대한안과학회지 2010 년제 51 권제 7 호 J Korean Ophthalmol Soc 2010;51(7):992-997 pissn: 0378-6471 eissn: 2092-9374 DOI : 10.3341/jkos.2010.51.7.992 = 증례보고 = 주시안을가진간헐외사시의편위안증량비대칭외직근후전술 송현재 백혜정 가천의과학대학교안과학교실 목적 : 주시안을가진간헐외사시의일차수술로편위안증량비대칭외직근후전술의결과를양안대칭외직근후전술과비교하고자하였다. 대상과방법 : 주시안을가진간헐외사시진단하에양안외직근후전술을시행받고술후 6 개월이상추적관찰이가능했던환자중, 양안대칭외직근후전술 27 명과편위안증량비대칭외직근후전술 24 명의의무기록을후향적으로분석하였다. 교대간헐외사시인경우와편위안의시력이 0.3 이하인경우를제외하였고, 편위안증량외직근후전술은편위안에주시안보다 2.0 mm 이상더많은양을후전하였다. 결과 : 술후 5PD 이내의내사위와 10PD 이내의외사위를수술성공으로정의하였을때, 최종내원시양안대칭외직근후전술군은 75.0%, 편위안증량비대칭외직근후전술군은 81.2% 의성공률을보여편위안증량수술군에서다소높았으나통계적으로유의하지는않았다 (P=0.261). 결론 : 주시안을가진간헐외사시환자의편위안에비편위안보다 2.0 mm 더많은후전을시행한편위안증량외직근후전술군은양안에동일한양을후전한대칭외직근후전술군에비해술후 24 개월까지유의한차이가없었다. < 대한안과학회지 2010;51(7):992-997> 간헐외사시는동양권소아에서가장흔한후천사시로아직그원인이명확하지않다. 1-4 기본형, 눈벌림과다형, 눈모음부족형, 거짓눈벌림과다형등으로분류되며, 그에따라여러가지수술방법들이술자의선호도및환자의시력상태, 교대성유무등에따라서결정된다. 수술후성공율에대한보고는보고자에따라서 40.0% 에서 86.5% 로다양했고, 5-13 이는각연구마다대상환자들이다르고수술후추적기간이나성공율의기준이다르기때문으로생각된다. 주시안을가진간헐외사시환자에서는수술후재발율이높은것으로알려져있으며, 대부분편위안에서재발이일어난다. Cho et al 14 은이러한근거로 29명의간헐외사시환자에서편위안에주시안의후전양보다최소 2.0 mm 이상더많은양의후전술을시행후, 재발율및속발내사시의발생율감소를보고했다. 이에저자들은주시안을가진간헐외사시환자에서대칭외직근후전술을시행한환자들 접수일 : 2010 년 1 월 18 일 심사통과일 : 2010 년 5 월 14 일 책임저자 : 백혜정인천광역시남동구구월동 1198 가천의과학대학교길병원안과 Tel: 032 460 3364, Fax: 032 460 3358 E mail: hjpaik@gilhospital.com * 본논문의요지는 2009 년대한안과학회제 101 회학술대회에서구연으로발표되었음. 과편위안증량외직근후전술을시행한환자들의술후정위율및속발내사시의빈도, 재발율, 입체시의변화를후향적으로비교, 분석하고자하였다. 대상과방법 2004년 3월부터 2007년 3월사이에본원에서문진및눈모음검사, 포인팅테스트, 워트 4등검사등으로확인된주시안을가진, 간헐외사시진단하에술후 6개월에서 30 개월까지추적관찰이가능했던대칭외직근후전술환자중 27명과편위안증량비대칭외직근후전술 24명의의무기록을후향적으로분석하였다. 수술성공은술후 10PD의외사위에서 5PD의내사위까지, 속발내사시는 6PD 이상의내사시로, 재발은 11PD 이상의외사시로정의하였다. 양안의시력이동일하고교대주시하는경우, 편위안의시력이 0.3이하인약시가있는경우, 사시수술경력이나신경학적이상및기질적인안과적이상이동반된경우, 감각외사시는대상에서제외하였다. 수술전검사는나안시력과교정시력, 현성굴절검사, 안근운동, 입체시검사, 안저검사를시행하였고, 사시각은원거리및근거리에서목표물을주시하게한후교대프리즘가림검사로측정하였으며측정이불가능한경우에는크림 992 www.ophthalmology.org
- 송현재 백혜정 : 간헐외사시의편위안증량외직근후전술 - Table 1. Patient characteristics of symmetric and asymmetric recession groups Characteristics Symmetric LROU Rec (N=27) Asymmetric LROU Rec (N=24) P value Sex 0.326 * Male 12 11 Female 15 13 Age at operation (yr)(mean±sd) 7.14±4.23 7.33±4.01 0.185 Follow up (mon) (mean±sd) 11.83±5.74 11.14±5.05 0.168 Deviated eye 0.257 * Right/Left 13/14 10/14 LROU Rec=bilateral lateral rectus recession; N=number of patients. * P value was calculated by Fisher s exact; P value was calculated by Mann-Whitney U test. Table 2. Comparison of preoperative deviation between symmetric and asymmetric recession group Deviation (PD) Symmetric LROU Rec (N=27) Asymmetric LROU Rec (N=24) 20~25 16 (59.3%) 14 (58.3%) 26~30 9 (33.3%) 9 (37.5%) 31~40 2 (7.4%) 1 (4.2%) Mean deviation (PD)(mean±SD) 22.8±3.7 * 22.7±3.4 * P * =0.974 by Mann-Whitney U test. LROU Rec: bilateral lateral rectus recession; PD: prism diopter. 스키검사를시행하였다. 주시안의교정시력은최소 0.8 이상, 입체시는티트무스검사에서 3,000초이하의시기능을보인환자들을대상으로하였다. 수술방법은양안의외직근에후전술을시행하였는데대칭외직근후전술군에서는 Park s formula 를기준으로양안같은양을후전하였고, 편위안증량비대칭외직근후전술군에서는주시안은 Park s formula 기준보다 1 mm 감량, 편위안은주시안보다 2.0 mm 증량하여후전하였으며이모든수술은단일술자에의해시행되었다. 통계학적분석은 Fisher s exact test 및 Mann-Whitney U test를이용하였고, p 값이 0.05 미만인경우를통계학적인유의성이있는것으로판단하였다. 결과 양안대칭외직근후전술을시행받은 27명중남자는 12 명 (44.4%), 여자는 15명 (55.6%), 편위안증량비대칭외직근후전술을시행받은 24명중남자는 11명 (45.8%), 여자는 13명 (54.2%) 으로두군의남녀분포는비슷했다. 수술시연령의분포는 3세에서 11세였으며, 평균나이는양안대칭외직근후전술군이 7.14±4.23세, 편위안증량비대칭외직근후전술군이 7.33±4.01세로두군의유의한차이는없었으며두군모두에서 5~7세범위가가장높은분포를보였다 ( 대칭군 : 14명 (51.8%), 편위안증량군 : 13명 (54.2%)). 평균경과관찰기간은양안대칭외직근후전술군이 11.83±5.74개월, 편위안증량비대칭외직근후전술 군이 11.14±5.05개월이었다. 편위안은양안대칭외직근후전술군에서우안이 13안 (48.1%), 좌안이 14안 (51.9%) 이었고, 편위안증량비대칭외직근후전술군에서우안이 10안 (41.7%), 좌안이 14안 (58.3%) 으로좌안이근소하게많았다 (Table 1). 1. 수술전사시각수술전사시각의분포는두군모두 20~40PD였으며, 양안대칭외직근후전술군은평균 22.8±3.7PD, 편위안증량비대칭외직근후전술군은 22.7±3.4PD였다. 20~25PD 범위가각각 16명 (59.3%), 14명 (58.3%) 으로가장많은분포를보였다 (Table 2). 2. 수술전시력양안대칭외직근후전술군에서주시안은평균 0.98±0.57, 편위안은 0.86±0.20이었으며편위안증량비대칭외직근후전술군에서주시안은평균 0.97±0.60, 편위안은 0.87± 0.19로두군에서모두주시안이약한줄씩좋은시력을보였다 (Table 3). 3. 수술전입체시양안대칭외직근후전술군에서 22명 (81.5%), 편위안증량비대칭외직근후전술군에서 18명 (75.0%) 이티트무스 www.ophthalmology.org 993
- 대한안과학회지 2010 년제 51 권제 7 호 - Table 3. Comparison of preoperative best corrected visual acuity (BCVA) between symmetric and asymmetric recession group BCVA Symmetric LROU Rec (N=27) Asymmetric LROU Rec (N=24) Fixing eye Deviated eye Fixing eye Deviated eye 0.4~0.5 0 (0.0%) 3 (11.1%) 0 (0.0%) 2 (8.4%) 0.6~0.7 0 (0.0%) 3 (11.1%) 0 (0.0%) 5 (20.8%) 0.8~1.0 27 (100.0%) 21 (77.8%) 24 (100.0%) 17 (70.8%) Mean BCVA (LogMAR) (mean±sd) 0.01±0.24 * 0.06±0.69 * 0.01±0.22 0.06±0.72 * P=0.017 by Mann-Whitney U test; P=0.029 by Mann-Whitney U test; LROU Rec=bilateral lateral rectus recession. Table 4. Comparison of preoperative stereopsis between symmetric and asymmetric recession group Stereopsis (seconds of arc) Symmetric LROU Rec (N=27) Asymmetric LROU Rec (N=24) 3000 1 (3.7%) 2 (8.4%) 400 1 (3.7%) 2 (8.4%) 200 3 (11.1%) 1 (4.2%) 100 22 (81.5%) 18 (75.0%) LROU Rec=bilateral lateral rectus recession. Table 5. Surgical outcome at postoperative 6, 12 and 24 months of follow-up between symmetric recession group and asymmetric recession group Symmetric LROU rec Asymmetric LROU rec P value 6 months follow-up(n) 27 24 Success 25 (92.6%) 22 (91.7%) 0.649 Overcorrection 1 (3.7%) 2 (8.3%) Recurrence 1 (3.7%) 0 (0.0%) 12 months follow-up(n) 22 21 Success 18 (81.8%) 18 (85.7%) 0.327 Overcorrection 1 (4.5%) 1 (4.8%) Recurrence 3 (13.6%) 2 (9.5%) 24 months follow-up(n) 16 16 Success 12 (75.0%) 13 (81.2%) 0.415 Overcorrection 0 (0.0%) 0 (0.0%) Recurrence 4 (25.0%) 3 (18.8%) LROU Rec=bilateral lateral rectus recession; N=number of patients. Overcorrection: Esotropia 6PD, Recurrence: Exotropia 11 PD. P value was calculated by Fisher s exact test. 입체시검사상 100초이하의정상적인입체시를보였으며, 두군모두에서 3,000초초과의입체시를보인환자는없었다 (Table 4). 4. 수술후안구위치수술후성공율은양안대칭외직근후전술군에서 6개월 92.6%, 12개월 81.8%, 24개월 75.0% 를보였고편위안증량비대칭외직근후전술군에서 6개월 91.7%, 12개월 85.7%, 24개월 81.2% 를보여편위안증량비대칭외직근후전술군에서다소높은성공율을보였으나두군에서유의한차이는없었다 (P>0.05). 속발내사시는양안대칭외직근후전술군에서 6개월과 12개월에각각 1예씩 3.7%, 4.5% 발생하였고편위안증량비대칭외직근후전술군에서 6개월 2예 (8.3%), 12개월 1예 (4.8%) 를보였다. 재발은 양안대칭외직근후전술군에서 6개월 1예 (3.7%), 12개월 3예 (13.6%), 24개월 4예 (25.0%) 에서보인반면, 편위안증량비대칭외직근후전술군에서는 6개월에재발이없었고, 12개월에 2예 (9.5%), 24개월에 3예 (18.8%) 가발생하여수술후시간이경과함에따라재발이늘어남을보였다 (Table 5). 5. 수술후입체시변화양안대칭외직근후전술을시행받은군에서술전입체시 3,000초 1명과 200초 2명이술후 6개월에 100초이하의정상적인입체시로, 술전 400초였던 1명이술후 12개월 200초로호전되었다. 편위안증량비대칭외직근후전술을시행받은군에서는술전입체시 3,000초 1명과 200초 1명이술후 6개월에, 술전 200초를보였던 1명이술후 994 www.ophthalmology.org
- 송현재 백혜정 : 간헐외사시의편위안증량외직근후전술 - 24개월 100초이하의정상적인입체시로회복되었고, 술전 3,000초를보였던 1명이술후 12개월 400초로호전을보였다. 고찰 치료를받지않은간헐외사시의자연경과는 Jampolsky 15 및 Von Noorden 16 의보고에의하면대부분의경우진행하는것으로알려져있고, 대부분이러한낮은자연회복가능성, 이상망막대응, 약시의발생및복시, 혼란시등을우려하여적극적인치료를시행하고있다. 일반적인치료는크게비수술적방법과수술적방법으로나눌수있으며비수술적치료로는굴절이상의정확한교정, 가림치료를이용한약시치료, 폭주부족의경우눈모임훈련그리고프리즘및렌즈를이용한치료등이있으나, 이러한비수술적치료는대부분수술전후의보조적인방법으로이용되고있다. 1966년 Burian 17 이근거리사시각과원거리사시각의차이에의한외사시의분류에따라다른수술방법을제안한이래대부분양안의외직근후전술과단안의외직근후전술및내직근절제술등수술적치료가흔히시행되고있다. 간헐외사시는술후빈번한재발및과교정이문제가되고있으며, 특히추적관찰기간이길어질수록재발율이높아지게된다. 6 많은연구에서술후재발에관련된요인들로술전사시각, 수술시나이, 굴절이상, 술후초기과교정도, 외사시의간헐성, 감각기능등다양한원인들을보고한바있다. 18-22 이중재발이되는경우주로술전편위안에외사시가다시발생하는것에착안하여 Cho et al 14 은간헐외사시의술후재발율을줄이기위한방법으로술전편위안에안구의외전장애가미치지않는범위인 8~9 mm를후전하여편위안과주시안에최소 2.0 mm에서최대 6.0 mm의차이가있게하였다. 이는헤링의법칙에따라주시안의정상내직근에는더강한신경의흥분이전달되어눈을모으는효과가커져서재발을방지할것이고, 물리적으로도편위안외직근의운동범위를감소시켜편위안의재발율을낮출수있을것이라는생각에기인한것이었다. Cho et al 14 은이러한방법으로술후 6개월 93.1%, 12개월 85.1%, 24개월 78.5% 의정위율을보고하여기존의여러연구보다다소높은결과를보였다. 본연구에서는주시안을가진간헐외사시환자를대상으로하여양안의대칭외직근후전술과편위안증량비대칭외직근후전술의결과를비교한결과, 각각술후 6개월 92.6%, 91.7%, 12개월 81.8%, 85.7%, 24 개월 75.0% 와 81.2% 의성공률을얻었으며이는이전연구들과비슷하거나다소높은성공률이었다. 또한술후경과 관찰이길어질수록두군모두외편위경향이증가하는것과수술성공율도조금씩감소하는비슷한양상을보였다. 이러한결과로미루어술자의경험및대상군의포함기준, 제외기준등수술전후의많은요인들이수술결과에작용하여영향을미쳤을것이라고생각된다. Kushner and Morton 23, Morris et al 24, Goldstein and Schneekloth 25 및 Lee et al 26 은외사시및내사시에서수술로사시교정을함으로써입체시의정상화및호전에대해서보고했고이는사시각의정상화및안구의정위를유지하여입체시의회복을가능하게하는것이라고했다. 특히간헐외사시의경우항상외사시와내사시에비해서이미뇌의양안시세포절속에사시발생이전에경험했던융합감각이입력되어술후안구가정위로유지되면서입체시의획득확률이높은것으로알려져있다. 27 본연구에서는간헐외사시환자중최소 3,000초이하의입체시를보유한환자를대상으로수술을시행했고, 결과적으로부분적인입체시를가지고있었던 3,000초에서 100초사이의양안대칭외직근후전술군과편위안증량비대칭외직근후전술군에서각각입체시의정상화 3명, 회복 1명을보였다. 또한수술전입체시가 100초이하로정상이었던환자들은모두수술후에도정상적인입체시를유지함으로써두수술군모두에서입체시회복및호전에있어서유의한차이는없었지만이전연구들처럼수술전정상입체시의경우수술후에도정상적인입체시를유지할수있음과입체시는후천적인반사임을시사해주었다. 본연구는주시안을가진간헐외사시환자에서양안대칭외직근후전술과편위안증량비대칭외직근후전술의술후 6개월, 12개월, 24개월까지의결과에대한비교를할수있었다는것에의의가있으며, 결론적으로 0.3 이하의심한약시가없으며편위안을가진간헐외사시환자에서는편위안증량비대칭외직근후전술은술후 24개월까지양안대칭외직근후전술과비교하여다소양호한결과를보였으나통계적으로유의하지는않음을확인할수있었다. 향후더많은환자를대상으로장기적인경과에대한전향적인연구가필요할것으로생각된다. 참고문헌 1) Friedmann L, Biedner B, David R, Sachs U. Screening for refractive errors, strabismus and other ocular anomalies from ages 6 months to 3 years. J Pediatr Ophthalmol Strabismus 1977;17:315-7. 2) Yu YS, Kim SM, Kwon JY, et al. Preschool vision screening in Korea: Preliminary study. J Korean Ophthalmol Soc 1991;32:1092-6. 3) Preslan MW, Novak A. Baltimore vision screening project. Ophthalmology 1996;103:105-9. 4) Rah SH, Jun HS, Kim SH. An epidemiologic survey of strabismus www.ophthalmology.org 995
- 대한안과학회지 2010 년제 51 권제 7 호 - among school - children in Korea. J Korean Ophthalmol Soc 1997; 38:2195-9. 5) Pratt-Johnson JA, Barlow JM, Tillson G. Early surgery in intermittent exotropia. Am J Ophthalmol 1977;84:689-94. 6) Scott WE, Keech RV, Marsh A. The postoperative results and stability of exodeviations. Arch Ophthalmol 1981;99:1814-8. 7) Hardesty HH, Boynton JR, Keenan JP. Treatment of intermittent exotropia. Arch Ophthalmol 1978;96:268-74. 8) Richard JM, Parks MM. Intermittent exotropia. Surgical results in different age groups. Ophthalmology 1983;90:1172-7. 9) Chang BL. Operative results in exotropia. J Korean Ophthalmol Soc 1983;37:729-34. 10) Kim MM, Cho ST. Long term surgical results of intermittent exotropia. J Korean Ophthalmol Soc 1994;35:1321-6. 11) Ko KW, Min BM. Factors related to surgical results of intermittent exotropia. J Korean Ophthalmol Soc 1996;37:179-84. 12) Kushner BJ. Selective surgery for intermittent exotropia based on distant/near differences. Arch Ophthalmol 1998;16:324-8. 13) Ing MR, Nishimura J, Okino L. Outcome study of bilateral lateral rectus recession for intermittent exotropia in children. Ophthalmic Surg Lasers 1999;30:110-7. 14) Cho YA, Kang SM, Roh GH. Asymmetric bilateral lateral recti recession in intermittent exotropia. J Korean Ophthalmol Soc 1999; 40:544-9. 15) Jampolsky A. Characteristics of suppression in strabismus. AMA Arch Ophthalmol 1955;54:683-96. 16) Von Noorden GK. Binocular vision and ocular motility. Theory and management of strabismus. 6th ed. St. Louis:Mosby, 2002:356-76. 17) Burian HM. Exodeviations: their classification, diagnosis and treatment. Am J Ophthalmol 1966;62:1161-6. 18) Scott AB, Mash AJ, Jampolsky A. Quantitative guidelines for exotropia surgery. Invest Ophthalmol 1975;14:428-36. 19) Keenan JM, Willshaw HE. The outcome of strabismus surgery in childhood exotropia. Eye 1994;8:632-7. 20) Stoller SH, Simon JW, Lininger LL. Bilateral lateral rectus recession for exotropia: a survival analysis. J Pediatr Ophthalmol Strabismus 1994; 31:89-92. 21) Gezer A, Sezen F, Nasri N, Gözüm N. Factors influencing the outcome of strabismus surgery in patients with exotropia. J AAPOS 2004;8:56-60. 22) Raab EL, Parks MM. Recession of the lateral recti. Early and late postoperative alignments. Arch Ophthalmol 1969;82:203-8. 23) Kushner BJ, Morton GV. Postoperative binocularity in adults with longstanding strabismus. Ophthalmology 1992;99:316-9. 24) Morris RJ, Scott WE, Dickey CF. Fusion after surgical alignment of longstanding strabismus in adults. Ophthalmology 1993;100:135-8. 25) Goldstein JH, Schneekloth BB. The Potential for Binocular Vision in Constant Exotropia. Am Orthopt J 1993;43:67-70. 26) Lee KS, Cho YA, Roh GH. Streopsis after surgery in longstanding adult horizontal strabismus. J Korean Ophthalmol Soc 1999;40:1656-62. 27) Yoon SC, Paik HJ. The Post-operative Changes of Stereopsis in Adult Strabismus. J Korean Ophthalmol Soc 2008;49:1807-11. 996 www.ophthalmology.org
- 송현재 백혜정 : 간헐외사시의편위안증량외직근후전술 - =ABSTRACT= Augmented Asymmetric Lateral Rectus Recession in Intermittent Exotropia With Fixing Eye Hyun Jai Song, MD, Hye Jung Paik, MD, PhD Department of Ophthalmology, Gachon University Gil Hospital, Incheon, Korea Purpose: To document and compare the clinical results of symmetrical rectus muscle recession and asymmetrical rectus muscle recession in intermittent exotropia. Methods: The medical records of 27 patients who had symmetric bilateral rectus recession and 24 patients who had asymmetric bilateral rectus recession for intermittent exotropia with at least six months of postoperative follow-up from March 2004 to March 2007 were reviewed retrospectively. The authors performed a recession of 2 mm or greater in the deviating eye than in the fixing eye. Results: The mean age was 7.14±4.23 (range 3 to 15) years for symmetric bilateral rectus recession and 7.33±4.01 (range 3 to 14) years for asymmetric bilateral rectus recession. The mean follow-up was 11.83±5.74 (range 6 to 26) months in the symmetric bilateral rectus recession group and 11.14±5.05 (range 6 to 30) months in the asymmetric bilateral rectus recession group. The mean preoperative angle deviations were 27.5±4.8 prism diopter (PD) (range 30 to 40PD) and 27.3±4.6PD (range 20 to 40PD) in each group. The outcome of final follow-up (postoperative 24 months) was favorable in both groups, and slightly more successful in the asymmetric bilateral recession group but not a statistically significant amount (75.5% in the symmetric bilateral recession group and 81.2% in the asymmetric bilateral recession group). Conclusions: The present study suggests that there are no significant differences at postoperative 24 months between symmetric bilateral recession and asymmetric bilateral recession in intermittent exotropia having a fixing and a deviating eye. J Korean Ophthalmol Soc 2010;51(7):992-997 Key Words: Intermittent exotropia, Fixing eye, Symmetric lateral rectus recession, Asymmetric lateral rectus recession Address reprint requests to Hye Jung Paik, MD, PhD Department of Ophthalmology, Gachon University Gil Hospital #1198, Kuwol-dong, Namdong-gu, Incheon 405-760, Korea Tel: 82-32-460-3364, Fax: 82-32-460-3358, E-mail: hjpaik@gilhospital.com www.ophthalmology.org 997