5th injection, 8 eyes (38.1%) and 3 eyes (14.3%) exhibited BCVA of 0.1 and 0.2, respectively. The BCVA at the 5th injection was significantly associated with that measured at 12 months after (p = 0.008). Conclusions: In eyes exhibiting BCVA of 0.1 or worse at the 5th injection, visual acuity was not significantly changed during 12-months of treatment, and the BCVA at the 5th injection was predictive of the 12-month visual outcome. Visual improvement was noted in some eyes, suggesting the need for continuous treatment for these eyes. Keywords: Aflibercept; Age-related macular degeneration; Anti-vascular endothelial growth factor; Choroidal neovascularization; Ranibizumab Address reprint requests to Jae Hui Kim, MD Department of Ophthalmology, Kim s Eye Hospital, #136 Yeongsin-ro, Yeongdeungpo-gu, Seoul 07301, Korea Tel: , Fax: kjh7997@daum.net Received: Revised: Accepted: *This work was supported by Kim s Eye Hospital Research Center. Copyright 2018 The Korean Retina 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.

2 Tae KS, et al. 5 회주사시시력과 1 년추적결과 서론 습성나이관련황반변성은실명의주된원인중하나이다 [1]. 습성나이관련황반변성의자연경과는매우좋지않아심각한시력저하가발생할수있으며 [2], 이와동반하여삶의질또한저하되는것으로알려져있다 [3]. 유리체강내항혈관내피성장인자주사는습성나이관련황반변성의치료에효과적인방법으로 [4,5] 현재이질환에대한표준치료로널리이용되고있다. 라니비주맙 (Lucentis TM ; Genentech, San Francisco, CA, USA) 과애플리버셉트 (Eylea TM ; Regeneron, Tarrytown, NY, USA) 는국내식품의학안전처의승인을받아습성나이관련황반변성의치료에이용되고있는약제로환자의시력을유지시키거나호전시키는데에뛰어난효과를보였다 [4,5]. 국내에서라니비주맙혹은애플리버셉트치료시건강보험의지원을받을수있는제도적뒷받침이있어왔으나 2017 년 12월 1일이전에는건강보험지원이가능한횟수에제한을두었다. 2017년 12월 1일부터보험제도의변경에따라횟수제한은없어졌으나 5회주사부터는교정시력이 0.1 이하인경우적절한사유없이는보험급여를적용받기어렵도록규정이변경되었다. 따라서국내환자를치료하는경우 5회주사시 0.1 이하로시력이측정된환자들의예후에대한연구는중요한의미를가질수있을것으로판단된다. 현재까지습성나이관련황반변성의치료결과를분석한수많은연구결과가발표되었으나 5회주사시시력에중점을맞추어분석한연구는없었다. 이에본연구에서는 5회주사시시력이 0.1 이하로측정된환자들의 1년추적결과를알아보고, 시력예후와관련된인자를분석하고자한다. 대상과방법 본연구는단일기관에서시행된후향적연구로헬싱키선언에입각하여시행되었으며, Institutional Review Board (IRB) 승인을획득하였다 (Kim s Eye Hospital-IRB) 년 5월부터 2015년 2월까지습성나이관련황반변성으로진단후최초치료로 1개월간격 3회의라니비주맙혹은애플리버셉트주사를시행받았으며, 5회주사시최대교정시력이 0.1 (decimal) 이하로측정된안을대상으로후향적의무기록분석을시행하였다. 다음과같은경우연구에서제외하였다. 1) 5회주사후 12개월미만의추적관찰기간, 2) 재발여부과관련없이지속적으로주사하는 proactive 치료를시행받은경우, 3) 첫 3회주사후기존약제에효과가제한적인것으로판정되어바로교체투여를시행한경우, 4) 심한매체혼탁, 5) 이전에유리체망막수술을받은병력이있는경우, 6) 5회주사후 12개월이내에백내장수술이나유리체망막수술을시행받은경우, 7) 증식당뇨망막병증, 망막혈관폐쇄, 8) 황반원공이나망막전막등황반미세구조와시기능에영 향을미칠수있는기타유리체망막질환이동반된경우. 양안이진단된경우증상이먼저나타난안을연구에포함하였다. 진단시환자의최대교정시력을측정하였으며, 세극등을이용한안저검사및빛간섭단층촬영 (SLO-OCT : OTI Ophthalmic Technologies Inc, Toronto, Canada; Spectralis : Heidelberg Engineering, Heidelberg, Germany; RS 3000 : Nidek Co., Ltd., Tokyo, Japan) 및형광안저혈관조영술을시행하였다. 모든환자는진단후 1개월간격으로 3회의라니비주맙 (0.5 mg / 0.05 ml) 혹은애플리버셉트 (2.0 mg / 0.05 ml) 주사를시행받았다. 유리체내주사는외래수술실에서시행되었다. 시술전 0.5% proparacaine (Alcaine ; Alcon, Fort Worth, TX, USA) 을점안한뒤 1.25% povidone iodine을시술할눈에점안하고속눈썹을포함하여눈주위를닦았다. 개검기를끼우고 1.25% povidone iodine을한번더점안한뒤각막윤부에서 3.0 mm 혹은 3.5 mm 하측사분면혹은상측사분면에 30게이지일회용바늘을이용하여주사를시행하였다. 첫 3회주사이후 1-2 개월간격으로경과관찰을시행하였으며, 장기간재발이없던경우의사의판단에따라 3-4개월까지경과관찰간격을연장하였다. 모든환자들은추적관찰시세극등을이용한안저검사및빛간섭단층촬영을시행하였다. 빛간섭단층촬영에서중심와를침범하거나위협하는망막하액 / 망막내액이발생한경우혹은안저검사에서망막 / 망막하출혈이발생한경우를질환의활동성이재발한것으로판단하고추가주사를시행하였다. 국내보험기준에따라첫 3회주사이후주사간격은라니비주맙은최소 4주, 애플리버셉트는최소 8주이상으로유지하였다. 진단당시, 3개월, 5회주사시및 5회주사후 12개월에각각측정된최대교정시력을확인하였으며, 5회주사의시기를추가적으로확인하였다. 5회주사 12개월후 0.1 혹은 0.2의시력을예측할수있는인자를확인하기위하여각인자들을아래와같이 2개군으로구분하였다 ; 환자의나이 : 71세이하 vs. 72세이상, 성별 : 남성 vs. 여성, 진단시병변의크기 : 6.20 mm 2 미만 vs mm 2 이상, 5회주사시점 : 진단후 9개월미만 vs. 진단후 9개월혹은그이후, 진단시의시력 : 0.1 이상 vs. 0.1 미만, 3개월시력 : 0.2 이상 vs. 0.2 미만, 5회주사시의시력 : 0.1 vs. 0.1 미만. 5회주사 12개월후의시력이 0.2 이상인경우의비율을양군간에서로비교하였다. 5회주사 12개월후시력의경우환자가정확히 12개월시점에방문하지않았을때에는그시점으로부터가장가까운시점의값으로대체하였다. 최대교정시력은통계분석을위하여 logarithm of minimal angle of resolution (logmar) 값으로변환하였다. 병변의크기는형광안저혈관조영술이미지를이용하여측정하였으며, 형광누출과염색및출혈범위전체를포함하여측정하였다. 통계분석에는 SPSS 프로그램 (SPSS ver for Windows; SPSS Inc., Chicago, IL, USA) 을이용하였다. 서 65

3 JOURNAL OF RETINA 로다른양군간의비교는 Fisher s exact test 를이용하였으며, 0.05 미만의 p 값을통계적으로유의한값으로정의하였다. 결과 전체 21 안 (21 명 ) 을대상으로연구를시행하였다 (Table 1). 남성 12 명, 여성 9 명이었으며, 평균연령은 72.9 ± 6.9 세였다. 5 회주 사가시행된시기는진단후평균 9.1 ± 3.2 개월이었으며, 진단 시부터 5 회주사후 12 개월까지시행된평균주사횟수는 7.2 ± 1.0 회였다. 최초진단시, 3 개월, 5 회주사시및 5 회주사후 12 개월시점 에측정한평균 logmar 최대교정시력은 1.20 ± 0.31, 0.96 ± 0.34, 1.14 ± 0.20 및 1.21 ± 0.40 이었다 (Fig. 1). 5 회주사시와 비교하였을때, 주사후 12 개월에 logmar 시력 0.3 이상의호 전을보인경우는 3 안 (14.3%), 0.3 이상의악화를보인경우는 6 안 (28.6%) 이었으며, 나머지 12 안 (57.1%) 은시력에큰변동이없었 다. 5 회주사시시력이 0.1 이었던 13 안중 10 안 (76.9%) 에서시 력이유지되거나호전되었으며, 5 회주사시시력이 0.1 미만이었 던 8 안중시력이유지되거나호전된경우는 5 안 (62.5%) 이었다. 진단당시최대교정시력이 0.1 이상및 0.1 미만으로측정된안 은각각 11 안 (52.4%) 및 10 안 (47.6%) 이었으며, 3 개월에는각각 17 안 (80.9%) 및 4 안 (19.0%), 5 회주사시에는각각 13 안 (61.9%) 및 8 Table 1. Characteristics of 21 patients (21 eyes) with neovascular age-related macular degeneration in whom the BCVA was 0.1 (decimal) or worse when the 5th anti-vascular endothelial growth factor injection was performed Characteristic Value Age (years) 72.9 ± 6.7 Sex Men 12 (57.1) Women 9 (42.9) Hypertension 10 (47.6) Diabetes mellitus 4 (19.0) Lesion size (mm 2 ) 6.2 ± 2.4 Baseline BCVA (logmar) 1.20 ± 0.31 Timing of 5th injection (months) 9.1 ± 3.2 BCVA at 5th injection (decimal) (61.9) Worse than (38.1) Values are presented as mean ± standard deviation or number (%). BCVA = best-corrected visual acuity; logmar = logarithm of minimal angle of resolution. 안 (38.1%), 5 회주사 12 개월이후에는각각 11 안 (52.4%) 및 10 안 (47.6%) 이었다 (Fig. 2). 5 회주사후 12 개월에시력이 0.2 로호전 된안은 3 안 (14.3%) 이었다 (Fig. 3). 이들 3 안은모두 3 개월에 0.2 이상, 5 회주사시 0.1 의시력을보인경우였다. 5 회주사시시력이 0.1 이었던 13 안중 10 안 (76.9%) 에서 12 개 월시력이 0.1 혹은 0.2 였던반면 5 회주사시시력이 0.1 미만이 었던 8 안중 1 안 (12.5%) 에서만 12 개월시력 0.1 혹은 0.2 로측정 되어 5 회주사시시력이 0.1 인경우, 0.1 미만인경우에비하여 주사 12 개월후시력이 0.1 혹은 0.2 로측정된비율이유의하게 더높은것으로나타났다 (p = 0.008, Table 2). 다른인자들인나 BCVA (logmar) Baseline 3M 5th lnj. 12M after Follow-up period Figure 1. Changes in logarithm of minimal angle of resolution (log- MAR) best-corrected visual acuity (BCVA) in all 21 included eyes. 3M = 3 months after diagnosis (1 month after 3 loading injections); 5th Inj. = when the 5th injection was performed; 12M after = 12 months after the 5th injection. Proportion patients 100% 80% 60% 40% 20% 0% Baseline 3M 5th lnj. 12M after Follow-up period , Figure 2. Changes in the proportion of eyes exhibited best-corrected visual acuity (BCVA) 0.2 (decimal) or better ( 0.2), 0.1 or better but worse than 0.2 ( 0.1, < 0.2), and worse than 0.1 (< 0.1). 3M = 3 months after diagnosis (1 month after 3 loading injections); 5th Inj. = When the 5th injection was performed; 12M after = 12 months after the 5th injection. 66

Tae KS, et al. 5 회주사시시력과 1 년추적결과 A B C D E F Figure 3.

injection. At diagnosis (A-C), the best-corrected visual acuity (BCVA) was measured as 0.1 (decimal). The BCVA improved to 0.

1 with recurrence of fluid (E) and 5th injection was performed.

2 (A, fundus photography; B, fluorescein angiography; C-F, optical coherence tomography). Table 2.

1 (decimal) or better at 12 months after 5th injection Factor BCVA at 12 months after 5th injection 0.

0) Sex 0.198 Male 8 (66.7) 4 (33.3) Female 3 (33.3) 6 (66.7) Lesion size 0.670 Smaller than 6.20 mm 2 4 (44.4) 5 (55.6) 6.

4 Tae KS, et al. 5 회주사시시력과 1 년추적결과 A B C D E F Figure 3. A representative case showing long-term improvement of visual acuity after 5th anti-vascular endothelial growth factor injection. At diagnosis (A-C), the best-corrected visual acuity (BCVA) was measured as 0.1 (decimal). The BCVA improved to 0.3 after 3 monthly anti-vascular endothelial growth factor injections (D). After 13 months BCVA had deteriorated to 0.1 with recurrence of fluid (E) and 5th injection was performed. Twelve months after the 5th injection (F), the BCVA had improved to 0.2 (A, fundus photography; B, fluorescein angiography; C-F, optical coherence tomography). Table 2. Factors associated with best-corrected visual acuity 0.1 (decimal) or better at 12 months after 5th injection Factor BCVA at 12 months after 5th injection 0.1 or better Worse than 0.1 p-value* Age years or younger 7 (63.6) 4 (36.4) 72 years or older 4 (40.0) 6 (60.0) Sex Male 8 (66.7) 4 (33.3) Female 3 (33.3) 6 (66.7) Lesion size Smaller than 6.20 mm 2 4 (44.4) 5 (55.6) 6.20 mm 2 or larger 7 (58.3) 5 (41.7) Timing of 5th injection Before 9 months after diagnosis 3 (30.0) 7 (70.0) 9 months or after 8 (72.7) 3 (27.3) Baseline BCVA or better 7 (63.6) 4 (36.4) Worse than (40.0) 6 (60.0) BCVA at 5th injection (76.9) 3 (23.1) Worse than (12.5) 7 (87.5) Values are presented as number (%). BCVA = best-corrected visual acuity. *Statistical analysis performed using Fisher s exact test. 67

5 JOURNAL OF RETINA 이 (p = 0.395), 성별 (p = 0.198), 병변의크기 (p = 0.670), 5회주사시점 (p = 0.086) 및진단당시시력 (p = 0.395) 은 5회주사 12개월후의시력과유의한연관성이나타나지않았다. 고찰 습성나이관련황반변성에서유리체강내항혈관내피성장인자주사의효과를평가한초기임상시험에서는비교적많은횟수의주사를시행하였는데, 라니비주맙의경우매달지속적으로주사하는방법을이용하였고 [4], 애플리버셉트의경우첫 3회매달주사후 2개월간격으로지속주사하는방법을이용하였다 [5]. 그러나이들약제가상당히고가라는점을고려하였을때, 이러한방식의치료를지속하는데에는경제적부담이커지는문제점이있었으며 [6], 약제의뛰어난효과에도불구하고치료비부담의증가는사회경제적문제로대두되었다 [7]. 현재는보다효율적인치료를위하여도입된 as-needed 방식이나 treat-and-extend 방식이널리이용되고있으나치료비용에관련된문제는여전히남아있는상태이다 [8]. 습성나이관련황반변성은비가역적인시력손상을유발할수있는질환으로항혈관내피성장인자치료를시행하는경우에도일부환자에서는지속적인시력의저하가나타나게된다 [9]. 항혈관내피성장인자치료의경제적부담을고려하였을때, 시력이이미많이손상된환자를대상으로한지속적인주사치료는비용-효과측면에서바람직하지않을수있다는우려가제기되었다 [10]. 따라서반대쪽눈이실명한 last eye 환자와같이특수한경우를제외한다면이러한환자들에대한치료방침을결정할때에는향후시력의유지혹은호전가능성을어느정도예측해보고, 추가주사가환자에게얼마나도움이될것인가를충분히생각해보아야할것이다. 일반적으로습성나이관련황반변성의시력예후를예측하는연구에서는진단당시를기준으로한시력, 질환및환자의특성들중에서치료후시력을예측할수있는인자가있는지를분석하였다 [11-13]. 기존연구결과에따르면나이 [12,13], 병변의크기 [12,13], 진단당시의시력 [12,13], 신생혈관의종류 [11], 혈전용해제의사용여부 [11] 등이장기시력예후와연관된것으로나타났다. 진단당시시력이 0.1 혹은그이하로좋지않았던안을대상으로항혈관내피성장인자치료결과를분석한기존연구들의경우 43-70% 에서시력이유지되거나호전되었는데, 이와같은연구결과는초기시력이좋지않은경우에도적극적인치료가도움이될수있다는점을시사한다 [14,15]. 그러나진단당시시력을기준으로한상기연구결과를본연구에서와같이치료도중에측정된시력에직접적으로적용하기는어려울것이다. 습성나이관련황반변성에대한치료를언제중단해야하는가? 에대해서는아직정해진기준이없으며, 치료자의경험과지식에기초하여개별적으로판단하는경우가많다. Elshout et al. [10] 은습성나이관련황반변성에서시력과삶의질사이의연관관계에대하여연구하였는데, 0.05 미만시력의경우시력의변화가삶의질에유의한영향을미치지않았다. 이와같은결과를바탕으로 Elshout et al. [10] 은 0.05 미만시력이회복불가능한것으로판단되는경우치료중단을고려할수있다고제안하였다. 그러나치료중단에대한판단은각환자의상태에따라다를수있음을추가적으로강조하였는데 [10], 이는습성나이관련황반변성에서치료중단에대한기준을명확하게정하기어렵다는점을보여주고있다. 본연구에서는 5회주사시 0.1의시력 을중요하게고려하는현행국내보험제도의특성을반영하여습성나이관련황반변성에대한 5회주사시시력이 0.1 이하였던환자들의 12개월추적결과에초점을맞춘분석을시행하였다. 기존연구들에서장기시력예후와밀접하게연관된것으로나타난진단당시의각종특성들의경우 [11-13] 본연구에서 5회주사 12개월후에측정된시력과는유의한관련성이나타나지않았다. 그러나 5회주사시의시력은이후 12개월에측정된시력을예측할수있는인자로나타났는데, 5회주사시시력이 0.1로측정된경우의대부분에서주사후 12개월시력이 0.1 혹은 0.2로측정되었으나, 시력이 0.1 미만이었던경우에는 0.1 혹은 0.2 시력으로회복될가능성이낮은것으로나타났다. 특히시력이 0.1이었던안들의 76.9% 에서시력이유지되거나호전되었는데, 이와같은결과는추가적인치료가 0.1 시력의환자들에게도움이될수있다는점을시사하는소견으로생각된다. 본연구에서는 14.3% 에서 logmar 시력 0.3 이상의호전을보였는데, 이는일반적으로 뚜렷한시력호전 의기준으로자주이용되는 시력표 3줄이상의시력호전 에해당하는변화이다. 기존의임상시험결과에따르면습성나이관련황반변성에서항혈관내피성장인자를매달주사하는적극적인방법을시행하였을때, 33.8% 에서 12개월시력이시력표 3줄이상호전된것으로나타났다 [4]. 일반적으로실제진료환경에서의치료결과는임상시험에비하여좋지않다는점을고려하였을때 [16], 본연구에서나타난 14.3% 라는비율은의미있는수치로생각되며, 추가치료가이들환자에서뚜렷한효과가있었음을보여준다. 다만 logmar 시력이 0.3 이상호전된 3안은모두첫 3회주사후시력이 0.2 이상으로측정되었으며, 5회주사시 0.1의시력을보인경우였다. 이와같은결과를고려해보면, 첫 3회주사후에도시력이 0.2 이상으로회복되지못하였거나 5회주사시시력이 0.1 미만으로측정된경우에는 5회주사후장기적으로시력호전의가능성이낮을것으로추측해볼수있다. 그러나본연구는소수의안을대상으로시행되었으므로, 이와같은부분에대해서는다수의안을대상으로한추가연구를통하여다시한번확인해야할것으로생각된다. 68

6 Tae KS, et al. 5 회주사시시력과 1 년추적결과 본연구에는다음과같은제한점들이있다. 우선본연구는후향적연구로소수의안을대상으로결과를분석하였다. 진단후 1개월간격 3회항혈관내피성장인자주사를시행받은안만을대상으로하였기에, 본연구의결과는 1회혹은 2회주사후경과관찰한경우에는적용하기어려울것이다. 또한본연구에서는 as-needed 치료에준한방법을이용하였는데, as-needed 치료시권장되는매달경과관찰하는방법 [17] 을엄격하게적용하지못하였으며, 치료자의판단에따라경과관찰사이의기간을 4개월까지연장하였다. 따라서일부환자들의경우재발하였을때, 적절한조기치료가이루어지지못하여시력결과에영향을미쳤을가능성이있다. 마지막으로본연구의결과는재발여부와상관없이지속적으로주사하는 proactive 방식으로치료한환자들에게는적용할수없을것이다. 요약하면, 본연구에서는 5회주사시시력이 0.1 이하였던안의실제임상에서 12개월추적시력결과와예후인자에대하여분석하였는데, 대부분의안에서 5회주사후 12개월동안시력이유지되거나호전되는결과를보였으며, 특히시력이 0.1이었던경우이와같은경향이보다뚜렷하게나타났다. 5회주사시시력은주사후 12개월의시력을예측할수있는인자로나타났다. 12개월후의시력이 0.2로호전된안의경우, 모두진단후 3개월에측정된시력이 0.2 이상이면서 5회주사시시력이 0.1 미만으로악화되지않았던경우였다. 본연구는실제진료환경에서습성나이관련황반변성을치료할때, 환자의시력예후를예측하는데에유용한정보를제공해줄수있을것이다. 그러나본연구에는여러제한점들이있으며, 연구에포함된환자들은국내보험급여기준에따라치료를시행받았다. 향후보다많은안을대상으로한잘통제된추가연구를통하여 5회주사시교정시력 0.1 이하 라는현행보험기준의효율성에대한평가가필요할것이다. References 1. Flaxman SR, Bourne RRA, Resnikoff S, et al. Global causes of blindness and distance vision impairment : a systematic review and meta-analysis. Lancet Glob Health 2017;5:e Wong TY, Chakravarthy U, Klein R, et al. The natural history and prognosis of neovascular age-related macular degeneration: a systematic review of the literature and meta-analysis. Ophthalmology 2008;115: Elshout M, Webers CA, van der Reis MI, et al. Tracing the natural course of visual acuity and quality of life in neovascular age-related macular degeneration: a systematic review and quality of life study. BMC Ophthalmol 2017;17: Rosenfeld PJ, Brown DM, Heier JS, et al. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med 2006;355: Heier JS, Brown DM, Chong V, et al. Intravitreal aflibercept (VEGF trap-eye) in wet age-related macular degeneration. Ophthalmology 2012;119: Smiddy WE. Economic implications of current age-related macular degeneration treatments. Ophthalmology 2009;116: Day S, Acquah K, Lee PP, et al. Medicare costs for neovascular age-related macular degeneration, Am J Ophthalmol 2011;152: Haller JA. Current anti-vascular endothelial growth factor dosing regimens: benefits and burden. Ophthalmology 2013;120(5 Suppl):S Rofagha S, Bhisitkul RB, Boyer DS, et al. Seven-year outcomes in ranibizumab-treated patients in ANCHOR, MARINA, and HORI- ZON: a multicenter cohort study (SEVEN-UP). Ophthalmology 2013;120: Elshout M, van der Reis MI, de Jong-Hesse Y, et al. Distinguishing between better and worse visual acuity by studying the correlation with quality of life in neovascular age-related macular degeneration. Ophthalmology 2016;123: Chae B, Jung JJ, Mrejen S, et al. Baseline predictors for good versus poor visual outcomes in the treatment of neovascular age-related macular degeneration with intravitreal anti-vegf therapy. Invest Ophthalmol Vis Sci 2015;56: Lanzetta P, Cruess AF, Cohen SY, et al. Predictors of visual outcomes in patients with neovascular age-related macular degeneration treated with anti-vascular endothelial growth factor therapy: post hoc analysis of the VIEW studies. Acta Ophthalmol 2018 Apr 16. doi: /aos [Epub ahead of print] 13. Regillo CD, Busbee BG, Ho AC, et al. Baseline predictors of 12-month treatment response to ranibizumab in patients with wet age-related macular degeneration. Am J Ophthalmol 2015;160: e Galbinur T, Averbukh E, Banin E, et al. Intravitreal bevacizumab therapy for neovascular age-related macular degeneration associated with poor initial visual acuity. Br J Ophthalmol 2009;93: Ehrlich R, Weinberger D, Priel E, Axer-Siegel R. Outcome of bevacizumab (Avastin) injection in patients with age-related macular degeneration and low visual acuity. Retina 2008;28: Holz FG, Tadayoni R, Beatty S, et al. Multi-country real-life experience of anti-vascular endothelial growth factor therapy for wet age-related macular degeneration. Br J Ophthalmol 69

7 JOURNAL OF RETINA 2015;99: Fung AE, Lalwani GA, Rosenfeld PJ, et al. An optical coherence tomography-guided, variable dosing regimen with intravitreal ranibizumab (Lucentis) for neovascular age-related macular degeneration. Am J Ophthalmol 2007;143: 국문초록 습성나이관련황반변성에서 5 회주사시시력이 0.1 이하였던환자들의 1 년추적결과 목적 : 습성나이관련황반변성에서 5회주사시 0.1 이하의시력이었던환자들의 1년추적결과를알아보고시력결과와관련된인자를분석하고자한다. 대상과방법 : 습성나이관련황반변성으로진단후최초치료로 1개월간격 3회의항혈관내피성장인자주사를시행받았으며, 5회째주사시시력이 0.1 이하였던 21안 (0.1: 13안, 0.1 미만 : 8안 ) 을대상으로후향적의무기록분석을시행하였다. 5회주사의시기를확인하였으며, 5회주사 12개월후시력 0.1 이상을예측할수있는인자를추가로분석하였다. 결과 : 5회주사가시행된시기는진단후평균 9.1 ± 3.2개월이었다. 5회주사및주사후 12개월시점에측정한평균 logarithm of minimal angle of resolution 최대교정시력은 1.14 ± 0.20 및 1.21 ± 0.40이었다. 5회주사후 12개월시력이 0.1 로측정된경우는 8안 (38.1%) 이었으며, 3안 (14.3%) 의경우 0.2의시력을보였다. 5회주사시측정된시력은주사후 12개월의시력과유의한연관성이있었다 (p = 0.008). 결론 : 5회주사시시력이 0.1 이하였던눈에대한 1년치료결과, 시력에유의한차이는없었으며, 5회주사시시력은 1년후시력을예측할수있는지표였다. 일부에서시력호전이있어선별적으로지속적인치료가필요할것으로생각된다. 70

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<31302D31362D B1E8B0E6B9CE2DB1E8C0E7C8D E687770> 대한안과학회지 2017 년제 58 권제 1 호 J Korean Ophthalmol Soc 2017;58(1):62-68 ISSN 0378-6471 (Print) ISSN 2092-9374 (Online) https://doi.org/10.3341/jkos.2017.58.1.62 Original Article 라니비주맙치료에반응이제한적인습성황반변성에서 3 회애플리버셉트주입술의효과