16-JKOS (황호식-김기현)-702.hwp
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1 대한안과학회지 2021 년제 62 권제 5 호 J Korean Ophthalmol Soc 2021;62(5): ISSN (Print) ISSN (Online) Case Report 데스메막각막내피이식술후이식편실패가온환자에서의데스메막각막내피이식술 Repeat Descemet Membrane Endothelial Keratoplasty after Descemet Membrane Endothelial Keratoplasty Graft Failure 김기현 하민지 장동진 황웅주 변용수 황형빈 나경선 노창래 이현수 정소향 김은철 조양경 김현승 김만수 황호식 Gee-Hyun Kim, MD, Min Ji Ha, MD, Dong Jin Chang, MD, PhD, Woong Joo Whang, MD, PhD, Yong-Soo Byun, MD, PhD, Hyung Bin Hwang, MD, PhD, Kyung Sun Na, MD, PhD, Chang Rae Rho, MD, PhD, Hyun Soo Lee, MD, PhD, So Hyang Chung, MD, PhD, Eun Chul Kim, MD, PhD, Yang Kyung Cho, MD, PhD, Hyun Seung Kim, MD, PhD, Man Soo Kim, MD, PhD, Ho Sik Hwang, MD, PhD 가톨릭대학교의과대학안과학교실 Department of Ophthalmology, College of Medicine, The Catholic University of Korea, Seoul, Korea Purpose: To report a case of secondary Descemet membrane endothelial keratoplasty (DMEK) for graft failure after primary DMEK. Case summary: A 47-year-old female underwent primary DMEK in her left eye with a diagnosis of Fuchs endothelial dystrophy. At 6 weeks later, corneal stromal edema with epithelial and subepithelial bullae was first observed. From that point on, the condition of the cornea and the visual acuity continued to degrade. After 7 months, a second DMEK procedure (i.e., a repeat DMEK) for graft failure was performed successfully without any complications. Since the second procedure, the cornea has been clear, and the best-corrected visual acuity has remained at 0.6 for 8 months. Conclusions: To manage graft failure after primary DMEK, we performed a second DMEK procedure. The removal of the previous graft was easy, and there were no complications. Thus, repeat DMEK may be a feasible procedure. J Korean Ophthalmol Soc 2021;62(5): Keywords: Descemet membrane endothelial keratoplasty, Fuchs endothelial dystrophy, Graft failure, Repeat Descemet membrane endothelial keratoplasty Received: Revised: Accepted: Address reprint requests to Ho Sik Hwang, MD, PhD Department of Ophthalmology, Yeouido St. Mary s Hospital, College of Medicine, The Catholic University of Korea, #10 63-ro, Youngdeungpo-gu, Seoul 07345, Korea Tel: , Fax: huanghs@hanmail.net * Supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI17C0659), Basic Science Research Program through the National Research Foundation of Korea (NRF), funded by the Ministry of Education, Republic of Korea (No. 2017R1A1A2A ), the Korea government (Ministry of Science and ICT) (no. 2020R1A2C ). The funder had no influence on the design, collection, analysis or interpretation of the data, or in writing the manuscript. * Conflicts of Interest: The authors have no conflicts to disclose. c2021 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. 702
2 - 김기현외 : 디멕후디멕 - 내피세포의이상이원인이되는각막질환은각막이식술의흔한적응증으로, 과거에는전층각막이식술 (Penetrating keratoplasty) 을주로시행하였지만, 한편으로내피세포층을선택적으로이식하려는부분층각막이식술 (Lamella keratoplasty) 의시도가지속적으로있었다. 이에따라각막내피와데스메막만을선택적으로이식하는데스메막내피각막이식술 (Descemet membrane endothelial keratoplasty, DMEK) 이 Melles et al 1 에의하여소개되기에이르는데, 푹스각막내피이상증 (Fuchs endothelial dystrophy) 200례에시행한연구에서 80% 의환자가 0.8 이상의최대교정시력을보이는등 2 조기에더나은시력회복을얻을수있는가장이상적인내피세포이식술임이입증되고있다. 하지만최근들어그시행횟수가증가함에따라이식실패사례또한많아지고있는데, 이로인하여 2차각막이식을시도할시전층각막이식술, 데스메막박리자동내피각막이식술 (Descemet Stripping automated endothelial Keratoplasty, DSaEK) 혹은데스메막내피각막이식술재시도등을계획할수있다. 저자들은데스메막내피각막이식술을시행한후이식편실패가발생한경우데스메막내피각막이식술을성공적으로재시행한증례를상세한설명과함께보고하고자한다. 증례보고 47세여자환자가양안푹스각막내피이상증진단으로타병원에서 2009년에첫우안전층각막이식술, 2013년에두번째우안전층각막이식술을시행받았고, 2018년저자중한명 (H.H.S) 에게세번째우안전층각막이식술을시행받았다. 그후좌안또한시력이지속적으로감퇴하여최대교정시력은우안 0.125, 좌안 0.02였으며, 골드만압평안압계로측정한안압은우안 13 mmhg, 좌안 33 mmhg였다. 세극등현미경검사에서우안각막이식편은잘유지되고있 었으나, 좌안은수포를동반한미만성의각막부종과혼탁, 데스메막주름, 각막내피층의구타타가관찰되었고, 반면백내장은거의진행되지않은상태였다. 경면현미경검사에서좌안은각막부종과혼탁으로정확한검사가불가하였다. 전안부빛간섭단층촬영으로측정한중심각막두께는우안약 560 μm, 좌안약 710 μm였다. 이에좌안푹스각막내피이상증에따른각막내피세포부전진단으로 2019년 5월 13일좌안데스메막내피각막이식술을저자중한명 (H.H.S) 에게시행받았다. 수술전레이저홍채절개술은따로시행하지않았다. 데스메막이박리처리된상태의각막을수입하여수술을진행하였는데, 술자가각막을펀치하고데스메막및내피세포층만을벗겨내는과정에서내피세포에손상이발생하였다. 각막이측에주된절개창을만들어이식편을삽입하고, 수여안구내에서이식편을편다음공기를전방에주입하여, 수여각막후부에부착시키는등의수술과정은무리없이진행되었다. 술후 1개월째좌안최대교정시력은 0.5까지측정되었고, 전안부빛간섭단층촬영으로측정한중심각막두께는약 500 μm 정도였으며, 이식편박리등특별한합병증없이경과관찰하였다. 그러나각막내피세포밀도는측정되지않았다. 수술후 6주째좌안각막이측에서부종및상피층수포가관찰되기시작하였다. 고장성식염수안약 (Muro 128 ; Sodium chloride 5%, Bausch & Lomb, Rochester, NY, USA) 을하루 2-4회점안하도록처방하였음에도갈수록좌안각막부종이악화되었다 (Fig. 1A). 수술후 7개월째상피층의수포및각막부종은전영역으로확대되어전안부빛간섭단층촬영으로측정한중심각막두께는약 680 μm 정도였으며 (Fig. 1B), 최대교정시력또한 0.06으로감소하여, 좌안각막내피이식실패로판단하여데스메막내피각막이식재수술을시행하였다. 재수술은대체로첫수술과동일한과정으로전신마취하 A B Figure 1. Preoperative images, before repeat Descemet membrane endothelial keratoplasty (DMEK). (A) Preoperative cornea at slit lamp examination. Moderate edematous cornea with Descemet s membrane foldings and microbullae were observed. (B) Preoperative anterior segment optical coherence tomography (DRI OCT Triton ; Topcon, Tokyo, Japan). 703
![, Zuiland, Netherlands) 으로 2분간염색후평형염액 (Balanced Salt Solution [BSS] Plus ; Alcon Laboratories Inc.](/docs-images/116/222432815/images/3-5.jpg ", Fort Worth, TX, USA) 으로염색약을세척, 그후트립판블루용액으로 2분간다시염색하였다.")
3 - 대한안과학회지 2021 년제 62 권제 5 호 - 에진행되었다. 우선수술시야확보를위하여각막상피를벗겨내었다 (Fig. 2A). 그후각막이측에다시주절개창을만들었고, 전방천자는각막주변부 2시, 4시및 10시방향에해두었다 (Fig. 2B). 첫번째데스메막내피각막이식에서는데스메막제거시에전방을공기로채운상태에서시행하였으나, 절개창으로공기가계속빠져수술에어려움이있었다. 재수술에서는점탄물질 (Hyal2000 ; LG Life Sciences, Seoul, Korea) 을전방에채운후 Reverse Sinskey hook을이용하여기존데스메막이식편을박리하였다 (Fig. 2C). 또한첫번째데스메막내피각막이식에서는벗겨낼데스메막을미리흠집을내는 scoring 후데스메막을벗겨냈으나, 두번째수술에서는 scoring이필요없었다. 데스메막을벗길때심한유착은발견되지않았다. 최종적으로수정체낭원형절개용포셉을이용하여데스메막이식편을제거하였다 (Fig. 2D). 제거한데스메막이식편은수술실현미경을통하여온전한제거가이뤄진것을확인하였다 (Fig. 2E). 그후전방내남아있는점탄물질등은 Irrigation & Aspiration 으로써제거하였다. 공여각막은내과적, 안과적병력이없는 52세여성뇌사자의국내기증각막으로, 각막내피세포수는 2,604/mm 2 로확인되었다. 본수술 6일전에적출되었고, 5일전저자중한명 (H.H.S) 에의하여다른환자의심부표층각막이식술에사용되고남은데스메막및내피세포층을각막보존액 (Optisol ; Chiron Ophthalmics, Irvine, CA, USA) 에보존한상태였다. 이식편의크기는첫데스메막내 피각막이식술때와같은크기인 7.5 mm로결정하였다. 이식편은수술실에서트립판블루용액 (Vision Blue, 0.06% Trypan blue; D.O.R.C., Zuiland, Netherlands) 으로 2분간염색후평형염액 (Balanced Salt Solution [BSS] Plus ; Alcon Laboratories Inc., Fort Worth, TX, USA) 으로염색약을세척, 그후트립판블루용액으로 2분간다시염색하였다. 그후저자들이개발한이중캐뉼라수기 (double cannula maneuver) 를통하여이식편을이중롤 (Double roll) 구조가되게한후 (Fig. 2F), 변형된존스튜브 (Modified Jones tube) 에데스메막의방향을확인하며빨아들였다 (Fig. 2G). 평형염액을전방에채워적당한전방깊이를유지하도록하였고, 이식편이뒤집히지않도록방향에유의하며변형된존스튜브를주절개창에삽입, 절편을전방에주입하였다 (Fig. 2H). 그후 10-0 Nylon으로주절개창을봉합하였고, 이식편의내피세포가아래로향하도록올바르게삽입된것을확인하였다. 그후 Dirisamer 술기 3 로각막외부표면을통하여한캐뉼라로는이식편한쪽끝을눌러고정하고, 두번째캐뉼라로는다른한쪽의롤을밀어펼쳤다 (Fig. 2I). 이식편이다펴진다음 4시방향의각막천자부위로캐뉼라를삽입, 이식편아래에위치하도록한후전방에공기를가득주입하였다 (Fig. 2J). 수술실에서환자는 60분간앙와위를유지하여절편이수여각막간질후부에최대한부착되도록하였다. 최종적으로동공차단을방지하고자전방의공기를전방전체용적의약 40% 정도만남기고수술을종료하였다. A B C D E F G H I J Figure 2. Intraoperative images of repeat Descemet membrane endothelial keratoplasty (DMEK). (A) The corneal epithelium was peeled off for better surgical field of view. (B) Three small incisions (blue arrows) and main incision at the temporal side were made. (C) Former DMEK graft was dissected by the reversed Sinskey hook. (D) The graft was totally removed by the continuous curvilinear capsulorhexis forceps. (E) Removed graft was observed. (F) Prestripped new DMEK graft was being prepared by "double-cannula" method. (G) The graft was being loaded into the modified Jones tube. (H) The graft was inserted into the anterior chamber through modified Jones tube. (I) The DMEK graft was centered by Dirisamer technique. (J) The anterior chamber was fully filled with air for 60 minutes. 704
4 - 김기현외 : 디멕후디멕 - 수술후충분히절편이유착될때까지환자는입원하여 1-2일간가능한한앙와위상태를유지하였으며, 감염예방을위하여비가목스점안액 (Vigamox, Moxifloxacin 0.5%; Alcon, Fort Worth, TX, USA) 을하루 4회, 이식편거부반응방지를위하여로테맥스점안액 (Lotemax, Loteprednol etabonate 0.5%; Bausch & Lomb, Rochester, NY, USA) 을하루 4회점안하도록하였다. 입원기간중이식편박리소견은보이지않아, 전방내공기주입술이추가로필요하지는않았다. 수술 6주후시행한좌안경면현미경검사에서다면성 40%, 다형성 48%, 각막내피세포밀도 667 cells/mm 2 로측정되었고, 전안부빛간섭단층촬영으로측정한중심각막두께는약 430 μm 정도로부종없이유지되고있었다 (Fig. 3A). 수술후 3개월좌안최대교정시력은 0.6, 안압은 18 mmhg로측정되었으며, 수술전관찰되었던각막부종및상피층수포부위는호전되었다 (Fig. 3B). 수술후 8개월째, 여전히이식편박리등합병증없이최대교정시력 0.6 내외를유지하면서외래통하여경과관찰중이다. 고찰 Han et al 4 은 9명 10안에서의데스메막내피각막이식술 1년임상경과를보고하면서일차각막절편생착실패가있었던 1안에서 2개월뒤데스메막내피각막이식술을재시행하였다고하였다. 그러나본증례보고에서는재시행된데스메막내피각막이식술에대하여기존데스메막이식편의제거를포함하여술기에중점을두고자세히묘사하였다는점에서차이가있다. 데스메막내피각막이식술은수여각막에서데스메막및내피세포층을제거하고, 공여각막에서도데스메막과내피세포층만을포함한절편을제작, 이를수여안구전방에삽 입하여공기를이용하여수여각막간질후부에부착하는부분층각막이식술이다. 이런특성은전층각막이식술의단점으로지적되는오랜창상회복기간, 봉합사로인한감염, 각막미란및궤양, 이차녹내장및백내장발생등의합병증 5 을현저히줄일수있다. 또한수술에의하여유발되는난시가전층각막이식에비하여거의없으며, 특히공여각막에서실질조직을제거하여공여-수여각막경계면의불균일함과실질두께의불규칙함을없애각막후면의균일함을증대시킴으로써 6 데스메막박리내피각막이식술에비해서도더빠르고나은시력호전을가져다준다. 7 면역거부반응또한전층각막이식에비하여훨씬적게나타내는것으로보고되었다. 8 이런장점에도불구하고데스메막내피각막이식술은술기의난이도가높아실패가능성이상대적으로높다. 이식편을만드는과정에서각막내피층에물리적손상이발생하여온전한절편을얻지못하는경우도있으며, 이식편의두께가얇아이식하는도중내피세포에손상이발생할가능성도크다. 특히초심자에의하여시행된데스메막내피각막이식술 25례에서술후 6개월에각막내피세포수가 45.5% 감소한보고 9 는이를뒷받침한다. 게다가절편의위아래가뒤집혀서각막내피가기능을못하는경우도있다. 그러나가장흔한실패이유는이식편이수여각막간질후부에완벽하게유착되지않고분리되는경우이다. 데스메막내피각막이식술은다른각막이식술에비하여이식편재부착을위해전방내공기주입을해야하는빈도가잦은데, Dirisamer et al 2 에따르면 200안의데스메막내피각막이식술후 9% 에서각막절편분리를보였고, 이중 4% 에서는완전분리, 5% 에서는부분분리를보였다. 데스메막내피각막이식술후전방내공기주입술을다시시행한경우는 11-82% 로 7,10,11 다양하게보고되고있으며, 각막부종이좀체호전되지않아재이식을시행해야하는경우도 4-22% 10,11 로보고되었다. 이러한절편유착의어려움과공 A B Figure 3. Postoperative images after repeat Descemet membrane endothelial keratoplasty (DMEK). (A) Anterior segment optical coherence tomography (OCT) (DRI OCT Triton ; Topcon, Tokyo, Japan) 6 weeks after repeat DMEK. No detachment of the graft was observed. (B) Three months after repeat DMEK, the cornea at slit lamp examination. 705
5 - 대한안과학회지 2021 년제 62 권제 5 호 - 기주입술의필요, 각막부종의지속등은데스메막내피각막이식술의한계점으로남아있다. 본증례에서첫번째로시행한데스메막내피각막이식술에서는데스메막이박리처리된상태의수입각막을사용하였는데, 술자가각막을펀치하고데스메막및내피세포층만을벗겨내는과정에서내피세포에손상이발생하였다. 바론기증각막펀치 (Barron Corneal Punch) 로기증각막의내피쪽에살짝펀치를한다음포셉으로가장자리데스메막을벗겨내는과정에서펀치가완벽하지않아중심부데스메막까지함께끌려나왔다. 당시술자는이를인지하지못하였고중심부데스메막을찾는동안중심부데스메막은주변부데스메막과함께뭉쳐진채방치되었다. 이를인지하고데스메막을다시평형염액에담근후미세가위로주변부와중심부의데스메막을분리하였다. 이러한과정에서내피세포의물리적손상이발생하였을것으로생각된다. 또한첫수술후각막부종이처음관찰된시기가수술후 6주째로비교적일렀다는점에서첫번째수술의실패원인이면역학적거부반응보다는이식편의기계적손상때문으로생각된다. 본증례에서두번째로시행한데스메막내피각막이식술의경우특별한합병증은아직발생하지않았으나술후각막내피세포수가 667 cells/mm 2 로낮게측정되었다. 그원인으로첫번째기증각막의버트닝 (Corneal buttoning) 과정에서발생한물리적인손상가능성이있다. 수술영상을추후분석한결과, 각막내피가트립판블루용액에염색된면적을측정해보니트립판블루용액에염색된손상면적비율은직경 8.0 mm의원영역에서 18.4% 로측정되었다 Figure 4. Prestripped cornea tissue for repeat Descemet membrane endothelial keratoplasty (DMEK). Damaged endothelium layer was stained by 0.06% trypan blue dye. (Fig. 4). 두번째원인으로는이식편을수여각막기질후부에부착하기위하여수술중 60분간전방을공기로가득채운채유지하는과정에서안압을측정하지않았는데, 당시안압이높게유지되어각막내피가손상받았을가능성도있다. Dapena 12 는이때전방의압력을약 20 mmhg로유지하도록권장하고있으나, 본증례에서는수술중안압을측정하지않아알수없었다. 세번째, 트립판블루용액으로 4분이하의시간동안이식편을염색하는경우통계적으로유의한각막내피손상이발생하지않는것으로알려져있으나, 13 본증례에서는정확히 4분간염색을시행하였으므로트립판블루에의한각막내피에손상의가능성을완전히배제할수는없다. 각막부종이동반된이식편실패가발생될시우선전층각막이식술을고려할수있지만, 최근들어데스메막내피각막이식술의보급이확대됨에따라그기법과예후또한발전하여이차부분층각막이식술로서데스메막내피각막이식술이점차시도되고있다. Baydoun et al 14 은데스메막내피각막이식술후재차데스메막내피각막이식술을시행한 17례를 1년간경과관찰한바를보고하였는데, 이중 3례의실패가최종적으로발생하였음을보고하였다. 1례에서는이식편박리가크게발생하였으나전방내공기주입술로써재부착에성공하여총 14건이특별한합병증없이유지되었다. 특히최대교정시력의경우 1.2 이상이 1례, 1.0 이상이 3례, 0.8 이상이 8례였으며, 각막내피세포수는수술전 2,580 ± 173 cells/mm 2 에서이식 1년후 1,294 ± 459 cells/mm 2 로양호한결과를보였다. 이식편실패가있는경우는각막부종이심한경우가많아, 재수술로서데스메막내피각막이식술을시행하게된다면전방에주입된얇은데스메막절편을다루기힘들것이라는우려가많은데, 이를극복하기위하여수술중전방을공기로가득채우고트립판블루염색약을사용하여이식편의가시도를높이는기법 14 또한해당연구에서제안하고있다. 본증례의경우데스메막제거시전방을점탄물질 (Hyal2000, LG Life Sciences) 로채우고시행하였다. 전방을점탄물질 (Hyal2000, LG Life Sciences) 로채우는방법의장점은전방이안정적으로유지된다는점이다. 전방을공기로채우면공기가절개창으로계속빠져나가공기를반복적으로주입하면서데스메막을제거해야한다. 전방을점탄물질로채우는방법의단점은공기를넣었을때에비하여박리중인데스메막이잘보이지않는다는점이다. 또한데스메막제거후에는전방의점탄물질은모두제거하여추후이식편의유착과정을방해하지않도록주의하여야한다. 특히분산성점탄물질 (Dispersive OVD, Viscoat ; Alcon Laboratories, Inc. Fort Worth, TX, USA) 의경우는 706
6 - 김기현외 : 디멕후디멕 - 각막기질후부에유착되므로사용하여서는안된다. 데스메막내피각막이식술을시행받은각막의경우데스메막이각막기질후부에더강하게유착되는경우가많다고알려져있어, 14 기존이식편을온전히제거하는것이까다로울수있다. 본증례에서는기존이식편의유착이심하지않았고 Reverse sinskey hook과수정체낭원형절개용포셉을사용함으로써비교적쉽게기존이식편을제거할수있었다. 본증례에서는이차데스메막내피각막이식술의이식편을일차와동일한크기로제작하여이식하였고, 추가적인공기주입없이한번에생착이잘이루어졌다. 이전이식위치에정확히새로운이식편이부착되는것은어렵겠지만, 이차데스메막내피각막이식술시행시이식편크기를일차수술때와같은크기로준비하여도무리가없는것으로생각된다. 본논문에서는일차데스메막내피각막이식술이후이차데스메막내피각막이식술을성공적으로시행한증례를상세한수술과정과함께보고한다. 기존이식편은예상과달리유착이심하지않았고, Reverse sinskey hook과수정체낭원형절개용포셉을사용함으로써비교적쉽게완전히제거할수있었다. 데스메막내피각막이식술후실패가발생할시전층각막이식이나데스메막박리자동내피각막이식술을고려하기쉬우나, 데스메막내피각막이식술을재시도하는것도좋은방법중하나일것이다. REFERENCES 1) Melles GR, Ong TS, Ververs B, van der Wees J. Descemet membrane endothelial keratoplasty (DMEK). Cornea 2006;25: ) Dirisamer M, Ham L, Dapena I, et al. Efficacy of Descemet membrane endothelial keratoplasty: clinical outcome of 200 consecutive cases after a learning curve of 25 cases. Arch Ophthalmol 2011;129: ) Dirisamer M, van Dijk K, Dapena I, et al. Prevention and management of graft detachment in Descemet membrane endothelial keratoplasty. Arch Ophthalmol 2012;130: ) Han GL, Hyun J, Lim DH, et al. Clinical outcomes of Descemet s membrane endothelial keratoplasty: a 1-year retrospective study. J Korean Ophthalmol Soc 2015;56: ) Ing JJ, Ing HH, Nelson LR, et al. Ten-year postoperative results of penetrating keratoplasty. Ophthalmology 1998;105: ) Rudolph M, Laaser K, Bachmann BO, et al. Corneal higher-order aberrations after Descemet s membrane endothelial keratoplasty. Ophthalmology 2012;119: ) Tourtas T, Laaser K, Bachmann BO, et al. Descemet membrane endothelial keratoplasty versus descemet stripping automated endothelial keratoplasty. Am J Ophthalmol 2012;153: e2. 8) Boisjoly HM, Tourigny R, Bazin R, et al. Risk factors of corneal graft failure. Ophthalmology 1993;100: ) Hlinomazová Z, Horácková M, Pirnerová L. DMEK (Descemet membrane endothelial keratoplasty)-early and late postoperative complications. Cesk Slov Oftalmol 2011;67: ) Price MO, Giebel AW, Fairchild KM, et al. Descemet s membrane endothelial keratoplasty: prospective multicenter study of visual and refractive outcomes and endothelial survival. Ophthalmology 2009;116: ) Dapena I, Ham L, Droutsas K, et al. Learning curve in Descemet s membrane endothelial keratoplasty: first series of 135 consecutive cases. Ophthalmology 2011;118: ) Dapena I. How to get started with standardized no-touch Descemet membrane endothelial keratoplasty (DMEK). Rotterdam: NIIOS, 2014;69. 13) Kim EY, Kim SY. Effects of trypan blue on corneal endothelial cell viability; Optimal time of Trypan Blue Dye Application to DMEK donor tissue. Acta Ophthalmologica 2017 Sep 7. doi: / j s ) Baydoun L, van Dijk K, Dapena I, et al. Repeat Descemet membrane endothelial keratoplasty after complicated primary Descemet membrane endothelial keratoplasty. Ophthalmology 2015;122:
7 - 대한안과학회지 2021 년제 62 권제 5 호 - = 국문초록 = 데스메막각막내피이식술후이식편실패가온환자에서의데스메막각막내피이식술 목적 : 데스메막내피각막이식술 (Descemet membrane endothelial keratoplasty) 시행후이식편실패가발생한환자에게데스메막내피각막이식술을재시도하여성공한경험을보고하고자한다. 증례요약 : 47 세여자환자에게좌안푹스각막내피이상증 (Fuchs endothelial dystrophy) 진단으로본원에서좌안데스메막내피각막이식술을시행하였다. 특별한합병증은없었으나수술 6 주후각막부종및수포가발생하여갈수록악화되었으며, 시력또한감퇴되어수술 7 개월후이식편실패진단하에좌안데스메막내피각막이식술을다시시행하였다. 재수술후 8 개월째특별한합병증없이각막은투명하며최대교정시력 0.6 내외로유지되고있다. 결론 : 데스메막내피각막이식술시행후이식편실패가발생한환자에서데스메막내피각막이식술을재시행하였는데, 수술중기존의데스메막은어렵지않게온전히제거할수있었으며합병증없이성공적인결과를얻을수있었다. < 대한안과학회지 2021;62(5): > 김기현 / Gee-Hyun Kim 가톨릭대학교의과대학안과학교실 Department of Ophthalmology, College of Medicine, The Catholic University of Korea 708
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Journal of Educational Innovation Research 2018, Vol. 28, No. 4, pp.441-460 DOI: http://dx.doi.org/10.21024/pnuedi.28.4.201812.441 A Study on Organizing Software Education of Special Education Curriculum
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The e-business Studies Volume 17, Number 4, August, 30, 2016:319~332 Received: 2016/07/28, Accepted: 2016/08/28 Revised: 2016/08/27, Published: 2016/08/30 [ABSTRACT] This paper examined what determina
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The e-business Studies Volume 17, Number 6, December, 30, 2016:237~251 Received: 2016/11/20, Accepted: 2016/12/24 Revised: 2016/12/21, Published: 2016/12/30 [ABSTRACT] Recently, there is an increasing
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The e-business Studies Volume 17, Number 6, December, 30, 2016:3~20 Received: 2016/12/04, Accepted: 2016/12/27 Revised: 2016/12/27, Published: 2016/12/30 [ABSTRACT] This study aims to comprehensively analyze
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