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1 대한안과학회지 2015 년제 56 권제 10 호 J Korean Ophthalmol Soc 2015;56(10): ISSN (Print) ISSN (Online) Original Article 백내장수술후난시교정용인공수정체를이용한난시교정효과 Effect of Toric Intraocular Lens Implantation on Astigmatism in Cataract Surgery 차용재 1 김미금 1,2 위원량 1,2 Yong Jae Cha, MD 1, Mee Kum Kim, MD, PhD 1,2, Won Ryang Wee, MD, PhD 1,2 서울대학교의과대학서울대학교병원안과학교실 1, 서울대학교의과대학서울대학교병원의생명연구원 2 Department of Ophthalmology, Seoul National University Hospital, Seoul National University College of Medicine 1, Seoul, Korea Biomedical Research Institute, Seoul National University Hospital, Seoul National University College of Medicine 2, Seoul, Korea Purpose: To evaluate the efficacy of Tecnis toric intraocular lens (IOL) implantation for the correction of astigmatism and rotational stability during cataract surgery in patients with cataract and astigmatism. Methods: We prospectively analyzed 17 eyes of 14 patients with 1 to 4 diopters (D) of corneal astigmatism who underwent phacoemulsification and Tecnis toric IOL implantation at Seoul National University Hospital from June 2013 to May Informed consent was obtained from all participants before the clinical trial. We evaluated the changes in visual acuity, refraction, astigmatism, IOL axis and higher order aberration for 3 months postoperatively. Power vector analysis was used to analyze astigmatism. Results: The mean uncorrected visual acuity (log MAR) significantly improved from 0.58 ± 0.34 to 0.26 ± 0.43 at 3 months postoperatively. The mean refractive astigmatism was significantly decreased by 77.9% from a mean value of ± 0.89 D to ± 0.48 D at 3 months postoperatively. According to power vector analysis, M, B, J 0, and J 45 were significantly reduced after the surgery. The mean difference between achieved and intended IOL axis was 3.26 degrees clockwise at postoperative 3 months, which was statistically insignificant. Most of the rotational changes were observed within a month after the surgery. Conclusions: Phacoemulsification and Tecnis toric IOL implantation in patients with cataracts and astigmatism showed efficacy for the correction of astigmatism and rotational stability. J Korean Ophthalmol Soc 2015;56(10): Key Words: Astigmatism, Cataract, Tecnis toric IOL, Vector analysis 최근에는백내장수술후시력개선에대한환자의요구 Received: Revised: Accepted: Address reprint requests to Mee Kum Kim, MD, PhD Department of Ophthalmology, Seoul National University Hospital, #101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: , Fax: kmk9@snu.ac.kr * This study was presented as a narration at the 111th Annual Meeting of the Korean Ophthalmological Society * This study was supported for grant by Abbott Medical Optics (AMO, Santa Ana, CA, USA) (grant number ). 도가높아지고, 또한기술의발달에힘입어다양한인공수정체가개발되면서, 난시및노안의병합교정에대한관심이증가하고있다. 1,2 특히백내장환자에서각막난시가 1.25D 이상인인구가 22-27% 임을고려하면, 3,4 각막난시가 1.25D 이상의환자에서단순히백내장수술과일반인공수정체를삽입하는경우수술후안경교정이필요할가능성이높고, 이로인한환자만족도가저하될우려가백내장수술이필요한인구의약 4분의 1에서발생할수있음을예측할수있다. 백내장수술과병합한난시교정으로는각막윤부이완절개술의병합이가능하며, 난시교정용인공수정체삽입또 c2015 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. 1544

2 - 차용재외 : 난시교정용인공수정체의난시교정효과 - 는각막에굴절교정각막절제술을시행할수있다. 이중굴절교정각막절제술은난시교정효과는우수하나백내장수술과동시에하기가어렵고추후시행해야하는불편함이있고, 5 백내장수술과동시에시행이가능한각막윤부이완절개술병합또는난시교정용인공수정체삽입술이많이시행되고있다 각막윤부이완절개술보다는난시교정용인공수정체삽입술이교정효과가더우수한것으로보고되고있으며, 9 비교적초기에널리공급된회절형의 AcrySof toric IOL (Alcon Laboratories Inc., Fort Worth, TX, USA) 의교정효과가국내외에서많이보고되었다. 11,12 난시교정용인공수정체의난시교정효과는여러가지요인에의해서영향을받는데, 13 술전난시검사의오차, 14,15 인공수정체축의회전, 16,17 각막후면난시 18 등이영향을줄수있고, 도수결정시반영되는전방깊이및각막굴절력, 안구축장 19 등이영향을줄수있다. AcrySof toric IOL은난시인공수정체도수결정프로그램에안구축장, 전방깊이가반영되어있지않아, 교정효과에영향을줄수있음이밝혀지면서, 10 최근개발되어난시도수결정프로그램에안구축장이반영된 Tecnis ZCT toric IOL (Abbott Medical Optics, Santa Ana, CA, USA) 의난시교정효과가국외에보고되었다. 20 그러나전체적인보고가아직은많지않아컨센서스가확립되어있지않고또국내에는전혀보고가없어 Tecnis ZCT toric IOL의난시교정효과에대한증거를축적하고자전향적연구를진행하였다. 대상과방법 본연구는전향적연구로헬싱키선언을준수하여시행되었고, 서울대학교병원임상시험심사위원회의심의및승인을받았다 (IRB number: ). 서울대학교병원에서 2013년 6월부터 2014년 5월까지임상시험설명후자발적동의서를받았으며, 백내장수술이필요한환자를대상으로하였다. 연구포함기준은 21세이상의노년성백내장환자중자동굴절검사계 (Automated refractor, KR890, TOPCON, Tokyo, Japan) 및 IOL-Master (Carl Zeiss, Meditec AG, Jena, Germany) 의각막굴절계로측정한각막난시가 1-4디옵터 (diopter, D) 이내의환자를대상으로하였다. 임부, 수유부, 수정체낭의안정성에영향을줄수있는기타다른질환이있는경우 ( 거짓비늘증후군, 녹내장, 외상성백내장, Marfan 증후군등 ), 피험자중스스로동의서를읽을수없는자와연구기간동안예정된경과관찰및검사를받지못한경우는대상에서제외하였다. 환자군은총 14명 (17안) 이었으며, 한명의술자 (K.M.K) 에의하여초음파유화술및 Tecnis ZCT toric IOL (a single-piece toric hydrophobic acrylic IOL, Abbott Medical Optics, Santa Ana, CA, USA) 후낭삽입술을시행받았고, 포함된모든환자에서수술시합병증은발생하지않았다. 대상수산출에필요한수치를확인하기위해 난시교정인공수정체삽입후임상결과 12 를근거로표준편차를 2.92로가정하였으며, 허용오차는 1.5로설정하고연구대상수를산출하여, 산출된연구대상수는 15안으로탈락률을 10% 로고려하여 17안이었다. 대상환자는수술전에나안시력및최대교정시력 (logmar), 자동굴절검사 (Automated refractor, KR890, TOPCON), 세극등현미경검사, 안저검사, IOL master 및 A-scan (Quantel medical, Clemont-Ferrand, France) 을이용한인공수정체도수측정검사, 각막지형도및고위수차 (Orbscan II, Bausch and Lomb Inc., Rochester, NY, USA) 를시행하였다. 인공수정체 Tecnis toric IOL은아크릴재질의접힘형연성인공수정체인데, 앞면이난시를교정할수있는 toric 비구면이다. 인공수정체의도수를결정하기위하여숙련된검사자를통하여 A-scan (Quantel medical, Clemont-Ferrand, France) 과 IOL master (Carl Zeiss, Meditec AG, Jena, Germany) 를이용하여안구축장을 3회측정하였고, 인공수정체도수를구하는공식에서 A값은 A scan은 118.8, IOL master는 을이용하였다. 각막곡률과각막난시의측정은자동굴절검사계 (Automated refractor, KR890, TOPCON), IOL Master (Carl Zeiss, Meditec AG, Jena, Germany) 및각막지형도 (Orbscan II, Bausch and Lomb Inc., Rochester, NY, USA) 를이용하여각각 3회측정하였으며, 각검사의굴절력, 난시축및난시양의 3회평균값을이용하였다. Tecnis toric 인공수정체의종류및삽입축은 toric IOL calculator 프로그램 ( 에각막곡률, 절개방향, 수술로인하여유발되는각막난시 (surgicallyinduced astigmatism, SIA), 인공수정체의 spherical power, 안축장등을포함한환자의정보를입력하여산출되는결과에따라결정하였다. 위에서언급한세가지검사의평균굴절력을각각대입하여얻은결과중검사간일치도가높으면서 ( 세가지중 2개이상일치하는값 ) 가장난시가 0에근접하고, 축은방향이변하지않는값으로인공수정체난시도수를선정하여과교정을피하고자하였다. 각막절개방향은 steep-on axis로시행하였고 ( 직난시 : 상측, 도난시 : 이측 ), 상측각막절개의경우 ( 직난시 ) 과교정을피하기위해 SIA를 0.5로설정하였고, 이측각막절개의경우 ( 도난시 ) 부족교정을줄이기위해 SIA를 0으로설정하였다. 1545

3 - 대한안과학회지 2015 년제 56 권제 10 호 - 수술방법기준표지자는수술직전환자를세극등현미경앞에앉혀정면을보게한상태에서얼굴의위치가기울어지지않았는지확인한후, 각막윤부의 3시, 9시방향에기준점을표시했다. 수술중환자가누운후에 Mendez ring (K3-7900, Katena) 과 toric axis marker (K3-7910, Katena) 를이용하여목표난시축을표시하였다. 모든수술은숙련된한명의술자 (K.M.K) 에의해이루어졌으며, 각막에 2.8 mm의각막절개 (clear corneal incision) 를시행하고, Infinity Vision System (Alcon Laboratories Inc., Fort Worth, TX, USA) 과 OZil TM Torsional Handpeice (Alcon Laboratories Inc., Fort Worth, TX, USA) 를이용하여수정체유화술을시행하였다. Monarch injector (Alcon Laboratories Inc., Fort Worth, TX, USA) 로인공수정체를후낭에삽입하였다. 점탄물질을제거후 toric axis marker (K3-7910, Katena) 로축방향을다시확인하였으며, 인공수정체를회전시켜미리표시해둔표지자 (marking) 를기준으로인공수정체의축을원하는방향으로교정하였다. 수술을마칠때각막봉합술은시행하지않았고, 수술중후낭파열등의합병증은발생하지않았다. 미만인경우만을통계적으로유의한것으로설정하였다. 결과 총 17안 14명의환자들의평균나이는 64.5(32-84) 세였으며, 총 17안중남자가 4안, 여자가 13안이었고, 우안이 9안, 좌안이 8안이었다. 술전시력및굴절력, 각막난시, 안축장은 Table 1에제시하였다. 시력나안시력 (logmar) 은수술전평균 0.58 ± 0.34에서수술후 1주에 0.22 ± 033, 수술후 1개월에는 0.21 ± 0.33, 그리고수술후 3개월에 0.26 ± 0.43으로각각의경과관찰시기에모두수술전에비해유의하게호전되었다 (p=0.023, p=0.013, p=0.033, Independent student t-test; Fig. 2). 굴절이상의변화및고위수차평균굴절난시는수술전 ± 0.89D였으며, 수술후 수술후검사수술후 1일, 1주, 1달, 3달에나안시력과최대교정시력 (logmar), 굴절이상의변화, 인공수정체축위치변화, 그리고고위수차의변화를분석하였다. 난시의벡터분석은 Cartesian astigmatism (J 0) 과 oblique astigmatism (J 45) 을이용한 power vector 분석법을통해 M=S+C/2, J 0=(-C/2) cos2θ, J 45=(-C/2) sin2θ, B M J J 와같은변수들을이용하여분석하였다. 21 인공수정체의회전안정성 ( 축의변화 ) 에대한분석은다음과같이시행하였다. 수술후 1주, 1달과 3달째에수술한눈을산동시킨후, 환자를세극등현미경앞에앉혀가능한최대한똑바로정면을보게하여역조명을비추어전안부사진을촬영하였다. Image J 소프트웨어를이용하여모든사진에서인공수정체면에표시되어있는기준표지자 (reference marks) 를참고하여두표식을서로잇는선을그려원래의도하였던삽입축과인공수정체가실제로삽입된축의차이를분석하였다 (Fig. 1). 모든사진은무작위로선택하여검사자의편견이개입되지않도록하였다. 통계분석방법통계분석은 SPSS 21.0 (IBM Inc., Armonk, NY, USA) 통계프로그램을이용하여수술전과후의차이에대하여 Wilcoxon s signed ranks test, Independent student t-test 등을사용하였다. 모든통계분석에서유의도 (p-value) 는 0.05 Figure 1. Image analysis for the rotation of the cylindrical axis on the toric intraocular lens. Table 1. Demographics and preoperative status of the enrolled patients Demographics Data No. of eyes (patients) 17 (14) Mean age (years, range) 64.5 (32-84) Sex (male:female) 4:13 Laterality (right:left) 9:8 UCVA (log MAR) 0.58 ± 0.34 Spherical equivalent (diopters) ± 3.52 Axial length (mm) ± 1.26 WTR versus ATR 10:7 Values are presented as mean ± SD unless otherwise indicated. UCVA = uncorrected visual acuity; WTR = with the rule; ATR = against the rule. 1546

- 차용재외 : 난시교정용인공수정체의난시교정효과 - 1주에 -0.85 ± 0.54D, 수술후 1개월에 -0.66 ± 0.39D, 그리고수술후 3개월에는 -0.59 ± 0.48D로수술전에비해유의하게줄어들었다 (p=0.008, p=0.002, p=0.003, Wilcoxon s signed-ranks test; Fig. 3).

4 - 차용재외 : 난시교정용인공수정체의난시교정효과 - 1주에 ± 0.54D, 수술후 1개월에 ± 0.39D, 그리고수술후 3개월에는 ± 0.48D로수술전에비해유의하게줄어들었다 (p=0.008, p=0.002, p=0.003, Wilcoxon s signed-ranks test; Fig. 3). 굴절난시의변화는수술후 1개월부터안정적으로유지됨이관찰되었다. 평균각막난시는수술전 ± 0.56D였으며, ± 0.53D, 수술후 1개월에 ± 0.44D, 수술후 3개월에 ± 0.62D로술전과비교하여유의한변화는없었다 (Fig. 4). 평균구면대응치 (spherical equivalent, SE) 는수술전 ± 3.52D 에서, 수술후 1주에 ± 1.06D, 수술후 1개월에 ± 1.07D, 그리고수술후 3개월에는 ± 0.98D로관찰되었다 (Fig. 5). 난시를 Power vector analysis로분석하여각변수들의변화를살펴보면 (Table 2), M값은수술전 ± 0.57D와비교하여수술후 1주에 ± 0.97D, 수술후 1개월에는 ± 0.94D로유의한변화가있었다 Figure 2. Changes in visual acuity. There were statistically significant improvements in visual acuity at postoperative 1 week, 1 month, and 3 months compared with pre-operative values. log MAR = logarithm of the minimum angle of resolution; Preop = preoperative. Figure 4. Changes in the corneal astigmatism between preand post- operation. There is no significant changes between the follow-ups. Preop = preoperation. Figure 3. Change in refractive astigmatism. There were statistically significant decreases in refractive astigmatism at postoperative 1 week, 1 month, and 3 months compared with preoperative values. Preop = preoperative. Figure 5. Changes in spherical equivalents between pre- and post- operation. Preop = preoperation. Table 2. Vector analysis of astigmatism Preop Postop 1 week Postop 1 month Postop 3 months M ± 6.57 D ± 0.97 D ± 0.94 D ± 0.94 D p-value * J ± 1.26 D ± 0.34 D ± 0.19 D ± 0.28 D p-value * J ± 0.41 D 0.05 ± 0.29 D ± 0.27 D ± 0.17 D p-value * * B 4.61 ± 5.92 D 1.03 ± 0.74 D 0.88 ± 0.67 D 0.82 ± 0.59 D p-value * * * Values are presented as mean ± SD unless otherwise indicated. p-value by Wilcoxon s signed-ranks test. Preop = preoperation; Postop = postoperation; J 0=x-coordinate of the astigmatism vector; J 45=y-coordinate of the astigmatism; M = spherical equivalent refraction; B = total dioptric power. * Statistically significant values. 1547

5 - 대한안과학회지 2015 년제 56 권제 10 호 - Table 3. Post-operative high order aberration of the enrolled patients High order aberration Mean ± SD Mean postoperative 3 months vertical coma (μm) ± 0.12 Mean postoperative 3 months horizontal coma (μm) ± 0.20 Mean postoperative 3 months SA (μm) 0.16 ± 0.12 Mean postoperative 3 months HOA RMS (μm) 0.36 ± 0.16 Values are presented as mean ± SD. SA = spherical aberrations; HOA = high-ordered aberration; RMS = root mean square. Figure 7. Absolute amount of rotation of a single-piece toric acrylic intraocular lens (IOL) compared with preoperative IOL axis. There was significant rotation between 1 week and 1 month after surgery. However, axis was stable after 1 month. Figure 6. Diagram showing refractive astigmatism in diopters measured before surgery and 1 week, 1 month, and 3 months after implanting a single-piece toric acrylic intraocular lens. Astigmatism is shown as vectors at J 0 and J 45. Each ring represents 1 diopter. (p=0.038, p=0.040, Wilcoxon s signed-ranks test). J 0 값은수술전 ± 1.26D와비교하여수술후 3개월에 ± 0.28D로 (p=0.028, Wilcoxon s signed-ranks test), J 45 값은수술전 0.18 ± 0.41D와비교하여수술후 1주에 0.05 ± 0.29D, 수술후 1개월에는 ± 0.27D로유의한변화가있었다 (p=0.021, p=0.034, Wilcoxon s signed-ranks test). B 값은수술전 4.61 ± 5.92와비교하여수술후 1주에 1.03 ± 0.74, 수술후 1개월에는 0.88 ± 0.67, 수술후 3개월에는 0.82 ± 0.59로유의한변화가있었다 (p=0.008, p=0.002, p=0.003, Wilcoxon s signed-ranks test; Fig. 6). 고위수차는수술전에는백내장으로측정이안되었고, 수술후 3개월의수차를살펴보면구면수차가 0.16D, 종축코마수차가 -0.17D, 횡축코마수차가 -0.29D의값을보였다 (Table 3). 인공수정체의회전안정성수술전의도하였던축과비교하여수술후인공수정체의회전움직임을분석해보면, 방향성을포함하여분석시수술전의도한축과수술후 3개월째실제인공수정체의 축사이의평균차이는 3.26 ± 8.96도만큼시계방향회전을보였으며, 이는통계적으로유의하지는않았다 (p=0.221, independent t-test). 회전값의절대값 rotated degree 을관찰시수술후 1주에는 5.17 ± 5.27도, 수술후 1개월과 3개월에는각각 8.24 ± 6.76도, 8.45 ± [rotated 6.74도만큼의 degree] 회 2 전움직임이관찰되었다. 수술후 1주와 1개월사이에서유의한인공수정체축의변화를관찰할수있었으나 (3.07도, p=0.017, independent t-test), 수술후 1개월과 3개월사이의축의변화는유의하지않았다 (Fig. 7). 수술후 3달까지의전체회전양의 62.7% 는수술후 1달까지의기간에발생함을알수있었다. 수술후 3개월에인공수정체축의움직임의방향은 55.5% 에서시계방향이었다. 고 찰 본연구는난시가 1D에서 4D 이내인백내장환자에서백내장수술시 Tecnis toric IOL 삽입이시력교정효과가우수하고, 난시감소효과는 78% 를보여, 최근국외에서난시감소효과 44.9% 를보고한연구 16 보다우수하였고, 75% 를보고한 Tecnis toric IOL의결과 20 에교정효과가필적함을확인하였다. Tecnis toric IOL의난시교정효과는가장널리사용되고있는 AcrySof toric IOL (Alcon Laboratories Inc., Fort Worth, TX, USA) 삽입의난시감소효 1548

6 - 차용재외 : 난시교정용인공수정체의난시교정효과 - 과 63.3% 에서 80.1% 정도에도필적함을알수있었다. 12,22,23 고위수차에미치는영향도 AcrySof toric IOL 삽입의보고와필적하였다. 24 실제로난시교정용인공수정체의난시교정효과는술전검사간오차, 난시축표기시의오차, 환자의술전각막전면난시상태 ( 직난시또는도난시 ), 환자의각막후면난시, 술중또는술후인공수정체축의회전, 각렌즈별도수결정프로그램등매우다양한요인에의해서복합적으로영향을받기때문에, 다양하게소개되고있는난시교정용인공수정체의교정효과를직접적으로비교하기는매우어렵다. 저자들은비교적국내에초기에공급된 AcrySof toric IOL을백내장환자의난시교정목적으로많이삽입하였는데, 교정효과가기대했던것보다는부족교정이되는경향을보여 (unpublished data), 여러가지요인에관심을갖고분석중에난시도수결정프로그램의요인이영향을미치는것에주목하였다. 각막의난시에서인공수정체의난시를환산하는과정에 ratio는 Effective lens position (ELP) 에따라영향을받게된다. 19,25,26 ELP는전방깊이에의해결정되고전방깊이는각막굴절력과안구축장의영향을받으므로, 이두가지요소가난시도수를결정하는데고려되어야하는데, Alcon사의난시환산프로그램은안구축장및전방깊이의요인이배제되어있어, 실제로각막굴절력이매우가파르거나안구축장이길어전방깊이가깊은환자에서는부족교정이될수밖에없다는것이알려졌다. 비교적후발주자로시장에출시된 Tenis toric IOL의난시환산프로그램은이점을보완하여안구축장을고려하게되어있어, 저자들은이러한차이가부족교정의개선에도움이될것이라판단하여, Tenis toric IOL 을이용한난시교정효과임상시험을진행하게되었다. 저자들이초기에삽입했던 AcrySof toric IOL의난시감소효과가 56% 였음에비해 Tecnis toric IOL은난시감소효과가 75% 로통계적으로유의하지는않았으나, 교정효과가증가하는경향을확인할수있었다 (Supplementary Table 1). Tecnis toric IOL의난시환산프로그램의개선에도불구하고난시교정효과가 90% 내지 100% 에미치지못하는것은그외에도여러가지요인이여전히작용하고있기때문이라고의심된다. 난시환산프로그램이직접적으로전방깊이를측정하여적용하는것이아니라, 각막굴절력과안구축장으로환산하는과정중에도오차가발생할가능성이있다. 최근에는난시환산프로그램에직접전방깊이를측정하여적용하는난시교정용인공수정체가개발되어연구가되고있어, 관심을모으고있다. 27 그외에도술전검사가영향을미칠수있으며, 많은논란이있으나기종에따른검사간오차에대해서는학계에서인정하고있는부 분이다. 15,28,29 최근각막후면난시의중요도가많이논의되고있으며, 후면난시를측정할수있는기종이아닌경우후면난시가고려되지않을때에도난시에서는부족교정이많이되고있다는것은널리인정되고있다. 18,30,31 본연구진의기종은후면난시를측정할수없는 Orbscan의난시값을참조하였기에, 부족교정을줄이고자도난시의경우는 SIA를 0으로설정하였지만, 그럼에도각막전면난시의방향과후면난시의방향이 100% 일치하는것은아니므로, 32 임의설정으로인한오차발생의가능성이있다고판단한다. 그리고술전검사의난시값및축의다양성은술자가선택을함에있어많은혼란을야기한다. 본연구진의분석에의하면난시가 1.5D 이상되면 automated keratometry, IOL master 및 Orbscan의난시축이많이일치하기는하지만, 여전히난시값에는차이가있고 IOL master의측정값이유의하게가장높게측정되었다. 14 본연구진은기존난시렌즈의교정효과가부족교정의경향이있음을주지하고있음에도불구하고, 과교정을항상우려하여세검사값중가장높은값을선택하지는못하였고, 일치하는최소두검사값을선택하여난시양을정하였기때문에이부분에서도오차가발생할수있었을것으로판단한다. 이러한부분은각술자가본인의환자데이터다량수집및분석을통해 ( 맞춤식최적화, customization) 어떤값을취할지결정하는것이궁극적으로는필요할것으로사료된다. 또한가지수술전오차는난시의기준축을표시하는과정에서발생이가능하다. 본연구팀은가장간단한방법인세극등하에서횡축세극을이용하여각막에술자또는보조의가기준점을표시하는방법을선택하였는데, 검사자간오차가발생가능하다고판단한다. 이러한오차를줄이기위해혈관을이용한세점기준축방법, 세극등스트립을이용하거나 software program을이용하는등다양한방법으로개선된검사방법이소개되고있다 마지막으로수술후에발생하는렌즈의회전이오차의요인중하나이다. 본연구는실제인공수정체축사이의평균차이는 3.26도시계방향회전이관찰되었고, 이는통계적으로유의하지는않았으며, 5.0도및 3.15도를보고한기존의국외연구와필적하는결과였다. 22,23 그러나회전절대값관찰시수술후 1주에는 5.17도, 수술후 1개월에는 8.24도로, 국외에보고된테크니스토릭인공수정체최근연구의 도보다높은값을보였다. 20 수술후 1주이내에는수술전검사의오차및렌즈의낭내자유회전에의한오차가능성이의심되고, 재질의특성상 AcrySof toric IOL보다덜끈적거림 (sticky) 이원인일가능성이있다고판단된다. 수술후 1일에렌즈회전이가장크게발생한기존의국외연구와달리, 본연구의렌즈회전은주로술 1549

7 - 대한안과학회지 2015 년제 56 권제 10 호 - 후 1주에서한달이내에유의하게변화하였는데, 국외보고에서수술후 1일까지의변화가컸던이유는수술중인공수정체축의위치를맞추는과정에서의오차또는수술마지막에점탄물질등의제거와연관이있다고추측되며, 20 이와는달리본연구에서수술후 1주에서한달이내의변화는낭내수축에의할가능성이의심되고, 본연구진의전낭원형절개술의크기가낭내수축의유발과연관이있을가능성이있다. 이를분석함으로써, 본연구진은다시한번난시교정효과에전낭원형절개술의크기가중요할가능성을확인하였으며, 앞으로의전낭원형절개술시행시낭내수축을최소화할수있는크기로최적화할예정이다. 결론적으로, 난시를동반한백내장환자에서 Tecnis toric IOL 삽입은시력및난시교정효과가우수함을확인하였으며, 이는국제적으로최근발표된국외보고결과를지지하는증거를축적하여학문적컨센서스를이루는데도움이되었고, 또한국내에서는최초의보고라는점에서그의의가있다고하겠다. 가능한오차요인을줄이기위해술자의환자결과분석을통한맞춤식최적화 (customization) 가난시교정렌즈삽입술에필요하다고사료된다. 참고문헌 1) Rubenstein JB, Raciti M. Approaches to corneal astigmatism in cataract surgery. Curr Opin Ophthalmol 2013;24: ) Kretz FT, Bastelica A, Carreras H, et al. Clinical outcomes and surgeon assessment after implantation of a new diffractive multifocal toric intraocular lens. Br J Ophthalmol 2015;99: ) Chen W, Zuo C, Chen C, et al. Prevalence of corneal astigmatism before cataract surgery in Chinese patients. 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Correction of moderate corneal astigmatism during cataract surgery: toric intraocular lens versus peripheral corneal relaxing incisions. J Cataract Refract Surg 2014;40: ) Jeon JH, Hyung Taek Tyler R, Seo KY, et al. Comparison of refractive stability after non-toric versus toric intraocular lens implantation during cataract surgery. Am J Ophthalmol 2014;157: e1. 11) Visser N, Beckers HJ, Bauer NJ, et al. Toric vs aspherical control intraocular lenses in patients with cataract and corneal astigmatism: a randomized clinical trial. JAMA Ophthalmol 2014;132: ) Na JH, Lee HS, Joo CK. The clinical result of acrysof toric intraocular lens implantation. J Korean Ophthalmol Soc 2009;50: ) Jeon HM, Lee KH. Analysis of miscorrection after implantation of the toric intraocular lens. J Korean Ophthalmol Soc 2014;55: ) Han JM, Choi HJ, Kim MK, et al. Comparative analysis of corneal refraction and astigmatism measured with autokeratometer, IOL Master, and topography. 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8 - 차용재외 : 난시교정용인공수정체의난시교정효과 - 29: ) Ale Magar JB, Cunningham F, Brian G. Comparison of automated and partial coherence keratometry and resulting choice of toric IOL. Optom Vis Sci 2013;90: ) Chang M, Kang SY, Kim HM. Which keratometer is most reliable for correcting astigmatism with toric intraocular lenses? Korean J Ophthalmol 2012;26: ) Savini G, Næser K. An analysis of the factors influencing the residual refractive astigmatism after cataract surgery with toric intraocular lenses. Invest Ophthalmol Vis Sci 2015;56: ) Hasegawa Y, Okamoto F, Nakano S, et al. Effect of preoperative corneal astigmatism orientation on results with a toric intraocular lens. J Cataract Refract Surg 2013;39: ) Miyake T, Shimizu K, Kamiya K. Distribution of posterior corneal astigmatism according to axis orientation of anterior corneal astigmatism. PloS One 2015;10:e ) Teichman JC, Baig K, Ahmed II. Simple technique to measure toric intraocular lens alignment and stability using a smartphone. J Cataract Refract Surg 2014;40: ) Kasthurirangan S, Feuchter L, Smith P, Nixon D. Software-based evaluation of toric IOL orientation in a multicenter clinical study. J Refract Surg 2014;30: ) George VE, George DS. Axis measurement strip for Haag-Streit BM900 series slitlamp. J Cataract Refract Surg 2014;40: ) Cha D, Kang SY, Kim SH, et al. New axis-marking method for a toric intraocular lens: mapping method. J Refract Surg 2011;27: Supplementary Table 1. Comparison of changes in astigmatism between Tecnis toric IOL implantation and Acrysof IQ toric IOL implantation in cataract surgery Tecnis toric IOL Acrysof IQ toric IOL (n = 17) (n = 14) p-value Mean preoperative refractive astigmatism (diopters) ± ± Mean preoperative corneal astigmatism (diopters) ± ± Mean postoperative 3 months refractive astigmatism (diopters) ± ± Values are presented as mean ± SD unless otherwise indicated. p-value by Mann-Whitney U-test. IOL = intraocular lens. = 국문초록 = 백내장수술후난시교정용인공수정체를이용한난시교정효과 목적 : 난시를동반한백내장환자에서백내장수술시테크니스토릭인공수정체삽입술의난시교정효과및안정성을분석하고자하였다. 대상과방법 : 1D 에서 4D 의각막난시를동반한백내장환자중 2013 년 6 월부터 2014 년 5 월까지서울대학교병원에서임상시험동의하에백내장제거술및테크니스토릭인공수정체삽입술을받은 14 명 17 안을전향적으로관찰하여분석하였다. 수술전과후의시력, 굴절력, 난시, 인공수정체축, 고위수차의변화를술후 3 개월까지관찰하였다. 난시분석에는 power vector analysis 가사용되었다. 결과 : 나안시력 (logmar) 은술전평균 0.58 ± 0.34 에서 3 개월에 0.26 ± 0.43 으로유의하게향상되었다. 평균굴절난시는술전 ± 0.89D 였고, 술후 3 개월에 ± 0.48D 로최종 77.9% 의유의한감소효과를보였다. 난시벡터분석시 M, B, J 0, J 45 모두술전과비교하여유의하게감소하였다. 수술전의도한축과술후 3 개월째실제인공수정체축간의평균차이는 3.26 도만큼시계방향으로회전하였지만통계적으로유의하지않았고, 회전은대부분술후한달이내에발생하였다. 결론 : 난시를동반한백내장환자에서초음파유화술및테크니스토릭인공수정체삽입술은우수한난시교정효과및회전안정성을보였다. < 대한안과학회지 2015;56(10): > 1551

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<30362D30382D313328C1A4BCD2C7E22DBEE7BCF8BFF E687770> 대한안과학회지 2016 년제 57 권제 2 호 J Korean Ophthalmol Soc 2016;57(2):200-207 ISSN 0378-6471 (Print) ISSN 2092-9374 (Online) http://dx.doi.org/10.3341/jkos.2016.57.2.200 Original Article 두가지토릭인공수정체삽입후임상결과분석 Comparison