대한안과학회지제 49 권제 2 호 2008 J Korean Ophthalmol Soc 49(2):288-292, 2008 DOI : 10.3341/jkos.2008.49.2.288 후낭이유지된인공수정체망막박리에서일차수술로유리체절제술과공막돌륭술의비교 강인성 오한진 박영걸 안재균 전남대학교의과대학안과학교실 목적 : 수술중합병증없이시행된초음파유화술후발생한인공수정체망막박리에서일차수술로시행한공막돌륭술과유리체절제술의임상결과를비교하였다. 대상과방법 : 2000 년부터 2005 년까지후향적고찰을통해한번수술후 1 년이상경과관찰된 63 안을대상으로일차수술로공막돌륭술을시행한 36 안과유리체절제술을시행한 27 안을해부학및기능적성공률을비교하였다. 해부학적성공은술후 1 년째망막이재유착된빈도로기능적성공은술후 1 년째 0.3 logmar 이상시력변화를기능적성공으로정의하였다. 결과 : 해부학적성공률은공막돌륭술은 86% (31/36) 였고유리체절제술은 82% (22/27) 로수술방법에따른차이는없었다 (p=0.733). 또한, 기능적성공률도공막돌륭술은 81% (29/36) 였고유리체절제술은 70% (19/27) 로공막돌륭술이나은경향을보였지만통계적인유의성은없었다 (p=0.065). 결론 : 후낭이유지된인공수정체망막박리에서공막돌륭술이나유리체절제술모두일차수술로선택할수있다. < 한안지 49(2):288-292, 2008> 후낭이잘유지된초음파유화술후인공수정체안은약 1% 의빈도로열공망막박리가발생하고수정체안에비해열공망막박리빈도가높으며시력소실을초래하는심각한다른합병증보다발생률이높은편이고시급한수술적처치가필요한질환이다. 1,2 수정체망막박리에비해인공수정체망막박리는진행속도가빠르고내원당시황반부가침범된빈도가높으며열공의크기가작거나적도부보다앞쪽에위치하며다발성인경우가많다. 3,4 또한, 여러원인들에의해열공의위치를정확히표시하기어려워부분공막돌륭술보다는유리체절제술이나공막두르기수술이안전하다고알려져있지만, 부분공막돌륭술또한효과적인치료방법으로제시되고 있다. 5-7 인공수정체망막박리의일차적인수술적치료방법의선택에대해수술결과가비슷하거나유리체절제술이좀더나은결과를보일수있다라는외국의보고들이있었다. 8-10 하지만, 연구에포함된환자들이다양한임상양상 ( 특히후낭의상태 ) 을가지고있는단점이있다. 또한, 후낭이잘유지된증식유리체망막병증을동반하지않은인공수정체망막박리에서일차수술방법에대해비교한국내연구결과는없었다. 본연구에서후낭이잘유지된증식유리체망막병증이동반되지않은인공수정체망막박리로일차수술로공막돌륭술과유리체절제술을받은환자들을시행후 1 년째해부학적성공률과기능적성공률을비교해보았다. < 접수일 : 2007 년 3 월 7 일, 심사통과일 : 2007 년 8 월 28 일 > 통신저자 : 안재균광주시동구학동 8 전남대학교병원안과 Tel: 062-220-6745, Fax: 062-227-1642 E-mail: jkahn@jnu.ac.kr * 본논문의요지는 2006 년대한안과학회제 96 회추계학술대회에서포스터로발표되었음. * 본논문은전남대학교병원임상연구비지원에의한것임. 대상과방법 2000 년 1 월부터 2005 년 12 월까지본원안과에서인공수정체망막박리로진단받고수술을시행받았던 92 명의환자중에서수술중합병증없이인공수정체를낭내로삽입한후발생한증식유리체망막병증이동반되지않은망막박리수술후 1 년이상추적관찰이가능하였던 63 명 63 안을대상으로의무기록을후향적으로조사하였다. 수술중수정체후낭의파열이발생했거나 ND: YAG 레이저후낭절개술을받았거나아토피피 288
대한안과학회지제 49 권제 2 호 2008 년 부염이동반되어있거나그외안외상, 당뇨망막병증, 포도막염이있는경우는제외하였으며황반원공이관찰된경우도제외하였다. 일차수술로 36 안에대하여공막돌륭술 (15 안부분공막돌륭술, 21 안공막두르기술 ) 을 27 안에대하여유리체절제술 ( 공막두르기술을같이시행한경우는제외 ) 을시행하였고망막이최소 1 년이상유착되어있는경우를해부학적성공으로정의하여두가지수술방법에따른성공률을비교하였다. 기능적성공은수술후 1 년째수술전황반박리유무에따라황반박리가있는경우술전에비해 0.3 logmar 이상시력이향상된경우를황반박리가없는경우 0.3 logmar 이내로시력이저하된경우를기능적성공으로정의하여성공률을비교하였다. 통계적분석방법은 SPSS 12.0 에서 Chi-square test, Fisher s exact test, Paired t-test 를이용하였고 p 값이 0.05 미만인경우를통계적으로유의하다고판정하였다. 형태는말발굽모양열공이두군모두가장많았으며열공의개수도비슷하였다. 열공의위치나망막박리범위또한두군간의차이가없었다. 일차수술로수술후 1 년째해부학적성공률은공막돌륭술은 86% (31/36) 였고유리체절제술은 81% (22/27) 두군간에통계적인차이점은없었다 (p= 0.733). 또한, 해부학적성공률은황반부박리여부와상관없이두군간유의한차이를 (Fig. 1), 수술후공 결 과 63 명 63 안중남자와여자는각각 48 안과 15 안이었고평균나이는 56 세 (17~88 세 ) 였고각군에서망막박리의임상양상의차이점은없었다 (Table 1). 열공의 Figure 1. One-year anatomical outcomes after surgical procedures in uncomplicated pseudophakic retinal detachment with intact posterior capsule. SB=scleral buckling; PPV=pars plana vitrectomy. Table 1. Patient Characteristics Scleral buckling (n=36) Vitrectomy (n=27) Mean Age, years (range) 53.5 (17-87) 56.1 (19-88) Sex (male : female) 26 : 10 22 : 5 Break type, number (%) Horse-shoe tear 24 (66.7) 13 (48.1) Hole 5 (13.9) 3 (11.1) Dialysis 3 (8.3) 5 (18.5) Mean break number±sd (range) 1.7±1.3 (1-7) 1.7±1.4 (1-6) Break location Anterior to equator 8 (22.2) 7 (25.9) Posterior to equator 25 (69.4) 19 (70.4) Not detected 3 (8.3) 1 (3.7) Superior half 16 (44.4) 17 (63.0) Inferior half 20 (55.6) 10 (37.0) RD extents 2Q 25 (69.4) 9 (33.3) >2Q 11 (30.6) 18 (66.7) SB=scleral buckling; PPV=pars plana vitrectomy; RD=retinal detachment; SD=standard deviation; Q=quadrant. 289
강인성외 : 후낭이유지된인공수정체망막박리에서일차수술로유리체절제술과공막돌륭술의비교 (A) (B) Figure 2. Visual outcomes after surgical procedures in uncomplicated pseudophakic retinal detachment with intact posterior capsule. (A) Scatterplot of preoperative vs. postoperative one-year visual acuity. (B) Comparison between the two surgical methods SB=scleral buckling; PPV=pars plana vitrectomy. 막돌륭술군이나평면부유리체절제술군모두에서의미있는시력의호전을보였다 (Fig. 2A). 그리고전체적인기능적성공률은공막돌륭술군에서나은경향을보였으나통계적으로유의성은없었으며 (p=0.065)(fig. 2B). 이러한수술결과는망막박리의범위나열공의위치및황반박리유무와도상관관계가없었다. 고 찰 본연구에서망막박리의대표적인두가지수술방법이후낭이유지된초음파유화술후발생한인공수정체망막박리에대해비슷한해부학및기능적성공률을보였다. 본연구에서일차수술후해부학및기능적성공률은기존의보고들과유사한결과로나타났다. 6-10 Arya et al 8 은기존의인공수정체망막박리논문들을분석한결과공막돌륭술의동시수술여부와상관없이유리체절제술을시행받은군에서해부학적성공률과시력예후가더좋다고보고하였으나, Weichel et al 11 은유리체절제술군에서합병증의발생률은더낮으나통계학적으로의미있는차이는아니었으며유사한정도의수술성공률을보였다고하였다. 하지만기존의보고들은후낭의상태가다양한경우들을포함하였고초음파유화술이외에낭외적출술환자들도포함된경우나심한증식유리체망막병증이동반되어있는경우그리고인공수정체의위치가다양한점들도인하여본연구와직접적인수술결과의비교는어려운측면이있다. 최근본연구와유사한외국의전향적인연구에의하면인공수정체망막박리에서공막돌륭술과유리체절제술이비슷한 해부학및기능적성공을보였다고하였지만경과관찰기간이 6 개월로짧은점이있다. 10 인공수정체망막박리특성에비추어유리체절제술은공막돌륭술에비해부분마취로수술이용이하며수술전발견하지못한열공들을찾을수있거나일차수술후해부학적성공률이상대적으로높고수술후굴절력의변화가미미하고비교적빠른시간에황반을유착시켜줄수있다는여러장점을가지고있어서 Brazitikos et al 9 은공막돌륭술에비해유리체절제술이인공수정체망막박리에보다더좋은수술방법이라고주장하였다. 최근하부열공에의한인공수정체망막박리에도일차유리체절제술의치료효과가있다고보고되고있고유리체대용물로공기나관류액으로치환하여도수술결과가좋은것으로보고되고있다. 12,13 따라서앞으로인공수정체망막박리에대해일차적인유리체절제술이차지하는역할이클것으로추정된다. 하지만유리체절제술이공막돌륭술보다높은수술숙련도를요구하고비용이높으며유리체대용물사용에의한합병증발생등단점이있다. 기존의보고들도인공수정체망막박리에공막돌륭술도좋은치료방법으로제시되고있으며, 7,14,15 Retna and Kivela 16 은인공수정체망막박리에서오히려공막돌륭술이유리체절제술에비해시력의예후가더낫다고보고하기도하였다. 따라서망막박리의상황을포함한눈소견뿐만아니라환자의경제적, 정신신체적요인및수술자의숙련도나수술상황을고려하여두가지수술방법모두선택이가능할것으로생각된다. 본연구에서도후낭이유지된초음파유화술후발생 290
대한안과학회지제 49 권제 2 호 2008 년 한인공수정체망막박리에서두가지수술방법을비교해볼때해부학적성공률은유사하고통계적인유의성은없었으나기능적성공률이공막돌륭술을시행한경우더나은경향을보였다. 이러한경향은후낭이잘유지된인공수정체망막박리의경우에는유수정체망막박리와유사한치료기준을적용할수있을것으로생각된다. 17,18 또한, 본연구에서망막박리의특성예를들면망막박리범위, 열공의위치나황반박리유무등이두가지수술방법모두수술결과에영향을미치지않았고두군간에수술결과에도차이가없었다. 이는상기인자들이일차수술결과에영향을주지않는다는기존의연구들과일치한다고볼수있다. 19,20 초음파유화술을이용한백내장수술시행건수가과거에비하여기하급수적으로증가하였고이에따라백내장수술후발생할수있는합병증의발생빈도도증가하고있다. 초음파유화술후발생하는인공수정체망막박리에대한수술방법에따른결과및예후는보고자마다차이를보이고있어수술방법의선택에있어어려운점이있다. 본연구의결과로비추어볼때후낭이잘유지된초음파유화술후발생한증식유리체망막병증이동반되지않은인공수정체망막박리에서공막돌륭술이나유리체절제술모두일차수술로선택할수있을것으로생각된다. 따라서각수술방법의특성과합병증을고려하여일차수술을선택할수있을것이다. 참고문헌 1) Boberg-Ans G, Henning V, Villumsen J, la Cour M. Longterm incidence of rhegmatogenous retinal detachment and survival in a defined population undergoing standardized phacoemulsification surgery. Acta Ophthalmol Scand 2006;84:613-8. 2) Russell M, Gaskin B, Russell D, Polkinghorne PJ. Pseudophakic retinal detachment after phacoemulsification cataract surgery: Ten-year retrospective review. J Cataract Refract Surg 2006;32:442-5. 3) Hwang US, Kim JI, Park JM. Clinical evaluation of pseudophakic retinal detachment. J Korean Ophthalmol Soc 2001;42:991-6. 4) Koo YM, Lee MS, Yoon IH. Comparison of clinical findings between phakic retinal and pseudophakic retinal detachment. J Korean Ophthalmol Soc 1998;39:2995-3002. 5) Devenyi RG, de Carvalho Nakamura H. Combined scleral buckle and pars plana vitrectomy as a primary procedure for pseudophakic retinal detachments. Ophthalmic Surg Lasers 1999;30:615-8. 6) Lois N, Wong D. Pseudophakic retinal detachment. Surv Ophthalmol 2003;48:467-87. 7) Park CS, Song SJ, Park YH. Surgical results of segmental scleral buckling in pseudophakic retinal detachments. J Korean Ophthalmol Soc 2004;45:570-5. 8) Arya AV, Emerson JW, Engelbert M, et al. Surgical management of pseudophakic retinal detachments: a meta-analysis. Ophthalmology 2006;113:1724-33. 9) Brazitkos PD, Androudi S, Christen WG, Stangos NT. Primary pars plana vitrectomy versus scleral buckle surgery for the treatment of pseudophakic retinal detachment: a randomized clinical trial. Retina 2005;25:957-64. 10) Ahmadieh H, Moradian S, Faghihi H, et al. Anatomic and visual outcomes of scleral buckling versus primary vitrectomy in pseudophakic and aphakic retinal detachment: six-month follow-up results of a single operation--report no. 1. Ophthalmology 2005;112:1421-9. 11) Weichel ED, Martidis A, Fineman MS, et al. Pars plana vitrectomy versus combined pars plana vitrectomy-scleral buckle for primary repair of pseudophakic retinal detachment. Ophthalmology 2006;113:2033-40. 12) Martinez-Castillo V, Zapata MA, Boixadera A, et al. Pars plana vitrectomy, laser retinopexy, and aqueous tamponade for pseudophakic rhegmatogenous retinal detachment. Ophthalmology 2007;114:297-302. 13) Martinez-Castillo V, Verdugo A, Boixadera A, et al. Management of inferior breaks in pseudophakic rhegmatogenous retinal detachment with pars plana vitrectomy and air. Arch Ophthalmol 2005;123:1078-81. 14) Sharma YR, Karunanithi S, Azad RV, et al. Functional and anatomic outcome of scleral buckling versus primary vitrectomy in pseudophakic retinal detachment. Acta Ophthalmol Scand 2005;83:293-7. 15) Le Rouic JF, Behar-Cohen F, Azan F, et al. Virtectomy without scleral buckle versus ab-externo approach for pseudophakic retinal detachment: comparative retrospective study. J Fr Ophthalmol 2002;25:240-5. 16) Retna P, Kivela T. Functional and anatomic outcome of retinal detachment surgery in pseudophakic eyes. Ophthalmology 2002;109:1432-40. 17) Halberstadt M, Chatterjee-Sanz N, Brandenberg L, et al. Primary retinal reattachment surgery: anatomical and functional outcome in phakic and pseudophakic eyes. Eye 2005;19:891-8. 18) Oshima Y, Yamanishi S, Sawa M, et al. Two-year follow-up study comparing primary vitrectomy with scleral buckling for macula-off rhegmatogenous retinal detachment. Jpn J Ophthalmol 2000;44:538-49. 19) Lee MV, Moon CS, Yang HS, et al. Factor influencing anatomical failure of simple rhegmatogenous retinal detachment. J Korean Ophthalmol Soc 2006;47:407-14. 20) Stangos AN, Petropoulos IK, Brozou CG, et al. Pars plana vitrectomy alone vs vitrectomy with scleral buckling for primary rhegmatogenous pseudophakic retinal detachment. Am J Ophthalmol 2004;138:952-8. 291
강인성외 : 후낭이유지된인공수정체망막박리에서일차수술로유리체절제술과공막돌륭술의비교 =ABSTRACT= Clinical Results between Scleral Buckling and Vitrectomy in Pseudophakic Retinal Detachment with Intact Posterior Capsule In Seong Kang, M.D., Han Jin Oh, M.D., Yeoung Geol Park, M.D., Jae Kyoun Ahn, M.D. Department of Ophthalmology, Chonnam National University Medical School & Hospital, Gwangju, Korea Purpose: To compare the clinical outcomes between scleral buckling and vitrectomy in the primary management of pseudophakic retinal detachment with an intact posterior capsule. Methods: The medical records of 63 eyes that underwent scleral buckling (36 eyes) or vitrectomy (27 eyes) as a primary operation of uncomplicated pseudophakic retinal detachment with intact posterior capsules with a follow-up of more than one year were retrospectively reviewed from 2000 to 2005. We compared the clinical outcomes using anatomical and functional success rates at postoperative one year. Anatomical success was defined by a reattachment rate and functional success was measured by a change of more than 0.3 logmar. Results: Anatomical success rates were 86% in the scleral buckling and 82% in the vitrectomy, respectively (p=0.837). Functional success rates were 81% in the scleral buckling and 70% in the vitrectomy, respectively (p=0.065). There were no significant differences of anatomical and functional success rates according to each surgical procedure. Conclusions: Either scleral buckling or vitrectomy may be chosen as a primary operation in the management of pseudophakic retinal detachment with intact posterior capsule. J Korean Ophthalmol Soc 49(2):288-292, 2008 Key Words: Primary vitrectomy, Pseudophakic retinal detachment, Scleral buckling Address reprint requests to Jae Kyoun Ahn, M.D. Department of Ophthalmology, Chonnam National University Medical School & Hospital #8 Hak-dong, Dong-gu, Gwang-ju 501-757, Korea Tel: 82-62-220-6745, Fax: 82-62-227-1642, E-mail: jkahn@jnu.ac.kr 292